The early struggles of the fledgling American Academy of Neurology: resistance from the old guard of American neurology.

The American Neurological Association, established in 1874, was a small exclusive society comprising senior neurologists at a select number of north-eastern academic institutions. In 1948, an attempt was made to establish a second neurological society in the USA. The American Academy of Neurology was formed around a group of young neurologists who represented the country's Midwest and other regions. The American Academy of Neurology is now the larger of the two organizations, even though the American Academy of Neurology began as a small and politically vulnerable organization, arising in the shadow of the powerful and established American Neurological Association. How did the 75-year-old association react when a second, seemingly redundant, neurological association attempted to organize? This question has not been the focus of historical work, and the purpose of this study was to address this. To do so, the author studied the primary source materials in the American Academy of Neurology Historical Collection and the papers of Dr Henry Alsop Riley, an American neurologist, who was influential in both the American Neurological Association and American Academy of Neurology. On its formation, the American Academy of Neurology did not enter a vacuum. Indeed, the long-existing American Neurological Association actively resisted the new organization. There was reluctance to accept the new idea on a conceptual level, a formal attempt to hijack the new organization and discussions about punitive actions against its founder, while at the same time an attempt to bring him into the American Neurological Association leadership. Although the American Neurological Association attempted to frame itself as the patrician 'upper chamber' of American neurology, the American Academy of Neurology leadership was ultimately savvier at political manoeuvring and use of government agencies and funding organizations. The struggle of the American Academy of Neurology with the American Neurological Association was in many ways one manifestation of a larger societal struggle in a post-bellum (post-World War II) America with a changing demographic. The struggle involved the rise of democratic medical populism in the country's Midwest versus establishment medicine (mainly situated in the Northeast), and perhaps, the rise of the middle class versus the aristocrats.


Introduction
The American Neurological Association (ANA, established December 1874) was founded 51 decade after the conclusion of the American Civil War. By design, it was a small exclusive society for scholarly established leaders of American academic neurology. Its leadership was dominated by a self-contained group of senior neurologists at a select number of north-eastern academic institutions.
In the aftermath of another war, World War II, a second neurological society was founded in the USA. The American Academy of Neurology (AAN) formed around a group of young neurologists who represented the country's Midwest and other regions. To the contemporary American neurologist, these two organizations coexist, serving side by side; in terms of size, the membership of the AAN (425 000) is far larger than that of the older ANA (2000).
The AAN began as a small and politically vulnerable organization, arising in the shadow of the powerful and established ANA. How did the 75-year-old association react when a second, seemingly redundant, neurological association attempted to organize? Even without express knowledge, one might presume a certain degree of resistance.
Resistance to new ideas and organizations may take a number of forms: (i) reluctance to accept the new idea on a conceptual level; (ii) reluctance to join as a member of the new organization; (iii) punitive action and/or exclusion of members of the new organization from professional activities ('blackballing'); (iv) providing a larger role for individuals in the existing organization so they drop their new initiatives and separate efforts; (v) depriving the new organization of opportunities; (vi) behind the scenes manoeuvring with third parties (government agencies, funding organizations, academia); or (vii) hijacking the new organization.
My aims in this article are (i) to review the origins and early development of the AAN, focusing on those issues that distinguished it from the ANA; and (ii) to assess which, if any, of the above-referenced forms of resistance seemed to have occurred. The article focuses on the critical formative years, between 1948 and the late 1950s. The focus of this research was on the frictions between the AAN and the other prevailing neurological professional organization, the ANA, rather than broader struggles between neurology and other medical professions (e.g. psychiatry), about which a great deal has been written (Grob, 1983(Grob, , 1994, or the rise of medical specialties, which is the focus of considerable scholarly attention (Abbott, 1988;Weisz, 2006).
Aside from the history of these specific organizations, this research more broadly touches on several larger historical and social themes. The first of these is the history and evolution of American neurology and its representative bodies. The organization and behaviour of these associations often provide a window into the manner in which the members perceive themselves and their discipline. The second is the rise of democratic medical populism (mainly situated in the country's Midwest) versus a differentiated elite (mainly situated in the Northeast), and the rise of the middle class versus the aristocrats. Finally, the article touches on the changing demographics in post-war America, as there was a movement to expand beyond the boundaries of the East Coast into the country's growing heartland.

Methods and sources
The following primary source materials were studied: (i) the AAN Historical Collection (AANHC, St. Paul, MN, USA). This 270-linear foot indexed collection includes correspondence, memos, documentation produced for annual meetings, Executive Board records, membership data, financial records, newsletters, publicity files and other materials from 1947 to 2008. (ii) Nineteen boxes of materials (11 linear feet) that related to the first 10 years of the AAN; and (iii) the papers of Dr Henry Alsop Riley (Archives and Special Collections, Augustus C. Long Health Sciences Library, College of Physicians and Surgeons, Columbia University) were selected and reviewed. This four-box collection  of Dr Riley's papers contains correspondence and other materials documenting the professional career of Henry Alsop Riley (1887Riley ( -1966, an American neurologist who was influential in both the ANA (President, 1946-47) and AAN (member, 1949-66).

