No. 2929.

OCTOBER 18, 1879.

Lectures ON THE

PHYSIOLOGICAL PATHOLOGY OFTHE BRAIN.

Delivered at the Royal College of Physicians of London,July, 1876.

BY C. E. BROWN-SÉQUARD,PROFESSOR OF MEDICINE AT THE COLLEGE OF FRANCE.

LECTURE III.-PART VII.1

ON PARALYSIS OF LIMBS AS AN EFFECT OF DISEASE OF THEMEDULLA OBLONGATA AND NEIGHBOURING PARTS.

Direct paralysis is more frequently caused than cross para-lysis by lesions of the medulla oblongata-Lesions of pos-terior parts of the medulla oblongata can produce directour cross paralysis-Lesions of the anterior pyramid causemore frequently direct than cross paralysis-Lesions be-ginning inside of the pons Varolii differ radically fromlesions beginning on the surface of that nervous centre-Lesions beginning inside of the pons, if they cause para-lysis, produce it almost always in the ordinary crosswisemanner-Pressure upon the pons Varolii either frontbehind, from the side, or from the front, produces morefrequently direct than cross paralysis, even when the pre-tended motor tract is considerably altered either in the ’

pons or in the crus cerebri or medulla oblongata.To those who admit the view that the right side of the

brain is the seat of the will-power for the movements of theleft limbs, and that the left side of that great nervous centreis the mover of the right extremities ; to those who admitthat paralysis of limbs caused by an organic disease in theencephalon is the result of the loss of function of the diseased.part, it must be absolutely impossible to explain the casesI have just mentioned (see THE LANCET of Sept. 27th),as in all but a few of those facts the paralysis should havebeen on the side opposite to that of the lesion, or on the twosides, instead of being merely on the very side of the disease.The existence of such facts furnishes, as I have alreadystated, a powerful argument against the admitted viewsconcerning the mode of origin of paralysis and the physio-logy of the brain as regards voluntary movements. Butthis argument acquires a much greater power from the fol-lowing result of my researches on the relative frequency of.cross and direct paralysis in cases of certain lesions of theisthmus of the encephalon. I find that lesions of any kindlocated almost in any part of either side of the medulla ob-longata, and also lesions of one lateral half of the pons Varoliidue to pressure from outside, especially from a tumour on itsantero-lateral surface, produce more frequently a direct thana cross paralysis. On the contrary, lesions of a lateral halfof the pons Varolii beginning inside of that half very rarelyindeed produce a direct paralysis. I have hardly been ableto collect more than seven cases of such a lesion producingparalysis of the limbs on the corresponding side.2 Cross sparalysis due to an internal disease of one side of the ponsis observed so frequently that, in researches I have made onthe diagnosis of such a lesion, I have collected more thantwo hundred such cases. There is no doubt whatever, then,that according to the part first affected in cases of lesion ofthe pons there is a greater frequency of cross or of directparalysis. Not so for the medulla oblongata, as shown by acomparison of the facts I will now give with the facts I havepreviously mentioned.3 In this nervous centre there is nodifference between those parts, which according to generally

1 Part VI. of this lecture appeared in THE LANCET, Sept. 27th, 1879.2 To the cases I have quoted of E. Stanley, J. Toynbee, Dr. G. May, Dr.

J. Browne, Martineau, and Darolles (see THE LANCET, Sept. 27th, p 452),I might have added a few less positive, among which is one of Mr. G.W. Callender (St. Bartholomew’s Hospital Reports, vol. v. 1869, pp. 8, 9)In this last case the patient, trying to walk, staggered, and his left leggave way. The left posterior half in the entire thickness of the ponswas diffiuent and considerably disorganised.

3 See THE LANCET, Jan. 4th, 1879, pp. 1 and 2, and Sept. 27th, 1879,p. 51.

No. 2929.

