HISTORY OF NEUROLOGY

SECTION EDITOR: CHRISTOPHER G. GOETZ, MD The Monakow Concept of Diaschisis Origins and Perspectives

Stanley Finger, MD; Peter J. Koehler, MD, PhD; Caroline Jagella, MD, PhD

he idea that damage to one part of the nervous system can have effects at a distance was popular during the 19th century. Constantin von Monakow, MD, accepted this idea and blended it with the newly formulated neuron doctrine early in the 20th cen- tury to account for ipsilateral paralyses and recovery of function. He called his theory Tof neural depression caused by loss of inputs to structures tied to the damaged area diaschisis.In this article, we examine the origins of diaschisis and the goals of Monakow. Credit is given to Mona- kow for drawing needed attention to the dynamics of the nervous system, remote lesion effects, and recovery of function, even though the fine details or specifics of his theory have had a mixed reception. Arch Neurol. 2004;61:283-288

During the 19th century, it was specu- will be maintained that his more basic no- lated that damage to one part of the ner- tion of temporary depressed neural func- vous system might have temporary de- tioning caused by damage at a distance is pressive effects on the same or opposite still an attractive concept to those hoping side of the brain or even at another level. to account for recovery of function. It was not until early in the 20th century, however, that ideas about remote lesion EARLIER SHOCK THEORIES effects became more specific. Most scien- tists and practitioners agreed that some Monakow was not the first physician to temporary “shock” effects could be due to emphasize that damage to the nervous sys- edema and pressure on surviving brain tis- tem could have effects at a distance. Ga- sue and to changes in blood flow. But now len1 contrasted the primary and second- there was another possibility—that sim- ary effects of disease in his treatise De Locis ply breaking neuronal ties between re- Affectis. Writing in Rome, Italy, during the gions could also produce temporary im- second century, he maintained that inter- pairments of function. The person most connections among certain nerves allow responsible for discussing shock effects in animal spirits to travel from one internal this context of the neuron doctrine was organ to another, effectively spreading the Constantin von Monakow (Figure). His message so they can respond in sympa- new theory was called diaschisis. thy. The very term sympathetic nervous sys- This historical review presents bio- tem stems from the idea of Galen that some graphical information on Monakow, ex- nerves are especially suited for inducing amines the origins of his new ideas about physiological reactions at a distance from transient lesion effects, and relates them the affected part. to cortical localization and recovery of Descriptions of secondary brain le- function. It will be shown that the specif- sion effects can be found in many publi- ics of the Monakow diaschisis theory have cations from the beginning and middle de- always been questioned. Nevertheless, it cades of the 19th century. For example, in 1861, John Call Dalton, MD,2 an Ameri- From the Department of Psychology, Washington University, St Louis, Mo (Dr Finger); can who attempted to replicate and ex- 3 the Department of Neurology, Atrium Medical Center, Heerlen, the Netherlands tend the findings of Flourens on the ef- (Dr Koehler); and the Neurological Department, University Hospital Zurich, Zurich, fects of cerebellar lesions, noted that Switzerland (Dr Jagella). pigeons with cerebellar damage often

(REPRINTED) ARCH NEUROL / VOL 61, FEB 2004 WWW.ARCHNEUROL.COM 283 Downloaded from www.archneurol.com at Princeton University, on October 20, 2011 ©2004 American Medical Association. All rights reserved. ment, to visit a number of asylums and laboratories in German-speaking countries. Hitzig’s suggestion led him tothelaboratoryofBernhardvonGud- den, MD, in Munich, Germany, where he learned to use the microtome and was introduced to new techniques for studying secondary degeneration af- ter cortical lesions. Many of the early experiments of Monakow were based on what he learned from Gudden and were carried out on young animals.23 In 1885, after spending 7 years as an assistant at the St Pirmins- berg Asylum at Pfa¨fers, Switzer- land, he established his own re- search institution in Zurich. Its purpose was to study secondary brain degeneration in humans, and Constantin von Monakow, 1853-1930. it was paid for by personal funds from his private practice. He be- showed severe motor incoordina- a distance, calling them inhibition and came Extraordinarius (associate pro- tion but then excellent recovery. He dynamoge´nie, and he studied these re- fessor) at the University of Zurich a thought this finding could be ex- mote effects not just in the clinic but little less than a decade later (against plained in either of 2 