Charles-Edouard Brown-Séquard.

Course of lectures on the physiology and pathology of the central nervous system : delivered at the Royal College of Surgeons of England in May, 1858 online

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tive impressions upon the upper limbs. Viewed in this light, this
case is quite favorable to our views, instead of being opposed to
some of them.

Wishing to find what is true, and not to try to establish a syste-
matic view, which, if false, would sooner or later be put down, I
have been hunting much more for cases that seem to be in opposi-
tion to the theories I propose, than for those which seem to sup-
port them. But, however extensive have been my researches in
this respect, I have hardly found two or three cases that seem to
6how that the destruction of the gray matter of the spinal cord may
allow sensibility to persist. In a paper of Prus, close by an in-
teresting case in which sensibility persisted till the last hours, the
white substance of the spinal cord being alone altered, there is
another case in which there was paralysis of movement alone, and
it was found that there were two places where the spinal cord was
softened, in both of which the gray matter is said to have been in-
visible. (Prus, in Revue Jfedicale, 1840, vol. iv. p. 395.)

I will merely remark that the mere assertion that the gray
matter was invisible, cannot be considered as a proof that this sub-
stance was missing, as a change of color may have rendered it in-
visible. Admitting, however, that its quantity had diminished,
there is nothing, in the short details of the autopsy, showing that
there was a total absence of this substance.

I shall not relate here cases in which not only the gray matter,
but the rest of the spinal cord was destroyed, and in which, never-
theless, according to some writers, there was a conservation of
voluntary movements and sensibility. I shall not try to explain
how these functions and properties subsisted, as I think my
hearers are too enlightened to content themselves with explanations
like those of Magendie, 1 who admitted that nervous transmissions

1 Journal de Physiol. Exp6r., vol. ill., 1823, pp. 187, 189.



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GRAY MATTER OP SPINAL CORD. 91

took place through the membranes of the spinal cord, or of M.
Hutin, 1 who imagined that the transmissions continued through the
serous fluid which had replaced the spinal cord ! Before trying
an explanation, it would have been prudent in these cases, as in the
celebrated case of the gold tooth in the last century, to ascertain that
the pretended facts were positive. We are perfectly sure that no
one knowing the effects of a transversal section of the spinal cord,
will have any doubt about these cases: it is quite evident that the
greatest part of the alteration found in this organ has taken place
after the last examination of the patient.

If we sum up the evidence that the gray matter of the spinal
cord is the principal channel of transmission of the sensitive im-
pressions, we find —

1st. That there are many cases of alteration only, or almost only,
limited to the gray matter, and in which both voluntary move-
ments and sensibility have been lost. To the cases of this kind
that we have already mentioned (see cases recorded by Mr. Curl-
ing, Cruveilhier, Grisolle, and Ollivier, in this lecture), Ws-will ah- /
add the following indications of similar cases which are eleven in '
number; one by Jeffreys, quoted by Ollivier, 1 one by Sir Everard
Home, 3 one by Calmeil, 4 one by Portal, 3 and a most remarkable
one by Ollivier, 6 which we shall have to relate by and by, for
another and interesting feature that it has presented.

2d. That there are many cases of deep alteration of all the white
substance of the spinal cord, the gray matter remaining normal, in
which sensibility has persisted. In addition to the cases by M.
Laboulb&ne, by Prus (Cases 22 and 26), and to others that I have
related, and to several that I shall have to relate, I will merely
mention one, recorded by Dr. J. Bostock, in which the whole cir-
cumference of the spinal cord had been pressed upon, so as to
present a kind of circular gutter, and in which sensibility had been
preserved.

From the cases I have adduced to prove ray views concerning
the transmission of sensitive impressions in the spinal cord, it may

1 Nouv. Biblioth. Me*dioale, 1828, vol. i. p. 159, Obs. 13.
1 Loco cit , vol. i. p. 333. * Philosophical Transactions, 1814.

4 De la ParalyBie, Obs. zliz.

6 Anatomie M6dicale, vol. iv. pp. 117, 118. A canal, the size of a quill, was
found in the spinal cord.
• Loco cit., vol. ii. p. 388.



