Neurological practice of medicine; a cursory course of selected lectures ..

Front matter

Columbia ®ntberfittp

tnttjeCitpof J^etogorfc

COLLEGE OF PHYSICIANS ANO SURGEONS

Chapter I

PRELIMINARY ESSENTIAL DEFINITIONS, ETC. NEUROANATOMY, NEUROL- OGY, NEURIATRY, PSYCHOLOGY, PSYCHIATRY, NEUROPHYSIOLOGY, NEUROPATHOLOGY, NEUROTHERAPY, PSYCHOTHERAPY, PSYCHOPATHOLOGY, ALIENIST, PSYCHIATER, NEURIATER, THE NEURONE, NERVE CENTER, ETC., ETC.

You cannot advance satisfactorily in the study of neurology, which comprehensively embraces neuroanatomy, neurophysiology, neuropathology, neurochemistry, neurodiagnosis, psychology, psychiatry, etc., without clearly comprehending at least the terms named in this chapter which we will define before proceeding further. Neuroanatomy is nerve anatomy, as its derivation implies, v€vpovt a nerve and TSfivav, to cut. avarofx-rj, dissection, dra-re/Aveiv, of or pertaining to the dissection of the nerve tissue. For example, veupov} nerve and 7ru#os, disease, suffering, neuropathology, the pathology of the nerves, relating to nervous system or nerve centers, etc. Neuropathy, disease of the whole or any part of the nervous centers; a condition of general or local nervous disease. A good example of a general nervous disease or disease of the general nervous system is, neurasthenia, a condition of general nervous debility dependent on general functional neuratrophia or deficient nerve center nutrition, with often an inherent constitutional predisposition to become nervously weak, and with, consequently, functional weakness and instability or unsteadiness of the nervous system; a general functional disease of the nervous system. (vevpov, a nerve, «, privative or minus — and flews, strength.) Another general nervous functional disease is hysteria, which is a very nervous condition, formerly attributed to the influence of the womb, though men may have it. The influence of the womb's diseases, the weakening effects of its functions when acting morbidly and of exhausting nursing, woman's indoor routine, sedentary and monotonous life, etc., the recurring catamenia and its stoppage at the change of life, or climacteric as it is called, though the life is not changed except to go on to another stage in its evolution till the decadence of. age appears, contribute to bring about states of nerve strain and exhaustion which give the preponderance of hysteria, neurasthenia and climacteric nervous states to the female sex in mankind. Great brain and nerve-strain at the climacteric and senile epochs and from brain overwork or worry tend to cause nervous break-down and grave nervous diseases.

Consult the derivations in your medical and unabridged general dictionaries and familiarize yourselves with the derivative terms wherever you can find them, since one term well understood in its derivation or derivations will often give you signal aid in the understanding of many other medical definitions, especially compound words, and thus lighten the labor of study and give a philological zest to it. Thus you have already discovered that the radical word neuron, pertains to nerve, nerve cell or center, and it is embraced in nearly all the words we have thus far mentioned, and plays a great part in medical nomenclature.

Other specially important derivations with which you should become familiar are pathos (^mAos), disease, thenos

(flevos), strength, and aesthesias, (<ua0»/<ns) sensibility, and itis't Latin for inflammation, wherever you may find it in your studies. You will encounter the words neuropathy, nerve disease, and psychopathy, mental disease, neuritis, nerve inflammation', phrenitis or cerebritis, delirious brain or cerebral disease, neurasthenia or nervous debility, hyperesthesia or increased general sensibility, anaesthesia or absence of sensibility, hypoaesthesia, lessened general sensibility, thermoaesthesia or sensibility to heat, hypo and hyper aesthesia meaning minus or plus heat sensitiveness, hypoalgesia and hyperalgesia signifying minus or plus sensibility to pain below or above the normal and so on.