The context
In 1948, when the AAN was established, the ANA was a small body of 5200 senior members of the neurological community; its membership was mainly drawn from the country's Northeast (Denny-Brown, 1975;Goetz et al., 2003). At the time, neurology departments were rare fixtures of the medical school landscape. Neurology and psychiatry were often construed as two sides of the same coin; psychiatry and mental hospitals dominated the landscape of state and national funding; and ANA members were comfortable with these circumstances. Even the recent establishment and naming of the American Board of Psychiatry and Neurology in 1934 had given precedence to psychiatry (i.e. 'P' before 'N' in the abbreviation), in what was labelled by the neurologists as a form of 'alphabetic idiocy' (Freeman et al., 1959). Thus, in 'a startling reversal of roles, the senior and previously more powerful field of neurology now played second fiddle to is upstart cousin', psychiatry (Pressman, 1998). Experience in World War II with central and peripheral nerve injuries had stimulated a rejuvenated interest in the treatment of neurological patients and the training of a young generation of practitioners to perform this treatment; indeed the numbers of such patients was sizable, with 44 000 of the 74 000 Veterans Administration hospital beds filled with neuropsychiatric patients in April 1946 (Farreras, 2004).
Also, neurologists were beginning to call for more of a separation of neurology from psychiatry (Aird, 1994). The AAN Historical Committee later wrote a report that summarized the historical context within which the AAN was established: Due to the restricted nature of organized neurology in the United States in the past, young neurologists frequently were forced to present their ideas and papers before societies only secondarily interested in neurology, such as psychiatry, internal medicine, neurosurgery and even pediatrics. After the last war and in part as a result of the affiliation of the Veterans Hospitals with Medical Schools which developed an expanded interest in neurology and in the treatment of neurological patients, a constructive effort was made to fill this vacuum. A younger generation of resident physicians in neurology developed, who looked forward to a practice in the field of neurology after the completion of their training period . . . . At that time the American Psychiatric Association was the only society with an unlimited membership and with varying categories of membership. Upon joining such an organization, however, one's identity as a neurologist soon disappeared . . . . The situation so greatly impressed Dr A. B. Baker [(1908-88), University of Minnesota, founding president of the AAN, Fig. 1] that he was stimulated to consult other neurologists concerning the need and desirability of an organization which would serve as a medium of expression and development for the young neurologists of the country (Aird et al., no date).
Several other Midwestern neurologists assisted Baker in this task; these included Dr Adolph L. Sahs (University of Iowa, AAN President 1961-63), Dr Joe Brown (Mayo Clinic, AAN President 1971-73), Dr Russell DeJong (University of Michigan, founding editor of the journal Neurology) and Dr Francis M. Forster (originally from Cincinnati, Ohio, AAN President 1957-59). Baker himself was a product of the University of Minnesota Medical School, having attended as a medical student (MD, 1930;PhD in Pathology, 1934) and eventually rising from a Teaching Fellow to Head of the Division of Neurology.
It was in this context, in October 1947, that A. B. Baker sent invitation letters to neurologists in the USA inviting them to join the AAN. In writing, for example, to Dr Robert S. Dow at the University of Oregon Medical School, he provided his vision for the AAN: With the increasing interest in neurology, there appears to be a great need for a neurological organization whose membership would be unrestricted and to which many of the younger men could belong. Such an organization would cultivate and encourage cordial relationships among all members of the neurological and allied professions. It would also serve to outline the scope of the neurological practice and to encourage recognition of this specialty among the profession and in medical schools . . . . It is because of this need for an unrestricted neurological association that the AMERICAN ACADEMY of NEUROLOGY is being organized (Baker, 16 October 1947). Dr Dow responded politely but with some misgivings, 'I would prefer to delay my acceptance of your kind invitation until I was more certain that the efforts of the Academy would not duplicate those of the American Neurological Association' (Dow, 1 November 1947). Baker responded in detail to Dow, . . . a great deal of thought was given to the possible relationship of this Society to the American Neurological Association. Everyone concerned was very much interested in not having two neurological organizations which would be competitive in nature. After thinking it over, we felt that there was a very definite place for such a Society. As you know, the American Neurological Association at the present time has a very limited membership. Many of the members are not neurologists but are predominantly interested in other fields such as psychiatry, neurosurgery, and neuropathology. Many of the younger men who have been or are being trained in neurology have absolutely no organization with which they can affiliate. Many of these doctors are interested only in private practice and will not write papers or even participate in academic work. Briefly surveying the number of such individuals available, I was surprised at the number of these young men who have already completed training or are in the processes of completing their training. These neurologists have no organization that they can call their own and are being forced to join the American Psychiatric Association because there is no neurologic society to which they can belong . . . . Perhaps one might be able to stimulate the American Neurological Association to change its policy and open its membership to all these young men, but I have my doubts as to whether this will be possible or even desirable (Baker, 18 November 1947).
