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vertebralis. The anterior part of the spinal cord at this part was "pressed on by the body of the seventh cervical vertebra, and was slightly softened," but there was no laceration of, or extravasation of blood into, its substance, nor was the cord more than usually vascular or otherwise affected. The lungs were congested, and the bronchial tubes filled with frothy serous fluid. The kidneys were also cysted and otherwise diseased, and the lining of their pelves, as well as that of the bladder, was highly inflamed and covered with soft fibrin, Abscess also of the prostate gland existed.
Remarks.-The most noteworthy point in this case is the fact that, along with loss of motility in the limbs, owing no doubt to injury of the anterior columns, there was loss of certain forms of sensibility of the skin, whilst the posterior columns of the spinal cord were uninjured. From the nature of the accident-viz., the projection of the seventh cervical vertebra to the distance of half an inch into the spinal canal, &c.—the anterior columns, and very possibly the middle grey matter also, must have been greatly injured. This would account of
course for the loss of motility, and also, according to Brown-Séquard's views respecting the functions and uses of the central grey matter, for the loss of sensibility as to certain tactile impressions of the surface of the body. This latter symptom of anesthesia, it will be remembered, came on at a later period than the affection of the voluntary motor power, and no doubt the grey centre of the cord, being at the onset less affected by the direct injury than the anterior columns which were more exposed to the influence of the accident, became secondarily involved in such softening as one might expect, and as was found to have occurred in the immediate vicinity of the directly injured part of the cord.
One or two points there are in the above case apart from the object of this paper, which, in connexion with the injury of the spinal cord, are deserving of a passing notice, such as the persistent flexing of the muscles of the arms. The congestion of the lungs found after death might well be considered to correspond with the loss of action of the chest-moving muscles (for the respiration was mainly effected by the diaphragm); but the question may plausibly be entertained, to what extent the accumulation of the fluid in the pericardium was fairly attributable to any paralysis of vasculo-motor influence, as respects the nerves accredited to that covering, owing to injury of the cervical part of the spinal cord.
CASE II.-Carcinomatous disease of the dura-mater at the edge of the foramen magnum, encroaching greatly on the outer or white parts of the spinal cord: absence of any anesthesia of the skin as to tactile impressions.
A woman, aged forty-nine, when brought into St. George's Hospital, could neither walk, stand, nor feed herself without assistance. She could, however, move both of her legs when in bed, although slowly; and the left arm and leg could be much more easily moved than those on the right side. She was frequently subject to sensations of numbness over the entire body, but she never experienced actual pain or had any convulsive attacks; and there was complete absence of anesthesia as regards pinching or pricking of any part of the integument, as was particularly noticed only six or seven days before death. It was stated that the patient originally had a "fit" of some kind or other, and
that she had been for some time in a state of unconsciousness, and subsequently that she was found to have quite lost the power of movement on the left side of the body. Of this want of power she had partially recovered, but latterly the right side of the body had fallen into a state similar to that of the left. Whilst under observation within the hospital, she was unable, on trying to draw up the legs in bed, to pull them up simultaneously, but first one and then the other slowly yielded to her efforts. As before said, there was no anesthesia as regards pinching of the skin, and this was the case to the last; but strange sensations of
numbness were complained of. Her power over the muscles became yet weaker, and the patient gradually sank and died, considerable dyspnea and cough, with abundant secretion of mucus into the bronchial tubes, having occurred.
Post-mortem examination. -A vascular but very firm encephaloid tumour, of the size of a small walnut, was found attached to the dura-mater, connected with the right and anterior border of the foramen magnum. This tumour (see fig. 1) indented the cerebellum and encroached greatly on the foramen magnum and the parts which passed through; having, moreover, hooked around it the seventh and eighth pair of cranial nerves. A small mass of a similar character was also found attached to the dura-mater at the opposite (the anterior) border of the foramen magnum, and these two encephaloïd growths interfered to such a degree with the aperture for the passage of the spinal cord, as to reduce it to a triangularly-shaped space, so small as barely to allow the tip of the little finger to enter. Two other and like growths were found to be connected with the falx cerebri and dura-mater near the optic commissure. Some softening also there was of the dorsal region of the spinal cord, and considerable evidence of congestion of the lungs existed.
