David A. Steinberg

Hughlings Jackson's theory of recovery

Article abstract-John Hughlings Jackson proposed a mechanism of neurologic compensation based on his theory of cerebral localization. According to Hughlings Jackson, there are three levels of evolution of the nervous system. Each element of each level contains a complete representation of the next lower level. Each element of the middle and highest levels contain a representation of the entire body, weighted for a particular part of the body. If the nervous system is damaged so that an area heavily weighted for a particular part of the body is destroyed, less heavily weighted areas are immediately activated according to their weighting. This activation partially compensates for the function of the destroyed tissue. As time passes, the weighting of representation in the unaffected areas changes, amplifying the degree of recovery. Recent clinical studies and PET cerebral blood flow studies show that various ipsilateral and contralateral areas are activated in recovery. The activated areas reside in what Hughlings Jackson would call the middle and highest evolutionary levels. Modern clinical and neurophysiologic observations are therefore consistent with Hughlings Jacksons theory of compensation. NEUROLOGY 1995;45: 834-838

Hughlings Jackson's suggestion for the treatment of epilepsy

John Hughlings Jackson articulated a neurologic method of systematically evaluating the anatomy, physiology, and pathology of every patient with neurologic disease. He used this mode of analysis to develop a theory of the physiology of epilepsy. We examined an example of his method in a newly discovered, unpublished manuscript containing his suggestions for the treatment of epilepsy based on his physiologic ideas. He had his private papers destroyed at the time of his death, but the Rockefeller Library of the University College London Institute of Neurology, Queen Square, contains a collection of his papers probably saved from destruction by his collaborator James Taylor. Among these articles is an 1899 memorandum, labeled “For Private Circulation” and entitled “A Suggestion for the Treatment of Epilepsy.” In it, Hughlings Jackson claimed that focal discharging lesions cause both focal and generalized epilepsy, and that the cells in the lesion discharge their energy more easily than normal tissue. Citing microscopic evidence that such lesions are congested and inflamed, and that tuberculin destroys such tissue in the lung, he reasoned that destroying these unstable neurons with tuberculin would improve epilepsy. In this private manuscript, Hughlings Jackson uses an unusually detailed analysis of the pathology, anatomy, and physiology of epilepsy to predict a scientific approach to its treatment.

Chapter 3 Neurology in Ancient Egypt

Neurology, in the modern sense, did not exist in ancient Egypt, where medicine was a compound of natural, magical and religious elements, with different practitioners for each form of healing. Nevertheless, Egyptian doctors made careful observations of illness and injury, some of which involved the nervous system. Modern scholars have three sources of information about Egyptian medicine: papyri, inscriptions, and mummified remains. These tell us that the Egyptians had words for the skull, brain, vertebrae, spinal fluid and meninges, though they do not say if they assigned any function to them. They described unconsciousness, quadriparesis, hemiparesis and dementia. We can recognize neurological injuries, such as traumatic hemiparesis and cervical dislocation with paraplegia, in the well known Edwin Smith surgical papyrus. Similarly recognizable in the Ebers papyrus is a description of migraine. An inscription from the tomb of the vizier Weshptah, dated c. 2455 BCE, seems to describe stroke, and Herodotus describes epilepsy in Hellenistic Egypt. We have very little understanding of how Egyptian physicians organized these observations, but we may learn something of Egyptian culture by examining them. At the same time, modern physicians feel some connection to Egyptian physicians and can plausibly claim to be filling a similar societal role.

Cerebral Localization in the Nineteenth Century — The Birth of a Science and its Modern Consequences

Although many individuals contributed to the development of the science of cerebral localization, its conceptual framework is the work of a single man—John Hughlings Jackson (1835–1911), a Victorian physician practicing in London. Hughlings Jacksons formulation of a neurological science consisted of an axiomatic basis, an experimental methodology, and a clinical neurophysiology. His axiom—that the brain is an exclusively sensorimotor machine—separated neurology from psychiatry and established a rigorous and sophisticated structure for the brain and mind. Hughlings Jacksons experimental method utilized the focal lesion as a probe of brain function and created an evolutionary structure of somatotopic representation to explain clinical neurophysiology. His scientific theory of cerebral localization can be described as a weighted ordinal representation. Hughlings Jacksons theory of weighted ordinal representation forms the scientific basis for modern neurology. Though this science is utilized daily by every neurologist and forms the basis of neuroscience, the consequences of Hughlings Jacksons ideas are still not generally appreciated. For example, they imply the intrinsic inconsistency of some modern fields of neuroscience and neurology. Thus, “cognitive imaging” and the “neurology of art”—two topics of modern interest—are fundamentally oxymoronic according to the science of cerebral localization. Neuroscientists, therefore, still have much to learn from John Hughlings Jackson.