received notions should not give rise to paralysis, and thoseparts which ought always, according to most physicians andto a few anatomists (especially Huguenin and Fiechsig) andphysiologists {especially Dr. D. Ferrier), give rise to cross

paralysis. Either one or the other of these different parts,when they cause paralysis, will produce it much moreoften on the side of the lesion than on the opposite side.The only cases I know of disease strictly limited to themedulla oblongata and located in one of its lateral halves,which had caused a cross paralysis of one or two limbs, arethe following :-1. Paralysis of the right limbs; a patch ofsoftening and a very small clot of blood at the place of thecommon nucleus of the facial and abductor nerves, near theeminentia teres on the left side.4 2. Paralysis of the rightlimbs ; a small glioma on the left side of the fourth ventricle,involving the common nucleus of the facial and abductornerves, near the eminentia teres.5 3. Slight paresis of the rightarm; a tubercle in the left half of the medulla oblollga.ta..64. Paralysis of the right arm ; left half of medulla oblongata,at level of anterior pyramid, compressed by displaced andhypertrophied odontoid process. 7 5. Complete paralysis ofthe right arm, incomplete of the right leg ; in the thicknessof the left anterior pyramid, in the upper part of the medullaoblongata, there was a tumour of the size of a small Spanishchestnllt.8 6. Paralysis of the left limbs; aneurism of theright vertebral artery pressing on the anterior pyramid and

: the olivary body.9These six cases are the only ones I know of cross paralysis

: due to a lesion limited to a part or the whole of a lateralhalf of the medulla oblongata. In the first two (Hallopeau’s

: and Dr. Broadbent’s) there was a lesion in the posterior partof the left lateral half of that nervous centre at the place of

. the common nucleus of the facial and abductor nerves. In

.

several of the cases I have related of direct paralysis (Conty’s,Dr. Waters’ of Liverpool, and Lebretou’s), the seat of thelesion which was more extensive must have included thatsame part. In one of the six cases of cross paralysis I havejust mentioned (Bayle’s) the seat of the lesion is not well

l defined, but in the three others (Bouchard’s, 13ri-)iissais’, and. Fontorbe’s) there was a lesion of one of the anterior pyramids

and of the neighbouring tissue. This is what was found, in more than seven of the cases of direct paralysis I have

related.) If we now add to the cases of disease entirely limited to

the medulla oblongata those, like the three following, inwhich, with a disease in that organ, some lesion coexistedin other parts, we find that the number of such cases withcross paralysis is also smaller than the number of cases

- of direct paralysis. In a case of Yel1ol,v’slO there was para-t lysis of the right limbs caused by a tumour sunk into the- pons at its posterior part, on the left side, extending to thef corpus pyramidale of the same side. In a remarkably well

recorded case of Dr. Samuel Annanll there was completeB paralysis of the left limbs, due to a considerate lesion of1 nearly the whole l’ight half of the me<&Igrave;u]]a oblongata and- the lower and anterior part of the 1’1:ght side of the pons,i from pressure by a tumour two inches long. In a case due

s to an excellent observer, Dr. Thomas Buzzal’il,12 paralysisof the left limbs had existed, and two lesions were found-

11 one in the right half of the medulla oblongata, which was

f twice the width of the left half, owing to a tumour chieflyyprominent at the place of apparent origin of the hypoglossuse nerve ; and the other in the left half of the cerebellum.g D, These three cases (admitting that in the last the cerebellars lesion had no share in the paralysis) are very similar ass regards the lesion of the medulla ob)ongata to five or six ofII the cases of direct paralysis which I have mentioned (Parent-a Duch&atilde;telet and Martinet’s, Gama’s, Johert de Lamballe’s,, Calvin Ellis’s, Dr. J. W. Ogle’s, and Penard’).f It seems evident, then, that lesions occupying the sameat part of the medulla oblongata, whether that part be con-a sidered as motor or not, can produce either a cross or ae direct paralysis, but will more frequently cause this last0

&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;&mdash;

Y 4 Hallopeau: Bulletins de la Soci&eacute;t&eacute; Anatoinique (Paris, 1876), p. 450.y5 5 Dr. W. H. Broadbent: Transactions of the Clinical Society (London,

1872), vol. v., p. 66.6 Rayle: Trait&eacute; de la Phthisie Pulmonaire (Paris, 1810), p. 155, nbs. 8.

r. 7 Bouchard in Hallopeau’s thesis : Des Paralysis Bulbaires (Paris,), 1875), p. 118.t. 8 Broussa.i3 : Traite des Phlegmasies Chroniques (3me edit., Paris,) 1822). p. 420.,g 9 Funtorbe : Un cas d’H&eacute;mipl&eacute;gie Alteriie par An&eacute;vrysme de la Ver.Is t&eacute;brale. These Inaugurale (Paris, 1874), No. 313, p. 5 et seq.