Look up these terms and their derivations often in your dictionaries (I speak to the juniors especially now), and we shall get along swimmingly for awhile. Do not be offended at my assuming that some of you may not know all these derivations and definitions. No harm will be done if I tell you something that you already know, but great harm to your progress may be done if I omit making your pathway as plain and easy to travel by these timely suggestions, as 1 can. It is my duty to clear the way for you as much as possible. I would make it plainer and easier if 1 could, but I do not "know it all" myself — not so much as some of the seniors, perhaps, for seniors know very much; they have caught on ahead of you, you know. But since our time of study together is so brief, if I am as explicit as I can be 1 may be able to impart to you most of what I know before the time shall arrive for your final examination. 1 will do it if 1 can and if you will give me your attention. You will not be examined beyond what you may hear or see in these lectures and demonstrations.

There is another and more special meaning of the term neuron, which some neurologists, especially that American neuroanatomical investigator, Lewellys F. Barker,* Associate Professor of Anatomy and Resident Pathologist of the Johns Hopkins University and Hospital, now calls neurone to distinguish it from the general term expressed in the original Greek root, and which, as I have said, signifies nerve or nervous. The term neurone or neuron has come into use since Golgi,of Pavia,the great Italian cerebro-anatomist, gave to the scientific world about two decades ago, his remarkable studies of the fine anatomy of the brain, which you may find, after you get further advanced in the study of the nervous system and acquire that insatiable thirst for deeper knowledge which invariably comes to the enthusiastic student of neurology, in back numbers of the Alienist and Neurologist (1883) which was the first and only English or American journal of that day to place before the English-speaking neurological reader the advanced work of this distinguished savant in the field of cerebral discovery. Golgi's lucid findings in the minute anatomy of the brain led to another remarkable epoch-making discovery in neuroanatomy, the naming, finding and defining of the neurone and its processes by those eminent micro-neuroanatomists and neurophysiologists, Ramon y Cajal, His and Schafer. They, with Nissl, Vangehuchten, Waldeyer, Harris, Held, Forel, our distinguished Barker, Hoch, and many others (more than I can mention) have added so much new light on the neurone and its relations to the rest of the nervous system, that you, will some day burn with desire to know them and their great work and to know the work of many others among foreign and American authors.

As the time passes, during this course, you will become familiar with other great names in neurology than those 1 have mentioned and learn a little of their contributions,

*The Nervous System and its Constituent Neurones, New York, 1S99.

but with whose entire work you will not find time to become thoroughly acquainted during this session or even during the time you are in college. Should you find opportunity, however, in connection with our present theme, the neurone, either now or during your vacation, you can read with profit the history of "The Development of the Neurone Concept, the Neurone as a Unit, and the Histogenic Relations of the Neurone" in the first five sections of Barker's great work to which 1 have already referred, making over three hundred pages of solid reading, every line instructive, in this more than one thousand page volume of neurological fact and concept. Great work and great names are of record there, besides those already referred to; Von Gudden, Von Lenhossek, Flesh, Flatau, Sandovsky, Biedl, Bernheimer, Marchi, Berkley, Marina. Names whose work will endure after we shall have passed away; names that will abide with that of the distinguished author who records their work, for Time to place on pages of immortal fame.

THE NEURONE DEFINED.

The term neurone has largely supplanted the term nerve cell, or ganglion cell of the older, but yet quite recent, neurological nomenclature. A neurone, or as it is still sometimes called a neuron in the neurocytological nomenclature and cytology or cell study of the present time, is a nerve unit. This nerve unit includes the nerve cell as yet described in most of your anatomies, its processes, collaterals, and terminations. For all practicable purposes you may still consider it a cell, a nerve cell, {vtvpo\>-\- KVT05) with the exception that it is not a network of nerves in the older sense, sending out prolongations that blend and intertwine with contiguous nerves, but a nerve mesh, or neuropilem {vtvpomXep.) distinct and disconnected but capable of communicating its influence by contact, as one student in the class may impress another by close or remote contact without grabbing him by the throat or intertwining his fingers in his hair; or as bricks standing in a row. Start one and they fall one after another. While the old nerve net of Gerlach is yet described in some of the books you have but lately studied, and the nerve mesh has taken its place, the ganglion cell, with its axis cylinder process, will still interest you as a fact in neurology, only differently and a little better understood as a nerve unit.

