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Deep Brain Stimulation Programming Principles and
Practice 1st Edition Erwin B. Montgomery Digital Instant
Download
Author(s): Erwin B. Montgomery
ISBN(s): 9780199738526, 0199738521
Edition: 1
File Details: PDF, 6.62 MB
Year: 2010
Language: english
Deep Brain Stimulation Programming
This page intentionally left blank
Deep Brain Stimulation
Programming
Principles and Practice

Erwin B. Montgomery, Jr., MD

Dr. Sigmund Rosen Scholar in Neurology
Professor of Neurology
University of Alabama at Birmingham
Birmingham, Alabama

1
2010
1
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Copyright Ó 2010 by Oxford University Press, Inc.
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Oxford is a registered trademark of Oxford University Press
All rights reserved. No part of this publication may be reproduced,
stored in a retrieval system, or transmitted, in any form or by any means,
electronic, mechanical, photocopying, recording, or otherwise,
without the prior permission of Oxford University Press.
Library of Congress Cataloging-in-Publication Data
Montgomery, Erwin B.
Deep brain stimulation programming : principles and practice / Erwin B.
Montgomery Jr.
p. ; cm.
Includes bibliographical references and index.
ISBN 978-0-19-973852-6 (alk. paper)
1. Brain stimulation. 2. Brain stimulation—Therapeutic use. I. Title.
[DNLM: 1. Deep Brain Stimulation. 2. Brain Diseases—therapy.
3. Neurologic Manifestations. WL 368 M787d 2010]
RC350.B72M66 2010
616.80 4—dc22
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9 8 7 6 5 4 3 2 1
Printed in the United States of America
on acid-free paper
 Disclaimer

The information in this monograph on deep brain stimulation (DBS) is advisory

only and is not meant to direct the specific management of any individual patient.
Physicians and other health care providers must use their own professional judgment
when evaluating this information and must consider the unique circumstances of
each patient when providing therapy. Patients and their caregivers are strongly
advised not to change patient care without approval from the treating physician or
health care professional.
The field of DBS is continually evolving, and physicians and other health
care providers are strongly advised to keep abreast of developments that could
alter the information and advisories contained here. They should review the
appropriate operation and safety manuals from the manufacturers of the
equipment they use. When in doubt, they should consult the manufacturer
directly.
As of this writing, the Food and Drug Administration (FDA) has approved four
DBS systems from a single manufacturer. These systems differ primarily in their
implanted pulse generators (IPGs). These include a single-channel IPG (Soletra;
Medtronic Inc.), a dual-channel IPG (Kinetra; Medtronic, Inc.), a dual-channel
IPG (Activa PC; Medtronic, Inc.), and a dual-channel rechargeable IPG (Activa
RC; Medtronic, Inc.). The latter two devices became available just at this book
was submitted to the publisher and before the author was able to gain extensive
experience with the uses of these devices. Comments regarding these devices were
based on materials made available by the manufacturer. However, the basic
concepts underlying their utilization have not changed from those presented in
this book.
The latter two IPGs incorporate both constant-voltage and constant-current
modes of stimulation, the implications of which are discussed in the monograph.
However, alternative systems are in clinical trials, and others are anticipated. Because
these anticipated systems are not yet FDA approved, the details of their use cannot be
discussed at a therapeutic level. Although the information provided in this mono-
graph will help the physician in deciding which specific DBS systems to use, the
decision in each case must be based on the treatment team’s own assessment of the
relative advantages and disadvantages of each system and the unique circumstance of
the team’s practice and particular patient.
This book should not be construed as an endorsement, either explicitly or
implicitly, of any particular medical device or treatment. Information that may not
conform to FDA guidelines is explicitly noted in the text.
The author was paid a consulting fee by St. Jude Medical Neuromodulation
Division (formally Advanced Neuromodulation Systems, Inc.) to write a white paper
for internal use by the company. The author subsequently expanded the white paper
vi DISCLAIMER

to become this monograph and is solely responsible for its content. The author has
no other conflicts of interest related to the preparation of this monograph.
Erwin B. Montgomery Jr. MD
Dr. Sigmund Rosen Scholar in Neurology
Department of Neurology
University of Alabama at Birmingham
Birmingham, Alabama
To Lyn Turkstra, a true miracle in my life, and to my sons Erwin, Steven, and
Matthew, who have been constant sources of pride and joy.
This page intentionally left blank
 Preface

