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THE LANCET.

a Journal of British and foreign Medicine, Physiology, Surgery, Chemistry,

Criticism, Literature, and News.

MDCCCLXIX BOSTON MEDICAL LIBRARY

IN THE
FRANCIS A. COUNTWAY

LIBRARY OF MEDICINE

IN TWO VOLUMES ANNUALLY,

VOLUME I.

EDITED BY

JAMES G. WAKLEY,

G. WAKLEY, M.D., M.R.C.S. ENG.

LONDON:

PUBLISHED BY JOHN JAMES CROFT, AT THE OFFICE OF "THE LANCET,” 423, STRAND.

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Lectures

ON THE

AND ON THE

FELLOW OF THE ROYAL COLLEGE OF

PHYSICIANS OF LONDOX,

Begin) or by a hæmorrhage (as in the case by Mr. S. Solly), or by a tumour, or a pressure by a bone, &c., in man, produces paralysis on the side where it exists, in the spinal cord, and not at all on the opposite side. The case by Oré,

which I related in the preceding lecture (THE LANCET, PHYSIOLOGY AND PATHOLOGY OF Dec. 26th, 1868, p. 823, Case 14), is an example of this kind

of cases. THE NERVOUS SYSTEM ;

These facts clearly prove that a lesion in a lateral half of the spinal marrow produces paralysis only in the correspond

ing side. It is, therefore, evident that I was right to conTREATMENT OF ORGANIC NERVOUS

clude, in my remarks on the cases reported in my first lecAFFECTIONS.

ture-1st, that the lesion was only in one half of the cord

when there was paralysis only in one side of the body; By C. E. BROWN-SÉQUARD, M.D., F.R.S., 2nd, that the lesion was in both halves of the spinal nervous

centre, but much more in one than in the other, when there MEMBER OF THE NATIONAL ACADEMY OF SCIENCES (C.s.), ETC. was paralysis in both sides of the body, but in a much

greater degree in one than in the other; 3rd, that the para

lysis or its greatest degree was on the side of the lesion or LECTURE II. - PART I.

of its greatest extent transversely in the spinal marrow. ON ORGANIC AFFECTIONS AND INJURIES OF THE SPINAL CORD, 2nd. A lesion in one side of the spinal cord produces anæsPRODUCING SOME OF THE SYMPTOMS OF

thesia in the limbs and trunk on the opposite side.—This proSPINAL HEMIPLEGIA.

position implies, of course, that the conductors of sensitive Facts proving that a lesion in one of the lateral halves of the impressions decussate in the spinal nervous centre, so that

spinal cord produces : 1st, paralysis of voluntary movements those coming from the left side, for instance, pass first in the same side; 2nd, anesthesia to touch, tickling, painful through that side of the cord, and thence into the right impressions, and changes of temperature in the opposite side ; side, in which they go up to the brain. The demonstration 3rd, paralysis of the muscular sense in the same side. that this decussation

exists in animals and in man is grounded GENTLEMEN,—Before I proceed to treat of the subject of relating to our species, referring those persons who might

on several series of facts. I will only speak here of the facts this lecture I must keep a promise given at the end of the wish to know the facts furnished by vivisections in animals preceding one. I stated that I would soon try to prove that to my publications on that subject. * All I will say about a disease or an injury, either limited to a lateral half of the animals is, that it may be that in them the decussation of spinal cord in the cervical region, or occupying transversely conductors of sensitive impressions is not complete in the a great part or the whole extent of such a half and also a

spinal cord. In man, as I will prove, the decussation is

complete. I will only give here two series of proofs. small part of the other half, was the cause of the symptoms

A. There are a great many cases of disease of the base of observed in the various cases I have related. To give this the brain, leading forcibly to the conclusion that the condemonstration, I will show, by a study of each of these ductors of sensitive impressions arising from the trunk and symptoms, that they are exactly those which must exist in limbs decussate before they reach the brain, and consecases of an alteration limited to a lateral half of the cervical quently in the spinal marrow. I have latelyt given an

account of twenty such cases, and also quoted many others. part of the spinal cord, or extending partly also to the other They show that the views put forward by Sir Ch. Bell, I half.