Indeed, the letter underscores what was a basic philosophical difference between the two organizations: the ANA was interested in attracting academic neurologists, whereas the AAN's aims were to include practitioners as well as academics.
The American Academy of Neurology: inclusivity and attempts to attract junior members Dr A. B. Baker, who was the main driving force behind the establishment of the AAN, recalled: 'the neurologic specialty has for some time assumed a traditional attitude of over-reserved dignity and isolationism, in spite of the fact that it was destroying every opportunity for growth and strength . . . . Unfortunately, neurologists themselves . . . traditionally . . . have fostered an aloof, erudite attitude towards their colleagues . . .' (Baker, 1952). Some members of the field had even begun to speak of the disappearance of neurology, as the sphere of their activity shrunk at the hands of neurosurgeons and psychiatrists in the 1920s and 1930s (Gavrus, 2011). Indeed, formal statements about proprietary rights to patients and clinical spheres of influence would come to preoccupy much of the speech making during the final evening of the first International Neurological Congress held in Berne, Switzerland in 1931 (Louis, 2010).
The ANA had enjoyed a niche membership of primarily older established members of the neurological and related communities (Baker, 1972(Baker, -1973. From its outset, the AAN attempted to be more inclusive, and the specific inclusion of young members was one of its central themes. In fact, the organization's Certificate of Incorporation (17 February 1948) proposed that 'junior members' be one of the four main categories of membership, with the requirements being fairly relaxed: 'persons who (a) have graduated from a Class A Medical School, (b) are engaged in postgraduate studies directed toward their qualification for the American Board of Psychiatry and Neurology in Neurology'.
A parallel phenomenon, of attempting to find a professional societal home for young practitioners, was also occurring in the field of neurosurgery (Congress of Neurological Surgeons, after 11 May 1951; Svien, 23 November 1951), a sign that the move reflected a broader undercurrent (Gavrus, 2011).
Soon after its incorporation, the AAN sent membership invitations to all diplomates of the American Board of Psychiatry and Neurology (Brown, 1949). Along with the invitation letter was a form, which attempted to derive new junior members from among individuals who were still in training. It read: 'I would like to suggest the following neurologists-in-training for Junior membership' (AAN Questionnaire, 1948). Interestingly, the attachment also solicited diplomates'/potential members' interest in serving on AAN committees, thus showing a willingness to open these traditionally coveted posts to junior members.
One clear strategy to attract junior members was to provide services for these individuals. Thus, in the summer of 1949, Baker wrote to the neurologist Dr Russell DeJong: I feel that we should start making a list of all the various types of Neurological Residencies that are available, the stipend that they offer, and the requirements for them, so that we may not only have a record of these but also have them circularized amongst our membership and applications can be made in case a Residency of some type is wanted. This would be a good record for the Academy and also would be an excellent service for the membership (Baker, 1 July 1949).
Early attempts of the AAN to enlist the support of as many junior members as possible are shown in the 9 May 1951 letter from Dr Clark H. Millikan (1915Millikan ( -2011, Chairman of the AAN Membership Committee, to Dr Pearce Bailey [(1902-76), second president of the AAN (1951-53)]: 'In addition, I expect to contact the chiefs of all the Neurology Services in the country (particularly those accredited for residency training) and suggest that application blanks be distributed to young men in training in those particular centers. We should be able to increase our Junior membership considerably by this technic' (Millikan, 9 May 1951).
The American Academy of Neurology: moving out of the Northeast Aside from its inclusive approach to younger neurologists, the AAN presented a departure from the ANA model in other central respects. Thus, the membership of the AAN, from its founders and organizers down to its constituent membership, represented the country's Midwest and other (western and southern) regions. Although the ANA meetings were held each year on the East Coast, in Atlantic City, by contrast, the initial concept for the AAN was that the annual meeting would alternate between a single meeting in the central part of the USA and a series of regional meetings in alternate years. The organization's certificate of incorporation read as follows (my italics): 'The Academy shall hold a national meeting once every two years in a central part of the United States, the time and place to be designated by the Board of Trustees. On the alternative years, the Academy Meetings shall be held regionally under the arrangement of the regional groups' (AAN Certificate of Incorporation, 17 February 1948).
Of the original fellows of the AAN, which numbered 52, 15 (28.9%) were from midwestern states ( Fig. 2) (Original Fellows, 1949). A breakdown of membership in 1950 noted that of the 526 members, fewer than half (243, 46.2%) were from the Northeast; 158 (30.0%) were from the Midwest (

Fragile financial beginnings
Like many fledging organizations, the AAN had few funds when it started, thus highlighting the vulnerability of the organization.