ways. The first in the laboratory.8-10 the wishes of the faculty!), and his was that remaining parts of the cer- Monakow also knew about the Hirnanatomisches Institut (Brain ebellum may have taken over for the theories of Friedrich Goltz, MD.11 Anatomy Institute) was then merged damaged parts, and the second was Goltz also wrote about how irrita- into the university. that the lesions could have tempo- tion from a lesion site could func- Following the model provided rarily depressed the remaining parts tionally disrupt healthy, remaining by Mieczyslaw Minkowski, MD,15 his of the cerebellum. Spared parts of the parts of the brain. Hence, the work biographer and successor in Zurich, cerebellum probably mediated mo- of researchers such as Dalton, Henle, the professional career of Monakow tor coordination but only after the and Brown-Se´quard, not to men- is typically divided into 3 parts. Dur- remote effects of the lesion wore off. tion others, helped to provide some ing the first period, which began One of Dalton’s contemporar- of the zeitgeist for Monakow, who around 1880, he performed many el- ies was Jakob Henle, MD.4 In 1840, viewed the nervous system as a dy- egant experiments on developmen- he discussed 3 types of remote le- namic entity and wished to know tal anatomy and on how cortical and sion effects using the spinal cord as more about transient lesion effects. thalamic areas are related. At this time, a model. Henle referred to them as he added significantly to what was symmetrical consent between the CONSTANTIN VON MONAKOW known about the thalamic nuclei in- nerves of the different sides, ascend- volved with vision and hearing and ing and descending consent within Monakow was born in Bobrezowo, cortical localization of function. He the same columns (anterior or pos- Russia, a town north of Moscow, in published his Gehirnpathologie24 terior), and consent between sen- 1853.12-22 Hismotherdiedwhenhewas (Brain Pathology), a massive text with sory and motor columns. Within this 4 years of age, and his father, who was more than 3000 references, in 1897, framework, he systematically dis- a difficult and religious man, took re- near the end of the first period. cussed how stimulation of one area sponsibility for his upbringing. The During his middle period, which might decrease or increase the re- Monakows moved to Dresden, Ger- started around 1900, his interest in sponsivity of another spinal part. many, for political reasons when traditional anatomical procedures for Monakow might not have read Monakow was 10 years of age. They studying localization waned and he Henle,5 but he was familiar with the next moved to Paris, France, before became considerably more involved ideas of Charles-Edouard Brown- finally settling in Zurich, Switzerland, with brain dynamics and functional Se´quard,MD,6 whouseddistantlesion in1866.Threeyearslater,theybecame issues. It was at this time that he wrote effects to question certain conclusions naturalized Swiss citizens. about levels of functioning, “chrono- about cortical localization of function Monakow was headstrong at logical localization” (the role of time), during the 1870s. Brown-Se´quard ar- home and in the classroom and went the interplay of the parts within the gued that “an irritative action, trans- on to study medicine in Zurich against nervous system, and diaschisis. The mitted at a distance, on a center be- his father’s wishes. In 1876, while still major publication that completed this siegedwiththatfunction”mayproduce a medical student, he was encouraged phase of his professional life was his “in this same center an inhibitory ac- by Eduard Hitzig, MD, who was then Die Lokalisation im Grosshirn und der tion.”7(p424) He distinguished between headoftheBurgho¨lzliAsylum,Zurich, Abbau der Funktion durch kortikale inhibitory and excitatory reactions at andinterestedininstitutionalmanage- Herde25 (Localization in the Cortex

(REPRINTED) ARCH NEUROL / VOL 61, FEB 2004 WWW.ARCHNEUROL.COM 284 Downloaded from www.archneurol.com at Princeton University, on October 20, 2011 ©2004 American Medical Association. All rights reserved. and Breakdown of Function Through in localization theory and in neu- of effect he was talking about was Cortical Lesions), which appeared in ron theory, which explained how the only an “abolition of excitability” or 1914. (Unless otherwise specified, different parts comprising these a “functional standstill.” He never what Monakow had to say about di- working units are connected. The wanted his theory to be associated aschisis comes from this source.) basic idea to emerge was that dam- with neural inhibition.25(pp66,67) In fact, The final period of Mona- age to one part must have disrup- he had a hard time even accepting the kow’s professional life was strongly tive effects on other parts, which may concept of inhibitory fibers or inhibi- affected by the events of World War later wear off and be associated