Mr. S. Solly, and by Prof. Longet,|| who thought that con1st. A lesion in one side of the spinal cord produces a para- ductors of sensitive impressions decussate in the base of the lysis of voluntary movement in the limbs and trunk on the same brain, must be abandoned. In these cases there was a disside. ---Since the time of Galen,* who made experiments on ease in a part of the base of the brain, near the median this subject, it has been almost universally admitted that a plane, having destroyed or altered the nervous tissue only lesion of a lateral half of the spinal cord produces paralysis or chiefly of the lateral halves of the brain. Some of the in the same side in the trunk and limbs. In this century cases relate to the crura cerebri, others to the pons Varolii, many experimenters, among whom I will name Sir Astley and a third set to the medulla oblongata. In all of the cases Cooper,t have repeated one of the experiments of Galen, in which the disease was limited to a lateral half of one of consisting in a section of a lateral half of the spinal mar- these three parts, there were paralysis and anæsthesia in the row. Most of the vivisectionists state that voluntary move- limbs and trunk on the opposite side, and not in the same ments are completely lost in all parts whose nerves arise side. from the side of, and behind or below, the transversal sec- If we suppose that the decussation of conductors of sensition of a lateral half of the spinal cord. Experiments on tive impressions takes place in the upper part of the pons frogs have led Stillingł to deny the exactitude of this asser- Varolii or between the two crura cerebri, a disease in one of tion. My own researches on dogs, rabbits, and other mam- the lateral halves in those parts should certainly produce mals have, long ago, given the following results :-Ist, that anæsthesia in both sides of the body, as it would destroy or voluntary movements are not completely lost behind and on alter conductors from the side of the disease before they the side of the injury; 2nd, that there is a weakness in the cross to the other side, and also those of this last side after voluntary movements on the opposite side: two facts which they have crossed and reached the diseased side. Now, give strength to each other to prove that the conductors there are cases in which one of the crura cerebri, or one serving for voluntary movements, in some animals, partly side of the pons Varolii in its upper part, was altered, and decussate in the spinal nervous centre. But clinical facts no such thing as anesthesia on the two sides was observed, leave no doubt that, in our species, there is no such decus- the loss of sensibility having been found to exist only in the sation in that nervous centre. I need not prove this asser- opposite side. tion by reporting the details of these cases, as I shall have The same argument may be used for cases of disease in hereafter, in this and in other lectures, to give a pretty full a lateral half, of the middle or the lower part of the pons, account of most of these cases. I will simply say that they or of the medulla oblongata. The facts relating to these show that a lesion, either by a wound (as in the case by parts are as clear and forcible as those relating to the crura * See his works “De Locis Affectis," lib.iii., cap. 14; and “ De Anatomicis

cerebri. Administrationibus," lib. viii., sect. 6.

* I will only quote here two of my publications : Journal de la Physiol. + Medico-Chirurgical Transactions, vol. i., p. 200, et seq.

de l'Homme, &c., vol. i., 1858, p. 183; and the Course of Lectures, already Untersuchungen über die Functionen des Rückenmarks, Leipzig, 1842, cited, p. 29, et seq. p. 140, et seq.

+ See Archives de Physiol. Normale et Pathol., 1868, p. 718. 9 My first researches on this point were published in the Comptes Rendus The Nervous System of the Human Body, 3rd edition, 1844, p. 236. de la Soc. de Biologie, 1850, p. 195. See also my“ Course of Lectures on the $ The Human Brain : its Structure, Physiology, and Diseases. 2nd edition, Physiology and Pathology of the Central Nervous System," p. 48. In an 1847, p. 242, fig. 94. interesting paper, Dr. Van Kempen (Journal de la Physiol. de l'Homme, &c., | Traité d'Anat. et de Physiol. du Syst. Nerveux, 1843, vol. i., pp. 385 & 421. vol. ii

. 1859, p. 528) announces also that a section of a lateral half of the I will only give here the names of some of the observers who have pubsides, especially in the cables mainain limba na kuporodulpianarandeconging to the airead the ideas esthese names are narkotior. Hermann

weder" of London Physiol. du Syst. Nerv., p. 384), from different experiments, conclud also an excellent observer), Lambroso, Brunnicke, Carré, Friedreich, S. Cooper, that the voluntary motor conductors decussate partly in the spinal marrow. my friend Dr. J. W. Ogle, Dr. T. Inman, Gendrin, Broussais, &c.

No. 2366.