A letter in June 1950 indicates: 'It might be added that at the onset the American Academy had no money and no resources and it was through the courtesy of the Journal Lancet Publications in Minneapolis that the original application forms, stationery, and general supplies were obtained without cost to the group' (Unsigned letter, 20 June 1950). (The connection with Lancet publications was through the publisher Louis M. Cohen, a friend of A. B Baker. Cohen owned Modern Medicine, a subsidiary of Lancet Publications) (Daroff, 1996).
Dr Pearce Bailey used his connections with the Veterans Administration to help defray the costs of photography at the 1950 regional meeting in Cincinnati. He wrote: Arrangements have been made for an Army photographer to make the trip to Cincinnati . . . . He will be able to make a photograph of each member as they register and of any groups that are considered desirable, including any banquet pictures . . . The Army will supply to photographer and the developed negatives without cost. They will not, however, make prints from these negatives, but we were of the opinion that in some way the Academy could undertake this project (Bailey, 24 March 1950). As 'funds for an adequate public relations program [were not] forthcoming', there was 'poor press coverage of the Cincinnati meeting' (Berg, 8 May 1950), another symptom of the precarious financial position of the newly founded organization.
In actuality, Dr Baker very much had to use his own resources to launch the new organization, which operated on a shoe-string budget; in the spring of 1951, a letter from Dr Baker (founding AAN president) to Dr Pearce Bailey (newly serving AAN president) reads: I should like to obtain your permission, therefore, to purchase another file for the cost of approximately $76.35. You might be interested to know that the Academy has never purchased any files. At the present time they are using my personal files which are now completely filled. I believe we will have to get permission from the Board of Trustees for this expenditure, but I should like to obtain this permission immediately so that we can proceed with the purchase so that we will have someplace to put our records (Baker, 26 April 1951). In the summer of 1953, Dr Howard Fabing (AAN president) received a detailed letter from Dr Dave Ruskin, the AAN treasurer, whose opinion was that the AAN finances were being handled in an unsophisticated and disorganized manner. Ruskin asked for a better financial organizational framework and a more formalized system of checks and balances. It was a sign of growing pains. Yet it was not a sign of organizational wealth; an exasperated Fabing wrote back: As I see it, the reason why the Army and big corporations require everything in triplicate or quadruplicate is because their ranks are filled with nincompoops and constant checks are therefore necessary to keep the train on the tracks. The Academy is not the Pentagon Building nor is it General Motors. It is a small organization which is as close to being dead broke as any with which I am acquainted. As I view its financial status, the Academy funds plus a dime would get you a cup of coffee (Fabing, 6 July 1953).
Ruskin's request was rejected. Early growth and success of the American Academy of Neurology Despite financial issues, the AAN could not be held back. Its inclusive nature had enormous popular appeal. By 23 June 1948, within 5 months of its certificate of incorporation, there were already 50 fellows and 329 active members; active members and fellows paid a small annual dues fee ($5.00, equivalent to $48.32 in 2012), and junior members paid an even smaller annual dues fee ($2.00, equivalent to $19.33 in 2012) (AAN Order of Business, 23 June 1948).
Indeed, the AAN was so successful at rapidly building a large membership base that the challenge of processing of these applications became a logistical and administrative problem. In response to a written query from Dr Pearce Bailey, in which he was asked why membership applications were not being processed quickly enough, Dr Clark H. Millikan, the Chairman of the Membership Committee, drafted a somewhat defensive letter. He began, 'I was indeed sorry and surprised to learn that you are displeased with my work as Chairman of the Membership Committee . . . . Soon after I accepted the position of Chairman of the committee in the summer of 1949, I was presented with a stack of over 500 applications' (Millikan, 17 October 1951).
On 31 March 1954, the History Committee of the AAN was able to issue a report summarizing the accomplishments of the organization during the previous 5 years, noting that the AAN had 'become one of the strongest, if not the strongest, organization of neurologists in the world . . . which had begun to exert powerful influence in neurological education; legislation, and clinical practice' (Committee Reports, 1954). Indeed the reporting of this and other AAN committees shows how large and successful the AAN had become in a relatively short span of time. Thus, the reach of the organization involved a wide range of activities including a branch that dealt with legislation and which tried to influence how much money the American government was appropriating to neurology and, through the epidemiology committee, a branch that was involved with issues of disease nomenclature and definition (important for informing the National Office of Vital Statistics) (Committee Reports, 1954).

Free-flow between the American Academy of Neurology and American Neurological Association
Lest one think that there was complete separation between the two societies, this was not the case, which adds a certain multidimensionality and nuance to the flow of events. For example, AAN business and AAN-topical discussions took place at ANA meetings. Writing to Mr. Roland Berg (public relations) on 15 May 1950, Dr Baker mentioned casually, 'I am going to discuss the contents of your letter with Dr Bailey next month at the meeting of the American Neurological Association. Dr Bailey is chairman of our [AAN's] public relations committee' (Baker, 15 May 1950). Such AAN work seemed to have been performed commonly at the ANA. Dr Edwin G. Zabriskie of New York (1874-1959, Neurological Institute of New York, president of ANA in 1944 wrote to Dr Bailey on 5 June 1951: 'In reply to yours of May 31st, I think I would prefer to wait until I see you in Atlantic City [ANA meeting] before making any appointments for the [AAN] Committee on Ethics' (Zabriskie, 5 June 1951).