The neurone has dendrites; cellulipetal or centripetal, the equivalent of afferent prolongations, and cellulifugal or centrifugal or efferent processes or neuraxons, conducting influences away from the cell body. With reference to the center of the neurone, therefore, the dendrite corresponds in function to the afferent nerve {ad and ferre, to carry to) of the spinal cord, while the axone or neuraxone corresponds to the efferent {ex and ferre, to carry from or eo, 1 go forth). The dendrites receive, and the axones carry, impression to and impulses from, the center, i. e., to and from the neurone or nerve center cell.

There are some exceptions to this law, as in those dendrites from which an axone occasionally takes its origin. An example may be found in the retina, but you need not concern yourselves about this just now; you will not be asked about these exceptions as they may be found in the amacrine cells of the retina, etc. The rule is general, but not universal. Barker would leave the question open, but some questions about which savants may wrangle must be closed to teachers and tyros as we approach the close of this lecture.

Here again you may for next summer's diversion, after this course is over, take with you the books of the neurophysiological masters when you go fishing, or retire to the shade of the trees to read and study out this intricate subject between nibbles and bites on your hook, for one of the great masters to whom I have already referred has said that "at present we are well acquainted with the evidence of the passage of impulses in neurones in one direction only, does not exclude the possibility that we may at some later time become cognizant of the facts which may demonstrate the conduction of impulses of some sort in the opposite direction, especially as physiological experiment has shown that impulses artificially exerted in nerve fibers travel in both directions from the point of stimulation." (Barker, p. 274, ed. 1899). Here then, is a chance for you to become famous while you fish, by working out the unsolved problems of nerve conduction, vicarious, alternate or substitutive nerve function, etc. The vagus nerve appears to have both afferent and efferent function. You may yet be able to demonstrate that the first or incoming, and the second or outgoing, impressions go over the same nerve strands. If you do your fame will be made.

Neuraxon or neurite means the axis cylinder process of a neurone, the principal projecting part of the neurone. Schafer also called it a neurone. He gave the name dendron or dendrite (SevSpoi', a tree) to the shorter protoplasmic branchings or prolongations or processes of the neurons. He called the dendron, a dendrite. Neuraxons vary in length from a millimeter or less to many centimeters. The largest neuraxons are in the pyramidal tract, measuring nearly a hundred centimeters. If you have time between the lectures or during your vacation you may consult with signal profit the first chapter of Mills* on the subject and more recent American authors. You will see in the very beginning of his book, on the first page, a cut taken from

*The Nervous System and its Diseases by Chas. K. Mills, Lippincott & Co., Philadelphia and London.

Quain's Anatomy and to be found in some other anatomies and neurological treatises to which I shall often refer and which I shall several times draw on the blackboard during this course of lectures, as I do now, with various modifications. I am accustomed from previous and consequent automatic habit to refer to the cerebro-spinal or encephalo-spinal axis, but I do not so often use the newer and shorter term neuraxis. The term neuraxis does not locate itself with the defined expressiveness (though it is shorter) of cerebro or encephalo-spinal axis, but is quite as expressive when you understand it. Both terms, however, mean the great brain and spinal center of the great neural organism of the body, an organism as omnipresent in the animal mechanism as the almost everywhere to be found blood vessels. The neuraxis is the axis for the entire nervous system. Axis is the Latin for axle as you know and means a thing about which something else revolves. It means here central or pivotal, as you have, all of you, learned in studying physics and anatomy. In your anatomy of the skeleton you will remember the second cervical vertebra above which and around whose odontoid process, the atlas, which holds up the cranium as the fabled Atlas did the world, and around which the atlas and the superimposed cranium, rotates. The term neuraxis, figuratively, but quite appropriately, answers for cerebro-spinal axis, because the rest of the nervous system proceeds from and figuratively revolves around it. Neuraxon, so like it in sound, means the axis cylinder process of neurone. It is a very essential part of the nerve cell or of the neuron, as you will see as we proceed.

