Международный неврологический журнал №4 (98), 2018
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Diaschisis: brief historical review
Авторы: Vinychuk S.M. (1), Fartushna O.Ye. (2)
1 - Oleksandrivska Clinical Hospital, Kyiv, Ukraine
2 - Ukrainian Military Medical Academy, Kyiv, Ukraine
Рубрики: Неврология
Разделы: Справочник специалиста
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Резюме
Актуальність. У статті наведено історичний екскурс концепції діашизу Монакова. Мета дослідження. Вивчення та узагальнення даних наукової літератури щодо відкриття, термінологічного позначення та патофізіологічних механізмів виникнення діашизу, історії проблеми. Матеріали та методи. Аналітичний огляд наукових публікацій за період 1900–2018 рр. із використанням сучасних наукометричних баз даних (Scopus, Web of Science, MEDLINE, ScieLo, PubMed, The Cochrane Library, EMBASE, Global Health, CyberLeninka, RINC) та фондів наукових бібліотек України, ЄС, Великобританії та США. Серед наукових книг та статей, які були знайдені за ключовими словами, 35 дослідницьких публікацій відповідали встановленим критеріям відповідності та були проаналізовані. Результати. Костянтин фон Монаков був швейцарським неврологом російського походження і видатним ученим свого часу, який вперше привернув наукову увагу до динамічності нервової системи, віддалених ефектів ураження мозку та відновлення його функції. Концепція діашизу, розроблена Монаковим, є центром розуміння функціонування мозку. Висновки. Наведено історичний екскурс поняття діашизу, обґрунтовані патофізіологічні механізми його виникнення.
Актуальность. В статье представлен исторический экскурс концепции диашиза Монакова. Цель исследования. Изучение и обобщение данных научной литературы об открытии, терминологическом определении, патофизиологических механизмах возникновения диашиза, истории проблемы. Материалы и методы. Аналитический обзор научных публикаций за период 1900–2018 гг. с использованием современных наукометрических баз данных (Scopus, Web of Science, MEDLINE, ScieLo, PubMed, The Cochrane Library, EMBASE, Global Health, CyberLeninka, RINC) и фондов научных библиотек Украины, ЕС, Великобритании и США. Среди научных книг и статей, которые были найдены по ключевым словам, 35 исследовательских публикаций отвечали установленным критериям и были проанализированы. Результаты. Константин фон Монаков был швейцарским неврологом российского происхождения и выдающимся ученым своего времени. Он впервые привлек научное внимание к динамичности нервной системы, отдаленным эффектам поражения мозга и восстановлению его функций. Концепция диашиза, разработанная Монаковым, является центром понимания функционирования мозга. Выводы. Представлен исторический экскурс открытия диашиза, обоснованы патофизиологические механизмы его возникновения.
Background. This article is devoted to the Monakow concept of diaschisis and its brief historical review. We analyze the origin and history of diaschisis. Materials and methods. We have overviewed scientific publications for the period of 1900–2018. The Scopus, Web of Science, MEDLINE, ScieLo, PubMed, The Cochrane Library, EMBASE, Global Health, CyberLeninka, and RINC databases were used along with databases of government scientific libraries of Ukraine, the European Union, the United Kingdom, and the USA. Among scientific books and articles that were found based on keywords, 35 research publications met the established eligibility criteria and were analyzed. Results. Constantin von Monakow was a Russian-origin Swiss neurologist and an outstanding scientist of his time. He will be remembered by his important contributions to our knowledge on the organization, location, and direction of tracts of the nervous system. The Monakow concept of diaschisis is placed at the center of the understanding of brain function. It draws scientific attention to the dynamics of the nervous system, remote lesion effects, and recovery of function. Conclusions. We have analyzed the origin of diaschisis, history of its discovery, and pathophysiological mechanisms.
Ключевые слова
діашиз; історія; походження; патофізіологія; концепція діашизу Монакова; Костянтин фон Монаков
диашиз; история; происхождение; патофизиология; концепция диашиза Монакова; Константин фон Монаков
diaschisis; history; origin; pathophysiology; Monakow concept of diaschisis; Constantin von Monakow
Introduction
This article is devoted to the Monakow concept of dia–schisis, and its brief historical review. We analyze the origin and history of diaschisis.