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92 THE CENTRAL NERVOUS SYSTEM.

certainly be concluded — 1st. That the posterior columns of the
spinal cord are not the principal channels for this transmission, and
that they even seem not to convey any part of the sensitive impres-
sions to the encephalon. 2d. That the gray matter of the spinal
cord seems to be the principal channel of transmission of the sensi-
tive impressions to the encephalon. These two principal conclu-
sions are borne out also by the experiments related in my second
and third lectures.



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93



LECTURE VII.

PATHOLOGICAL CASES SHOWING THAT THE CONDUCTORS OP SENSITIVE
IMPRESSIONS FROM THE TRUNK AND LIMBS DECUSSATE IN THE SPINAL
CORD AND NOT IN THE ENCEPHALON, AND THAT THE CONDUCTORS OF
THE ORDERS OF THE WILL TO MUSCLES DECUSSATE IN THE LOWER
PART OF THE MEDULLA OBLONGATA AND NOT IN THE PONS VAROLII.

The decussation of the conductors of sensitive impressions, from the trunk and
limbs, does not take place in the crura cerebri, neither in the pons Varolii, nor
in the medulla oblongata. — Cases proving that this decussation takes place in
the spinal cord. — Cases of loss of voluntary movements in one side of the body,
and of loss of sensibility in the opposite side. — The decussation of the con-
ductors, for voluntary movements does not take place, as has been imagined, all
along the basis of the encephalon. — This decussation seems to take place almost
entirely in the lower part of the medulla oblongata. — Symptoms of alteration in
a lateral half of the spinal cord, the lower part of the medulla oblongata, and
the rest of the encephalon, as regards voluntary movements and sensibility.

Mr. President and Gentlemen: We now come to the ques-
tions relating to the place of decussation of the conductors of sensi-
tive impressions in the cerebrospinal axis. In one of the preceding
lectures, I have related the experiments by which we have been
led to the idea that this decussation takes place in the spinal cord,
for most, if not all, the conductors of sensitive impressions arising
from the various parts of the trunk and limbs. (See Lecture III.)
I will now try to show that the same view seems to be proved
by pathological facts observed in man.

Anatomy teaches that there is a decussation of nerve-fibres all
along the spinal cord, the medulla oblongata, the pons Varolii,
and the crura cerebri. Let us see what would take place in cases
of disease in a lateral half of one of these nervous centres, if the
decussation of the conductors of sensitive impressions existed in
the encephalon. Admitting that it is in the crura cerebri that these
conductors decussate, as Longet has imagined, an alteration in one
of these peduncles should produce a diminution of sensibility in
the two sides of the body, because conductors belonging to these
two sides should then be injured, those of the right side being in



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94 THE CENTBAL NEBVOUS SYSTEM.

the right and in the left crura, and those of the left side being also
in the left and in the right crura. This view does not agree with
pathological cases, which show that an alteration in one of the crura,
or above them in the two quadrigeminal bodies of one side, causes
no diminution of sensibility in the corresponding side, and pro-
duces anaesthesia in the opposite side. So it was in cases recorded
by Burnet, 1 Andral, 1 Mohr, 3 and Duplay. 4 These cases, as also
several others, seem to show conclusively that the conductors of
sensitive impressions, in their way to the brain proper, have already
made their decussation before they reach the crura cerebri and the
basis of the tubercula quadrigemina. Therefore the fibres, which
really decussate beneath these tubercles, and which come chiefly
from the cerebellum (see Fig. 18,/), cannot be considered as the
conductors of sensitive impressions.

Is it in the pons Varolii that the decussation of these conductors
takes place? If it were along.the whole length of this organ, we
should find a loss of sensibility in the two sides of the body, when
one side only of the pons Varolii is altered, because, in each lateral
half of the pons, there should be conductors belonging to the two
sides of the body; the right side of the pons, for instance, containing
the conductors which come from the right side of the body, in their
way to the left side of tJie pons, and also the conductors from the left
side of the body after they have passed through the left side of the pons.
Clinical facts do not agree with this view, as they show that anaes-
thesia in one side of the body alone is the result of an alteration in
one lateral half of the pons.