Deep brain stimulation (DBS) is a remarkable therapy. For many neurological and
psychiatric disorders, DBS is more effective than the best medical therapy. For other
disorders, DBS may be the only therapy (see Commentary 1.1).
It is difficult to convey the impact on the patient, family members, caregivers, and
health care professionals of the nearly miraculous effect of DBS on some patients.
Patients severely disabled for years are suddenly able to function nearly normally.
The only comparable experience might be that which followed the introduction of
levodopa for Parkinson’s disease. But unlike the effects of levodopa, for some
patients, the improvement with DBS is present at the click of a switch. For
neurologists, the nearly immediate improvement of many neurological disorders
provides a gratification not usually afforded in the discipline.
The adoption of DBS by neurologists lags far behind its promise. Several
factors may explain this lag, including vicissitudes in financial reimbursement,
but a potentially critical factor is that DBS appears foreign to many people in the
field. Most health care professionals have never been exposed to the technology
and so do not fully appreciate it. Most medical and professional schools no longer
teach, or at least do not teach to an appropriate degree, the neuro- and
electrophysiological principles that would facilitate the greater appreciation and
acceptance of the technology, particularly in this era of molecular neurobiology.
One purpose of this book is to redress this dearth of understanding of electro-
physiological principles.
The lack of understanding of neuro- and electrophysiological principles makes it
difficult for the physician or health care professional to feel comfortable using DBS.
Often, the lack of familiarity creates the impression that DBS is “magical.” In such
cases, the investment in time, effort, and resources needed to learn DBS program-
ming appears to be too great to justify, particularly when health care professionals are
already overworked. Lack of knowledge and skills often results in programmers
resorting to the “average” stimulation configurations and parameters and rarely
venturing beyond, thereby potentially denying patients the benefit that unusual or
atypical settings might provide. This is an increasing danger because some devices
may offer “cookbook” guides to DBS programming, which potential programmers
may take too literally. The result is that many health care providers are giving up too
early (Moro et al., 2006). Often they resort to a reliance on medications that
previously failed, leading to the DBS surgery in the first place.
Knowing the electrophysiology and the neuroanatomy near the DBS electrodes
would make DBS far less foreign. DBS programming does not need to be magical or
involve blindly trying every one of the thousands of different DBS parameters. The
premise of this book is that treating patients with DBS can be made more efficient
and effective by understanding the principles on which it is based. An understanding
x PREFACE

of the fundamental principles will serve the programmer in good stead regardless of
future technical developments. The knowledge will never become obsolete.
DBS is more than a remarkable therapy. It also provides a unique opportunity to
probe brain function and dysfunction. Already, DBS-related research has made
obsolete several cherished notions of physiology and pathophysiology. Also, the
history of DBS provides remarkable insight into the strengths and weakness of how
we conduct research and deliver clinical care. For example, in response to case reports
of rare conditions responding to DBS, some physicians have called for randomized
controlled clinical trials, but the statistical sample size required would exceed the
number of potential cases in any reasonable time frame. Though not widely appre-
ciated, DBS is a symptomatic therapy, not disease specific. Just as it would be
unreasonable to require separate randomized clinical trials of a pain relief medication
for every conceivable cause of pain, similar judgments should apply to DBS.
In surveying the clinical and scientific response to DBS, one is struck by how DBS
is seen as intruding on more traditional therapies. The risks of DBS are often
exaggerated and this sometimes discourages its use or further research. The excite-
ment regarding DBS pales in comparison to that of stem cell treatment, despite the
failure of fetal cell transplants and the lack of a cogent argument that dopamine
replacement therapy with stem cells will fare any better. Interest in DBS also pales in
comparison with that of gene therapy and despite the fact that the clinical benefits of
DBS exceed those of gene therapy, at least at this early stage. Also, curiously missing
from the discussions of both stem cell and gene therapy is mention of their surgical
risks, which likely equal or exceed those of DBS because the risks are proportional to
the number of times the brain is penetrated.
Assuming this apparent poorer risk-to-benefit ratio of dopamine stem cell and gene
therapy, why then is there greater interest in them? The likely answer is that scientists
and health care professionals are more predisposed to stem cell and gene therapy
because these therapies more closely resemble current concepts of disease pathogenesis
and the mistaken notion that treatment is synonymous with reversal of the pathogen-
esis. What could be more intuitive than the notion of dopamine cell replacement
when Parkinson’s disease is thought to be synonymous with dopamine cell loss? What
could make more sense than converting the excitatory output of subthalamic nucleus
neurons, which in the disease state excite an already overactive globus pallidus internal
segment (GPi), to an inhibitory output to reduce the overactive GPi? The intuitive
appeal notwithstanding, these notions are misleading (see Chapter 12).
Current research suggests that the therapeutic mechanisms of DBS action are not
related to direct effects on dopamine neurotransmission. This clearly implies that
there are nondirect dopaminergic mechanisms and, consequently, other potential
therapeutic targets. It is likely that dopamine depletion sets up a cascade of effects
throughout the basal ganglia–thalamic–cortical system, and these effects could be
potential therapeutic targets. However, the lesson is clear. Pathogenesis of the disease
is not synonymous with the pathophysiology, and it is the pathophysiology that leads
to the disabilities associated with the disease. Failure to recognize that pathogenesis is
not the same as pathophysiology likely will lead to failure to develop alternative and
potentially better treatments. One could argue that the success of DBS is a case
against the claims made previously. That would be the case if the development of
DBS were the result of deliberate application of reason and science. The truth of
 PREFACE xi