Materials and methods
We have overviewed scientific publications for the period of 1900–2018. The Scopus, Web of Science, MEDLINE, ScieLo, PubMed, The Cochrane Library, EMBASE, Global Health, CyberLeninka, and RINC databases were used along with databases of government scientific libraries of Ukraine, the European Union, the United Kingdom, and the USA. Among scientific books and articles that were found based on keywords, 35 research publications met the established eligibility criteria and were analyzed.
Results
The idea that damage to one part of the nervous system can have effects at a distance was popular in XIX century. Constantin von Monakow, MD, accepted this idea and blended it with the newly formulated neuron doctrine early in the XX century to account for ipsilateral paralyses and recovery of function [1]. In 1914, Monakow presented a new concept of neural depression due to loss of inputs to structures connected to the focal brain lesion, named it diaschisis [2–4].
Definition
Diaschisis (from Greek diaschisis — splitting, dividing) [1] is a state of inactivity of nerve centers or accumulation of cellular elements located at a distance from the primary lesion, but functionally connected with it by a system of conducting paths [5–10].
As a result of the sudden cessation of the influx of physio-logical stimulating impulses to the nervous structures of the functional system with effector functions, the responsive reactions are damaged and focal neurological symptoms do not correspond to the localization of the underlying anatomical lesion [4, 11]. That is why there is no correlation between the primary focus and the overall neurologic deficit [9].
Constantin von Monakow: an outstanding scientist of his time
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The notion of diaschisis was introduced by the famous Russian-Swiss neurologist, neuroanatomist and neuropsychologist Constantin von Monakow [9, 10]. He was also known as a critic of the theory of neuropsychological functions localization. Monakow (1853–1930) was born in village Bobretsovo in the Vologda pro-vince (Russia). In 1863, the family immigrated to Germany, and then in 1866 moved to Zurich (Switzerland) [12, 13]. In 1877, he graduated from the Medical Faculty of the University of Zurich, where he conducted research on the anatomy of the brain and gave lectures on neurology [14, 15]. In 1894, Monakow became a professor and in 1891 founded the Institute of Brain Anatomy in Zurich, and later became its director. In 1917, he founded the Swiss magazine Archive of Neurology and Psychiatry (Schweizer Archiv für Neurologie und Psychiatrie) being its editor and organized Swiss Neurological Society [16].
Providing aforementioned experimental studies, Mo-nakow was also successfully collaborating with many internationally known scientists such as neurologist-psychiatrist Vladimir Bechterev (1857–1927), the neurologist and neuroscientist Constantin von Economo (1876–1931), Cornelis Winkler (1855–1941), Jules Joseph Déjérine (1849–1917), Augusta Déjerine-Klumpke (1859–1927), Gennosuke Fuse (1880–1946), and Paul Charles Dubois (1848–1918) [12]. In 1923, von Monakow retired as professor of neurology, but still sustained to work in the Neuroanatomical Institute and his outpatient clinic [17]. Von Monakow died peacefully on October 19, 1930. He left a manuscript autobiography which was deposited in the Central Library of Zurich, where it rested for four decades. Following the death of his last surviving daughter in 1967, hundreds of letters addressed to von Monakow, his autobiographical sketches and scientific manuscripts were turned over to the Zurich Medizinhistorisches Institut [18]. Editors found all these documents to be not only of great importance for the history of medicine and science but also of great human interest. Reflections about his most interesting scientific life were published in 1970 entitled as Vita Mea — Mein Leben [19].
According to Luria, Constantin von Monakow was “one of the most profound and cautious neurologists of our time” [20].
Monakow concept of diaschisis
The concept of diaschisis von Monakow interpreted as “...a state of decline or absence of function after a brain trauma and an effect on the site of the nervous system that is remote from the source of damage”. Von Monakow first developed and scientifically substantiated the doctrine of diaschisis and applied this doctrine to explain the neurological symptoms arising from damage of specific levels of the brain [3, 16]. His work was grounded on the concept the hierarchical organization of brain functioning and subordination of brain centers, developed by the Scottish neurologist John Hughlings Jackson [21].
Causes and pathophysiological mechanisms of diaschisis: a historical review
Diaschisis is a complex pathophysiological process triggered by the action of biomechanical forces or hemodynamic disorders in the brain. Disturbances, associated with diaschisis, can develop in minutes after a brain injury [10, 22].