Fig. 1. This illustration exhibits a large rounded mass of carcinomatous material (of which a section has been made), in connexion with the dura mater at the right
and anterior part of the edge of the foramen magnum (seen from above), encroaching considerably upon the nervous substance passing through that opening. A similar but much smaller mass is seen to the left of the larger one.
Remarks. In this case the chief point of interest is found in the fact that sensibility to pinching and pricking of all portions of the skin's surface remained undiminished, and this certainly to within a few days of death, whilst at the same time there existed so considerable an encroachment upon the external or superficial portions (the anterior and posterior parts, &c.) of the spinal cord as it passed through the aperture, that this organ did not exceed the tip of the little finger in magnitude at this spot. In such a case it could not be otherwise than that those columns, generally hitherto supposed to be the medium for the conveyance of sensibility, were very considerably pressed upon. This specimen is now in the St. George's Hospital Pathological Museum, as Preparation No. 1 b, Sub-series vii., Series xxi.
These external parts of the cord receiving directly and immediately the pressure (in this instance slowly exercised), would to a considerable degree, as it were, shield the enclosed or grey central portions, which consequently would be less injured. Hence it came to pass, as we may from Brown-Séquard's theory conjecture, that the original sensibility of the skin persisted.
The softening of the upper part of the dorsal region of the spinal cord came on, doubtless, during the last week of life, and with it, in all probability, corresponded the extreme dyspnoea, the cough, and the excessive outpouring of mucus into the bronchial tubes. Before quitting the consideration of this case, the peculiarity regarding the voluntary muscles must receive a passing notice; for although there is a distinct mention of impairment of their power, first on one side and then on the other, yet when the patient was within the hospital there was indeed not so much a deficiency of actual motor ability, as of promptness on the part of the muscles in replying to the mandates of the will.
CASE III.-Fracture of the dorsal vertebræ and sternum. Softening of the anterior and central parts of the spinal cord; the posterior columns, entire. Loss of power in moving the lower limbs. Considerable anesthesia as regards pinching and pricking of the surface (but incomplete) of the integument of the lower limbs.
J. H., aged thirty-one, a carter, was thrown out of his cart backwards, and pitched on to the ground, alighting chiefly upon the lower part of his neck and shoulders. He was at the time quite sober, and was raised from the ground perfectly sensible. When brought home it was ascertained that he had almost, but not entirely, lost all voluntary power of moving the muscles of the lower limbs. On the day following, the bowels acted thrice from medicine without any loss of power over the sphincters of the rectum; the bladder was emptied naturally. Two days after the accident the respiration became oppressed, and large crepitations with gurgling were heard in the bronchial tubes; and the bladder could not be emptied without the aid of the catheter. Slight power of moving the lower limbs still existed as before, and the sensibility of the skin of these parts as to pinching or pricking was much blunted but not actually destroyed. Numbness of the legs was complained of. As to the arms, it was ascertained that he could voluntarily raise the right one to the head, but not so the left one, as its movement was restricted, although this really appeared to be contingent rather upon the external contusions than upon the loss of central nervous power. The respiration was entirely diaphragmatic, the abdomen being tense and tympanitic; and there was a sense of constriction around the body on a level with the umbilicus. On the third day after the accident all power of moving the lower limbs was found to be lost, and more numbness of the limbs was complained of, but still sensibility of the skin to such tactile impressions as were tested was found to be not annihilated. The bowels became constipated, the urine also still requiring the catheter for its removal. The patient remained in the same state until death, excepting that the bronchial tubes became more clogged up, and consequently the breathing more laborious, the phlegm being expectorated with the utmost difficulty. Prior to death, which occurred April 9th, the evacuations were several times passed involuntarily.
Post-mortem examination. In addition to the extravasation of blood, &c., amongst the muscles of the neck and back, the following structural changes
were met with. The veins of the spinal membranes were very distended with blood, and a slight amount of dark coagulated blood was seen extravasated between the lamina of the vertebrae and the membranes, at a point corresponding to the bodies of the two last cervical and first dorsal vertebræ. The spinal cord itself, opposite to the effusion of blood just mentioned, was in parts very soft for the distance of about one inch, the softening not involving the whole cylinder of the cord, but being limited to its anterior half and to the grey
matter in the middle of the cord, which also contained numerous minute ecchymosed spots. The posterior columns of the spinal cord were quite entire. A transverse fracture of the body of the first dorsal vertebra, but without displacement, existed, and the anterior and posterior common ligaments of the neighbourhood were uninjured. There was also fracture of the sternum. The lungs were in part only congested, and in part quite hepatized.
