spinal cord, but chiefly in the side corresponding to that of the greater degree of paralysis. 2nd. When a complete or very marked anæsthesia exists in one of the lateral halves of the body, with some diminution of sensibility, instead of hyperæsthesia, in the other half, the lesion exists chiefly in the lateral half of the spinal cord corresponding to the side of least anæethesia, but it extends slightly to the other half of the spinal nervous centre. With the help of these last two propositions and of the six others previously given, it will be. come evident to any one studying the cases I have related in my first lecture, that they really were, as I have asserted, cases in which the lesion existed either only or chiefly in one of the lateral halves of the cervical region. It being positively proved that such was the seat of lesion in these cases, they become as valuable as if an autopsy had confirmed the diagnosis, and they may serve as types of the kind of paralysis I intended to illustrate in the preceding lecture. This demonstration will also serve the purpose I have in view in the present lecture—namely, to show how certain lesions of the spinal cord will produce some of the symptoms of spinal hemiplegia, and not the others. If, for instance, an organic affection or an injury is limited to a part only of the transverse extent of a lateral half of the spinal marrow, in the cervical region, the symptoms will be slighter in intensity and less numerous than in cases where the whole transverse extent of the spinal nervous centre is injured or diseased. On the other hand, if a lesion (from disease or injury)'occupies the whole, or nearly the whole, of the transverse extent of a lateral half of the spinal cord, and also a part of the other half, in the cervical region, symptoms will exist in both sides of the body. Before relating the cases I intend to report in this lecture, I must say, that although some important symptoms are not mentioned in the history of a case, they may have existed, and either been unknown to, or neglected by, the reporter of the case. The fact that medical men will sometimes overlook even a most important symptom is well shown by a case published by the eminent French surgeon, Boyer, which I will presently relate, and in which the existence of anthesia in the side of the body opposite to that of an injury to the spinal cord was discovered only by a mere accident. Other features of organic affections or injuries in the cervical region of the spinal cord deserve notice before I come to the history of the cases I intend to relate in this lecture: I mean some peculiarities, on which I will insist hereafter, as no attention has been paid to them either by physiologists or medical men, notwithstanding the important physiological and pathological conclusions they lead to. I will only say now, that these peculiarities are― 1st, that a lesion in the upper part of the cervical region of the spinal cord can produce anæthesia in the lower, or in the upper limbs, according to its location, and that, consequently, the conductors of sensitive impressions for the lower extremities do not pass through the same part of the spinal nervous centre as those of the upper extremities; 2ndly, that a lesion, in the upper part of the cervical region of the spinal marrow, can produce paralysis of voluntary movement in the lower limbs alone, or in the upper limbs alone; and that consequently the conductors serving to that kind of movement for the upper extremities do not pass through the same part of that nervous centre as those going to the lower extremities. After this rather long preamble I come to the history and discussion of some cases of organic affections of, or injury to, the spinal narrow, presenting several of the symptoms of the complete and genuine spinal hemiplegia described in the previous lecture. I will first relate the case of Boyer, already alluded to, giving it almost entire, on account of its importance. CASE 17. Wound of the upper part of the cervical region of the spinal cord, on the right side; paralysis of voluntary movement on the same side; anasthesia on the left side.-A drummer of the Paris National Guard was wounded by a sabre, thrown at him from behind. The point entered the neck in its superior and posterior part. The wounded man at once felt his legs giving way, and fell. The next day he was brought to the Charité hospital. The wound, two inches long, was situated at the posterior and lateral part of the right side of the neck, immediately below the occipital bone. The right upper limb had completely lost the power of motion; but it had retained all its sensibility. The right inferior limb seemed to be a little weakened; but its sensibility was quite normal. Respiration was somewhat uneasy; the pulse was frequent, strong, and full. On the fourth day the weakness of the lower limb had completely disappeared; the patient could slightly extend the forearm, but was unable to flex it. On the thirteenth day the patient had recovered his general strength, and walked about; but the paralysis of the right upper extremity remained unchanged. Playing with a nurse, who pinched him, he found that the left side of his body was anaesthetic. He told me so the next day, and I observed the following facts:- The lef. inferior limb and the left side of the trunk had their natural size, movements, and nimbleness; but the patient had no feeling whatever when the skin of those parts was