Not only was some behind-the-scenes AAN work being conducted at the ANA meetings, but some of the kingpins of the ANA had agreed to take on leadership roles on AAN committees. Thus, Dr Henry Alsop Riley, who had had numerous prominent leadership roles in the ANA, including its presidency (1947), was one of six members of the AAN Ethics Committee . Also, many of the leaders of the ANA were  (Merritt, 3 January 1949).
Although some of the acquiescence of ANA members, in agreeing to join and serve the interests of the young AAN, was done in a collegial manner, some of it was likely to have been self-motivated by those who did not wish to be left behind. In addition, the ANA leadership in some cases probably used membership in their organization to try to stem the tide of the AAN. Thus, Baker was appointed to the prestigious Council of the ANA (Baker, AAN Newsletter 2, July 1949). This may have been perceived as an attempt to provide a larger role for Baker in the ANA so he would drop his separate efforts with the AAN.
Butting heads: competition between the American Academy of Neurology and the American Neurological Association for the same resources There was some cooperation between the two neurological organizations, yet this was initially slow in coming and restricted to specific activities. Thus, the two organizations sponsored a joint survey of neurological education in the USA (Baker, Report of the Committee on Education, 1954). Yet they were competing for the same resources.
Early on, the timing of the annual meeting had been carefully managed so as to avoid a conflict between the two vying organizations. By intention, the annual AAN meeting had been scheduled early in the calendar year. Yet, in the fall of 1951, Dr Baker wrote to Dr Pearce Bailey of his concern that the ANA might be moving its 1953 annual meeting from June to May, 'very close to the meeting of the American Academy . . . I am a little concerned about this step of moving the [ANA] neurologic meeting ahead . . . As you will recall, we [AAN] purposely moved our meetings ahead to April at the request of the American Neurologic [ANA] so that it would not conflict with the American Neurologic's June meeting'. Being carefully politic, he added, 'I am wondering whether it might not be a good idea for you to drop H. Houston Merritt [1902-79, Neurological Institute of New York, and ANA president 1957] a note indicating that you have heard rumors about this move in 1953; and that as the president of the Academy, you would like to request that if possible their meetings be kept in June and not inconvenience those members who would like to attend both meetings' (Baker, 20 November 1951).
On many levels, the two organizations were competing for some of the same resources and attentions. For example, the AAN attempted to obtain separate representation on the American Board of Psychiatry and Neurology. Despite the fact that two of the AAN's original charter fellows (Dr Frederick P. Moersch and Dr Roland P. McKay) (Original Fellows, 1949) were members of the nine-member Board of Directors of the American Board of Psychiatry and Neurology, the AAN leadership was unsuccessful at further breaking in, in part owing to existing representation by the ANA. Thus, a letter from F. J. Braceland While the AAN-ANA conflict played itself out on the American stage, it was the international stage that served as the focal point for the greatest conflict. Although this will be reviewed more fully later in the text, as far back as 1951, Dr Matthew T. Moore, a Fellow of the AAN, wrote to Dr Pearce Bailey of his recent trip to South America, and the opportunities in terms of forging links with colleagues in Uruguay, Brazil and Argentina. He added as a postscript, '. . . I learned that the American Neurological Association has been considering inviting our South American colleagues to their forthcoming meetings. This is merely in the formative stage, and I think that we should take advantage of the situation by stealing a march on them' (Moore, 4 October 1951).

American Academy of Neurology versus American Neurological Association: meeting resistance
Dr Joe Brown (1911Brown ( -2004, founding member of the AAN and first Secretary-Treasurer), providing a bullet-point history of the AAN, wrote: '. . . many established neurologists in ANA openly opposed and criticized the idea [of the AAN]' (Brown, typed notes, no date). A document in the AAN archives entitled 'Academy-ANA Relationships' indicates that '. . . some members of the ANA were strongly opposed to the establishment of the proposed American Academy of Neurology. This opposition was centered in the Boston-New York-Philadelphia area and included some prominent neurologists, some of whom suggested disciplining Dr A. B. Baker should he proceed with the plans to form the Academy' (Academy- ANA Relationships, no date).