10 Medico-Chirurgieal Transactions (London, 1809), vol. i., p. 181.g, 11 American Journal of the Medical Sciences (July, 1841), p. 105.

) la Transactions of the Clinical Society of London, vol. vii. 1874, p. 165.Q

566

kind of paralysis (the direct) than the other. We are ledto a similar conclusion, and with much more force, when wecompare the cases of cross paralysis due to a tumour pressingon the antero-lateral surface of the pons Varolii and on theanterior surface of the crus cerebelli, of the cerebellum, andsometimes also of the medulla oblongata. The best of thecases I know of tumours located in that place havingcaused a cross paralysis are those published by Dr. T. C.Allbutt,13 Bouvier,14 Dr. Bright,15 Duguet,16 F&eacute;r&eacute;ol,17 Fried-reich,18 Drs. Gairuner and Haldane,19 Jobert de Lamballe,20Leaden,2’ Dr. J. W. Ogle,22 Professor Rosenthal,23 Riihle,24Salter,25 Tessier.26 In those cases, as well as in the casesfrom similar lesions producing direct paralysis (see THELANCET, Sept. 27th, p. 452), the tumour had its centre atthe place of origin of the fifth nerve, or between that pointand the crus cerebelli. In either of the two sets of cases wefind that sometimes the pressure was slight, and producedonly superficial alterations of the pons and crus cerebelli.In either set also we find that, on the contrary, the tumouroften extended as far down as the lower part of the medullaoblongata on its side or on its anterior pyramid, and as farup as the crus cerebri. Between these two dimensions (smallor very large) there were, in the two sets of cases, tumoursof intermediate sizes. In some of the cases the pressure waschiefly on the lateral parts of the pons ; in other cases theprincipal alteration was in the supposed motor tract in thepons, and sometimes also in the crus cerebri and the medullaoblongata. Facts of those various kinds are found in thegroup of cases of direct as well as in that of cross paralysis.The point most worthy of attention is that the number ofcases of alteration of the so-called motor tract producingdirect paralysis was notably larger than the number of casesof similar lesion causing cross paralysis.

It is clear, therefore, that the views that are admitted asregards the mode of origin of paralysis in cases of disease ofthe pons Varolii and medulla oblongata, and as regards thechannels of transmission of the orders of the will to musclesthrough those parts, must be rejected.27

Clinical LectureON A

CASE OF RENAL CALCULUS.Delivered at St. George’s Hospital,

BY THOMAS P. PICK, F.R.C.S.,SURGEON TO THE HOSPITAL.

GENTLEMEN,-The case to which I propose to draw yourattention to-day is one of renal calculus-that is to say,stone lodged in the pelvis of the kidney. In the particularinstance before us there were, in fact, two stones, and wewere enabled to diagnose their presence with absolute

certainty, by the fact that we could, by rubbing themtogether, elicit distinct grating-a point of no little im-

portance, for, as I shall have occasion to show you, the

diagnosis in these cases is by no means certain, and instances13 Transactions of the Pathological Society of London, vol. xix. 1868,

p. 20.14 Gazette Medicale de Paris, 1840, p. 430.115 Guy’s Hospital Reports (London), vol. ii. 1837, p. 286.16 Bulletins de la Soci&eacute;t&eacute; Anatomique (Paris, 1865), p. 496.17 Id. Id. Id. (Paris, 1857), p. 111.18 Beitrage zur Lehre von den Geschwiiisten inherhalb der Schadel-

hohle (Wiirzburg, 1853), tow o cases, pp. 15 and 29.19 The Edinburgh Medical Journal (March, 1861), p. 795.20 Etudes sur le Syst&egrave;me Nerveux (Paris, 1838), p. 456.21 Klinik der Riickenmarks-Erankheiten (Berlin, 1875), vol. ii., p. 154.Jl2 Transactions of the Pathological Society (London, 1854), vol. v., p. 26.S3 Traite Clinique des Maladies du Syst&egrave;me Nerveux. Traduction

Franeaise (Paris, 1878), p. 210.24 Quoted by Ladame : Symptomatologie u. Diagnostik d. Hirnge-

schwiilste (Wiii-zburg, 1865), p. 255.25 Edinburgh Medical and Surgical Journal, vol. xi., p. 470. Quoted

by Abercrombie : PathoJog. and Practical Researches on Diseases of theBrain, fourth edition (Edinburgh, 1845), p. 450.