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Another argument is as powerful as the preceding: if the but his senses and general sensibility were unaltered. The decussation of the conductors of sensitive impressions took autopsy revealed the existence of an aneurismal tumour place above the medulla oblongata, an alteration of a lateral pressing upon the medulla oblongata. The anterior pyrahalf of that organ would surely produce anæsthesia on the mids, except at their upper part, had been completely desame side. I will give here a short summary of a decisive stroyed. * case which proves clearly that the conductors of sensitive The second case was reported by my late friend Dr. Stuart impressions do not decussate above the medulla oblongata. Cooper.f In a patient who had been attacked with anæs

CASE 15. Anesthesia and paralysis of voluntary movements thesia in the right limbs, without paralysis, a tumour was in the left side of the trunk and limbs ; tumour in, and softening found in the left side of the pons, which had not altered the of, the lower part of the pons and almost the whole of the me- anterior bundles of nerve-fibres (the prolongation of the dulla oblongata, on the right side.-A woman, after having pyramids). recovered from a fit of insensibility, found that she had These two cases complete each other, and leave no doubt entirely lost the power of motion in her left arm, and in a that the anterior pyramids are not the channels of sensitive great degree also in her left leg. Sensibility of the left side impressions. We can therefore conclude, from the case of was destroyed. The right side of the face was paralysed of Dr. Annan: 1st, that there is no decussation of the conmotion and sensibility. The right cornea was ulcerated. ductors of sensitive impressions in the medulla oblongata ; Paralysis of all the parts affected became complete, after 2nd, that these conductors reach that nervous centre having which she died. The autopsy was made twelve hours after already made their decussation ; and, as a necessary consedeath. A fibrous tumour was found on the right side of the quence from this last conclusion, that the spinal cord is the pons. It extended from the origin of the trigeminal nerve place where these conductors from one side of the body cross down two-thirds of the medulla oblongata ; and was about those of the other side. two inches long. The surface of the right crus cerebelli When I treat of diseases of the base of the brain I will and of the pons, on which it pressed, was softened. It was relate other cases of lesion of one side of the medulla incorporated with the substance of the right side of the oblongata and of the pons Varolii, resembling Dr. Annan's medulla oblongata, and had produced a softening which case, and leading to the same conclusions. extended through the posterior tract, but became less as it Before passing to another subject, I will repeat that approached the posterior surface. The anterior tract was a many clinical facts positively prove: 1st, that there is no pulpy mass. The left side was healthy.

decussation conductors of sensitive impressions from the The observer of this case, Dr. S. Annan, justly says,

trunk and limbs in any part of the base of the brain; 2nd, “ The right side of the medulla oblongata was softened to that these conductors reach the oblong medulla having the extent of complete disorganisation. There was complete already made their decussation, so that it is evident that paralysis of motion and sensation on the left side. The de- their crossing takes place in the spinal cord. cassation of the fibres of the corpora pyramidalia explains the seat of the decussation of conductors of sensitive im

B. The second kind of proof that the spinal marrow is the loss of motion on the opposite side, but as we have no facts proving a similar interlacement of the fibres of the pos- pressions might be considered as useless, owing to the deterior or sensory tract, it is not easy to discover how it hap- cisive evidence of the first kind of proof, just given, if it pened that the right side was deprived of sensation. Motion were not that this second kind brings with it the demonand sensation were unimpaired in the extremities of the side stration of something more than the fact of a decussation diseased. Are we not justified from this in making the in- in the spinal nervous centre. The question whether the ference that there is a decussation of the filaments of sen- conductors of sensitive impressions decussate only in cersation as well as those of motion ?” The inference is cer- tain parts of the spinal marrow, or all along that organ, tainly well grounded, but Dr. Annan did not go further, and does not receive the least elucidation from cases of disease left undecided the question whether the decussation of con- of the base of the brain; while it might, on the contrary, ductors of sensitive impressions takes place below the me- be completely solved by cases of disease of, or injury to, the dulla oblongata-i. e., in the spinal cord or in that medulla, spinal cord. Unfortunately, with only one exception, we with the motor fibres that form the anterior pyramids. have not yet cases in which an autopsy has shown what was

However strange may appear the supposition, that some the real seat of the lesion when the cervical region of the of the fibres which decussate to form the anterior pyramids cord was diseased or wounded; but there are already at are conductors for sensitive impressions, I must discuss this least five cases in which a lesion in a lateral half of the hypothesis here, as we are led forcibly, not only by Dr. spinal cord was found in persons who had had paralysis of Annan's case, but by many cases of disease of the medulla voluntary movement on the side of the alteration, and oblongata and the pons Varolii, to admit either this strange anæsthesia in the opposite side. These cases I will report view or the opinion I maintain, that the spinal cord is the in a lecture on hemiparaplegia. I will only say now, that place of decussation of the conductors of sensitive impres- they show that the nerve-fibres serving to convey sensitive sions.

impressions from the lower limbs and the trunk decussate Putting aside all the reasons grounded upon our know- almost at once after entering the spinal marrow. ledge of the structure and physiology of the medulla ob- Reverting now for a moment to the question above dislongata, which might be brought forward against such a sup-cussed, relating to the anterior pyramids, I will say that position, I will mention two sets of positive facts against it. these cases of disease of the spinal cord show conclusively