The same reasoning may be made as regards the medulla oblon-
gata. When an alteration exists in one lateral half of this organ,
there should be a loss of sensibility in the two sides of the body if
the medulla oblongata were the seat of the decussation of the con-
ductors for the sensitive impressions. Pathological facts do not
leave room for doubt in this respect ; they show that there is anaes-
thesia only in one-half of the body, and that this hemi-anaesthesia
exists in the side of the body opposite to the side injured in the
medulla oblongata.

Imagine an injury or an alteration anywhere you choose, near

1 Journal Hebdomadaire, 1829, vol. v. p. 439.
» Ciinique MGdicale, 2d edit., vol. v. p. 326*
• In Casper's Wochenschrift, 1840, p. 479.
4 Archives de M6decine, &c, Nov., 1834.



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DECUSSATION OP SENSITIVE FIBRES. 95

the median line and only in one lateral half, from the upper part
of the crura cerebri and the tubercula quadrigemina down to the
medulla oblongata; and if this injury produces anaesthesia, it is in
one lateral half only, and this half is the opposite one. Now, to
point out, another time, but in other words, the signification of
these clinical facts, suppose that the injury is in the crura cerebri,
the hemi-aneesthesia being in the opposite side of the body, it results
that the decussation must take place in a part of the cerebro spinal
axis situated below the place altered. If the alterations are in the
upper, the middle, or the lower parts of the pons, on one side, as
the decussation must take place below the seat of the injury, we
are led to the conclusion that it must be in the medulla oblongata
or in the spinal cord. At last, in examining what occurs when the
injury exists in the medulla oblongata, we find that the decussation
must occur in the spinal cord.

As regards the spinal cord, we find also that, the injury existing
in one lateral half, there is loss of sensibility in the opposite side.
This, of course, is a direct and a better proof than the preceding
that the conductors of sensitive impressions decussate in the spinal
cord; but the cases of this kind are not numerous, so that, to give
more power to our demonstration, I will relate the cases referring
to the pons Varolii and the medulla oblongata. I will, there-
fore, divide into two series the cases I have to adduce in proof of
the decussation of the conductors of sensitive impressions in the
spinal cord. In the first series we place the cases of alterations of
a lateral half of the spinal cord ; and in the second series, those of
alterations of a lateral half of the medulla oblongata, the pons
Varolii, &c.

First Series of Cases proving that the Conductors of Sensitive Impres-
sions make their Decussation in the Spinal Cord.

In the name of a committee of the Soci£t£ de Biologie, we have
published a report on a paper by Dr. Ord, of Bordeaux, in which
there are two important cases observed by this physician, in the
Hospital St. Andrd in the wards of Professor Gintrac. Here is an
abstract of these cases : —

Case 29. — A patient was admitted into the St. Andrd Hospital.
He had a paralysis of voluntary movements in the right side of the
body, in which sensibility was preserved. In the left side, on the



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96 THE CENTRAL NERVOUS SYSTEM.

contrary, the voluntary movements existed, but there was a great
diminution of sensibility.

Autopsy. — There was a fungoid growth (v6g6tationfung<nde) press-
ing upon the right lateral half of the spinal oord. (MSmaires de la
Societe de Biologie pour 1854.)

Case 30. — A patient had lost voluntary movements in the two
limbs of the left side, in which sensibility was preserved. In the
right side sensibility was much diminished (tris obtuse.)

Autopsy. — A clot of blood was found in the left lateral half of the
spinal cord in the cervical region. (Memoires de la Soci&ti de Bio-
logic, pour 1854.)

These two cases are certainly extremely valuable, and they agree
perfectly with the results of my experiments on animals. It is
so also with the following cases: —

Case 31. — A man, after having felt a sudden pain in his back,
became incompletely paralyzed of voluntary movements in the
right lower limb. Sensibility was not altered in this limb, but in
the left side, where voluntary movements were not impaired, sensi-
bility was entirely lost from the breast to the foot.