26 Bulletins de la Soci&eacute;t&eacute; Anatomique (Paris, 1834), p. 171.27 In a very learned work of Professor H. Nothnagel, which I have

just received ("TopischeDiagnostik der Gehitnkrankheiten,"BerI.,1879),I have vainly looked for new cases of cross or direct paralysis due to dis-ease of the medulla oblongata. Only a few of the cases I have quotedare mentioned. It is indeed a most remarkable fact that a part of thecerebro-spinal centres so often diseased as is the medulla oblongata,ia 10 rarely the cause of hemiplegia or of paralysis of one limb.

have occurred in which the presence of a calculus in thepelvis of the kidney has been determined on, an operationfor its removal performed, and no stone found. For thenotes of the case I am indebted to my clinical clerk,Mr. Bulteel.Anne R-, aged forty-four, a married woman, was

admitted into Harris ward under the care of Mr. Pick.She stated that she had had two children. Her father andmother both died of asthma; one sister died of phthisis;one brother has also died, but she does not know of whatdisease. Some years ago she began to experience greatpain in the left loin, which was very violent and too " badto explain." Soon afterwards matter began to come awayin her urine, and has continued to do so ever since. Thepain is not now so bad as it used to be; it comes on inparoxysms about every five minutes, and is of a " shootingcharacter and extends from the left loin down to the regionof the bladder, but is not accompanied by a desire to passwater. She has never noticed any blood in the urine. Thecatamenia are not regular.Upon admission she was found to be an emaciated subject,

and had an anxious expression of countenance; the pulsewas 102, weak and thready ; the heart-sounds normal ythe face pale; the tongue white and cedematous. The painis described as extending from the left loin down to the-hypogastric region, and thence to the vulva, but does notextend down the inner side of the thigh. It is not increasedby moving about, but is equally severe when she remainsquiet in bed. She generally requires to pass her urine everytwo hours, and the desire to do so is not greater or more-frequent when she is up than when she is in bed. In theleft lumbar region, at about a level with the spine of thefirst lumbar vertebra, a hard mass can be felt. This can bebest perceived from behind, between the last rib and thecrest of the ilium, firm pressure being made on the front ofthe abdomen so as to push the mass backwards. It isof about the size and shape of a sheep’s kidney, but appearsto be made up of two if not more lobules. It is freelymovable and very hard. On one occasion, upon examiningit, a slight grating was thought to be felt. The urine isthick and cloudy, and about one-fourth of its volume is pusaIt contains no crystalline deposit and no blood.A day or two after admission she was placed under the-

influence of ether, in order that a more careful examinationof the mass might be made. It was then easily felt t&consist of two hard, rounded substances, which could bemoved on each other, and on doing so a distinct grating wasperceived. The patient absolutely refused to entertainthe question of any operation, and, at her own request, wasdischarged.Such, gentlemen, was briefly the history in this case, and

you see from the peculiar circumstance of there being two>

stones, and that they could be moved on each other, thusproducing a grating, we had no difficulty in arriving at adiagnosis. Had it not been for this fact, however, thedifficulties in arriving at a determination as to the exactnature of the case would have been great, for there wereseveral features in it which would have tended to throw usoff our guard or on a wrong scent; and I would desire, there-fore, in the first instance, to say a few words on the sym-ptoms to which stone in the pelvis of the kidney gives risebefore proceeding to discuss the operation which has beenproposed, and, in some few instances, performed for itsrelief.

As, no doubt, all of you are aware, calculi may ori-ginate either in the kidney or in the bladder, and they areformed in consequence of some peculiar state of the system,or diathesis, as it is generally called. And of these diathesesthere are three principal forms, in addition to some otheruncommon forms, of which it is not necessary at presentthat I should say anything : the lithic-acid diathesis, the-oxalic, and the phosphatic. Now it may be taken as abroad rule, to which, however, of course, there may be ex-ceptions, that when a calculus originates in the kidney thenucleus is either of lithtc-acid or oxalic-acid formation ;whereas, on the other hand, if the stone is formed in thefirst instance in the bladder, the nucleus is either phosphaticor consists of some foreign body in the bladder, probably in-troduced into that viscus from without. All renal calculimay be said, therefore, to be constitutional and to arisefrom some morbid state of the urine, this state or conditiondepending on malassimilation. Now, when a stone formsin the pelvis of the kidney, it may either remain there, or itmay pass down the ureter into the bladder. If it remains,