The first set is furnished to us by vivisections All phy- that the conductors of sensitive impressions of the trunk siologists who have made experiments on the anterior pyra- and of the lower limbs have no need of a decussation in the mids agree in admitting that they are not sensitive, and that medulla oblongata, as they make their crossing in the they can be divided transversely without any appearance of spinal nervous centre, and, therefore, go up to the base of diminution of sensibility anywhere.

the brain, those belonging to the left side of the body within The second set of facts, having been observed in our own the right side of the cord, and those of the right side of the species, has much more value. In the first place, there are body within the left side of that organ. many cases of disease of, or injury to, one or both of the These cases prove that a lesion of a lateral half of the anterior pyramids or their prolongation through the pons cervical region of the spinal marrow must produce Varolii, in which sensibility was not impaired in the trunk anæsthesia in the lower extremity and in the trunk on the and limbs. I shall relate some of these cases in a lecture opposite side. The case of Oré (Case 14, THE LANCET, on the medulla oblongata, contenting myself now with the December 26th, 1868) shows, besides, that a lesion in one mention of the principal features of two cases : one showing side of that region produces anæsthesia also, in the upper that the anterior pyramids may be diseased without anæs- limb of the opposite side. thesia; and the other, that the conductors of sensitive From the two series of proofs I have given, it resultsimpressions are placed behind the prolongation of these first, that a lesion of one side of the spinal cord, if extenpyramids in the pons Varolii.

sive enough to produce anæsthesia, will make it appear in The first of these cases was published by my friend Prof. the opposite side of the body, and not in the corresponding Lebert. A patient was attacked with general paralysis, in- one; secondly, that a lesion located in both halves of the creasing slowly but persistently; he suffered from aphonia, spinal marrow, much more extensive transversely in one difficulty of speech and deglutition, with increasing dyspnea;

* See Traité des Maladies de la Moëlle Epinière. Par Ollivier (d'Angers). * The American Journal of the Medical Sciences. New Series, vol. ii., 3rd ed., 1837, vol. i., p. 455. July 1841, p. 105.

+ See Journal de la Physiologie de l'Homme, &c., vol. i. 1858, p. 761.

sense.

than in the other, will produce anæsthesia in both sides of of cholera and of the fungoid theory of these eminent Gerthe body, but in a greater degree in the side opposite to man Professors, will doubtless be interesting to our readers. that side of the cord where the lesion is most extensive.

We publish the Report on the interviews with Professor Reading by the light of this conclusion the cases I have reported in the preceding lecture, it will be seen that in Pettenkofer this week, and those with Professors De Bary Cases 1, 2, 4, 5, 11, 12, and 13 (see THE LANCET, November and Hallier shall follow. The Director-General informs us and December, 1868), there was a lesion, almost entirely that nothing could exceed the interest the German Profeslimited to one-half of the spinal cord, in its cervical region. sors took in the inquiry, and they showed the greatest kindOn the contrary, there was a lesion extending to both sides

ness in discussing the subject with the two gentlemen. The in Cases 3, 6, 7, 8, 9, and 10. 3rd. A lesion in one side of the spinal cord produces a para- Mr. Simon, Dr. Thomas Thomson, Dr. Burdon-Sanderson,

same may be said also of the Rev. Mr. Berkeley, Mr. Huxley, lysis of the muscular sense in the corresponding, and not in the opposite, side.-We are not much advanced yet, as regards and others in this country, who all most kindly gave Drs. the physiological and pathological history of the muscular Cunningham and Lewis the benefit of their suggestions.

We do know, however, that the conductors serving Ed. L.] to give us an accurate notion of the state of contraction of our muscles are absolutely distinct from the conductors

During our stay at Munich Professor Pettenkofer went which give us the variety of painful sensations we may re

over the subject of cholera with great care, and at the close ceive from these contractile organs. We know, also, that of our interviews with him made the following statements in cases in which an autopsy has been made, and the spinal | as a summary of his views :cord found injured or diseased in one of its lateral halves,

In my opinion four conditions (momente) are essential in there was no alteration of the muscular sense in the parts order to bring about an epidemic of cholera:that were not paralysed; and as the paralysis was on the

1. A specific germ. side of the lesion in the spinal marrow, it is clear that the

2. Certain local conditions. conductors serving to the muscular sense do not decussate

3. Certain seasonal conditions. in that nervous centre, or, in other words, that they remain,

4. Certain individual conditions. up to the brain, in the same side of the cord to which belong

I have not investigated the nature of the cholera germ as the muscles from which they come.