Part 2: history of 20th century neurology: decade by decade.

Neurology in the 1900s: 1900–1909 H. Richard Tyler, MD The first decade of the 20th century (1900–1909) saw dramatic changes and advances in virtually every aspect of neurology. The basic science framework for neurology was solidified by fundamental advances in neurophysiology, led by Sir Charles Sherrington and his collaborators. Equally important advances were made in the study of the histology and pathology of the nervous system by Cajal and others (Tables 1 and 2). The clinical spectrum of neurology was broadened and enriched by many contributions still remembered eponymously today (see Table 1). A very subjective and selective selection of additional landmark contributions in different fields of neurology are listed in Table 2. Prominent among these were the studies that led to Nobel Prizes for Pavlov in 1904 on digestive physiology and to Golgi and Cajal in 1906 for their work on the neuron theory. Few neurodiagnostic tests were available to clinicians in the first decade of the 20th century, with arteriog-

Commentary. The diseases of Alexander the Great.

The accompanying articles that speculate that Alexander the Great had a traumatic carotid dissection or congenital cervical scoliosis demonstrate the difficulties in retrospective diagnosis as a historical enterprise. The extant primary sources were written centuries after Alexander’s death and are ambiguous in their original languages, and even more so in translation. Thus we cannot be certain what illness Alexander actually had. Furthermore, anachronistic diagnosis removes Alexander from the medical context of this time, telling us little of historical significance about him. Such investigations also illustrate the more general limits that the absence of context imposes on the study of ancient history.

The origin of scientific neurology and its consequences for modern and future neuroscience

John Hughlings Jackson (1835-1911) created a science of brain function that, in scope and profundity, is among the great scientific discoveries of the 19th century. It is interesting that the magnitude of his achievement is not completely recognized even among his ardent admirers. Although thousands of practitioners around the world use the clinical applications of his science every day, the principles from which bedside neurology is derived have broader consequences-for modern and future science-that remain unrecognized and unexploited. This paper summarizes the scientific formalism that created modern neurology, demonstrates how its direct implications affect a current area of neuroscientific research, and indicates how Hughlings Jacksons ideas form a path toward a novel solution to an important open problem of the brain and mind.

The Sydney Symposium on the History of Cerebral Localization An Introduction

On Monday, November 7, 2005, the World Federation of Neurology Research Group on the History of the Neurosciences held a symposium on the history of cerebral localization as part of the World Congress of Neurology in Sydney. The participants focused on concepts of localization to be found in different eras from antiquity to the present. Each contributor was invited to use one’s own definition of cerebral localization, and each brings a unique perspective to the question. We will not summarize each contributor’s views, but we are grateful to Frank Clifford Rose, Axel Karenberg, Mervyn Eadie, and Richard Frackowiak for their prodigious contributions. Cerebral localization as practiced in every neurologist’s office around the world might seem an unlikely topic for an international symposium, since it is useful yet unobtrusive. By comparison, the conceptions of the ancients on topics of localization might appear to reflect a confused biology. However, the medical and scientific context in which these conceptions arose can illuminate attitudes toward the individual, and on nature, that might otherwise be hidden. It might not be possible to know precisely how the scientists of the past thought about things, but we can get a lot of insight by looking at how they approached the function of the brain. One beauty of cerebral localization is that it is scientific, yet requires no instruments to practice it. A pin, a percussion hammer, and an ophthalmoscope are handy accessories, but they are not absolutely necessary to come to a reasonable diagnosis. Assiduous attention to a patient’s history, followed by careful inspection, palpation, percussion, and auscultation, can produce a reasonably consistent prediction of the presence of pathology in the nervous system. A Martian in the examining room might find the rituals of cerebral localization strange or even incomprehensible. It is all the more surprising, then, that this practice is demonstrably scientific. We include ourselves among those who are interested in how science happens, how it emerges from the maelstrom of human activities to become, at least partially, a privileged form of human knowledge. We do not make any great claims to the supremacy of science over other human endeavors, only that science allows a degree of predictability that literature, or music, do not allow. That humans do not always use scientific predictions safely is cause for concern but does not change the science itself. Medical ideas reflect thinking about the world and nature, even in antiquity, and medical ideas can be found in texts that do not appear, at first, to be scientific in character. The workings of the body offer ready