Diaschisis is a type of shock of the central nervous system, limited only by separate anatomical and functional systems, while the other forms of shock (trauma-tic, apoplectic, psychogenic, infectious) to some extent complete inhibition of the cerebral cortex and the disruption of vital functions of the body [23, 24]. That is why diaschisis causes disturbance only of those anatomo-topographic levels of the nervous system with which the damaged site is connected by a system of conducting paths.
The main cause of diaschisis is the sudden cessation of the receipt of specific physiological impulses to the corresponding nerve centers of the functional system with effector functions [25].
Disruption of motility occurs during the dysfunction of the spinal cord caused by spine vertebral damage at the cervical and upper thoracic level (for instance, vertebrae dislocation or fractures of its body and arch). This damage can occur, for example, by diving in shallow water, falling head-down, striking the neck, or by sudden over-extension of the neck. In acute and subacute period traumas of the spinal cord and vertebral cord at cervical and upper thoracic level cause the following type of damage: tendon and periosteal reflex depression, muscle hypotony with flaccid paralysis of the extremities with areflexia of deep reflexes, or disturbances of all kinds of sensitivity by the conductor type [10]. These are symptoms of spinal cord function disorders, which occur during the spinal injuries, and are named a “spinal” shock [26]. Neurological deficit during a “shock of the spinal cord” is not necessarily combined with general symptoms of traumatic shock.
Bastian’s law, 1890
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The above described symptoms of cervical and upper thoracic level damage to the spine and vertebral cords have been known for a long time. In 1890, they were analyzed by the English neurologist Henry Charlton Bastian (1837–1915) as Bastian’s law — the termination of tendon and periosteal reflexes at spinal cord injury at the higher upper thoracic level [27–29]. The author considered these neurolo-gical deficits to be regular, constant, and explained them by different mechanisms [27]:
— prolapse of hypertonic cerebellar pulses at the transection of the spinal cord;
— violation of blood and lymph circulation in the lower to the transection parts of the spinal cord;
— increased pressure of cerebrospinal fluid and da-mage of spinal cord roots;
— and exposure to toxins.
Further experimental and clinical studies have shown that Bastian’s law has no absolute significance [30].
Lapinsky’s experimental studies refuted Bastian’s law
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In a series of experimental studies, the professor at the University of St. Vladimir, Mykhailo Mykytovych Lapinsky, for the first time proved that the state of reflexes in the paralyzed part of the body of a patient with total spinal cord interruption was interrelated with the nature of the trauma and chronological factor [31–33]:
— a high transection of the spinal cord (in a dog) did not cause areflexia but caused revival of reflexes if the surgery was performed with due caution;
— a coarse trauma to the lower stump led to the reflex function extinction, but the reflexes were revived again after a cautious transection of the spinal cord below the stump.
The results of Lapinsky’s experimental studies, as well as clinical observations of those wounded during World War II [31–35], refuted Bastian’s law about the persistent loss of appropriate reflexes in the anatomical transection of the spinal cord.
However, in most cases, with the total anatomical break of the spinal cord in humans, Bastian’s law still remains valid.
Spinal diaschisis is a dynamic phase process
Spinal shock is not a simple consequence of trauma, since after restoration of reflex functions, re-cutting of the spinal cord below the level of a previous cut does not cause a spinal shock. For the pathophysiological explanation of motor disorders in patients with spinal shock, diaschisis, described by Constantin von Monakow as a dynamic phase process, is of the greatest importance [6, 10].
Spinal diaschisis (shock) is a dynamic phase process. After a certain period, the extremities’ limp paralysis is replaced with a spastic one, caused by disappearance of the paralysis of the motor cells of the anterior horns of the spinal cord caused by diaschisis. The reversal of spinal diaschisis occurs on average during 4–8 weeks after trauma [10, 34].
Conclusions
Monakow was an outstanding scientist of his time. He will be remembered by his important contributions to our knowledge on the organization, location, and direction of tracts of the nervous system [12]. His concept of diaschisis is placed at the center of the understanding of brain function.
Conflicts of interests. Authors declare no conflict of interest that might be construed to influence the results or interpretation of their manuscript.
Additional information
Role of the funding source — none
Disclosures — none
Author contributions: S.M. Vinychuk — study concept and design, interpretation of data, data acquisition; O.Ye. Fartushna — article concept and design, data acquisition, literature overview, interpretation of data, and drafting the article.
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