You see this little Greek word vs.vpovt with its contractions neu, neur, neuro, etc., is constantly recurring in our precursory incursions into the interesting domain of neurology. Term after term will come into use like neurectomy, (vevpov, a nerve, and rgwav, to cut) nerve cutting, a thing the surgeons are sometimes too prone to do, (as neurologists sometimes think) before the neurologist has exhausted his resources or with) it consulting the

neurologist as we sometimes think they should, and a thing they often do to our great relief and to the relief of the patient as well, sometimes before neurotheraphy has been thoroughly tried as we think we know best how to try it, as in that formidable capital operation of the nervous system Gasserian Gangliectomy or Gasserian neurectomy or neurotomy, the cutting out of the ganglion of Gasser from the under surface of the brain, an operation which only skilled surgeons should undertake after wise neurological counsel. You will learn more about this subject when we come to discuss trifacial neuralgia or neuralgia of the fifth nerve (from ver^or, a nerve, and aAyos, pain) sometimes also called prosopalgia, from prosopon, the face, and the Latin algia, pain, a shooting pain involving the branches of the fifth nerve or three branch nerves of the face and its ganglion (Gasserian) ; a nerve which Sir Charles Bell, a great Englishman, once attempting to operate upon including with his knife the seventh nerve, and thus producing surgically a form of that characteristic facial expression palsy which now so universally bears his honored name, now so interesting to neurologists.

Neurilemma (Ae^u?, sheath or husk, sheath of the nerve, epinurium, «", upon, and vevpov, nerve). Neurility signifies nerve power or power of nerve life, impulse, perception or power to muriate, if by warrant of philological analogy we may be permitted to use such an expression. In this connection there is one term which, by contrast you will remember, after 1 mention it, as having no just warrant for its derivation, a gelatinous, bad-smelling product of animal or fish putrefaction, a non- poisonous ptomaine when unmixed with other ptomaines. This is called neuridin, which I consider an unfortunate misnomer, for there is little or no nerve in it, though the vagus nerve goes to the viscera whose decomposition sometimes causes it, and nerves go to the muscles whose decay may engender it. It and its poisonous fellow ptomaine called murine, obtained partly from the same source, which acts so much like curare on the motor nerve terminals, causing dyspnoea, convultions and death, ought to be substituted by more suitable terms. Neurine should pertain to the nervous system only and not to products of either poisonous or non-poisonous decomposition of fish, fowl, flesh or viscera. Sheppard has used and applied the term more appropriately, though in an unusual way, to the gray matter of the layers of the cerebral hemispheres, which he called the neurine batteries of the brain.

There is also the term psychosis, from ^xq, the soul, the mind, meaning a disease of the mind usually functional, and sycosis, from o-vkov, a fig, used to designate a disease of the hair follicles. The dermatologists should give this term up to us. Everything should make way for advancing psychiatry and its designating terms. I do not like terms that confuse the student of neurological science and make his task of acquisition more difficult than it is. My business is to simplify your work and clarify your course through your curriculum. The ponderous volumes written up to date and by meritorious authors on neurology and psychiatry are paralysing enough to contemplate, but if you will listen to me faithfully and observe the illustrations 1 give you during the session, I will elucidate the subjects upon which they treat to the best of my ability, so that you may comprehend them when you consult the great text- books of the great masters and enjoy the leisure of the early days of your practice and the coming decades of your professional career in mastering them. You are expected to master the salient points only and not the entire science of neurology during your undergraduate life.

We expect to make you successful students during your course in neurology and not expert masters of the subject; to blaze a clear pathway and clear out the underbrush of the thickly wooded and tangled forest, so that the light will shine through it, and to direct you aright so that you may traverse alone and better, when without us and at your leisure, in delighted companionship with greater leaders of our great science and art. There are great names in neurology, greater than the name of Agamemnon; great names since, as well as before that great Agamemnon in neurophysiology, Claude- Bernard. Immortal names whose memories you will revere, and yet living names whom you will honor. Charcot, Claude-Bernard, Marshall-Hall, Beard, among the immortals abroad, Brown-Sequard, Seguin, Hammond, Amidon, Amariah-Brigham, Benjaman Rush among our own honored dead and hosts 1 cannot now recall, and Virchow, the venerable chief among the yet living. May he live forever. You may be surprised that 1 mention our Benjamin Rush as chief among my gallery of immortals, for he was only an American, and great names in American medicine are not yet in good form. He lived and died on the wrong side of the Atlantic, like McDowell and Morton, and yet awaits a place in Fame's Pantheon. But scan his works and words well and you will see that even he, an old-time American doctor, deserves a place, if not in the temple of modern psychiatry, yet upon Fame's eternal camping ground.