the matter is that the origins of DBS were serendipitous. DBS followed from
the demonstration of therapeutic electrical stimulation effects only as a test of
location preceding surgical ablation (Cooper et al., 1980).
Unfortunately, the mechanisms of action of DBS are largely unknown.
However, this knowledge is increasing (Montgomery and Gale, 2008). For
example, DBS at any frequency excites various neuronal elements, such as axons
and presynaptic terminals in the vicinity of the DBS electrode including those that
project to and from neurons in the stimulated target. In addition to generating
action potentials that run down the axon to presynaptic terminals in the usually
(orthodromic) direction, these action potentials travel upwards to the cell body in
reverse (antidromic) direction from the usual. DBS activates axons near the
stimulated target, and activation of these axons may have more to do with the
therapeutic benefit of DBS than stimulation of neurons within the stimulated
target. Unfortunately, none of these neuronal responses map conveniently onto
preconceived notions of pathophysiology and, consequently, seem to be given
little credence. It is human nature to discount observations that are counter to
current theories (Johnson-Laird, 2006), but these new observations are the source
of new and better theories. DBS-related research could revolutionize theories of
brain function if given a chance. So far, the chances do not look good, but like
Pascal’s Wager, one tries to be optimistic.
The use of DBS also challenges how new therapies are justified and approved. As is
the case with other complex, expensive, and less commonly used technologies, DBS
has not fared well under the current preoccupation with evidence-based medicine,
where randomized, placebo and blinded trials are the preferred and often the
exclusive form of evidence (Montgomery and Turkstra, 2003). Case reports of
DBS for rare disorders have been greeted by demands for randomized clinical trials
requiring sample sizes that may exceed the numbers of candidate patients. Whereas
in the past, these patients might still benefit by the “off-label” use of Food and Drug
Administration (FDA)-approved devices, such off-label use is under increasing
attack. Compounding the problem, the costs of such studies and the low likelihood
of finding financial sponsors mean that off-label uses are not likely to become
“on-label” uses and patients with off-label disorders clearly responding to DBS will
not treated. The increasing FDA censorship of physicians who speak of their own
judgment in recommending the long-respected off-label use of FDA-approved
therapies increasingly may endanger these patients.
The importance of DBS for understanding brain function cannot be overstated.
In this era of remarkable advances in molecular neurobiology, we forget that the
brain is essentially an electrical device. Although the prevailing view is that neurolo-
gical disease is caused by a deficiency or surplus of neurotransmitters, DBS reminds
us that the brain processes information electrically. Thus, neurological and psychia-
tric disorders can be seen as “misinformation” related to the patterns of electrical
activities in and among neurons. The old saws of clinical neurology that there are
“positive” symptoms, such as abnormal gain of function, “negative” symptoms, such
as loss of function, and “disconnection” symptoms need to be updated based on
symptoms related to misinformation. The information and misinformation in the
brain most likely is primary and proximately represented in the electrical activities of
neural systems. Neurotransmitters are the messangers not the message and it is the
xii PREFACE

message that is of paramount importance.The brain has more in common with a

computer circuit board than with a stew of chemicals.
The history of DBS also reflects much about the good and bad of research and
clinical care. Personal accounts related to DBS have been both inspiring and disheart-
ening. They include accounts of scientist–physicians who have displayed great
perseverance and courage, such as Dr. Nicholas Schiff and his colleagues in New
York in their work with DBS and minimally conscious patients, as well as physicians
who have shamelessly exploited DBS for personal gain and compromised the
scientific and clinical contributions that could have been made. But these accounts
are for another time and place.
The primary goal of this book is to provide an aid to the many health care
professionals who have volunteered to care for patients receiving DBS therapies but
at the same time to enlarge the scope of the discussion as befits a truly revolutionary
approach to the understanding and treatment of neurological disorders. Some will
disagree with the approaches and recommendations made here. That is fine; we learn
more when we disagree. However, it is important to recognize what is the basis of
disagreement and the problem is that many times it appears to be based on habits and
uncritical imitations of others. These do not represent knowledge. Even that is
important to recognize and discuss. We should not be shy or coy about it.
Writing this book made clear the recognition of how lucky I have been. My
experiences range from the outpatient clinic to the operating room, the human and
nonhuman primate laboratory, and computational modeling and simulations. This
led me to value the unique opportunities for cross-fertilization of ideas, particularly
through interactions with colleagues representing these different areas. There is no
question that insight gained in the clinic and operating room greatly facilitated work
in the human, nonhuman primate, and computer laboratories. Similarly, the insights
gained in the labs enhanced my abilities as a physician. This experience reinforced my
belief in the unique and valued position of an academic neurologist/scientist fully
immersed in the ethos of a true university. Unfortunately, such neurologists/
scientists are increasingly an endangered species. The habitat for neurologists/
scientists is shrinking, and it is a pity that some universities do not recognize or
cynically deny the potential for the unique contributions possible by academic
neurologists/scientists, perhaps as an excuse for their failure to support neurologists/
scientists.
It is not possible here to recognize the many scientists whose work has greatly
influenced DBS. Most of the citations in this book are to reviews or perspective
papers, and I hope that interested readers will refer to those papers for citations of
much of the original work.
The writing of this book was greatly aided by numerous discussions with
esteemed colleagues and friends. I acknowledge discussions with John Gale,
PhD, who started as an employee, became a student, then a colleague, and was
always a friend. I also acknowledge a great debt to Cameron McIntyre, PhD;
Jerrold Vitek, MD, PhD; He Huang, MS; Frank Moss, PhD; and the National
Primate Research Center of the University of Madison–Wisconsin, directed by
Joseph Kemnitz, PhD.
The science reported here, and that not reported but that nevertheless was a basis
for much of the work, was made possible by grants from the University of
 PREFACE xiii