pinched, pricked, and even cut. Pins were pushed to the depth of three or four lines, and the man whose face was turned away, had no notion that anything was done to him. He, however, had some kind of feeling, but only extremely obscure and faint, when a large surface of skin was touched, as was the case when a whole hand was placed upon the skin and moved to and fro. This anæsthesia existed every where in the foot, the leg, and the thigh, on the left side; it was complete also on the left side of the abdomen; but it ceased abruptly at the median line both in the front and the back of the body, with this remarkable peculiarity, that near that line, when the patient was pinched on the left side, he affirmed that he felt a slight sensation in the corresponding point on the right side. There was an equally complete lack of sensibility at the base of the chest; but a little higher an obtuse sensation began to be perceived, and became more and more powerful when the exploration was carried upwards, so that, at the level of the fourth rib, the skin had a degree of sensibility equal to that of the rest of the body. The upper left limb was in a perfectly normal state. Twenty days after the accident the patient left the hospital, cured of the wound in the neck, and having no pain or stiffness in that part; but the arm, forearm, and hand, on the right side, were almost completely paralysed, and the left side (trunk and lower limb) was in the same state of anesthesia which has been described. A few months later he came to see me; his condition had hardly changed. tended, and he could only imperfectly close them on anything. The right abdominal limb was completely deprived of movement. Sensibility was quite normal in the limbs and trunk on that side. Visceral functions were in a perfect condition. Respiration, however, after having been normal for three or four days, became quick and difficult, and death occurred from apnœa. This case, like several others I have related, Autopsy. - A fragment of a knife was found shows that a division of a part of the spinal cord, lodged in the spine, the point entering the posterior even high up, not far from the madulla oblongata, part of the pharynx between the sixth and seventh can be borne without any bad influence on the cervical vertebræ, and the base firmly fixed in the great organic functions. It presents these two right lamina of the sixth vertebra. The right most essential symptoms of spinal hemiplegia-side of the spinal cord had been divided obliquely 1st. Paralysis of voluntary movement on the side from the line of origin of the posterior roots to the injured. 2nd. Anæsthesia on the opposite side. anterior median sulcus. The fact that the paralysis was almost entirely located in one of the limbs (the right arm), and that the anesthesia was confined to the left side of the trunk and the left lower limb, shows that the lesion occupied only a part of the right side of the spinal marrow, above the origin of the nerves of the upper limbs. It is a feature of importance in this case that respiration was so little disturbed. Evidently the cord was injured above the origin of the phrenic nerve, and (as I will show in another lecture) a great part of its lateral column was divided. Had Schiff's theory been true, respiration should have been notably impaired in the right side of the chest. * In the following case, one of the most prominent features of spinal hemiplegia was not noted, although it must have existed, at least in some degree: I mean anesthesia on the opposite side to that the of injury. It is not stated that it existed, but there is no statement also that sensibility persisted, and most likely, as in the above case, no search was made to ascertain whether sensibility had been at all disturbed in that side of the body. The case, however, is a most interesting one, and excited a good deal of attention at the time of its first publication by Bégin. I only give a summary of the case. - CASE 18. Transverse division of the right antero-lateral column of the spinal cord at the level of the sixth pair of nerves; paralysis of motion in the corresponding side, with conservation of sensibility. L was wounded on the 21st October, 1840, at the posterior part of the neck. He fell at once on the right side, and tried vainly to get up. The next day he was brought to the Val de Grâce Hospital, where Dr. Bégin saw him. He had no pain, and complained only of some feeling of numbness in the right side. The succeeding day it was ascertained that the wound, which had healed, was transverse, 13 millimetres long, on the right side. at the level of the fifth cervical vertebra, 24 millimetres from the spinous process of that side. There was a feeling of heaviness in the right thoracic limb, with formication in the hand. He could with difficulty move the arm and forearm; but the fingers were half flexed, could not be ex * I found, long ago, that the lateral columns of the spinal marrow, which Schiff supposes to be the only channels between the encephalon and the respiratory muscles, can be divided transversely without any impairment of respiration, and that, in most instances, there is, on the contrary, an increased power in the diaphragm and other inspiratory muscles after such a lesion above the origin of the phrenic nerve. (See " Archives de Physiologie Normale et Pathol.," 1869, p. 299.) In this case the instrument had injured the spinal cord obliquely from behind forward, di viding the lateral