Some day in your time the world will applaud more than now the merits of Benjamin Rush. He was a neurological giant in his day. He saw things in psychiatry with astonishing precision.

Bourgery's outline lateral view anatomical diagram of the cerebrospinaUaxis or neuraxis, from Quain's anatomy, showing the cerebro-spinal cavity from the top of the brain within the cranium to the end of the spinal cord, cauda equina and coccyx. F, T and O are the frontal, temporal and occipital lobes of the cerebrum; C, P and Mo are the cerebellum, pons Varolii and medulla oblongata; M and Ms show the upper and lower extremities of the spinal cord; Ce, the cauda equina at the lower end of the spine beginning with the last lumbar spinous process; V, ganglion of the fifth nerve or the trigeminal, or ganglion of Gasser with its three branches faintly shown; C L shows the first of the spinal nerves or first cervical coming out under the occiput, and CviII is the last or lowest cervical; DI is the first dorsal or thoracic and DXII is the twelfth or lowest and last dorsal. The first sacral nerve begins at Si ; SV is the fifth sacral ; S is the sacral plexus and Col is the coccygeal nerve.

Chapter II

THE NEURONE AND THE NERVE CELLS: THEIR COMPOSITION AND CHARACTERISTICS.

Notwithstanding the delicate structure of the higher functioning neurones, their morphological or shape differences, corresponding to their grander activities in the scale of being, eminent physiologists tell us that these high power neurones, like other cells of the body of lower anatomical station and physiological dignity, possess protoplasm and nuclei, the morphological characteristics of which, so far as can at present be unraveled by the highest powers of the microscope, would scarcely seem to differ from those of the cells of less noble tissues, to account for their greater dignity. There are, nevertheless, and there must be, certain delicate differences in the neurone structure, since structure and function throughout all nature, are correlative, like the varied mechanical adjustment of varying movement, which, though no eye has yet seen and no glass can now reach them, must yet some day by more delicate means of research than are now at hand be brought to light, by sight of science, just as we know in daytime there are stars above us, though we see them not save by the revelation of astronomy. In fact, notwithstanding the remarkable uniformity in type of the nerve cells in the most diverse parts of the central nervous system, Barker assures us that the neurones are not everywhere so similar as to be practically indistinguishable from one another and cites a wealth of morphological peculiarities revealed specially by the research methods of Golgi and Ehrlich, which neurophysiologists were formerly unable to

obtain. Barker gives differences of internal structure of different cell groups recorded by the method of Nissl, which he regards as of equal importance for purposes of classification to the external form from relations discovered by Golgi's stain, and "Barker knows his business" as well as Golgi and Nissl, Held, Apathy and Foster, or any other in the profession's galaxy of cytologic stars. "There are many neurones which from the appearance of a single example stained black with silver, permit an absolute decision as to their source" and Barker here mentions the cells of the sensory ganglia, those of Purkinje in the cerebellum, the pyramidal cells of the cortex and certain cells of the hippocampus. Some of you may be able to verify in the biological laboratory before your studies here are ended, the truth of this verifiable statement. You must not stop where I leave you, but press on beyond to the entrancing neuroanatomical and neurophysiological landscape, now pointed out and with wider and ever widening microscopical vision, as you grow in knowledge of the wondrous and complicate mechanism of man's marvelous nervous system, till you pass beyond the horizon which now apparently, but not in reality, bounds your progress. There is light for you in the far beyond, and in the sweet by and by, but we have not time to go there now and many suns must rise and set before you may reach the glorious goal.