Wisconsin–Madison; ST/Dystonia, Inc.; Medtronic, Inc.; and the American

Parkinson Disease Association.
In the interest of full disclosure of potential conflicts of interest, the project
of writing this book followed the commissioning of an internal advisory report
(a “white paper”) for St. Jude Medical Neuromodulation Division. The information
and content of the book is the sole responsibility of the author and no other entity
was involved in the preparation or editing of the materials contained in this book.
Some of the research described in this publication was made possible in part by
grant number P51 RR000167 from the National Center for Research Resources
(NCRR), a component of the National Institutes of Health (NIH), to the
Wisconsin National Primate Research Center, University of Wisconsin–Madison.
This research was conducted in part at a facility constructed with support from
Research Facilities Improvement Program grant numbers RR15459-01 and
RR020141-01. This publication’s content is solely the responsibility of the author
and does not necessarily represent the official views of NCRR or NIH.
Erwin B. Montgomery Jr. MD
Dr. Sigmund Rosen Scholar in Neurology
Department of Neurology
University of Alabama at Birmingham
Birmingham, Alabama
This page intentionally left blank
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A PROSPECT
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the other side?"
"It is called Mynydd Mawr, or the Great Mountain. Yonder rock,
which bulks out from it, down the lake yonder, and which you
passed as you came along, is called Castell Cidwm, which means
Wolf s rock or castle."
"Did a wolf ever live there?" I demanded.
"Perhaps so," said the man, "for I have heard say that there were
wolves of old in Wales."
"And what is the name of the beautiful hill yonder, before us
across the water?"
 "That, sir, is called Cairn Drws y Coed," said the man.
"The stone heap of the gate of the wood," said I.
"Are you Welsh, sir?" said the man.
"No," said I, "but I know something of the language of Wales. I
suppose you live in that house?"
"Not exactly, sir; my father-in-law here lives in that house, and my
wife with him. I am a miner, and spend six days in the week at my
mine, but every Sunday I come here, and pass the day with my wife
and him."
"And what profession does he follow?" said I; "is he a fisherman?"
"Fisherman!" said the elderly man contemptuously, "not I. I am
the Snowdon Ranger."
"And what is that?" said I.
The elderly man tossed his head proudly, and made no reply.
"A ranger means a guide, sir," said the younger man—"my father-
in-law is generally termed the Snowdon Ranger because he is a tip-
top guide, and he has named the house after him the Snowdon
Ranger. He entertains gentlemen in it who put themselves under his
guidance in order to ascend Snowdon and to see the country."
"There is some difference in your professions," said I; "he deals in
heights, you in depths; both, however, are break-necky trades."
"I run more risk from gunpowder than anything else," said the
younger man. "I am a slate-miner, and am continually blasting. I
have, however, had my falls. Are you going far to-night, sir?"
"I am going to Bethgelert," said I.
"A good six miles, sir, from here. Do you come from Caernarvon?"
"Farther than that," said I. "I come from Bangor."
"To-day, sir, and walking?"
"To-day, and walking."
"You must be rather tired, sir; you came along the valley very
slowly."
 "I am not in the slightest degree tired," said I; "when I start from
here, I shall put on my best pace, and soon get to Bethgelert."
"Anybody can get along over level ground," said the old man,
laconically.
"Not with equal swiftness," said I. "I do assure you, friend, to be
able to move at a good swinging pace over level ground is
something not to be sneezed at. Not," said I, lifting up my voice,
"that I would for a moment compare walking on the level ground to
mountain ranging, pacing along the road to springing up crags like a
mountain goat, or assert that even Powell himself, the first of all
road walkers, was entitled to so bright a wreath of fame as the
Snowdon Ranger."
"Won't you walk in, sir?" said the elderly man.
"No, I thank you," said I; "I prefer sitting out here, gazing on the
lake and the noble mountains."
"I wish you would, sir," said the elderly man, "and take a glass of
something; I will charge you nothing."
"Thank you," said I—"I am in want of nothing, and shall presently
start. Do many people ascend Snowdon from your house?"
"Not so many as I could wish," said the ranger; "people in general
prefer ascending Snowdon from that trumpery place Bethgelert; but
those who do are fools—begging your honour's pardon. The place to
ascend Snowdon from is my house. The way from my house up
Snowdon is wonderful for the romantic scenery which it affords; that
from Bethgelert can't be named in the same day with it for scenery;
moreover, from my house you may have the best guide in Wales;
whereas the guides of Bethgelert—but I say nothing. If your honour
is bound for the Wyddfa, as I suppose you are, you had better start
from my house to-morrow under my guidance."
"I have already been up the Wyddfa from Llanberis," said I, "and
am now going through Bethgelert to Llangollen, where my family
are; were I going up Snowdon again, I should most certainly start
from your house under your guidance, and were I not in a hurry at
present, I would certainly take up my quarters here for a week, and
every day make excursions with you into the recesses of Eryri. I
suppose you are acquainted with all the secrets of the hills?"
"Trust the old ranger for that, your honour. I would show your
honour the black lake in the frightful hollow, in which the fishes have
monstrous heads and little bodies, the lake on which neither swan,
duck nor any kind of wildfowl was ever seen to light. Then I would
show your honour the fountain of the hopping creatures, where,
where——"
"Were you ever at that Wolf's crag, that Castell y Cidwm?" said I.
"Can't say I ever was, your honour. You see it lies so close by, just
across that lake, that——"
"You thought you could see it any day, and so never went," said I.
"Can't you tell me whether there are any ruins upon it?"
"I can't, your honour."
"I shouldn't wonder," said I, "if in old times it was the stronghold
of some robber-chieftain; cidwm in the old Welsh is frequently
applied to a ferocious man. Castell Cidwm, I should think, rather
ought to be translated the robber's castle, than the wolf's rock. If I
ever come into these parts again, you and I will visit it together, and
see what kind of a place it is. Now farewell! It is getting late." I then
departed.
"What a nice gentleman!" said the younger man, when I was a
few yards distant.
"I never saw a nicer gentleman," said the old ranger.
I sped along, Snowdon on my left, the lake on my right, and the
tip of a mountain peak right before me in the east. After a little time
I looked back; what a scene! The silver lake and the shadowy
mountain over its southern side looking now, methought, very much
like Gibraltar. I lingered and lingered, gazing and gazing, and at last
only by an effort tore myself away. The evening had now become
delightfully cool in this land of wonders. On I sped, passing by two
noisy brooks coming from Snowdon to pay tribute to the lake. And
now I had left the lake and the valley behind, and was ascending a
hill. As I gained its summit, up rose the moon to cheer my way. In a
little time, a wild stony gorge confronted me, a stream ran down the
gorge with hollow roar, a bridge lay across it. I asked a figure whom
I saw standing by the bridge the place's name. "Rhyd du"—the black
ford—I crossed the bridge. The voice of the Methodist was yelling
from a little chapel on my left. I went to the door and listened:
"When the sinner takes hold of God, God takes hold of the sinner."
The voice was frightfully hoarse. I passed on; night fell fast around
me, and the mountain to the south-east, towards which I was
tending, looked blackly grand. And now I came to a milestone, on
which I read with difficulty: "Three miles to Bethgelert." The way for
some time had been upward, but now it was downward. I reached a
torrent, which, coming from the north-west, rushed under a bridge,
over which I passed. The torrent attended me on my right hand the
whole way to Bethgelert. The descent now became very rapid. I
passed a pine wood on my left, and proceeded for more than two
miles at a tremendous rate. I then came to a wood—this wood was
just above Bethgelert—proceeding in the direction of a black
mountain, I found myself amongst houses, at the bottom of a valley.
I passed over a bridge, and inquiring of some people, whom I met,
the way to the inn, was shown an edifice brilliantly lighted up, which
I entered.