disseminated by human intercourse. I have only taken for There is, therefore, a radical difference between the con- granted that it exists in the intestinal discharges of persons ductors which serve to give the peculiar kinds of sensation coming from infected places. (Vide “ Untersuchungen über that belong to the muscular sense and those nerve-fibres die Verbreitungsart der Cholera,” Munchen, 1855.) My which serve for all other inds of sensation arising either own investigations have been chiefly confined to the second from muscles or from joints, from the skin, or from other and third before-mentioned conditions. Hitherto I have parts of the trunk and limbs. The conductors serving for considered the human subject only so far as he is the bearer the muscular sense behave just like the voluntary motor of the infecting matter of cholera, or of the germ of this conductors, and seem to follow exactly the same course in matter; and have with facts contended against the pure the spinal marrow. These two sets of conductors, I repeat, contagionists, who declare that the infecting matter is prodo not decussate in that organ; while, on the contrary, the duced by a process of multiplication within the bodies of conductors of impressions of tickling, of touch, of pain, those affected by the disease. My chief proofs of this have and of temperature, all decussate before reaching the base always lain in simple facts (independent of any theory) as of the brain.

to the spread of cholera over large districts. (See, for I can conclude, therefore, that in the cases I have related example, maps No. 8 and 11 in the Bavarian Cholera Report.) in which the muscular sense was lost or diminished, in one There are certainly places enjoying complete immunity from side of the body (Cases 1, 2, 3, 4, and 7, in THE LANCET, cholera, also periods of immunity. (Refer to my article on the Nov. and Dec. 1868), there was a lesion in the corresponding Immunity of Lyons from Cholera, and the occurrence of side of the spinal cord.

Cholera on board ships, “ Zeitschrift für Biologie,” Bd. iv., pp. 400_414.)

The development of epidemics, and the immunity of many SCIENTIFIC INVESTIGATION INTO THE places, is totally inexplicable by the simple assumption of CAUSES OF CHOLERA.

contagion from person to person. Observe the spread of

epidemics along the course of railways and other ways of I. A REPORT OF INTERVIEWS WITH PROF. MAX intercommunication indicated in the above-named maps. VON PETTENKOFER AT MUNICH, Nov. 1868.

Nor are they to be explained by certain individual disposition of person (food, drinks, domestic arrangements, age,

position, &c.); but the circumstances require, besides these, DR. D. DOUGLAS CUNNINGHAM the existence of local and seasonal aiding causes, which

have to be assumed. DR. TIMOTHY LEWIS.

Are these in immediate relation to the cholera germ itself,

or to the individual disposition ? Facts speak in favour of [This and the two subsequent reports on interviews with the first opinion only. 1. Persons from an unaffected place Professors De Bary and Hallier were kindly placed at our

going to an affected one, are attacked quite as numerously

and as soon as the persons who constantly reside in these disposal by the Director-General of the Army Medical De- places. 2. Cases are on record where a person from an inpartment. The writers, Dr. Cunningham, of the Indian fected district conveys (in a way not yet clearly ascertained) Medical Service, and Dr. Lewis, of the British Medical infecting matter into a place enjoying complete immunity Service, having passed through the Army Medical School of infecting matter, infects a few persons who themselves

from cholera ; and there, by means of this limited amount with great distinction, were selected by the Senate of the had never been subject to the local conditions of an infected School for special service in India, in connexion with a place, and therefore could not have had their individual disthorough investigation of cholera which has been lately position altered by it. (See the article on Lyons, where ordered by the Government. Before proceeding to India it the enigmatical example of cases of cholera in Stuttgart was thought desirable that they should receive special in- in connexion with the cholera in Munich are recorded, struction on the methods of investigating the forms of fungi, pp. 424 to 426; see also cases recorded of persons infected

on board ship who had not been on land, p. 428.) Facts (as so much importance has been attached to this point,) imperiously demand that we should consider that the "seaand they were accordingly directed to go to Halle and Jena sonal” and “ local conditions are intimately connected with to see Professors De Bary and Hallier. Subsequently they the cholera germ, although they may in addition be in a proceeded to Munich to talk over the best methods of in condition to act on the individual predisposition also. vestigating cholera with Professor Von Pettenkofer. On the human intestines, but of the soil

. In so far as we con.

The infecting matter, in my opinion, is not a product of returning home they presented short reports of their inter- sider the cholera germ of an organised nature, and capable views, which, as expressing the latest views on the subject of various degrees of development, it is possible—nay, very

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