with tory synapses. In addition, diaschi- I (1914-1918) and the Russian Revo- some recovery of function. sis was not to be equated with irri- lution of 1917. Although not in the It was during the late 1890s that tation, a mechanism deemed trenches, he was appalled by the Monakow began to emphasize the important by some of his predeces- senseless destruction of people and importance of transient, remote le- sors, including Brown-Se´quard and things, which he believed reflected sion effects. At that time, however, Goltz. spiritual degeneration.14 He be- the basic mechanisms that he Thus, in 1914, Monakow de- came depressed and retreated from thought could account for these ef- fined diaschisis as: his neurology and friends in Zurich fects differed from the one that to the Swiss mountains. There he de- would later characterize his diaschi- An “interruption of function” appearing voted his time to blending his ho- sis theory. His evolving ideas can be in most cases quite suddenly...andcon- listic ideas about biology with his appreciated by comparing his state- cerning widely ramified fields of function, ethical and philosophical beliefs.14 ments from 1897 with his more ma- which originates from a local lesion but Monakow retired from the uni- ture formulations from 1914. has its points of impact not in the whole versity in 1928 at 75 years of age but Monakow attempted to ex- cortex (corona radiata, etc) like apoplec- still devoted himself to understand- plain ipsilateral hemiplegia in the tic shock but only at points where the fi- ing his hypothetical self-actualiz- 1897 edition of his Gehirnpatholo- bers coming from the injured area enter ing force (horme), conscience, the gie.24(pp292-296) He wrote that ipsilat- into primarily intact grey matter of the whole central nervous system....Speak- basis of good and evil, the pitfalls of eral paralyses occur immediately af- ing quite generally, the process of diaschi- modern civilization, and spiritual re- ter injury, in a period he called the sismayberegardedasbeingcausedbyabo- generation until his death in 1930. reaction period. He also discussed a lition of excitability (functional standstill) Three years later, a biographical stage of chronic symptoms, observed due to local disruption of brain substance piece was published about him by after the transient lesion effects di- within one neuron group, which is trans- Swiss novelist Maria Waser,26 to minish.24(p756) He reasoned that the mitted to neuron groups closely adjacent whom he had turned for help on reduction of most secondary symp- to and directly related with the afflicted how best to express his most spiri- toms is due to the release of pres- part of the brain.29(pp28,29) tual thoughts in writing. sure, reduction of edema, and other mechanical factors.24(pp208,209) He did TheinsightsofMonakowledhim DEVELOPMENT OF not use the term diaschisis and only to argue that localization of symptoms DIASCHISIS THEORY hinted at his later theory when he andlocalizationoffunctionshouldnot attempted to account for recovery of be equated, as they tended to be by Monakow wanted to differentiate be- finger movements, the last func- some map makers.20(p34),30 Diaschisis tween the deficits that result di- tion to return on the ipsilateral side. also gave him the key he needed to un- rectly from focal brain lesions and the The term diaschisis was intro- derstandavarietyofneurologicalprob- transient effects of such lesions, duced by Monakow in 1902. By lems and phenomena. One riddle that which he believed could be attrib- 1905, when the second edition of his suddenly seemed solvable had to do uted to depression of neurally con- Gehirnpathologie27 was published, with acute right-hemispheric lesions nected but distant parts of the brain. readers found a small chapter with impairing speech, at least for a while, When he coined the term diaschisis, a title that could be translated as in right-handed people. Now, by it was specifically to describe the in- shock and diaschisis. Here he men- thinking of effects at a distance,—in jury-induced drop in activity in func- tioned flaccid paralysis (an initial this case in the mirror locus on the op- tionally connected brain areas. Dias- symptom) preceding spasticity (a re- posite hemisphere—severe but tran- chisis was never intended to describe sidual symptom) due to a shock- sient impairments of speech could be anything more than the depressive ef- like disconnection.20(p33),27(p245) better understood.28 fects of breaking connections be- One year later, he gave a talk on Monakow was always very in- tween functionally related parts of the aphasia and diaschisis at the Neu- sistent about how the word diaschi- brain. The word itself came from the rological Section of the Stuttgart sis should be used. He pointed out Greek schizien (to split) and has been Naturalist Meeting.28 Then, from that diaschisis has only limited focal variously translated as “splitting off” 1906 to the end of World War I, the consequences (such as loss of volun- or “separated.” theory of diaschisis underwent fur- tary movement in one leg), leaving The Monakow concept of di- ther refinements as it rose to repre- the vital functions intact. In con- aschisis was based on the notion of sent a dominant theme in his dy- trast, circulatory changes and edema, a working unit with parts that must namic and holistic neurology. which may also be associated with cooperate to assure normal func- As Monakow developed his traumatic injuries, have more global tioning.25(pp27-30) But it also had roots concept, he made it clear that the type and less localizable effects, which may