and the anterior white columns and the anterior grey cornua on the right side, but had left uninjured the whole white posterior column and a good part of the central grey matter and of the posterior cornua on the same side. The fact that the posterior column was not injured explains why there was no increase in the sensibility on the side of the wound. It is much to be regretted that the state of sensibility in the opposite side was not recorded, as the autopsy showed so well-defined a lesion that it would have been most interesting to know exactly the effect on sensibility in that side. There must have been, at least, some anesthesia, although some part of the grey matter remained undivided. Had a thorough examination been made, some anesthesia would also have been found in the right arm, owing to the injury that some roots of the sixth or seventh pair of nerves must have suffered both outside and inside of the right half of the spinal cord. If we compare the case with the other cases of incised wound of that organ which I have related, we find that death occurred quickly in this case and not in the others-a dif ference the cause of which is chiefly, if not entirely, in the fact that there was a foreign body irritating the spinal marrow in this case, while there was no such thing in the other cases.* The following case differs from the two preceding in this respect: that the cause of the symptoms was an organic affection, and not a wound. It differs, also, from them in this other important feature: that Dr. Charles B. Radcliffe, who observed it, knew my views pretty well when he saw the patient, and therefore paid attention to some symptoms which otherwise might not have been noticed. I will only give here a summary of the case. CASE 19. Paralysis of the right arm, with hyperæsthesia, and a slight elevation of temperature; considerable anesthesia of the left arm. - Short and thin man; head twisted to the right shoulder, and jaws clinched by muscular spasm. He can, by strong effort, separate his teeth and turn his head round a little. Mastication impossible, and swallowing difficult from spasm in the throat. From the occiput to the fourth or fifth cervical vertebra there is a hard swelling, not tender on pressure, but painful when the neck is turned. *This cause of difference, as I will show elsewhere, is extremely important as regards the treatment of fracture of the spine by removal of the broken pieces of bone, which may act like the foreign body in the above case, and cause death by irritating the spinal cord. The right arm is almost entirely paralysed, and its cutaneous sensibility appears to be decidedly exaggerated; the left arm, on the contrary, preserves its power of voluntary movement, and its cutaneons sensibility is in a great measure abolished. Reflex movements can be excited in both arms, especially in the left. The right hand and arm are a trifle warmer than the left. No difference between the two sides of the face as regards warmth and vascularity; pupils equal. No head symptoms; no weakness or numbness in the legs; bladder and rectum normal. After a few months the head was still a good deal turned; but mastication aud deglutition were unattended with difficulty, and the right arm was still somewhat weak and the left numb. In this case a pressure from outside upon the right side of the cord produced the symptoms. I will not now speak of the peculiar feature that the upper limbs alone were affected, as 1 shall soon have to revert to that point, and will then speak again of this case. LECTURE VIII.-(Concluded.) ON DISTORTIONS OF THE TRUNK AND NECK. Lateral curvature of the spine (continued).The pathological conditions which result from lateral curvature of the spine may be divided into those effects which are produced immediately upon the spine and trunk, and those which are consequent upon these changes. Confirmed lateral curvature is not purely a lateral deviation; for so soon as the curves become more or less permanent, the vetebræ which are involved in them become rotated on their axes in such a manner that the anterior surfaces of the bodies of the vertebræ occupy the convexities of the curves, and consequently present more or less laterally. In a severe case, such as that from which Fig. 24 was taken, the anterior surfaces of the bodies of the vertebræ have undergone such an amount of rotation that they have acquired a lateral instead of their normal direction, and occupy the greatest convexities of the curves. But although the bodies of the vertebræ may have become thus rotated, the spinous processes may perhaps undergo only slight change, so as scarcely to indicate a lateral curve. These points are well shown in Figs. 25 and 26, especially in the dorsal curve, which, if traced by a novice, would scarcely be recognised as a spinal curve, although the bodies of the vertebræ are rotated to the extent of nearly a quarter of a circle. Perhaps, however, the course of the spinous processes in the lumbar portion of the spine is even more remarkable, considering the greater rotation which has taken place in this portion of the spine -rotation equal to one-fourth of a circle. Thus it is that a spiral twist of the spinal column may exist to a very great extent through rotation of the bodies of the vertebræ, without the apices of the spinous processes describing a corresponding Fig 24. curve. It is important to remember this circumstance; for many become hopelessly deformed, because the