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Fourthly. Great numbers of clinical records evidently display considerable research into the question of anesthesia in one form or another; but there is obvious neglect of attendant observation (and this also to a great extent) as respects "hyperæsthesia" or the exaltation of the various forms of sensibility.
Fifthly. We have in very numerous instances an entire want of evidence, and in many a deficiency, at least, of evidence, as to the temperature of the skin or mucous membrane of the affected parts of the body (the thermometer being in only few instances resorted to). In many cases the subjective sensations of the patients are all that is alluded to,
Sixthly. We frequently have observations, obviously rigid and complete, as to all needful particulars respective of the side or portion of the body mainly affected and therefore pre-eminently attracting the attention of the observer, whereas there has been at the same time a total neglect of any mention of the "opposite side" as to the existence of any affection of sensibility or voluntary power of motion (although, of course, such may have been present to a very subordinate extent).
Seventhly. We often find vague mention made of such symptoms as "strabismus," "distortion of the eyes," &c., but no indication as to which form of squinting existed, or even as to which eye was affected, and we are in consequence utterly ignorant as to what sets of muscles or what nerves have been implicated. Also the pupils are oftentimes spoken of as being "dilated" or "contracted," but it is manifest that sufficient care has not been taken to observe whether the pupils harmonized with each other or not, or whether they deviated from their natural condition as to size or form; or whether they were constant or variable in size. Again, with regard to the special senses, or the faculties of deglutition or swallowing, symptoms are very often quite unmentioned, or when at all alluded to, the statement is often omitted as to the particular side on which the sight, or smell, or taste, or hearing, &c., was subjected to interference.*
Eighthly. Constant omissions exist as regards the powers of reflex nervous action enjoyed by various affected parts of the body; or if they at all attracted attention, their presence or abeyance have only been studied in the case of the soles of the feet. Again, touching the determination of the degree of excito-motory power enjoyed, very often, perhaps most frequently, this has only been effected by means of tickling the skin (the use of heat or cold, or galvanic stimuli, being not at all resorted to).
Ninthly. Symptoms, precise and extensive enough, are often noted, either wholly without reference to date, or without relative dates of their occurrence as regards the exact time of death, so that the reader is often at a loss to conjecture with any degree of accuracy as to the
Dr. Brown-Séquard shows that when deglutition is impaired, indicating an affection of the pharynx, it may be diagnostic of the exact part of the nervous system interfered with, for in cases of alteration of the pons Varolii, this symptom is observed to exist unaccompanied by loss of speech; whilst, if the latter co-exists, the lesion is probably situated in the medulla oblongata or the “vagi” nerves.
connexion between such and such a symptom on the one hand, and the morbid lesion observed after death on the other hand.
Of this kind are the numerous omissions as regards Clinical histories, especially as concerns injuries and diseases of the nervous system, often encountered in our attempts to connect varied and isolated cases in support of any dominant view or theory-omissions which obviously quite prevent that accuracy of diagnosis which it is so desirable to possess, and which is at the present time to a very great degree attainable, considering the multifarious results of recent experimental and pathological researches.
I will now proceed briefly to delineate some of the defects frequently experienced in our attempts to systematize and, so to say, co-ordinate the Post-mortem Pathological appearances detailed in many records. They may be conveniently disposed as follows:
Firstly. In post-mortem statements as to affections of the brain and spinal cord, such phrases as the following are pretty constantly met with the cord or brain "softened," "harder than usual," "lacerated,” "containing extravasated blood," "ecchymosed," "discoloured," and the like; and this very frequently unattended by any mention as to which precise portion of the brain or spinal cord was affected, or to what extent the given lesion extended. Omissions on these latter points are especially disastrous (considering the important interests of diagnosis and physiology), in the case of disease or injury of the pous Varolii or medulla oblongata, in which parts the disposition of nervefibres allotted to different actions is more complex than in the spinal cord proper.
Secondly. Pathological observers have too often rested satisfied with the examination of one only of the large central nervous organs; at one time the spinal cord alone having been examined, whilst at another time, and this of course much more frequently, the brain has been subject to scrutiny, to the neglect of the spinal cord. The nerves, and especially the origin and the roots of the spinal nerves, have frequently altogether escaped examination; and at times, only that part itself of the spinal cord which was previously supposed to have been affected, has been submitted to examination, the remaining portion of the cord, and especially the "chorda equina," having been quite overlooked.