(REPRINTED) ARCH NEUROL / VOL 61, FEB 2004 WWW.ARCHNEUROL.COM 285 Downloaded from www.archneurol.com at Princeton University, on October 20, 2011 ©2004 American Medical Association. All rights reserved. include changes in respiration, pulse, some connections, one cannot dis- Diaschisis corticommisuralis, an- and consciousness. In 1914, Mona- miss the possibility that alterations other variety, involved the corpus kow explained: in distant areas could be contribut- callosum. It can account for how an ing to the residual symptomatol- injury to one hemisphere can alter There is no doubt that the develop- ogy. Regarding the future of local- the functional activity of the other ment of diaschisis is enormously en- ization theory and the role played by hemisphere, a phenomenon ob- hanced by latent circulatory disorders in diaschisis theory, Monakow had this served with some frequency in clini- the affected as well as in other areas of to say: “However the problem of lo- cal populations. Ipsilateral hemiple- the brain (vasomotor disorders, pres- calization will develop in the fu- gia, for example, could be explained sure effects, or accumulation of CSF, toxic factors, etc). These disorders per ture, I am convinced that it will not with this type of diaschisis. se, however, are never able to bring about be able to do without the dissocia- Diaschisis associativa, yet an- a functional disorder in the sense of lo- tion of function by diaschisis or a other type, pertained to cortical sup- cal initial symptoms.29(p32) similar conception.”30(p250) pression of other cortical areas via as- It is worth adding that Mona- sociation fibers. It may be involved in Hence, Monakow never de- kow had little use for vicariation forgetting highly specific informa- nied the importance of edema, pres- theory, which was also popular at the tion, such as a person’s address or per- sure on the brain, circulatory time. On purely logical grounds, he haps the name of a friend’s wife. It changes, or other dynamic events could not comprehend how brain may also explain why polyglots who that can follow brain lesions and areas could take on new and un- become aphasic typically regain the cause effects at a distance. These fac- usual functions without severely af- use of their long-used native tongues tors, he noted, are important, and fecting their own specialized func- well before they recover newly learned they may add significantly to the tions. He did not dismiss vicariation foreign languages. clinical picture. But they can and outright when trying to account for Monakow contended that dif- must be distinguished from diaschi- recovery long after brain damage. But ferent types of diaschisis could oc- sis, which is neurally mediated and he always made it clear that the wear- cur simultaneously. But because the has specific focal consequences; a ing off of diaschisis is a more reason- varieties may vary in degree, one type point that is sometimes overlooked able and parsimonious explanation could dominate over the others at any in books and articles, especially for recovery than any hypothetical given moment in time.25(pp31-34) where the specific term he coined “morphological reorganization.” has been used generically and inter- SUSCEPTIBILITY changeably with shock effects.31,32 CAUSES AND TYPES TO DIASCHISIS OF DIASCHISIS LOCALIZATION THEORY Because every structure in the brain AND DIASCHISIS Signs of diaschisis, which are most is directly or indirectly connected to obvious with sudden injuries and all other structures, all nervous Monakow was far from convinced strokes, are less noticeable with fast structures can be affected by dias- that brain lesions could serve as a re- growing tumors and are usually ab- chisis and its effects can be distant liable guide for localizing func- sent with slowly growing neo- and widespread. Nevertheless, based tions. In part, this was because he plasms. Recognizing this differ- on what he was observing in the thought the highest functions of the ence, Monakow initially reserved the clinic, Monakow postulated that dif- brain, such as associative learning, term diaschisis for the effects caused ferent parts of the nervous system creativity, and abstract thinking, by lesions of sudden