The Development of Modern Neurological Thinking in the 1860s

THE DEVELOPMENT OF MODERN NEUROLOGICAL THINKING IN THE 1860s SAMUEL H. GREENBLATT* This article will attempt to show that modern modes of thinking in clinical neurology began to take shape during the 1860s. In essence, by the 1870s physicians thought about diseases of the nervous system in ways that were fundamentally different from their approaches in the 1850s. Since this transformation occurred gradually over the decade, the process was still very incomplete by 1870. Therefore, it was not clearly perceived at the time. The significance of the change may have been obscured by the general excitement in the larger realm of biology and medicine during the 1860s [I]. Indeed, the boundaries of the alteration remain difficult to define even now. Nonetheless, with the benefit of hindsight, we can see that a real change in thinking did occur. Whether it was of "revolutionary" proportions is probablyjust a matter of semantics, but it was a "paradigm change," as Kuhn [2, p. 68] uses that term. That is, a community of working scientists (neurologists) eventually agreed that they could solve their problems in a better way by using a different analytical approach. Neurological Nosology The way we think about diseases is revealed in how we classify them. The "science of the classification of diseases" is called "nosology" [3]. It is the conceptual framework that we use to understand how one disease entity relates (or does not relate) to another, usually in the sense of etiology or causation. Thus, in modern pathology and medicine, our nosology is a major part of our paradigm. Historiographically, then, we The author is indebted to his colleague James Nyce for his very cogent comments on an earlier version of this paper. *Brown University Neurosurgery, Memorial Hospital of Rhode Island, Pawmcket, Rhode Island 02860.© 1991 by The University of Chicago. AU rights reserved. 0031-5982/92/3501-0755$01.00 Perspectives in Biokgy and Medicine, 35, 1 ¦ Autumn 1991 129 should be able to investigate changing paradigms by looking at how nosologies changed. We can do so quite easily by looking at the tables of contents in old neurology textbooks. Some texts are explicitly organized nosologically, that is, by categories of disease. Even in those that are organized anatomically, the authors' classifications of disease are readily apparent in the titles of the chapters or sections for each region of the nervous system. In 1840-1846, Moritz Romberg (1795-1873) of Berlin published his monumental work [4], "the first systematic treatise in neurology" [5, p. 274]. Romberg's second edition of 1851 was translated into English in 1853 [6]. He based his classification of neurological diseases on the "physiological principle" of the distinction between sensory and motor function in the nervous system. These fundamental elements of the reflex had been worked out at the physiological level by Charles Bell, François Magendie, and Johannes Müller in the period from 1811 to 1831 [7; 8, pp. 110-112]. Thus, Romberg divided all neurological disorders into "Neuroses of Sensibility" and "Neuroses of Motility" [6, l:xv— xviii]. The term "neuroses" is utterly pre-Freudian. It is a carryover from the "neuropathology" of William Cullen, which was a late eighteenth-century theory of disease, with its own corresponding nosology [9, pp. 29-32]. Romberg's next subcategorization was largely clinical-anatomical. Among the neuroses of sensibility, there were neuralgias, hyperesthesias , and anesthesias. Each of these semiological terms was then connected to an anatomical region to create the subject of a chapter, for example, neuralgia of the lumbo-sacral plexus, anesthesia of the vagus, and so forth. This approach might make some sense with the examples just given, but "Anaesthesia of the Brain" is a bit broad and nonspecific by modern standards. The same basic approach was also used in Romberg 's 50 chapters on "Neuroses of Motility." The great majority of the chapters discussed either "spasm" or "paralysis" in the distribution of some neuroanatomical structure. So, for example, there were chapters on "Spasms in the Range of the Facial Nerve," "Paralysis of the Hypoglossus Nerve," and "Spasms from Excitement of the Brain." However, there was no discussion of paralysis arising from cerebral problems, because the motor tracts were not yet known to...