In 1959, Dr Baker recalled the early days of the AAN: In planning the Academy, you must keep in mind that one was breaking with tradition. The American Neurological tradition at that time was the American Neurological Association and to consider a new neurologic group on a broad democratic scale was not to be tolerated. Therefore, for two years, I spoke to many important leaders in the neurologic field trying to stimulate some support for this new idea. Therefore, it was fairly well known that such a Society was being considered and I believe most people felt that no one would have the courage to start such a group. In the 'Old Guard' or older members of Neurology, the chief support and encouragement came from Drs. Lewey, Wortenberg, Schaller and Nielsen (Baker, 4 November 1959).
He continued: The next event at the meeting [the first meeting in Chicago] almost spelled the end of the Academy before it really had gotten off the ground. The second item of business was the election of officers. I was elected president for the next two years. When it came to the election of a president-elect, apparently the Eastern Group had come to the meeting prepared to take over the new society. On the other hand we were very inexperienced and had not come with a carefully selected slate. As soon as the selection of a president-elect was opened, the Eastern Group nominated Dr Walter Freeman of Washington, and before any further nominations could be made, one of his students proposed that nominations be closed. Dr Freeman then was automatically elected president-elect or the next Academy president, much to the alarm of the entire founding group. After the meeting and for the next few weeks many meetings were held to determine what to do, since the future of the Academy depended upon its guidance during these first years and Dr Freeman had shown no interest nor concept of the new Academy policy. It was finally decided that perhaps the Academy should be dissolved and a new attempt made to organize with better prepared plans. This was a tremendous disappointment to most of us who had worked so hard to get things started right (Baker, 4 November 1959).
Writing many years later, Dr H. Houston Merritt wrote: 'The development of the Academy [AAN] was one of the most significant factors in the rebirth of Neurology in our generation'. He added, 'Followers of King Canute existed in those days and it may be many years before we see the last of them' (Merritt, 3 November 1975). 'Canute' is a reference to the Danish King (985-1035), who is remembered now for having been so self-impressed that he thought his command could hold back the ocean tide.
The ANA continued to try to dominate the AAN. As noted previously, the two organizations decided to combine some of the efforts of their educational committees, but the ANA preferred that the results be discussed at the ANA meeting rather than the The fledgling AAN Brain 2013: 136; 343-354 | 349 AAN meeting, which was the later of the two. Dr Baker wrote a letter to Dr Pearce Bailey, venting some steam: You can rest assured how annoyed I actually was, since it was apparent that Doctor Pollock consciously or unconsciously would like to use the drive and energy of the American Academy to collect all the data for him so that it might be presented at the American Neurologic. It also means that during the next year the American Academy will have to work and slave to get these panels organized while the members of the American Neurologic sit back and wait for the results (Baker, 25 March 1952).
International representation, the American taxpayer and conflict between the young Turks and the old guard As noted earlier, the issue of international representation was a particularly sensitive one, and provides an interesting window into the growth of the AAN during the mid to late 1950s and the reaction of the old guard.
Three issues must be reviewed. First, the AAN still lacked international representation at that time. Second, the International Neurological Congresses and the newly forming World Federation of Neurology (established in 1957) provided a potential forum for such representation. Third, the establishment of the National Institutes of Neurological Disease and Blindness (created in 1950) provided the AAN with the monetary leveraging power to achieve this representation.
For the first decade of its existence, the AAN both wanted yet lacked formal representation at international neurological congresses. The First International Neurological Congress had taken place in Berne in 1931, followed nearly every 4 years by that in London (1935), Copenhagen (1939), Paris (1949), Lisbon (1953), Brussels (1957 and Rome (1961) (Louis, 2010). In 1949, AAN members were present at the AAN Banquet at Rotisserie Peridourdine (Fig. 3), although the AAN was not formally represented in Paris or at the later Lisbon meeting.
Planning ahead for the 1953 Lisbon meeting, Dr Baker wrote: It is a little hard to tell just exactly what is going to happen in the very near future regarding international affairs, but it is my feeling that the Academy must carry on in a normal fashion . . . . It think it is quite important that the Academy institute some energetic activity as regards the International Congresses as I would dislike to have others make plans for the entire United States, disregarding the Academy as was done during the Paris Meeting . . . . I am sure you will receive tremendous opposition from the old guard who have always been active in this affair. I had my run-in with them when I tried to make some plans for the last meeting. You will probably get even more resistance, although this time the Academy is much better organized (Baker,6 February 1951) (Fig. 4).
Unfortunately, the AAN's plans did not succeed. After the Lisbon meeting, Dr Pearce Bailey wrote to Dr Howard Fabing, then the President of AAN: 'Dear Howard. . .Relative to the Committee on International Collaboration, I have purposely proceeded slowly. As you know, this is a delicate problem . . . the only Society recognized so far by International Congresses is the ANA' (Bailey, 25 November 1953).
