beneath the articular lamella, and it is this hyperemia which gives rise to the symptoms usually supposed to be produced by ulcerating cartilage. 7thly. That simple degenerative diseases of the cartilage, as they produce no hyperæmia, produce no symptoms. ART. IV. Series of Clinical Cases (with Observations) illustrating the Views recently put forward by Dr. Brown-Séquard, as regards certain points connected with the Physiology of the Nervous System. By JOHN W. OGLE, M.D. Oxon, F.R.C.P., Assistant-Physician to St. George's Hospital, Secretary to the Pathological Society of London. I DESIGN by the relation of the following clinical cases, which, with one exception, are selected from the records of medical experience in St. George's Hospital, to assist in rendering human pathology instrumental in elucidating the truthfulness of some of the ingenious and profound generalizations based mainly on experiment, and brought forward of late years by Dr. Brown-Séquard. The members of the medical profession in England are now fully conversant with, and fully appreciate, most of the special researches of that dexterous experimental physiologist respecting the blood, muscle, animal heat, and the nervous system in general; and therefore any formal enunciation of his varied deductions would here be quite superfluous and misplaced. I will consequently, by way of premise to the cases which I shall detail, merely content myself with bringing before the mind of the reader, in a manner as concise as the intentions of this communication permit, those conclusions from facts observed by Brown-Séquard connected with the minute organization of the nervous system, the certainty of which I purpose to illustrate by the cases which I shall adduce, and which are in direct opposition to the conclusions arrived at by other physiologists, French, German, or English. These cases will, I think, tend most materially to corroborate the following deductions ascertained by Brown-Séquard : (a) That the posterior columns of the spinal cord do "NOT" form, as was thought by Longet and many other observers, the means for the entire (en totalité) conduction of sensitive impressions to the brain; but (b) That these columns form a medium to a slight extent only for the passage of sensitive impressions; such conduction along the spinal cord chiefly occurring in the central or grey matter of the cord, into which part the fibres of the posterior sensitive roots of the nerves, by means of transverse, ascending, and chiefly descending fibres, find their .way almost immediately after gaining the cord, via the posterior columns, the posterior grey cornua, and, in part, the lateral columns. And that if there be any fibres conducting sensitive impressions ascending from the trunk or limbs along the entire length of the cord, their number must be very inconsiderable. (c) That the fibres conveying sensitive impressions to the brain do not at any rate decussate at a point higher up in the cerebro-spinal axis than the pons Varolii. (d) That the decussation of fibres conveying sensitive impressions must be of necessity not only at a part below the level of the upper margin or central part of the pons Varolii, but even for the most part, if not entirely, below the medulla oblongata itself. That is to say, this crossing or interlacement of sensory nerves must take place in the spinal cord itself, and that not in any particular spot, but in every portion of the cord almost immediately after the entrance therein of the afferent fibres. (e) That all the motor or efferent fibres decussate at a distinct point immediately below the pons Varolii—that is to say, at the anterior pyramids and the neighbouring parts, contrary to the views of Valentin, Cruveilhier, Longet, Foville, &c. Having thus enumerated in a succinct manner the various physiological positions which I purpose to illustrate and strengthen in this pathological communication, I will, without further circumstance or digression, proceed to narrate my cases, the true interpretation of which at the time of their occurrence, and upon the old theories then commonly in acceptance, could obviously not have been apparent. CASE I.-Dislocation of some of the vertebra, and projection of bone into the anterior surface of the spinal cord, the posterior columns remaining entire; perfect loss of sensibility and power of movement in the lower limbs. History.-P. S-, aged sixty-two, was brought into St. George's Hospital, having fallen a height of eleven feet, and received a scalp wound. He was for ten minutes stunned by the fall, but after admission walked into the ward, complaining only of pain at the neck. He had a slight cough. Nothing fresh was complained of until three days afterwards, when he felt numbness in the legs and tottered in walking. Sensibility of the skin to pinching and pricking was everywhere perfect. Seven days after the accident he had to such a degree lost power in the legs, that he scarcely was able to move them; still, sensibility of the skin remained as before. The bowels were constipated, and the catheter had to be used, the urine, too, becoming purulent. Stiffness also of the arms came on, and nine days after the accident he could with difficulty move them; they were also much flexed. All power also of voluntary movement below the diaphragm had disappeared. Eleven days after the accident the soft parts over the larger trochanter of the right femur began to slough, and two days later his cough was attended by dyspnoea. On the thirty-second day after the accident all sensibility of the skin, as well as all power of movement in the legs, was found to be lost: the respiration was chiefly abdominal. After some difficulty in swallowing, the patient died September 27th. Post-mortem examination.-Dislocation forwards of the sixth cervical vertebra was found to exist, so that the body of the seventh vertebra projected for at least half an inch into the spinal canal behind. The dura mater opposite the sixth and seventh cervical vertebræ was thickened, and a slight amount of recently-formed soft fibrin existed at this spot between the bone and the theca 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 BrownSéquard'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 anæsthesia, 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 disesae 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 anæsthesia 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 anæsthesia as Her regards pinching of the skin, and this was Post-mortem examination.-A vascular but very firm encephaloid tumour, of the size of a small walnut, was found attached to the dura-matter, 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-matter at the opposite (the anterior) border of the foramen magnum, and these two encephaloid 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, aud 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. 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 This specimen is now in the St. George's Hospital Pathological Museum, as Preparation No. 1 b, Sub-series vii., Series xxi. 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 anasthesia 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 vertebræ 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 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 columnsthose (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 regionsymptoms 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 Varolii. 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 anæsthesia 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, had given way at the thinnest part during the Fig. 2. This illustration exhibits a cyst in the substance of the right portion of the pons Varolii, which has been freely opened to show the interior. 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 con |