OF UMBRELLAS
Wending my course to the north, I came to the white bare spot
which I had seen from the moor, and which was in fact the top of a
considerable elevation over which the road passed. Here I turned
and looked at the hills I had come across. There they stood, darkly
blue, a rain cloud, like ink, hanging over their summits. O, the wild
hills of Wales, the land of old renown and of wonder, the land of
Arthur and Merlin.
The road now lay nearly due west. Rain came on, but it was at my
back, so I expanded my umbrella, flung it over my shoulder and
laughed. O, how a man laughs who has a good umbrella when he
has the rain at his back, aye and over his head too, and at all times
when it rains except when the rain is in his face, when the umbrella
is not of much service. O, what a good friend to a man is an
umbrella in rain time, and likewise at many other times. What need
he fear if a wild bull or a ferocious dog attacks him, provided he has
a good umbrella? he unfurls the umbrella in the face of the bull or
dog, and the brute turns round quite scared, and runs away. Or if a
footpad asks him for his money, what need he care provided he has
an umbrella? he threatens to dodge the ferrule into the ruffian's eye,
and the fellow starts back and says, "Lord, sir! I meant no harm. I
never saw you before in all my life. I merely meant a little fun."
Moreover, who doubts that you are a respectable character provided
you have an umbrella? you go into a public-house and call for a pot
of beer, and the publican puts it down before you with one hand
without holding out the other for the money, for he sees that you
have an umbrella and consequently property. And what respectable
man, when you overtake him on the way and speak to him, will
refuse to hold conversation with you, provided you have an
umbrella? No one. The respectable man sees you have an umbrella
and concludes that you do not intend to rob him, and with justice,
for robbers never carry umbrellas. O, a tent, a shield, a lance and a
voucher for character is an umbrella. Amongst the very best friends
of man must be reckoned an umbrella.[2]
[2] As the umbrella is rather a hackneyed subject two or three
things will of course be found in the above eulogium on an
umbrella which have been said by other folks on that subject; the
writer, however, flatters himself that in his eulogium on an
umbrella two or three things will also be found which have never
been said by any one else about an umbrella.