At the 1957 meeting in Brussels, the International Neurological Congress gave rise to the formal organization, the World Federation of Neurology (Louis, 2010). Dr Ludo van Bogaert (Belgium, 1897(Belgium, -1989 spearheaded the effort. The World Federation of Neurology provided a potential forum in which to achieve AAN representation; indeed, Dr Pearce Bailey was to be the World Federation of Neurology Secretary. The National Institutes of Neurological Disease and Blindness was established in 1950. Writing to the AAN membership in the fall of 1951, Dr Baker noted: 'Dear Fellow-Member: As you know, the National Institute of Neurological Diseases and Blindness in the Public Health Service was created last year . . . . It is my great pleasure to inform you that your present President, Dr Pearce Bailey, has just been appointed to this position' (Baker, 27 September 1951). In his role as director of National Institutes of Neurological Disease and Blindness, Bailey could provide the monetary leveraging power to advance the goals of the AAN. This is where events took an interesting turn. In 1959, The World Federation of Neurology received two grants totalling $138 207 from the National Institutes of Neurological Disease and Blindness, thus becoming the first international organization to receive federal aid of this kind. The larger grant ($126 190) provided partial support for a small central staff in Belgium (Announcement, 21 March 1959). Thus, the National Institutes of Neurological Disease and Blindness, with Dr Pearce Bailey at its helm, was in large part underwriting the operating costs of the World Federation of Neurology.
The larger issue, outside of institutional neurology, relates to the post-war inequality of resources between the USA and Europe, American hegemony and the projection of American power into post-war continental Europe (Krige, 2006).
The news of the two grants evoked an immediate reaction from the ANA. Dr Charles Rupp, Secretary-Treasurer of the ANA, wrote with sarcastic bite to Dr Henry Alsop Riley, attaching the grant announcement. On the surface, he indicates that he is unhappy that American taxpayers are underwriting an international programme; the subtext relates to his perception that Bailey is attempting to wrest control of the international congress in an effort to position the AAN rather than the ANA as the predominant international representative of American neurology: 'Dear Hal: I enclose herewith a clipping which I stumbled upon in the March 21 issue of the JAMA . . . . I am sure that when you make your annual contribution to the Director of Internal Revenue on April 15 that you will do so happily knowing that your modest mite will be expended for such a worthy cause. If only we could bring back poor Mr. McKinley and the cowboy Roosevelt' (Rupp, 1 April 1959 Perhaps nothing drastic will be done and we can relax. At any rate, it is just as well that we are forewarned and that we should be in a position to prevent the Academy from running away with all the interests of American neurology in the Congresses (Riley, 6 April 1959).
In a letter to Riley, Rupp's anger is palpable: Apparently Pearce is not up on his protocol. He probably has been so busy giving our money away and 'politicing' for the Academy that he has not had time to bone up on his International Congress Emily Post. To use one of the Colonel's good old Anglo-Saxonisms, 'to h-with him'. I am off this evening for sunny California and will put a quarter in the slot machine in Las Vegas in the hopes that I will hit the jackpot and pay Rupp's and Riley's expenses in Rome. In case I see your dear friend Pearce, I shall give him a great big hug and tell him how much you love him (Rupp, 11 April 1959).
The issue continued to ruffle feathers. In a letter to Riley, Dr Augustus Rose (UCLA, AAN President 1959-61) wrote: I am not sure how I might help in this matter but I assure you that the Academy is anxious to avoid misunderstanding and seeks to cooperate with the ANA in all matters pertaining to international Neurology. From correspondence and talk in the last several months, I find there are a fair number of thoughtful individuals who are confused about the relationships between the Neurological Societies, the WFN [World Federation of Neurology] and the sponsorship of the International Congress (Rose, 27 July 1960).
Writing back to Rose, Riley indicated: I am sorry that all the fuss and fury has unnecessarily been stirred up. I was somewhat disturbed by seeing somewhere, but I forget just where, a notice about the Rome meeting which appeared under the heading of the American Neurological Association and below it the American Academy of Neurology. I do not think it looks well for the two organizations to be mentioned as if they were competing groups of neurologists. As I have said, no other country has done this, and I think that it is a mistake to emphasize that there are two groups of neurologists who may be either competing or cooperating. Of course you must appreciate that at the present time Pearce Bailey, as Secretary-General of the World Federation of Neurology, is going to do everything possible to push the Academy, perhaps to the detriment of the American Neurological Association. I think that this is unfortunate but it is part of the present Congress picture (Riley, 4 August 1960  One of the first difficulties I ran into on becoming president was this question of international representation of American neurology. It is only part of an increasing political activity of the American Academy that has become more and more troublesome in the last five years. It has now reached a point where I am convinced that some firm and positive action must be taken by the ANA if very considerable tension, jealousies and unhappiness are to be avoided in the future. As I see it, this is the most pressing problem facing my presidency . . . . The basis of our present difficulties seems to be the attitude which considers the ANA and the AAN as two rival societies of neurology, whereas in fact the ANA is a limited membership society comprising the elite of the virtually unlimited membership of the AAN. It would obviously have been a much happier arrangement if the AAN had become 'young Turks' of neurology . . . . At this point I think the best to aim for is a general recognition of the ANA as a Senate or upper house, and this is the general principle that I hope to get established. The importance of this relates not only to international representation but to a host of other matters . . . . The whole question seems to me of such importance for neurology in the future that I feel I must devote a proportion of my presidential address next year to it, aiming to establish a general principle that will serve neurology for many years to come. As far as the ANA is concerned, it will have a profound relation to our selection of new members, for obviously if we are to have a senatorial function, then this becomes a prime requisite in terms of each new member (Denny- Brown, 29 October 1959).