mode in which spinal curves are formed is not rightly understood. While a lateral deviation of the spine is incipient only, the intervertebral cartilages become compressed laterally, and they recover their form when the superincumbent pressure is removed; just as is well known to occur in health, when a man of ordinary stature, who has been in an upright position during the whole day, loses from half an inch to three-fourths of an inch, through the compression which takes place of the intervertebral substances, and which he regains only after some hours spent in a recumbent posture. When, however, these intervertebral substances, become unequally compressed, and this effect is continued from day to day, they lose in a measure their elasticity, and do not recover their full form during the period of repose, but remain somewhat compressed and wedge-shaped. Curvature is then permanent, and rotation of the bodies of the vertebræ commences. The bodies of the vertebræ are not all in the same measure rotated; but those are most rotated which are nearest to the centre of the curve, and that vertebra which is central is rotated and most wedge-shaped. This is shown in Fig. 27, where the vertebra in the centre of the lumbar curve is represented as rotated to the extent of one-fourth of a circle and wedge-shaped, while those above and below are both less rotated and less wedged-shaped. And in the same manner the intervertebral substances which enter into the curve are reduced in thickness. Fig 25. Fig 26. On the convex side of the curve this bone is thrust up, and is placed obliquely, through the Fig 27. These changes in form of the vertebræ during the development of a lateral spinal curve are very remarkable; but the most striking change which takes place in relation to spinal curvature is that which is effected in the shape of the thorax. The ribs necessarily follow the altered positions of the vertebræ to which they are attached, and undergo a movement of rotation backwards on the convex side of the curve, so that their angles are rendered more prominent, and they become more horizontal in their direction, while the intercostal spaces become wider than in their normal state; but on the concave side of the curve the ribs sink and become flattened, the intercostal spaces also become more or less effaced through overlapping of the ribs, and the ribs are carried foward, and become prominent on the anterior and lower part of the chest. On both sides of the chest the ribs are flattened; but on the convex side of the curve, in consequence of the rotation of the vertebræ into the convexity and of the flattening of the ribs, the lung is much compressed. Through these changes in the form of the thorax, and others which are coincident with them, the capacity of the chest is diminished. Also, the appearance of distortion is much increased by the prominence of the scapula. increased angularity of the ribs, and it is stil futher raised by muscular action. The pelvis is not materially affected in an ordinary instance of lateral curvature of the spine. It becomes oblique, as has been already observed; and when the superincumbent weight is unequally transmitted to the ground, it becomes slightly flattened. When, however, the pelvis is effected with rickets, it becomes flattened from above downwards, both by the superincumbent weight and by the resistance of the lower limbs; so that the space between the promontory of the sacrum and the symphysis of the pubes is diminished. A case of this description is on record, where it was necessary to perform the cæsarean section, in which the pelvis was so much deformed that a ball of one inch in diameter would not pass through the brim. I will, in the second place, proceed to consider, cursorily, the changes which result to the parts contained within the compressed thorax, and to those which are attached to the trunk itself. The thoracic space, on the convex side of the curve, is diminished by the flattening of the ribs, and by the rotation of the bodies of the vertebræ; and the heart is in consequence somewhat displaced towards the concave side of the curve. Respiration is considerably affected; and in consequence of the imperfect expansion of the chest and lungs, the right side of the heart becomes dilated, and the blood is insufficiently aërated. The aorta follows the inflections of the vertebræ in spinal curvature. It is bound down to the spine by its branches, and, therefore, always follows the curves of the spine. Its course, under these circumstances, is well shown in a preparation numbered 3416 in the museum of the Royal College of Surgeons. In a practical point of view, this course of the aorta may appear to be a matter of only small importance. It deserves to be remembered, however; for in a thin person, with the convexity of the lumbar curve towards the right side, the aorta may be felt immediately under the finger, lying out of its normal course, and to the right of the umbilicus. I have known the pulsation of the artery to suggest ideas of aueurism. Together with severe lumbar curvature, there is always found obliquity of the pelvis. This obliquity of the pelvis is not a simple tilting to one side (one side being raised while the other is depressed), but there is at the same time a slight movement of rotation of the pelvis itself,-which, indeed, is necessitated by the circumstance of the lumbar curve and the rotation of the lumbar vertebræ; so that the anterior superior spinous