Team of Titans: Arthur Abramson, Albert Einstein, and a Second Generation of Physiatrists

During the weekly grand rounds held in the Department of Rehabilitation Medicine at Albert Einstein College of Medicine (AECOM), its chairman, Arthur S. Abramson, MD (Figure 1), would quietly roll his wheelchair to a set of short parallel bars at one side of the conference room, lock his metal long-leg braces, and pull himself up to his considerable height. For him it was part of a daily regime of standing to stretch his spastic muscles and provide weight bearing to his lower extremities that he continued even 30 years after his spinal cord injury. But for the persons who were privileged to receive their residency training under his supervision, this image of a literally and metaphorically towering figure, the personification of the triumph of will over a severe physical disability, remains indelible. Not the least of his many accomplishments during a long and distinguished career was his wisdom in recruiting an extraordinary trio of physiatrists who formed the nucleus of a department that, along with its eponymous medical school, celebrates its 60th anniversary in 2015. Arthur Abramson's phoenix-like ascent from the ashes of World War II to the heights of his profession, along with the closely related careers of physiatrists Edward F. Delagi, Heinz J. Lippman, and Matei S. Roussan, provide a glimpse into the evolution of physical medicine and rehabilitation (PM&R) during the era subsequent to that of its founding fathers, including Frank Krusen, Robert Bennett, and Howard Rusk, each of whose contributions to the genesis of the specialty have been previously documented in this journal 1-3. Another less well recognized first-generation physiatric pioneer, Karl Harpuder, also played a crucial role as mentor to these 4 physicians who made the rehabilitation medicine program at AECOM a center of clinical, academic, and research excellence from its inception. Arthur Abramson, MD. (Photograph by Ted Burrows, courtesy of the Archives, Albert Einstein College of Medicine.) In 1950, Samuel Belkin, PhD, President of Yeshiva University, a Manhattan-based institution of higher education combining Jewish and liberal arts studies, proposed that it should add a medical school. Part of the mission of this school would be to enhance the opportunity for Jewish college students to earn a medical degree at a time when quotas were significantly limiting their opportunities. Belkin and his colleagues contacted Albert Einstein, the most celebrated scientist of the 20th century and a notable humanist, with the proposition that this new medical school be named in his honor. Approaching age 75 years and nearing the end of his life, Einstein eventually agreed to the plan and was able to see the early stages of the school's development, although he did not live to see its completion (Figure 2). Having a large hospital in close proximity to the school was essential for clinical teaching, and the construction of the 898-bed Bronx Municipal Hospital Center (also known as Jacobi Hospital and later Jacobi Medical Center), adjacent to the Einstein campus, met this requirement. When AECOM opened on September 12, 1955 4, Jacobi Hospital included 4 founding clinical services: medicine, surgery, psychiatry, and rehabilitation medicine. It is a reflection of Abramson's formidable powers of persuasion that his specialty, which had only been recognized by the American Board of Medical Specialties in 1947, was included among those 3 far more widely recognized areas. For him it represented the culmination of a dramatic personal odyssey that had abruptly begun 11 years earlier on a battlefield in Belgium. Albert Einstein and the original model for the medical school named in his honor. (Courtesy of the Archives, Albert Einstein College of Medicine.) Midway through his life's journey, on December 27, 1944, during the Battle of the Bulge, a German sniper's bullet shattered Abramson's thoracic spinal cord and ended his career as a surgeon. At the age of 32 years, he was already Chief of Orthopedic Surgery for the United States Army in the European theatre, and until that pivotal moment his life had been characterized by a steady series of accomplishments. Born in Montreal in 1912, he earned his undergraduate and medical degrees at McGill University, where his extracurricular activities included membership on the wrestling team. His surgical training took place in New York City, including the Montefiore Medical Center, where he likely encountered Karl Harpuder, MD, Chief of Physical Medicine, for the first but certainly not the last time. His progress through the surgical ranks was remarkably rapid, culminating in a leadership role during the European invasion that commenced on June 6, 1944. Within 7 months of D-Day, his life nearly came to a premature end. Fortunately, he survived as a result of treatment with antibiotics and sophisticated emergency care, neither of which had been available during World War I and had resulted in 1-year mortality rates of 90% for soldiers with spinal cord injuries sustained during that earlier conflict. Facing the supreme crisis of his life, Major Abramson had to draw upon his experience as a wrestler, waging a fierce battle against dependency and despair. His coach during this struggle was none other than Karl Harpuder, who became simultaneously his doctor, mentor, and professional role model. During inpatient treatment at the Bronx Veterans Administration (VA) Medical Center, Harpuder initiated the vocational rehabilitation process by directly challenging his patient with the question, "When are you going back to work as a doctor?" The measure of how that question was answered is evident when reviewing the milestones that