The way lay over dreary, moory hills: at last it began to descend
and I saw a valley below me with a narrow river running through it
to which wooded hills sloped down; far to the west were blue
mountains. The scene was beautiful but melancholy; the rain had
passed away, but a gloomy almost November sky was above, and
the mists of night were coming down apace.
 I crossed a bridge at the bottom of the valley and presently saw a
road branching to the right. I paused, but after a little time went
straight forward. Gloomy woods were on each side of me and night
had come down. Fear came upon me that I was not in the right
road, but I saw no house at which I could inquire, nor did I see a
single individual for miles of whom I could ask. At last I heard the
sound of hatchets in a dingle on my right, and catching a glimpse of
a gate at the head of a path, which led down into it, I got over it.
After descending some time I hallooed. The noise of the hatchets
ceased. I hallooed again, and a voice cried in Welsh, "What do you
want?" "To know the way to Bala," I replied. There was no answer,
but presently I heard steps, and the figure of a man drew nigh half
undistinguishable in the darkness and saluted me. I returned his
salutation, and told him I wanted to know the way to Bala. He told
me, and I found I had been going right. I thanked him and regained
the road. I sped onward and in about half an hour saw some
houses, then a bridge, then a lake on my left, which I recognised as
the lake of Bala. I skirted the end of it, and came to a street
cheerfully lighted up, and in a minute more was in the White Lion
Inn.
SUPPER—AND A MORNING VIEW
The sun was going down as I left the inn. I recrossed the
streamlet by means of the pole and rail. The water was running with
much less violence than in the morning, and was considerably lower.
The evening was calm and beautifully cool, with a slight tendency to
frost. I walked along with a bounding and elastic step, and never
remember to have felt more happy and cheerful.
I reached the hospice at about six o'clock, a bright moon shining
upon me, and found a capital supper awaiting me, which I enjoyed
exceedingly.
How one enjoys one's supper at one's inn, after a good day's
walk, provided one has the proud and glorious consciousness of
being able to pay one's reckoning on the morrow!
 The morning of the sixth was bright and glorious. As I looked from
the window of the upper sitting-room of the hospice the scene which
presented itself was wild and beautiful to a degree. The oak-covered
tops of the volcanic crater were gilded with the brightest sunshine,
whilst the eastern side remained in dark shade and the gap or
narrow entrance to the north in shadow yet darker, in the midst of
which shone the silver of the Rheidol cataract. Should I live a
hundred years I shall never forget the wild fantastic beauty of that
morning scene.
George Borrow,—"Wild Wales."
Song of the Open Road
Afoot and light-hearted I take to the open road!
Healthy, free, the world before me,
The long brown path before me, leading where-ever I choose!

Henceforth I ask not good-fortune, I myself am good-fortune,

Henceforth I whimper no more, postpone no more, need
nothing,
Done with indoor complaints, libraries, querulous criticisms,
Strong and content I travel the open road.

The earth—that is sufficient,

I do not want the constellations any nearer,
I know they are very well where they are,
I know they suffice for those who belong to them.

Still here I carry my old delicious burdens,

I carry them, men and women—I carry them with me
wherever I go,
I swear it is impossible for me to get rid of them,
I am fill'd with them, and I will fill them in return.

You road I travel and look around! I believe you are not all
that is here!
I believe that something unseen is also here.

Here is the profound lesson of reception, neither preference

or denial;
The black with his woolly head, the felon, the diseased, the
illiterate person, are not denied,
The birth, the hasting after the physician, the beggar's tramp,
the drunkard's stagger, the laughing party of
mechanics,
The escaped youth, the rich person's carriage, the fop, the
eloping couple,

The early market-man, the hearse, the moving of furniture

 into the town, the return back from the town,
They pass, I also pass, any thing passes, none can be
interdicted,
None but are accepted, none but are dear to me.

You air that serves me with breath to speak!

You objects that call from diffusion my meanings and give
them shape!
You light that wraps me and all things in delicate equable
showers!
You paths worn in the irregular hollows by the road-sides!
I think you are latent with curious existences—you are so
dear to me.

You flagg'd walks of the cities! you strong curbs at the edges!
You ferries! you planks and posts of wharves! you timber-
lined sides! you distant ships!

You rows of houses! you window-pierced façades! you roofs!

You porches and entrances! you copings and iron guards!
You windows whose transparent shells might expose so
much!
You doors and ascending steps! you arches!
You grey stones of interminable pavements! you trodden
crossings!
From all that has been near you I believe you have imparted
to yourselves, and now would impart the same secretly
to me,
From the living and the dead I think you have peopled your
impassive surfaces, and the spirits thereof would be
evident and amicable with me.

The earth expanding right hand and left hand,

The picture alive, every part in its best light,
The music falling in where it is wanted, and stopping where it
is not wanted,
The cheerful voice of the public road—the gay fresh
 e c ee u o ce o t e pub c oad t e gay es
sentiment of the road.

O highway I travel! O public road! Do you say to me, Do not

leave me?
Do you say, Venture not?—If you leave me you are lost?
Do you say, I am already prepared—I am well beaten and
undenied—adhere to me?

O public road! I say back I am not afraid to leave you—yet I

love you,
You express me better than I can express myself,
You shall be more to me than my poem.

I think heroic deeds were all conceived in the open air,

I think I could stop here myself and do miracles,
I think whatever I meet on the road I shall like, and whoever
beholds me shall like me,
I think whoever I see must be happy.

From this hour, freedom!