Thirdly. Clinical observation, with a view to the establishment of physiological questions, has been, as a rule, more addressed to instances of "primary disease" of the nervous centres; whereas, perhaps, more information (especially after the early effects of shock, loss of blood, injury by contusion of muscles, &c. have quite passed away*) relative
I may here opportunely draw attention to the precaution (forcibly pointed out by Dr. Brown-Séquard as being so imperative) not to be misled in our estimate of the effects of injury to nervous structures by the results almost always attendant on the division and laceration of powerful muscles, entailed in the act of obtaining access to central nervous structures, lesion of which would obviously give the appearance at first sight of nerve. paralysis. He of course alludes to experiments on the lower animals, but the hint may be taken also in respect of injuries in man, as it no doubt often happens that injury (such as laceration and contusion) of muscles from extensive accidents involving the spinal region, produces a semblance of serious lesion of some of the spinal nerves or even of the spinal cord itself.
to the healthy functions of certain parts of the nervous centres, would have been elicited by the study of cases of "surgical injuries" of those textures, or of such rapid diseases of the spinal or cranial bones as affect those subjacent nervous textures in a secondary manner as by pressure. This latter kind of cases is particularly serviceable in the study of the physiology and properties of the nervous centres, inasmuch as we have therein a probability of a quicker fatality, and in consequence less chance of such extensive structural changes taking place as would go far to complicate and obscure the phenomena chiefly regarded; whether such textural alterations be indeed pathological, having occurred before death, or are essentially of post-mortem origin, and attributable in the main to chemical decomposition, which will be the more complete in proportion to aute-mortem pathological disintegration.
In drawing to a close the above enumeration of omissions noticeable in many recorded cases of injury and disease, bearing upon the invaluable propositions advanced of late years in the field of our studies of the nervous system, I am anxious emphatically to repeat, that many of the shortcomings of observation which I have commented upon are such as were in past years quite inevitable by reason of the uninformed state of our pathology and physiology, as regards multifarious points connected with the nervous system. Not a few of them have been the natural consequence of the absence of any pervading and regulating theory, in support and under the influence of which, observation should have been conducted.
Convincing, but yet fully capable of more extended proof, especially by means of clinical cases sedulously and minutely observed, as are the demonstrations of Dr. Brown-Séquard in regard to the interesting physiological questions, of which the foregoing cases are illustrative, it is to me a subject of regret that these cases which I have just cited are so scanty in number. I was anxious, and thought I should be able in some way to show why so large a mass of material as that at my disposal has, comparatively speaking, yielded so little product, and that was my reason for bringing forward the various points of omission to which I have alluded, as occurring to one's mind in supervising clinical records in various quarters.
I also felt assured that in our future investigations connected with disease and injury of the nervous system, greater care and precision of observation will be called for than hitherto we have been in the habit of bestowing in the matter.
For this reason, therefore, having the hope and expectation that from their consideration a few practical suggestions may occur to the reader's mind for future use and guidance in the prosecution of researches connected with the multiform and too often embarrassing lesions of the nervous system, I have taken this opportunity of noticing such defects in our methods of examination as rise into prominence on reflection upon the ends which in such examination we must ever keep in view.
Chronicle of Medical Science.
HALF-YEARLY REPORT ON MICROLOGY.
By JOHN W. OGLE, M.D., F.R.C.P.
Assistant Physician to St. George's Hospital, and Honorary Secretary to the Pathological Society.
PART I.-PHYSIOLOGICAL MICROLOGY.
On the Structure of Cylindrical and Ciliated Epithelium. By Dr. N. Friedrich, of Heidelberg.* -The author first alludes to the observations of Kölliker and Funke upon the perpendicular markings supposed to be porous canals at the broad end of intestinal epithelium, and thought to serve the purpose of resorption of fat. He then adverts to some former observations of his own on the epithelium of the bile-ducts of the foetus, which left it doubtful whether the perpendicular markings were broadly-striped coverings of the cells or adherent cilia, and speaks of having met with cylindrical epithelium of the gall-bladder and ducts in the adult as well as in the infant, which often possessed striped terminal edges, as also of the stripings of the cell-covering in ciliated epithelium of the bronchi in man and the ox, and in the ventricles of the human brain.