marked the decade following his injury. Despite having T5 paraplegia, within a span of 10 years, Arthur Abramson completed his own rehabilitation, retrained in a PM&R residency by 1948, obtained his PM&R board certification in 1949 (American Board of PM&R certificate #114), and took charge of the program at the VA where he had previously trained. Finally, in 1955, he was named Chairman of PM&R of the newly established AECOM, a position he held until his death at age 70 years. The quarter century he spent in that role was an eventful time in the development of PM&R, as the field forged its legitimate place within medicine with an interdisciplinary model of care that was as relevant for the civilian population as it had been for other injured World War II veterans. Abramson was a highly visible and prominent participant in that era of expansion as the specialty gained increased recognition. In addition to creating and leading the AECOM program, Abramson held many national positions. He was one of the founders of the American Paraplegia Society and served on the Board of Directors of the American Board of Physical Medicine and Rehabilitation (AAPM&R) from 1957 to 1968, on the President's Committee on Employment of the Physically Handicapped, and as President of the AAPMR from 1971 to 1972. Among the many honors bestowed on him were the President's Handicapped Man of the Year Award in 1955 (Figure 3) and the Gold Key Award from the American Congress of Rehabilitation Medicine (ACRM) in 1966. He delivered the ACRM John Stanley Coulter Memorial Lecture at the 1967 national meeting and the Walter J. Zeiter Memorial Lecture at the AAPMR Annual Assembly in 1975. In 1980, he became the sixth physiatrist to receive the Frank Krusen Award. Dr Abramson receiving the President's Award as Handicapped Man of the Year from Vice-President Richard Nixon in 1955. (Associated Press, courtesy of the Archives, Albert Einstein College of Medicine.) Abramson was named the first Samuel Belkin University Professor of Medicine at Yeshiva University in 1977. His numerous publications included articles and book chapters on spinal cord injury rehabilitation, spasticity management, neurogenic bladder, therapeutic exercise, phantom pain, and innovative models of patient care such as the Rehabilitation Day Hospital (which provided the equivalent of a full day of inpatient rehabilitation services without requiring hospitalization) 5 and the "Therapeutic Community" (a project fostering active patient participation in the treatment process as a means to improve the patient's perception of their social functioning—a novel idea at that time) 6. His close collaborator in these latter 2 projects was Bernard Kutner, PhD, a social scientist whose participation added a unique perspective to the clinical and academic atmosphere within the Department. Similarly innovative was his establishment of a close alliance with the School of Physical Therapy at Ithaca College beginning in 1959, a program that was coordinated by Justin Alexander, a physical therapist who also became an integral part of the Department as an educator of physiatrists and therapists. Abramson's inclusion of Kutner and Alexander illustrates his deep commitment to a truly interdisciplinary model of rehabilitation care. One of Abramson's most meaningful contributions to his profession and its literature was his championing of the rights of people with disabilities. The Bill of Rights for the Disabled, which he created together with Bernard Kutner and which appeared in the 1972 issue of the Archives of Physical Medicine and Rehabilitation 7, identified persons with disabilities as a population whose civil rights had thus far been largely overlooked by society and by the Federal government. It presented 16 resolutions addressing the health, employment, housing, architectural, transportation, income, and educational needs of people with disabilities. Historian Richard Verville comments that the Bill of Rights for the Disabled was essentially an expansion of the Civil Rights Acts of 1964 and the Voting Rights Acts of 1965 and that it cited most of the areas that were subsequently included in the National Council on Disability's Report to the President and Congress in 1988 8. The Americans with Disabilities Act, signed into law by President George H. W. Bush 2 years later, clearly reflects many of the concepts first articulated in this seminal document. Abramson proudly displayed a copy of it on his office wall for the remainder of his life. Along with his role as national advocate for disability rights, Abramson had a more personal impact on the lives of hundreds of patients with spinal cord injuries whose initial rehabilitation care took place at Jacobi Medical Center and at the Hospital of the Albert Einstein College of Medicine (now the Jack D. Weiler Hospital/Montefiore Medical Center). His interactions with these patients were unforgettable experiences for them, because he was a living demonstration that a person with paraplegia could not only be independent in self-care, wheelchair mobility, and bladder management but could drive an automobile with hand controls, work as a physician, and serve as a departmental chairman. When he made teaching rounds on the rehabilitation unit, the patients sat up taller in their wheelchairs (John F. Ditunno, Jr, MD, personal communication). Similarly, resident physicians in his training program and students from the medical school saw him as a superb role model of successful reintegration into society, the ultimate goal of the rehabilitation process. During his final years, Abramson endured a number of physical and academic hardships. He had often remarked that since his injury he never had a day totally free of pain, but now it worsened as a