In response to Denny-Brown, Riley wrote: Bailey representing the International Division of the N.I.N.D.B. [National Institutes of Neurological Disease and Blindness], would seem to be assuming the entire conduct of International Neurology, including the direct control of the Congresses themselves. I consider that this situation has arisen as a direct result of the initiative assumed by Bailey as Director of the N.I.N.D.B., which, so far as I know, is supported by funds coming from taxes paid by all of us in the United States and appropriated by Congress for the various institutes of the Public Health Service. I think that, as you say, sooner or later this matter must be brought to a head and the relative relations of the A.N.A. and A.A.N. in all things neurological in the United States must be stabilized. Otherwise I feel that Neurology is on the way to becoming a hotbed of politics, ambition and self-seeking, which has never been the case before the A.A.N. began to assume such an aggressive attitude in regard to all things neurological (Riley, 10 November 1959).
Denny-Brown replied: 'I hope to end once for all this continued bickering on the part of the Academy, and at the same time to maintain the dignity and advice coming from mature experience of the ANA' (Denny- Brown, 4 December 1959).

Broader societal issues
The struggle of the AAN with the ANA may be interpreted more broadly as one manifestation of a set of larger societal issues in a post-bellum (post-World War II) America. One may frame the struggle in a number of possible ways: the rise of democratic medical populism versus the established elite, the rise of the country's Midwest versus the Northeast, a class struggle (populism versus aristocracy) or the changing social and political face of the medical profession during those times. Which of these factors, alone or in combination, was operative is not entirely clear (Farreras, 2004;Weisz, 2006). The late 1940s and 1950s saw a profound rise in the middle class in the USA. One major contributor was the GI Bill, which included home loans, healthcare benefits and educational funds, all facilitating the upward social mobility of returning veterans. The rise of the middle class was linked with the rapid rise in young families, a population surge, the growth of suburbia (i.e. spacious, low-cost housing outside of the city centre) and especially, the ascent of the automobile. Automobiles were being mass produced and were becoming an affordable option for the middle classes, and enabled people to live in suburbia (Thompson, 1982). In 1955, for example, a staggering $65 billion was spent on automobiles; this represented 20% of the gross national product (Humes, 2006). Indeed, by the mid-20th century, one in every six working Americans was employed directly or indirectly by the automobile industry, and Detroit and the upper Midwest were at the epicentre of an industry that consumed vast amounts of steel, glass, copper and plastic. By the end of the 1940s, the 'Big Three' auto companies, positioned in the Midwest, offered generous wages and extensive benefits, making auto workers among the best paid in the country. Auto workers, who enjoyed hefty pay cheques and good benefits, had become 'embourgeoised', entering the ranks of the middle class. By the mid-20th century, for example, a majority of Detroit residents were homeowners, and tens of thousands could even afford lakeside summer cottages (Sugrue, 1996).
Baker, in recalling the 'saga' of the history of neurology in the USA echoed many of these larger social themes: The scope of the Academy is nationwide and hence antagonistic to the geographic sectionalism which always has hemmed in the neurology of the past. It should be recalled that the early American neurologists were all aristocrats, originating for the most part from the northeastern section of the United States and guided by the principles of rugged individualism. There were no middle or lower classes in the neurology of the early days . . . . Neurology needs a progressive middle class and the Academy, by virtue of its organizational plan, is equipped to help develop such a group (Bailey, 14 April 1950).

Conclusion
There is little published on the early history of the AAN. Dr Joe Brown (1974) discussed the early organization of the Academy, but it is written as a personal reminiscence rather than one that uses the primary source documents at the AAN archives, and the emphasis is not on the resistance met by the ANA, although this is discussed briefly in one area.
Indeed, the AAN, on its formation, did not enter a vacuum. The long-existing ANA actively resisted the new organization. There was reluctance to accept the new idea on a conceptual level, as well as discussion about punitive actions against its founder while at the same time attempting to bring him into the ANA fold. There was even a formal attempt to hijack the new organization. Although the ANA attempted to frame itself as the patrician upper chamber of American neurology, the AAN leadership was savvier with political manoeuvring and use of government agencies and funding organizations. Funding E.D.L. was the 2011 recipient of the Richard Tyler Award (American Academy of Neurology) for historical research that uses the American Academy of Neurology Library Collection. The American Academy of Neurology had no role in the conduct of the research or the preparation of the manuscript.