In the ventricles of the brain the epithelium was seen by the author to have the following striking characteristics. The cilia were seen through the homogeneous edges of the cells to pass directly into the cells more or less deeply, in some cases only just passing within, in others passing to the nuclei, and in others, but rarely, quite down to the base of the cell. In these cases each single cilium appeared to correspond to a striping of the border, and each line traversing the cells appeared to be a downward projection of a marking on the cell-cover. In many cases the cilia were adherent, so that only the striping of the border, with its continuation into the cell, could be seen; but for the most part the latter were absent, and only a simple cylindrical cell with a striped cover existed. Sometimes fat-drops were seen in or upon the threads as they pass through the cells, or at the termination of the cilia within the cell. In some cases also the bile-tinged epithelium-cells of the gall-bladder showed similar stripings, but less clearly.
With regard to these observations, the author acknowledges that they are not absolutely and entirely new, as Valentint has spoken of normal ciliated epithelial cells, in which the cilia sank deeply into them; and Bühlmann,‡ Donders, &c., have seen cells under various conditions in the midst of which the cilia have existed, or rows of fat and granules corresponding to the striping of the bright border. The fact of the discovery of these ciliary threads in epithelial cells of bronchi, and the ependyma of cerebral ventricles as well as
• Virchow's Archiv, Band v. Hefte 5, 6, p. 535.
† See article Flimmerbewegung im Handwörterbuch der Physiologie, Band i. s. 500. Virchow's Archiv, Band xi. s. 576. § Moleschott's Untersuch., Band ii., 1857, s. 115.
in the intestines and gall-ducts, quite removes the supposition that their presence is connected with the metamorphosis of fat elements.
The striping of the cell-cover is connected by the author with the functions of resorption in general, as in this way we have an arrangement of lines forming a regular system of exceedingly fine capillary tubules from the tips of the cilia to the base of the cells. The author then speculates upon the connexion between the lower end of the epithelium of the ependyma with the projections of the subjacent areolar-tissue cells, and on the probability of the areolar-tissue corpuscles being the commencement of the lymphatics; and refers to the probability of the contents of the cerebral ventricles being taken up by the termination of the ciliary threads, and carried directly into the lymph stream, the ciliary movement subserving the motion in the tubes and the onward progress of new molecular matter.
The author then draws an analogy between epithelial cells and the areolartissue corpuscles (justifiable in certain places at least), looking upon the former as being in fact a modified instance of the latter, only destitute of any intervening substance.
He proceeds to describe a species of epithelial cell which he had met with, which led him to believe that in some cases more than a single cell was placed on a common stalk, communicating below by the union of their processes. Similar cells had been seen by Heidenhain in the cylindrical epithelium of the intestines of the rabbit.*
The author concludes by giving the details of two cases of chronic inflammation about the brain of children, in which alterations in the epithelium were met with, and from which he is inclined to suppose that the more obvious existence of the lines seen traversing the cells is only a species of hypertrophy allied to the indistinct hypertrophy of the general ependyma of the ventricle.
On the Minute Structure of Muscular Fibre. By Professor Amici.-The author in his communication describes the muscular fibre of the fly as follows. In the centre, and passing through it longitudinally, there exists a canal filled with spherical or oval vesicles containing very fine granules. This canal is surrounded by a kind of sheath, consisting of a series of flat rings placed one above the other at a small distance, and united by numerous longitudinal threads. Close upon these threads a soft cellular tissue exists, and external to this another sheath, formed of rings united by threads. Lastly, surrounding the entire fibre we have a thin transparent wrinkled membrane.
The author then describes the process of manipulation resorted to by him, and the appearances presented during the examination of such a muscular fibre. The cross stripes correspond to the profile of the flat rings of the double sheath, and consist each of three flat layers forming the thickness of a single ring; the dotting of the transverse stripes is produced by the middle one of these three layers which is punctate, whilst the two others are more transparent. The dotting is probably the result of the insertion of the longitudinal threads which bind one ring to another. Each fibre has its tendinous termination, to which it is united by the numerous diverging fibrils into which the tendon divides, and which are fixed to the free convexity of the last ring of the fibre. In the wing of the fly, whilst one end of the muscular fibre is so terminated by a single tendon, the other is attached by means of the
*See Moleschott's Untersuch., Band iv. Heft 3, s. 264, 1858.
+ Il Tempo Giornale Ital. di Medicina, Chirurgia, &c., vol. ii. p. 328, quoted in Virchow's Archiv, Band xvi. Hefte 3, 4, p. 414.