onset. Indeed, might be more or less susceptible to were personal or idiosyncratic. As a his theory was largely based on cases diaschisis. Some brain areas, in fact, result, they may involve a dynamic of trauma, hemorrhage, and other seemed much more sensitive than interplay among different brain parts acute types of brain insult. others. For instance, the motor cor- in different people. Monakow introduced differ- tex seemed more sensitive than the For sensory and motor func- ent terms for different types of di- sensory cortex. And even within the tions, the situation was different. aschisis. For example, diaschisis motor strip, the parts responsible for Monakow believed that after an in- could proceed from the cerebral cor- the fingers and toes were more likely jury of such an intricate mecha- tex to the spinal cord, hence, dias- to be affected by diaschisis than those nism as the mammalian brain, other chisis cerebrospinalis or diaschisis cor- controlling the shoulders or hips.5 structures that are anatomically re- ticospinalis. This is the type of Moreover, and with regard to higher lated to the region destroyed must diaschisis that can affect the spinal cognitive functions, older, more used be affected. Hence, if anything at all cord via the long pyramidal tracts, circuits appeared more resistant to is to be gleaned about localization and it is most likely to be observed diaschisis than newer and less used with the lesion method, it must come in highly evolved organisms whose ones.25(p40),33(p29) from the study of residual symp- cerebral hemispheres dominate over In addition, although Monakow toms after diaschisis and the more lower parts of the brain. Diaschisis hypothesized that the wearing off of general effects of the lesion have dis- could, however, also go in the op- diaschisis is always a passive process, sipated.30(p238) But, he warned, even posite direction, hence diaschisis there may be considerable variability this is dangerous. Since other brain spino-cerebralis, diaschisis bulbo- in the speed with which it dissipates. areas would now be deprived of cerebralis, and the like. InDieLokalisationimGrosshirnundder

(REPRINTED) ARCH NEUROL / VOL 61, FEB 2004 WWW.ARCHNEUROL.COM 286 Downloaded from www.archneurol.com at Princeton University, on October 20, 2011 ©2004 American Medical Association. All rights reserved. Abbau der Funktion durch kortikale in the brain to account for recovery Riese, who had been a close per- Herde, it is maintained that diaschisis of function. And fifth, it did not call sonal friend of Monakow, made the is likely to be most protracted in older for neuronal rewiring or reorganiz- concept of diaschisis a focal point in peopleandofshortestdurationinchil- ing, for which the microscopic evi- his monographs, case studies, and dren.Monakowattributedsuchdiffer- dence at the time was virtually non- theoretical reviews.5,40-43 He repeat- ences largely to the nature of the con- existent. Simply put, the beauty of the edly used it to explain transient apha- nections between the neural units, but Monakow concept of diaschisis was sia after right-hemispheric lesions, henotedthatotherfactorsaffectingthe that it fit well with both the concept functional differences following le- condition of the brain could also affect of a static, hard-wired nervous sys- sions of rapid and slow onset, and a the time needed for recovery: tem and with that of a dynamic or- host of other neurological phenom- gan, the interconnected parts of ena. Riese was particularly instru- The different rate in the regression of di- which share responsibilities and co- mental in disseminating the Mona- aschisis is due to variations in the way in- operate to execute functions. kow theory in both German and dividual neuron groups are linked, and in Nevertheless, the Monakow di- English in the mid-20th century. the type of excitability in different tec- aschisis theory was not quickly em- tonic groups (everything else being equal, the groups that are more frequently used braced by the scientific community. CURRENT STATUS as a unit and are fortified by training will HissuccessorMinkowskicitedseveral recover earlier than others), as well as to factors that did not help, including the What none of the early supporters of variations in the associated disorders of publication of Die Lokalisation im Monakow was able to do was to com- circulation, etc.29(pp31,32) Grosshirn und der Abbau der Funktion bine bedside observations with more durch kortikale Herde on the eve of directmeasuresofbrainactivity.Itwas COMPLICATING THE THEORY World War I; the difficulty of the sub- not until the second half of the 20th ject matter; the multitude of associa- centurythatinvestigatorsdealingwith Hans-Lukas Teuber, MD,34,35 and oth- tions,clauses,insertions,brackets,and clinical patients began to look at con- ers have argued that Monakow might footnotes used by Monakow; and his tralateralcerebralbloodflow(metabo- have