Remarks. In this case it must be noticed that integrity of the posterior columns-those (formerly) supposed conductors of sensation -was found after death, whilst during life the sensibility of the skin of the lower limbs was greatly impaired, whether as regards pinching or pricking of the surface. These symptoms accord well with the textural changes discovered after death-viz., the softening and the ecchymosis of the central grey, and of the posterior white parts of the spinal cord. The oppression of the breathing, the loss of thoracic respiration, along with the bronchial effusion and râles, and, finally, the pulmonary hepatization, may be considered as coinciding with the destruction of the upper portion of the dorsal division of the cord. Another point of interest not to be overlooked in the history of this case, is the distended and tympanitic state of the abdomen, and the feeling of constriction around the umbilical region-symptoms most probably referrible to a paralysed and yielding condition of certain portions of the muscles forming the parietes of the abdomen.
CASE IV.-Cyst of considerable dimensions in the right portion of the pons Varoli. Great loss of power of motion and of sensibility to pricking and pinching in the "left" arm and leg, and side of the trunk. Also numbness and diminished sensibility of the skin of the "right" side of the face and nose, and of the "right" temple, with increased vascularity of the conjunctiva of the "right" eye.
The patient, a girl, aged eighteen, was brought into St. George's Hospital in the following condition. There was greatly impaired power of motion in the left leg, arm, and hand, and there was great numbness and loss of sensibility of the skin, as regards pinching and pricking, of the whole of the left side of the body, as high up as the middle of the neck. The condition of the right arm and leg was natural, both as regards power of motion and sensibility of the skin. Numbness also, and contactile anesthesia of the integument of the right side of the face and nose and right temple, existed, along with very great vascularity of the conjunctiva of the right eye and much lachrymation. The right eyeball was drawn inwards, and could not be abducted, and the right pupil was "constricted," the left one being "dilated." The right eyelids could not be approximated, and some difficulty was found respecting the power of opening the mouth and of swallowing. Subsequently, vomiting and constipation came on, along with greater vascularity of the conjunctiva of the right eye, and great dulness of the cornea. Death was preceded by coma, with lividity of the face, immediately following what was termed by the nurse a "fainting fit."
Post-mortem examination.-A large cyst, of the capacity of a bantam's egg, was met with, situated in the right portion of the pons Varolii (fig. 2). The parietes of this cyst, which consisted of attenuated nervous structure,
Fig 2. This illustration exhibits a cyst in the substance of the right portion of
had given way at the thinnest part during the removal of the brain, owing to the firm adhesion which had formed between the cyst-wall and the dura-mater lining the base of the cranium; and the interior of the cyst was seen to have been occupied by a quantity of light coloured and glairy albuminous fluid, containing a number of white albuminous particles, being also lined by a thin film of albumino-fibrinous material. Its outer surface in one or two places had recent shreddy fibrinous material connected with it.* By means of the cyst, the anterior part of the under surface of the right side of the cerebellum was much indented, the whole cerebellum having been, as it were, slightly twisted, and somewhat pushed over to the left side. The under surface of the middle cerebral lobe on the same side was also indented. Moreover, the cyst, owing to its position, interfered with the fourth, fifth, and seventh pair of cranial nerves on the right side. Excepting thickening of the arachnoïd membrane around the cyst, and distension of the lateral cerebral ventricles with clear fluid, the other parts of the brain were healthy.
Remarks. This cyst was no doubt the result of softening of some scrofulous deposit within the pons Varolii. Besides the symptoms clearly referrible to interference with the fourth, fifth, and seventh cranial nerves above mentioned, and which for my purpose require in this place no comment or further enumeration, this case shows
This preparation is now in the St. George's Hospital Pathological Museum, as Preparation No. 11 a, Sub-series iv., Series XX.