From this hour I ordain myself loosed of limits and imaginary
lines!
Going where I list—my own master, total and absolute,
Listening to others, considering well what they say,
Pausing, searching, receiving, contemplating.
Gently but with undeniable will divesting myself of the holds
that would hold me.
I inhale great draughts of air,
The east and the west are mine, and the north and the south
are mine.

I am larger than I thought!

I did not know I held so much goodness!

All seems beautiful to me,

I can repeat over to men and women, You have done such
good to me, I would do the same to you,
 good to e, ou d do t e sa e to you,
I will recruit for myself and you as I go,
I will scatter myself among men and women as I go,
I will toss a new gladness and roughness among them,
Whoever denies me it shall not trouble me,
Whoever accepts me he or she shall be blessed and shall
bless me.

Now if a thousand perfect men were to appear, it would not

amaze me,
Now if a thousand beautiful forms of women appear'd, it
would not astonish me.

Now I see the secret of the making of the best persons,

It is to grow in the open air, and eat and sleep with the earth.

Here a great personal deed has room,

(Such a deed seizes upon the hearts of the whole race of
men,
Its effusion of strength and will overwhelms laws and mocks
all authority and all argument against it.)

Here is the test of wisdom,

Wisdom is not finally tested in schools,
Wisdom cannot be pass'd from one having it to another not
having it,
Wisdom is of the soul, is not susceptible of proof, is its own
proof,
Applies to all stages and objects and qualities and is content,
Is the certainty of the reality and immortality of things, and
the excellence of things;
Something there is in the float of the sight of things that
provokes it out of the soul.

Now I re-examine philosophies and religions,

They may prove well in lecture-rooms, yet not prove at all
under the spacious clouds and along the landscape and
flowing currents
 flowing currents.

Here is realization,
Here is a man tallied—he realizes here what he has in him,
The past, the future, majesty, love—if they are vacant of you,
you are vacant of them.

Only the kernel of every object nourishes;

Where is he who tears off the husks for you and me?
Where is he that undoes stratagems and envelopes for you
and me?

Here is adhesiveness, it is not previously fashion'd, it is

apropos;
Do you know what it is as you pass to be loved by strangers?
Do you know the talk of those turning eyeballs?

Here is the efflux of the soul,

The efflux of the soul comes from within through embower'd
gates, ever provoking questions.
These yearnings why are they? these thoughts in the
darkness why are they?
Why are there men and women that while they are nigh me
the sunlight expands my blood?
Why when they leave me do my pennants of joy sink flat and
lank?
Why are there trees I never walk under but large and
melodious thoughts descend upon me?
(I think they hang there winter and summer on those trees
and almost drop fruit as I pass;)
What is it I interchange so suddenly with strangers?
What with some driver as I ride on the seat by his side?
What with some fisherman drawing his seine by the shore as
I walk by and pause?
What gives me to be free to a woman's and man's good-will?
what gives them to be free to mine?

The efflux of the soul is happiness here is happiness

The efflux of the soul is happiness, here is happiness.
I think it pervades the open air, waiting at all times,
Now it flows unto us, we are rightly charged.

Here rises the fluid and attaching character,

The fluid and attaching character is the freshness and
sweetness of man and woman,
(The herbs of the morning sprout no fresher and sweeter
every day out of the roots of themselves, than it
sprouts fresh and sweet continually out of itself.)

Toward the fluid and attaching character exudes the sweat of

the love of young and old,
From it falls distill'd the charm that mocks beauty and
attainments,
Toward it heaves the shuddering longing ache of contact.

Allons! whoever you are come travel with me.

Travelling with me you find what never tires.

The earth never tires,

The earth is rude, silent, incomprehensible at first, Nature is
rude and incomprehensible at first,
Be not discouraged, keep on, there are divine things well
envelop'd,
I swear to you there are divine things more beautiful than
words can tell.

Allons! we must not stop here,

However sweet these laid-up stores, however convenient this
dwelling we cannot remain here,
However shelter'd this port and however calm these waters
we must not anchor here,
However welcome the hospitality that surrounds us we are
permitted to receive it but a little while.

Allons! the inducements shall be greater,

We will sail pathless and wild seas
We will sail pathless and wild seas,
We will go where winds blow, waves dash, and the Yankee
clipper speeds by under full sail.

Allons! with power, liberty, the earth, the elements,

Health, defiance, gaiety, self-esteem, curiosity;
Allons! from all formulas!
From your formulas, O bat-eyed and materialistic priests.

The stale cadaver blocks up the passage—the burial waits no

longer.

Allons! yet take warning!

He travelling with me needs the best blood, thews,
endurance,
None may come to the trial till he or she bring courage and
health,
Come not here if you have already spent the best of yourself,
Only those may come who come in sweet and determined
bodies,
No diseas'd person, no rum drinker or venereal taint is
permitted here.

(I and mine do not convince by arguments, similes, rhymes,

We convince by our presence.)

Listen! I will be honest with you,

I do not offer the old smooth prizes, but offer rough new
prizes,
These are the days that must happen to you:
You shall not heap up what is call'd riches:
You shall scatter with lavish hand all that you earn or achieve,
You but arrive at the city to which you were destin'd, you
hardly settle yourself to satisfaction before you are
call'd by an irresistible call to depart,
You shall be treated to the ironical smiles and mockings of
those who remain behind you,
Wh t b k i fl i h ll l
What beckonings of love you receive you shall only answer
with passionate kisses of parting,
You shall not allow the hold of those who spread their reach'd
hands toward you.