taken away from the elegance of inability to communicate in an easily lism) after strokes that left one hemi- his theory when he went on to pos- understandable way. Following a pre- sphere undamaged. One early study tulate that the natural wearing off of sentationbyMonakowinAmsterdam, was conducted by Høedt-Rasmussen diaschisis, which typically subsides in theNetherlands,in1907,forexample, and Skinhøj44 in Denmark. These re- a matter of hours or days, can some- hisDutchcolleagueCornelisWinkler, searchers noted that damage to one times be delayed indefinitely. Mona- MD, wrote a letter to him in which he hemisphere can temporarily depress kow employed the term diaschisis pro- explained that the majority of the at- the metabolism of the other, a finding tractiva for remote diaschisis effects tendeesdid“notquiteunderstand,and consistent with the Monakow diaschi- that do not undergo diminution, pos- neither did I. I was in the more favor- sis corticommisuralis, which has been sibly because of interactive factors (eg, able position as I had spoken with you verified many times.32 vascular problems) that can affect the and Valkenburg several times.”36(p2575) Inaddition,researchersconduct- status of the distant brain area. The ideas of Monakow seemed inglaboratoryanimalstudieswitheven Another postulate that bothered to have had their best reception in his more informative and creative meth- some of his followers was that diaschi- adopted Switzerland, in part because ods have generated increased interest siscansometimesfollowlesionsofslow ofitsisolationduringWorldWarIand in diaschisis as a viable concept. The onset. As noted, strokes, injuries, and theso-calledMonakowschesKra¨nzchen earlycorticalelectrophysiologicalstud- war wounds provided the bulk of the (MonakowCircle),whichevolvedinto ies on cats by Warren Kempinsky45,46 materialheneededfortheformulation the Zurich Society of Neurology and stand out in this regard. ofhistheory,becausetheseacute-onset Psychiatry in 1904. But it was also In the last few decades, a wealth cases tend to show the most dramatic picked up elsewhere. In England, of new studies involving neurotrans- recovery soon after injury. Neverthe- Charles Sherrington, MD,37(p245) wrote mitter assays, metabolic measures, less, Monakow argued that acute on- that diaschisis fit well with his own and pharmacological agents have set of damage is not a prerequisite for conceptionofspinalshock,andHenry been designed to test the theory of the theory and that a “slowly creeping Head,MD,38(p93) usedtheconceptwhen diaschisis.32,47-54 The results of these in diaschisis” could be due to slowly discussingthedynamicsofaphasiaand studies have been mixed, causing de- breaking neuronal connections.25(p35) apraxia. Another prominent writer bates in the literature.55-58 who was drawn to the concept was Today, no one who works with RECEPTION OF THE THEORY Kurt Goldstein, MD,39 the German- clinical patients or brain-damaged born gestalt neuropsychiatrist who laboratory animals doubts that acute The concept of diaschisis proved at- emigrated to America in the 1930s. brain injuries can have secondary ef- tractive for several reasons. First, it The most ardent supporter of the fects. But whether transient, localiz- made intuitive sense. Second, it could ideas of Monakow was, however, an- able deficits are caused specifically by account for some troublesome phe- other German, Walther Riese, MD,18 the disruption of neural connections nomena in a seemingly rational way. who practiced neurology in several and can only passively undergo remis- Third, it was both economical and German cities and in Paris before emi- sion, as specified by Monakow, is an- parsimonious. Fourth, it did not de- grating to Virginia. More than any- other matter. At the heart of the prob- mand the formation of new centers one else in the mid-20th century, lemisthefactthatmanybrainchanges

(REPRINTED) ARCH NEUROL / VOL 61, FEB 2004 WWW.ARCHNEUROL.COM 287 Downloaded from www.archneurol.com at Princeton University, on October 20, 2011 ©2004 American Medical Association. All rights reserved. can overlap in the first few days after NeuroscienceAcrosstheCenturies.London,England: jury in man. In: Outcome of Severe Damage to the Smith-Gordon and Co Ltd; 1989:135-138. Central Nervous System, Amsterdam, the Neth- an injury. They include edema, vas- 10. Koehler PJ. Brown-Se´quard and cerebral local- erlands: Elsevier; 1975:159-186, 476. Ciba Foun- cular changes, intracranial pressure, ization as illustrated by his ideas on aphasia. J Hist dation Symposium Paper. cell death, dispersions of toxic waste Neurosci. 1996;5:26-33. 36. Koehler PJ, Jagella C. The correspondence be- 11. Goltz FL. Der hund ohne grosshirn: siebente ab- tween Winkler and Von Monakow. [in Dutch]. Ned products, neuroglial proliferation, handlung u¨ber die verrichtungen des grosshirns. 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