Raymond Delacy Adams, considered by his peers the pre-eminent neurologist of the twentieth century and Bullard Professor of Neuropathology Emeritus at Harvard Medical School died on Oct. 18, 2008 at Brigham and Women’s Hospital. Dr. Adams was born in spare circumstances in a rural area near Portland, Oregon in 1911, the first child of William Henry Adams, an oil truck driver and Union Pacific baggage clerk, and Eva Mabel Morriss.
Dr. Adams’s childhood was spent outdoors in sports, a harbinger of his vigorous adult pursuits of tennis and golf, but he began to work at physically demanding jobs from an early age. After graduating high school at 17 he crewed on an oil tanker from Alaska to Salvador. His first aspiration was to become a professional baseball pitcher but at the insistence of his parents he entered University of Oregon and chose to study psychology. While digging ditches to make money in Monmouth Oregon he eloped with Margaret Elinor Clark, a teacher in a one-room schoolhouse, who was orphaned and brought up by aunts.
He attended the new Duke University School of Medicine in its third class by serendipity and remained a great supporter of the school. It required great effort to make ends meet while studying during the depression. He and a classmate were offered rooms in a janitor’s closet under the amphitheater in exchange for cutting large blocks of ice for the cafeteria and men’s bathrooms.
Dr. Adams began his training in psychiatry as a Rockefeller fellow, first at the Massachusetts General Hospital and later at Yale. He could not reconcile the then grip of psychoanalysis with what he knew of brain diseases and he left for Boston City Hospital to study the physiological causes of mental and neurological diseases under Dr. Derek Denny-Brown. Relegated to the neuropathology laboratory, over ten years and thousands of gross and microscopic brain examinations, he developed the basis for modern clinicopathological correlation that was to establish HMS and MGH as the academic centers of American Neurology at the time.
He came to prominence as a neuropathologist and neurologist during a ten year career at Boston City Hospital. He was recruited to the Massachusetts General Hospital in 1951, where he directed the neurology program for over 25 years. Adams was a spectacularly successful builder of institutions. When he took over the department at Massachusetts General Hospital, the entire neurology staff amounted to a handful. He built the first large program in pediatric neurology with specialized faculty, residency training, and new research laboratories. As a part of this effort he founded the Eunice K. Shriver Center for mental retardation research and patient care. His combined staff numbered in the hundreds by his retirement. The birth of the Neuroscience Study Program, with founders at MIT, the creation of the Department of Neurobiology, and the emergence of a general university doctoral program in Neuroscience at HMS were all supported by Dr. Adams.
His HMS course in neuropathology was legendary in its breadth for a generation of medical students. He relished teaching, all from slides he had collected and distributed to each student, abandoning this role only when he felt the curriculum no longer accorded adequate time for his efforts.
Raymond Adams and his close friend and colleague C Miller Fisher lead the clinical service and residency training program as a team. A sense of their presence, the force of their intellect, character and intensive concern for clinical analysis, patient care and the preparation of their residents were pervasive. For those who trained with Raymond Adams, it was an experience of unremitting effort and attention. His was an insistence upon “the details” essential to a coherent narrative of disease that was structured with a theory of disease process. There was no place for “dualistic copout” in his view that whatever we feel, think and do – the brain does it. He was dispassionately skeptical of his own formulations. He drew conscientiously upon contributions of our predecessors in clinical neuroscience with no barriers across the major Western European languages that were the reservoirs of our history. He placed great importance upon a test of ideas and observations through discussion with colleagues and his residents. His presentations whether in the informal rush and go of the patient’s bedside or in public, were never “a performance.”
In an interview, he stated “when I arrived at the Massachusetts General Hospital as chief of the service, the field of neurology was extremely narrow”. It was important to “determine more precisely what the natural limits of neurology were”. “It was necessary to redefine the specialty of neurology.” He wanted to make it “inclusive of all diseases in which there was a lesion in the nervous system, or by inference from genetic and special clinical data, one could predict a lesion would be found by the development of refined methods”. Thus muscle disease, child neurology, mental retardation, developmental diseases and metabolic diseases created by medical problems, i.e., renal disease, hepatic disease, pulmonary disease, inflammatory and degenerative disease “were as much neurology as medicine”. He had the wisdom to, as chief of service, find “gifted people to develop subspecialty fields such as these far beyond my reach”.
Many of his academic contributions were seminal. In cerebrovascular disease, he and Miller Fisher determined that the major cause of ischemic stroke was embolus rather than thrombosis and that the principal source was the heart. This laid the groundwork for attention to atrial fibrillation and the necessity of anticoagulant prophylaxis. Other contributions in the field of vascular disorders included a detailed elaboration of the syndrome of basilar occlusion and aortic dissection. His studies of a range of bacterial infectious processes and of syphilis directed attention to the leptomeninges as the primary site of disease that secondarily led to vascular damage and infarctions. He ascertained the features clinically and cytopathologically in a wide spectrum of hepatic disorders including encephalopathy following upon Eck fistula undertaken surgically for cirrhosis and varices that is now called hepatic encephalopathy. Studies of liver disease arose naturally out of a wider attention shared with Maurice Victor to the various syndromes with differential topographic expression associated with alcoholism and where they emphasized the importance of underlying nutritional deficiency and in particular deficiency of B vitamins. With Joseph M. Foley, he described asterixis.
Other contributions include characterization of the clinical and pathological features of primary CNS lymphoma, designating them as reticulum sarcoma; a range of inflammatory, metabolic and degenerative disorders of muscle and peripheral nerve; the establishment of the clinical characteristics and concept of normal pressure hydrocephalus (NPH); and his initiative in the neurology of the developing fetus and child. The creative and productive career of Raymond Adams must be viewed as the conceptual platform for the era of molecular neurobiology, imaging and computational cognitive neuroscience. He strongly supported an eclectic view of psychiatric disease, considering them to be problems of the brain, and stood behind numerous psychiatrists who had been ostracized from the community, at the time dominated by psychoanalysts.
Dr. Adams published over 250 original papers and seven monographs. His lasting influence on American medicine began as one of the founding editors of Harrison’s Principles of Internal Medicine, for which continued to write almost all the neurology material through six editions. The other editors chided Ray gently that his neurological treatises in the book led them to consider renaming it to the “Principles of Internal Medicine and the Details of Neurology”. Ray took their advice and he and Maurice Victor wrote Principles of Neurology, the true classic of the field now in its 9th edition and considered by far the leading textbook in the field.
Dr. Adams recognized the need for an international neurology community and regularly visited laboratories in Europe and elsewhere. He developed an abiding relationship with the American University of Beirut and extended himself to take residents from there and many sites abroad. Dr. Adams knitted together solid professional and personal relationships among residents and their mentors at MGH and abroad that endured over the half century that followed.
All his trainees have remarked on Ray’s personal availability and his dedication to teaching. He was demanding, direct and honest, and always courteous. Team morale and collegiality were pervasive as result of his model behavior, looming personal presence, and work ethic. All were aware that they were part of an enterprise inspired by Ray Adams that constructed the core for the intellectual growth of neurology in the second part of the twentieth century. He is widely credited with establishing neurology’s and neurosciences’ place in modern medicine. He will be greatly missed.
Joseph B. Martin, chairperson
J. Philip Kistler