process of the ilium is not only raised above that of the opposite side, but it is also in advance of it. In the female, this obliquity is of less importance than in the male; but in the male the triangular ligament of the urethra together with the rest of the pelvis, being twisted, the direct course of the urethra, behind the ligament no longer corresponds with that in front of it. This twisted condition of the urethra may cause an impediment to the introduction of a catheter into the bladder; and it should always be borne in mind when stricture of the urethra exists in such a case. Whenever in cases of severe lumbar curvature it is required that an elastic catheter shall be used, this is always withdrawn, moulded into a double curve, similar to the urethral curve. The treatment of lateral curvature can only be undertaken with advantage when the cause of the curvature is understood, and, further, when the order in which the various curves have been formed is understood. It must be obvious to all who reflect on the subject that it is useless to endeavor to remove a spinal curve whilst the cause of curvature yet remains; for, even should the curve be removed, it will recur so soon as the means which were adopted to remove it are discontinued, and the same cause will immediately again distort the spinal column in the same manner as before. Thus, let us, for instance, suppose that some affection of the lower limbs has occasioned obliquity of the pelvis, a primary lumbar curve and a compensating dorsal curve. The treatment which was formerly adopted was, without reference to the cause of curvature, to make pressure on the convexity of the dorsal curve. This mode of treatment was not only useless, but positively injurious: it increased the lumbar curve, and flat tened still more the flattened ribs. The course of treatment which should be adopted is, in the first instance, to remove the cause of the obliquity of the pelvis. Whatever this may be—whether it be some affection of the foot, knee, or hip,-it should be treated and removed, if not before, at least at the same time as the lumbar curve is being treated. Again, when the dorsal is the primary curve, it may be treated by means of a portable instrument, while the lum bar curve is supported by another portion of the same instrument. In this form of curvature, muscular exercises are useful to develop the muscles on the concave side of the curve. The treatment of spinal curvature should be undertaken so soon as the slightest distortion is perceived. It is difficult to remove a spinal curve at any time; especially it becomes difficult when the disposition to curvature is inherited, and it can only be removed when mechanical means are rightly directed to this end. It was with good reason that Sir Benjamin Brodie said: "The treatment of the disease cannot be begun too soon after the first signs of spinal curvature are perceptible." * A slight curvature of the spine is by some considered to be a matter of such trivial importance as to be unworthy of attention. It is a very serious error to offer such advice, however, and in later years it must occasion great distress. However trivial spinal curvature may appear in the commencement, its course is necessarily to produce increasing deformity, with more or less pain, and impairment of the general health. So little are the laws of equilibrium understood, that it is imagined by some that a wry-neck, or a "growing out" shoulder, or an oblique pelvis is an affair of small importance, and that distortion will probably not increase beyond that which is at the time observed. Some even are bold enough to imagine that a child will "grow out" of these distortions. These are delusions which observation quickly dispels. When curvature of the spine, from whatever cause, has commenced, it must go on increasing until, by the formation of compensating curves, the equilibrium of the body is restored. Having explained how pathological spinal curves are formed, and how they are compensated, so that the equilibrium of the body may be restored, I will proceed to consider the application of mechanical means to the removal of spinal curves. So long as a spinal curve is incipient, it may not be necessary to have recourse to mechanical support to the spine itself; but it may be sufficient to remove the exciting cause of distortion, and to develop the muscular system by means of welldirected exercises. When, however, these measures are found insufficient, support should be given to the spine itself without more delay. If it be a fact that one curve is first formed, and that others are formed as compensatory of this primary curve-and no one can doubt it who has watched these cases attentively, then it should follow that treatment must in the first instance be directed especially to the removal of this primary curve; for to remove a secondary curve without giving efficient support to the primary curve is the most certain mode that could be devised of increasing the original curve. Having determined, then, which is the primary curve, force should be applied (not on the greatest convexity of the dorsal curve, to flatten still more the ribs and render the sternum prominent) in that direction which shall tend to restore the positions of the ribs, and also to restore the vertebræ, which have undergone some rotation. This is most effectively done by applying the force to be used to the lower are of the curve, both of the primary and of the sec |