Allons! after the great Companions, and to belong to them!

They too are on the road—they are the swift and majestic
men—they are the greatest women,
Enjoyers of calms of seas and storms of seas,
Sailors of many a ship, walkers of many a mile of land,
Habitués of many distant countries, habitués of far distant
dwellings,
Trusters of men and women, observers of cities, solitary
toilers,
Pausers and contemplators of tufts, blossoms, shells of the
shore,
Dancers at wedding-dances, kissers of brides, tender helpers
of children, bearers of children,
Soldiers of revolts, standers by gaping graves, lowerers-down
of coffins,
Journeyers over consecutive seasons, over the years, the
curious years each emerging from that which preceded
it,
Journeyers as with companions, namely their own diverse
phases,
Forth-steppers from the latent unrealized baby-days,
Journeyers gaily with their own youth, journeyers with their
bearded and well-grain'd manhood,
Journeyers with their womanhood, ample, unsurpass'd,
content,
Journeyers with their own sublime old age, of manhood or
womanhood,
Old age, calm, expanded, broad with the haughty breadth of
the universe,
Old age, flowing free with the delicious near-by freedom of
death.
Allons! to that which is endless as it was beginningless,
To undergo much, tramps of days, rests of nights,
To merge all in the travel they tend to, and the days and
nights they tend to,
Again to merge them in the start of superior journeys,
To see nothing anywhere but what you may reach it and pass
it,
To conceive no time, however distant, but what you may
reach it and pass it,
To look up or down the road but it stretches and waits for
you, however long but it stretches and waits for you,
To see no being, not God's or any, but you also go thither,
To see no possession but may possess it, enjoying all without
labour or purchase, abstracting the feast yet not
abstracting one particle of it,
To take the best of the farmer's farm and the rich man's
elegant villa, and the chaste blessings of the well-
married couple, and the fruits of orchards and flowers
of gardens,
To take to your use out of the compact cities as you pass
through,
To carry buildings and streets with you afterward where-ever
you go,
To gather the minds of men out of their brains as you
encounter them, to gather the love out of their hearts.
To take your lovers on the road with you, for all that you
leave them behind you,
To know the universe itself as a road, as many roads, as
roads for travelling souls.

All parts away for the progress of souls,

All religion, all solid things, arts, governments—all that was or
is apparent upon this globe or any globe, falls into
niches and corners before the procession of souls
along the grand roads of the universe.
Of the progress of the souls of men and women along the
grand roads of the universe, all other progress is the
needed emblem and sustenance.

Forever alive, forever forward,

Stately, solemn, sad, withdrawn, baffled, mad, turbulent,
feeble, dissatisfied,
Desperate, proud, fond, sick, accepted by men, rejected by
men,
They go! they go! I know that they go, but I know not where
they go,
But I know that they go toward the best—toward something
great.

Whoever you are, come forth! or man or woman come forth!

You must not stay sleeping and dallying there in the house,
though you built it, or though it has been built for you.

Out of the dark confinement! out from behind the screen!

It is useless to protest, I know all and expose it.

Behold through you as bad as the rest,

Through the laughter, dancing, dining, supping of people,
Inside of dresses and ornaments, inside of those wash'd and
trimm'd faces,
Behold a secret silent loathing and despair.

No husband, no wife, no friend, trusted to hear the

confession,
Another self, a duplicate of every one, skulking and hiding it
goes,
Formless and wordless through the streets of the cities, polite
and bland in the parlours,
In the cars of railroads, in steamboats, in the public assembly,
Home to the houses of men and women, at the table, in the
bed-room, everywhere,
Smartly attired, countenance smiling, form upright, death
S a t y att ed, cou te a ce s g, o up g t, deat
under the breast-bones, hell under the skull-bones,
Under the broadcloth and gloves, under the ribbons and
artificial flowers,
Keeping fair with the customs, speaking not a syllable of itself.
Speaking of anything else, but never of itself.

Allons! through struggles and wars!

The goal that was named cannot be countermanded.

Have the past struggles succeeded?

What has succeeded? yourself? your nation? Nature?
Now understand me well—it is provided in the essence of
things that from any fruition of success, no matter
what, shall come forth something to make a greater
struggle necessary.

My call is the call of the battle, I nourish active rebellion,

He going with me must go well arm'd,
He going with me goes often with spare diet, poverty, angry
enemies, desertions.

Allons! the road is before us!

It is safe—I have tried it—my own feet have tried it well—be
not detain'd!

Let the paper remain on the desk unwritten, and the book on
the shelf unopen'd!
Let the tools remain in the workshop! let the money remain
unearn'd!
Let the school stand! mind not the cry of the teacher!
Let the preacher preach in his pulpit! let the lawyer plead in
the court, and the judge expound the law.

Camerado, I will give you my hand!

I give you my love more precious than money,
I give you myself before preaching or law;
Will you give me yourself? will you come travel with me?
 you g e e you se you co e t a e t e
Shall we stick by each other as long as we live?

Walt Whitman.
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