After the bird's-eye view I have given you of the beautiful beyond opportunities of investigation, it will interest you just now to know that you are not expected to know all, as only the great masters see the entrancing field of cytology, (for that is what it is called, kvtos, a cell, Xoyos, a discourse), in order to get your degree from his college, but you will be expected to know something of what the master minds are doing, and a good deal of what we show you, that you may wisely follow them after you shall have learned to walk and not creep in their cytologic footsteps. The cytologic way in physiology will interest you quite as much as the Milky Way may have entranced you in your preparatory college survey of astronomy, for it is strewn with marvels of light on the wondrous life and potencies of living animal matter. Cytology is a study of the neurones, or cells, and astronomy is a study of the stars and, used like astronomy in its broader sense, the study of the neurones is a study of all that pertains to the cells, or neuronomy, if the philologists and the linguists will permit the term, in the sense that it means a grazing among the nerve cells and their belongings. The neurone then is the complete nerve cell or ganglion cell, embracing the nucleus, nucleolus, axis cylinder process, or axone and dendrites (all processes, collaterals and terminations) grouped into a nerve individuality or independent unit. The neurone does not, through prolongations, intertwine with processes from neighboring cells; it does not anastomose like terminals of the vascular system as in the capillaries.

It is a separate and distinct personality, so to speak, capable of coming into contact, but not of mixing or interlacing or merging with other neurones so as to lose its individual identity. It is not a mixer, but stands upon its own individuality and here are some examples for your inspection of the nerve units which we now call neurones. With this wider and more definite understanding they might as well have been called cells as heretofore; for they are the same cells known before, only we have become a little better acquainted with them and know their nature, relations, and distinctive individuality more familiarly, and talk of them in a broader and more inclusive sense. When we say neurone, we mean all that pertains to the cell; its nucleus, nucleolus, its axis cylinder process or neuraxon, the dendrites, the myelin sheath of its collaterals and its split up end brushes or terminal arborizations. The neuraxons and dendrites of different cells come together, but do not anatomically anastomose. The neurones mingle but do not mix, they associate but do not join together, they are well acquainted with each other, especially the psychic neurones of the several layers of the gray cortex of the brain, and they are of the same blood as their neighbors, but they are neighbors only, units of adjoining families, not married to each other. They are separate and distinct but yet intimate friends, working side by side, often in the same nerve center to the same neurophysical or neuropsychical purpose.

The neurones, like cells everywhere, reveal under the microscope evidences of change in composition from excessive and toxic impression. Dexterity and disintegration in exercise, waste and work, rest and repair, are correlative terms in the nervous system, as in the muscular. The microscope shows this among the muscle cells, as it does the ravages of disease, among the neurones. Micro-physiologists have, by diligent labor, made brilliant discoveries concerning the peripheral and central nerve cells. The neurones of the cerebro-spinal nerve centers and the peripheral nerves have been examined before and after exercise, before and after alcohol and mercury, nicotine, lead, phosphorous, arsenic, strychnia and various other poisons and after the withdrawal of the blood supply from the neurones, as in anemic ' neurasthenia and before, which experiments have thrown much light on the beginnings of disease, not only in the neurones, (or entire nerve cells) but of disease found in the neurones in connection with persons who have died of other than recognized nervous diseases.

Neurones directly or indirectly suffer in many diseases, probably in all, as we might learn through more extended research. So that all diseases may interest you in the study of the normal and abnormal nerve cell or neurones. All acute and chronic degenerative processes in the nervous system appear to begin or end in the involvement of nerve cells. You will learn in the biological laboratory something of toxic cells, their chromatolysis, cell swellings and cell shrinkages, of- remote and central degenerate reaction from cell or peripheral nerve injury, the effects of infections and intoxications, chronic and acute, from disease, autotoxins from within, or poisons from without, or from intense heat and the restitution which follows the restoration to normal temperature. We cannot here discuss these matters in extenso, but a hint to the wise is sufficient. You will not need to seek diversion in novel - reading or the theatre. You will find it in the study of the neurones, beyond what we can teach you in this amphitheatre and there discover how much stranger is scientific neurological truth than any fiction.

The composition of the cell body or bulb of the neurone is much like the white of an egg and is called protoplasm, and in cytologic technicality cytoplasm. All nerve cells or neurones have a nucleus and the nucleus a nucleolus or ultimate or lower nucleus.

The neurone is not throughout a homogeneous substance, as you are ready to infer from its divisions for functionating purposes, since modifications of structure, in the nerve cells as elsewhere, as we can discern by analogical reasoning if not by search of scientific resource, vary with differences of function. A viscid-like plasma is thrown around and between the net- like work of granular fibers, which make up the body of the neurone (neuroglia). The neurone has within it chromophile granules, so- named because they may be stained by aniline, silver and other color agents.