result of the effects of diabetes mellitus, and he ultimately required a below-knee amputation that further impaired his mobility. At the same time, as the Einstein and Montefiore clinical and residency programs were in the process of being unified, there were major threats to their continuation as a distinct department rather than being subsumed under the Department of Neurology. After 25 years as its undisputed leader, he was essentially "demoted" to the role of acting chairman, an indignity that he bitterly resented and that was still unresolved at the time of his death in 1982. It is a tribute to the professional stature of his physiatric associates, and above all to the determination of his successor, Matei Roussan, MD, that the Montefiore and Einstein PM&R Departments did not come to an end at this critical juncture in their history. One of the marks of great leaders is the high quality of the persons they select to fill key positions in their organizations. By recruiting Edward Delagi, MD, in 1954, Heinz Lippman MD, in 1955, and Matei Roussan, MD, in 1958, Abramson demonstrated shrewd and visionary leadership. Each of them broadened the range of expertise within the Department, becoming highly respected clinicians, researchers, and teachers. Any one of whom could easily have served as chairmen of other programs, but, fortunately for future trainees, they spent their entire professional careers at AECOM, providing the stability and academic credibility so essential for a fledgling department. In his choice of associates during the subsequent decade, Abramson added such illustrious colleagues as Gabriella Molnar, MD (pediatric rehabilitation), Victor Cummings, MD (amputations, prosthetics), Aldo Perotto, MD (electrodiagnosis), Samuel Levine, MD (inpatient rehabilitation), and Harold March, MD (cardiac rehabilitation); Drs Molnar and Cummings went on to receive the Distinguished Clinician Award from the AAPMR in 1989. The 4 members of Abramson's "dream team" (Abramson, Delagi, Lippman, and Roussan) shared a number of characteristics typical for the second generation of physiatrists, who, to paraphrase Sir Isaac Newton, saw further by standing on the shoulders of the first-generation giants who had established PM&R as a medical specialty in 1947. All 4 entered PM&R from other specialties rather than choosing it at the outset of their careers, and, with the exception of Delagi, they were all international medical graduates. Their shared first-generation physiatric mentor also mirrored those characteristics. Karl Harpuder, MD (1894-1974) was born in Munich, received his medical training in Germany, and emigrated to the United States in 1934, where he became the head of physical medicine at Montefiore Medical Center from that year until 1961 (Figure 4). Board certified in internal medicine, he also became one of the earliest board-certified physiatrists in 1947 (Certificate #24). His personal experience with spinal tuberculosis may have contributed to his professional transformation from internist to physiatrist. Harpuder was an editor for the American Journal of Physical Medicine, and his contributions to the specialty were recognized when he received the Gold key Award from the ACRM in 1957 9, 9 years before his most illustrious disciple was similarly honored. Karl Harpuder, MD. (Courtesy of the Archives, Montefiore Medical Center.) Although Montefiore's Physical Medicine Department was among the earliest of its kind in the United States, Harpuder actually had a 19th-century predecessor in the same institution, Simon Baruch, MD, who could be described as a proto-physiatrist, and whose family continued to be intimately involved in the development of PM&R throughout much of the 20th century. When it opened in 1884 as the Montefiore Home for Chronic Invalids, Simon Baruch was the chief of its medical staff. He had previously served as a surgeon in the Confederate army, where he performed the first documented surgical removal of a ruptured appendix. A strong advocate for the use of hydrotherapy in the treatment of medical disorders, he was in many respects a physical medicine physician 50 years before the recognition of the specialty 10. Of equal significance, he was the father of financier and philanthropist Bernard Baruch, who played a prominent and decisive role in the early history of PM&R through his close relationship with first-generation physiatrists including Krusen 1 and Rusk 3. Simon Baruch's name also endures through his endowment of the Simon Baruch Professorship in Rehabilitation and Regenerative Medicine at the College of Physicians and Surgeons, Columbia University. Born in the Bronx in 1911, Edward Delagi, MD (Figure 5) initially planned to be a neurosurgeon. He completed his residency in PM&R at the Bronx VA Hospital in 1954 under Abramson, who promptly recruited him for the new Rehabilitation Medicine Department he was forming. As Clinical Director, Delagi spent the next 3 decades at AECOM, where his gifts as a clinician, teacher, and electromyographer earned him the accolades of his professional peers and the deep affection of hundreds of residents, who particularly cherished his weekly kinesiology sessions. One mark of that affection was their renaming of the test for intrinsic hand tightness as the "Delagi Test." Another mark of that affection was the fact that residents felt they could share professional or personal concerns with him, knowing that they would always find a sympathetic ear and wise counsel. He particularly loved making a difficult problem simple and making a topic easier to grasp (Gerald Herbison, MD, personal communication). This attribute is clearly demonstrated in the book he co-authored with Perotto and Iazetti on anatomic localization in clinical electromyography 