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 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 dyspnoea 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 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, 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 and anterior part of the edge of the foramen magnum made), in connexion with the dura mater at the right (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 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 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 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 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. decisively that the decussation of nerve-fibres (at least of the majority of them) devoted to the conduction of sensory impressions, does not at any rate take place, as some have held, at a point higher up in the cerebro-spinal axis than the pons Varolii; for here we have a loss of sensibility of the skin on the "left" side of the body (the same side on which power of motion was destroyed) produced by disease on the "right" side of the pons Varolii (the left side being unaffected). Had it been otherwise-that is, had the bulk of the sensory fibres coming from the left side of the body (that affected with contactile anæsthesia) passed through the pons Varolii prior to their crossing or decussation then they must have penetrated the uninjured left portion of the pons Varolii, and in this way escaped all implication; and we should not have had any anæsthesia of the limbs on the left side of the body. In like manner, this case also shows that the nerve-fibres addicted to the conduction of voluntary power passing downwards from the brain to the right side of the body, intercross at a point below the lower margin of the pons Varolii. CASE V.-Extravasation of blood on one side of the median line of the pons Varolii. Complete loss of power of movement in the muscles of the right arm and leg, and also of sensibility, as regards pinching and pricking, of the integument on the same side of the body. This case, which I venture to quote from the Transactions of the Pathological Society,' was brought before the notice of that Society* by my late friend, Mr. W. Barlow, formerly resident officer at the Westminster Hospital. It was that of a woman, aged thirty-four, who, after falling down suddenly, was found to have lost all power of motion in the right arm and leg, and also to have anæsthesia, as regards the impressions of pricking or pinching, of the paralysed limbs. There was, moreover, paralysis of the muscles of the left side of the face, the left eyelids not being capable of closure, and the mouth being greatly drawn to the right. Reflex action of the affected limbs could easily be excited. Consciousness was unimpaired, and even intelligence remained until within a few hours of death, which occurred five days after the accident. Post-mortem examination.—A coagulum of blood as large as a filbert, which had ruptured into the fourth ventricle, was found so situated in the pons Varolii that a section of this organ in the mesial line passed almost, “but not quite," through the centre of the effused blood. The brain and cerebellum were otherwise natural. Remarks. Here I would premise, that if the description of this case by Mr. Barlow had been somewhat more precise and fuller of detail, it would have been, for the purpose to which I am applying it, more available; but it is nevertheless most useful. The post-mortem record certainly implies that blood-clot was located more on one side than the other of the pous Varolii, but fails to state on which side it preponderated. The probabilities are, and I think it must, from the symptoms, be assumed, that the blood-clot was situated more on the left side of the median line than on the right, and that it involved the left part of the pons more especially-along, no doubt, with a considerable portion of the right part of this organ. Thus we have • Transactions of the Pathological Society of London, 1852-3, p. 28. |