Sense, Twitch And Soul: An Essay On The History Of Neurology
Dr. Ian Carr
Professor Emeritus, Faculty of Medicine, University of Manitoba
Neurology, said Thomas Willis, who coined the word, is the study of the nervous system. The peculiar glory of neurology is that it deals with the part of the body which makes humankind human, the seat of sleeping and waking, the harbour of love and hate, the secret of swinging a golf club, and driving into the rough, the engine which writes a sonnet, the spirit which makes each of us unique, the madness which sends us to the psychiatrist, the immortal soul which some of us believe we have--all of these have a local habitation and a name, if they have any such in the nervous system; wherever it lives, the soul does not reside in the sigmoid colon. Neurology is about all these things, and neurologists are the high priests thereof.
I am going to try to describe some stages in our knowledge, and name a few of the famous names. This is an essay and not a complete or formal account. It is randomly selective -- and insolent. Anyone, who is neither an historian, nor a neurologist, who talks about the history of neurology, deserves at least the pillory, and possibly the scaffold.
It outlines briefly and selectively the history of our knowledge of the nervous system, with a few words on several of the major figures. The objectives are that the reader should be able to describe one way of approaching the historical literature, and then to list some of the major advances in neurology. It stops in 1932; the rest is modern neurology. The limits are the books in the University of Manitoba Health Sciences Library.
How does one go about preparing a seminar on something one knows nothing about? The Internet is the last place to go. Start off with a book, a general history of medicine, identified from the local library catalogue, then look for a history of neurology in the same place. Then look for the books written by some of the major figures listed in sources, or for the biographies of these individuals. These point to the original papers written by one or other of the important figures, and in one or other source there are pictures.
In the beginning there was observation, the Sumerians illustrated paraplegia in a bas-relief of a lion with an arrow in its back. The Egyptians described the effect of high transection of the spinal cord in the human. Hippocrates wrote of epilepsy that it was a natural disease, not a sacred disease. The Alexandrian Greeks dissected the human brain and distinguished cerebrum from cerebellum. Galen dissected the nervous system, in a variety of species, including the ape. Of recurrent laryngeal nerves he wrote: "If one cuts these nerves, the voice of the animal is damaged and its resonance is lost."
These were beginnings. The god remained hidden behind the altar; the veils remained until the sixteenth century, when they were rent asunder, one after another, to reveal the brain. A complete history would encompass brain function, cortical localisation, vision, hearing, touch, pain, smell, motor function, sleep and dreaming, emotion, intellect, memory and speech; it would take 500 pages and 50 hours.
The first milestone was the anatomy of the brain. Vesalius described it and much else; he had little notion of function, thinking that it lay mainly in the ventricles. He did not remove the brain from the skull before cutting it.
Thomas Willis (1621-1675) in 1664, published his Anatomy of the Brain, followed by Cerebral Pathology in 1676. He removed the brain from the cranium, and was able to describe it more clearly, setting forth the arterial supply, the famous circle. He had some notions as to brain function, including a vague idea as to localization and reflexes, and described epilepsy, apoplexy and paralysis. He called neurology neurology.
Only when cells were identified microscopically was it possible to progress beyond the crudest anatomical notion. JE Purkinje (1787-1869) in 1837 gave the first description of neurones, indeed a very early description of cells of any kind. Later Golgi and Cajal stained the beautiful ramifying branches of nerve cells; these could only touch, or synapse.
A beginning of the understanding of disease came with the first morbid anatomists, morbid anatomical illustration, and the development of effective colour printing. Matthew Bailie (1761-1823) and Jean Cruveilher (1791-1874) illustrated the lesions in stroke, in 1799 and 1829 respectively.
The brain now had demonstrated form, without localised function. How could it work? Philosophers think, sometimes without evidence. Rene Descartes (1596-1650) speculated that every activity of an animal was a necessary reaction to some external stimulus; the connection between the stimulus and the response was made through a definite nervous path. Luigi Galvani (1737-1798) demonstrated that electrical stimulation of nerve produced muscle contraction, and the competing work of Charles Bell (1774-1842) and Francois Magendie (1783-1855 ) led to the view that the ventral horns of the spinal cord were motor and the dorsal horns sensory. A hemiplegic patient who could not speak led Paul Broca (1824-1880) to the view that functions in the cerebral cortex were anatomically localised. Ivan Pavlov (1849- 1936) realised as his dogs dribbled that a simple reflex could be modified by higher brain functions. These neurological ideas were co-ordinated and integrated by the neurophysiologist C.S. Sherrington (1857-1952).
The stage had been set for the clinical doctors: they came in one brand. Clinical neurologists, or neurological physicians, were grave, highly intellectual people with dismal expressions, partly because the brain confused them totally, and partly because they could not do anything for their patients but diagnose them. Only when antibacterials and neurosurgeons appeared, were neurological diseases treatable.
Doctors could use the ideas of neurology in practice only if they developed proper tools and procedures for clinical investigation. This happened step by step in the nineteenth century -- tendon hammer, ophthalmoscope, pin and tuning fork, syringe and lumbar puncture. X rays, the electro-encephalography, angiography, and CAT scans were to follow. The clinical neurologists correlated their findings after death with those of an even more dismal specialist who could do even less for the patient than the clinical neurologist--the neuropathologist. They scribbled long books, as a substitute for cure. It may not cure the patient, but it gets the doctor a promotion. The best known was W.R. Gowers (1845-1915) who owned a major text in two volumes, and a cerebrospinal tract.
By the end of the nineteenth century, there was a tie between stroke and hemiplegia, between trauma and paraplegia, between the spirochaete and the paralysed demented people who filled the mental hospitals. The first chemotherapeutic cure of a serious infection was salvarsan for syphilis, followed by the induction of fever in neurosyphilis. The clinical neurologists became highly effective when antibiotics were introduced.
Neurology had however become a more hopeful science when the surgeons took a hand. In 1878, William McEwen (1848-1924) removed a meningioma, and the patient survived for many years. As usual the English did it five years later, and Victor Horsley (1857- 1916) was revered, and the Americans did it even later, and Harvey Cushing (1869-1939) was canonized. Cushing in 1909 successfully removed a pituitary adenoma from an acromegalic, the first of many; treating endocrine hyperfunction by neurosurgery was a major neurological landmark. Modifying personality was the next trick; many years before, a metal bar through the head of an unfortunate railway worker had demonstrated that mechanical disruption of the brain could alter personality. Egas Moniz (1874-1955) in Portugal developed neurosurgical treatment of severe psychiatric disorder.
This brief account should end with a question. Descartes thought that the soul was localised to the pineal; he was probably wrong. What is the anatomical localisation of the human spirit, what makes you you, and of the soul, which may outlast the brief fabric of the body? What is truth, said jesting Pilate, and would not wait for an answer.
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Bowman, AK. The Life and Teaching of Sir William Macewen: A Chapter in the History of Surgery. Hodge : London; Edinburgh; Glasgow, 1942 .
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Fulton, JF. Harvey Cushing, A Biography. CC Thomas: Springfield, 1946.
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Olmsted, JMD. Francois Magendie: Pioneer in Experimental Physiology and Scientific Medicine in XIX Century. France Schuman's: New York, 1944.
Pavlov, IP. Lectures on Conditioned Reflexes : Twenty-five Years of Objective Study of the Higher Nervous Activity (Behaviour) of Animals. International Publishers: New York, 1928.
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