11, which is now in its fourth edition. In 1983 his clinical and academic contributions were recognized when he received the Distinguished Clinician Award at the AAPMR annual meeting. He was a fascinating contrast to Arthur Abramson's intense and sometimes intimidating persona. Delagi was less physically imposing, modest, soft-spoken, easygoing, and optimistic, but with an equally powerful intellect. His veneration of his Chairman never flagged, and they often appeared to be unconsciously emulating the "good cop/bad cop" model. Delagi was content to remain second in command, devoting himself to patient care and teaching. Starting in 1985, he enjoyed a long and happy retirement in Florida, during which he was able to indulge his lifelong for He also became a who was in the a measure of his MD, personal communication). He in at the age of years. Edward Delagi, MD. (Courtesy of the Archives, Albert Einstein College of Medicine.) Heinz Lippman (Figure was born in in where he completed his medical after the establishment of the he to where he in and internal medicine. In 1 day before invasion of he emigrated to where he at He in the United States the following year and in the department at the of Harpuder, he did his residency in PM&R and became board certified in Heinz MD. (Courtesy of the Archives, Albert Einstein College of Medicine.) When Lippman Abramson and Delagi at Einstein in 1955, he established and for more than years a at Bronx Municipal Hospital of residents from him the of the for the and of often with in patients whose previously had for years. A of professional he a close to and throughout his performed in and played with Albert Einstein He also in the life of the medical school, the for its the and often as for In one of the articles his he the among was being that it be the Delagi, Lippman received a Distinguished Clinician Award from the AAPMR but him, he never an active of the AECOM until a to his death in He short of his Matei Roussan, MD (Figure was born in in and received his medical education in After to the United States in he Abramson the following year and was his as Chairman of the Einstein and Montefiore program, the Arthur S. Abramson Department of Physical Medicine and Rehabilitation in The 5 years during which he was Chairman to were the in the and its as a was much in may well be that, these and to his the Department ultimately and subsequently Matei Roussan, MD. (Courtesy of the Archives, Montefiore Medical Center.) His was for clinical care, and teaching rather than for academic He in the of Delagi and Lippman by receiving the AAPMR Distinguished Clinician Award in making him the AECOM physiatrist to be so during the years 1983 and his and which his European he residents and students during patient teaching The which he and at Jacobi Medical Center, was a of of the earliest on the role of in in patients with spinal cord injuries who had a neurogenic bladder Although he only part time after MD, him as in continued patients within the department because most of them on him as their physiatrist. When he at age years, after a and years after the of Heinz Lippman, it truly marked the end of a age for PM&R at Montefiore and One of Arthur Abramson's not from the of a from or from only to more In of his life he was the of that When he was he to be an and in many he this choosing a medical by creating an PM&R department from the by a that ultimately into the Americans with Disabilities and by his own life following his spinal cord injury with such determination that it could serve as a for the rehabilitation The that formed the of a PM&R department that now his name were the persons he as his Drs Delagi, Lippman, and were the first of a that now to hundreds of physiatrists throughout the United States and the is his most In a resident at AECOM, I had the unique of being Dr Abramson's during the annual meeting in During those I more disability and rehabilitation from him than I did from all the teaching programs during that entire Despite being in a that was not wheelchair he was totally independent in all his and only was to his wheelchair the which had that made The had during those long from to conference were a opportunity to to this extraordinary in a much more personal I was at the of and required for a person with paraplegia to and bladder care. But he had his his and of physical he he the with his as his him did the residents when he was not was He could be and As John from his months at AECOM, which he the high of his Arthur Abramson's relationship with medical of his associates could be even he did not a it was to (John Ditunno, personal communication). his in choosing his 3 associates Lippman, and Roussan) was by their own of which them to up to his without being Fortunately, for members of the residency program, he was a and New York PM&R residents during the and had the to him in more during the and held in the New York of these he displayed a and that made him A final image I is that of his at the end of the work After the side of his and the he the side of the and, with a pull of his to literally of his into a standing as he was to pull the side of the rather than himself into the he over to up his wheelchair and it into the back with one in the were not the of more and the involved in that was of the of a metal It was of the that this demonstration of and the and more for such Drs John Ditunno, and provided personal of their experiences with Drs Abramson, Delagi, Lippman, and Dr Dr Lippman, shared and of his AECOM and Montefiore Medical Center to and that the content of this The office of the American Board of Physical Medicine and Rehabilitation provided Board certificate and for the physiatrists in this

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