Autopsy. — Brain and its membranes normal. In the spinal cord
an hemorrhage had taken place, and blood was found in the right
side of the gray matter, having destroyed also its horns, and a part
of the right anterior column in the dorsal region. (Monod, in Bul-
letin de la SociSte Anatomigue, No. XVIII., p. 349, Obs. 3, and in
Ollivier, loco cit., vol. ii. p. 177.)

This is a very remarkable case, teaching, not only that there is
a decussation of the conductors of sensitive impressions in the spi-
nal cord, but also that the gray matter is the principal channel for
these impressions. The reporter of the case, M. Monod, I hardly
need to say, is one of the best surgeons of Paris. I subjoin here
three figures, representing sections of the spinal cord, to show the
place where the blood was found.

If we had time, we could show, by some details of this case
which we have not mentioned, that the hemorrhage was, at first,
entirely confined to the gray matter of the right side of the spinal
cord, high up in the dorsal region, and that afterwards the blood
destroyed almost the whole of the gray matter and its horns, in a
great extent, in that same side, and at last injured a little the cen-
tral gray matter of the left side. Had the symptoms, as regards



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DECUSSATION OF SENSITIVE FIBBES. 97

movement and sensibility, been noted after the first days, they
would have been somewhat different from those above related. In
another lecture we shall have to speak again of this most import-
ant case.

In the three preceding cases there is no mention of hyperes-
thesia, although it must have existed on the side of the injury in
the spinal cord ; we shall find it mentioned in the following cases,
and especially in the next one, which we give almost in full on ac-
count of its extreme importance: —

Cask 32.— On the 4th of February, 1850, a man, aged twenty-
eight, was admitted into the St. Louis Hospital, in Professor N£la-
ton's ward, a short time after he had been wounded by a police
officer. Besides a slight wound of the scalp, he had been wounded
by a sword, in his back. The point of the sword was eight milli-
metres large; there was a transversal wound about one centimetre
and a half (half an inch) between the ninth and tenth dorsal ver-
tebrae, and three centimetres (an inch) from the line of the spinous
processes. A physician, who had seen the patient at onoe, had in-
troduced a stylet in the wound, and ascertained that its direction
was oblique from the right to the left, and a little upwards. The
patient complains of slight pains, only near the wound. The lower
limbs are completely deprived of voluntary movements. The next
morning a better examination is made ; the patient has not slept ;
he has suffered violent pains, principally in the left lower limb; he
feels a kind of burning and numbness, as if he were receiving elec-
tric shocks. The sensibility of the left lower limb is quite evi-
dently increased. When a hand is simply applied upon this limb,
the pains become very acute, and the very least pressure makes
him shriek out This morbid state of sensibility exists in the
whole length of the limb, and also upon the left side of the sacrum
and coccyx, and the upper and anterior part of the thigh. Higher
up, sensibility is normal. Even cold air, when the sheet is drawn
down, causes pain in the left lower limb. Voluntary movements
are impossible in all this limb, exoept in the toes, Which can
slightly move.

The right lower limb has a diminution of sensibility; the patient
knows when he is touched, but when pricked with a pin he does
not feel pain, and he does not distinguish a pressure by the finger
from the pricking of a pin. In both cases he has only a sensation

G



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98 THE CENTBAL NERVOUS SYSTEM. *

of contact. This limb is not deprived of movement as it was the
previous day. The flexion of the foot on the leg, and of the leg
on the thigh, are executed; the movements are extensive, but the
patient cannot altogether lift up his limb from the bed.

The temperature of the lower limbs is the same as that of the
re6t of the body, and 'there is no difference between those limbs.
All the organic functions are in a normal condition, except that
there is a retention of urine, and of the fecal matters. Voluntary
movements and sensibility are not altered in the abdomen, and all
the upper parts of the body. In the afternoon, the hyperesthesia
has extended a little higher on the left side in the upper parts of
the abdomen, and the genital organs have also become very sensi-
tive. When a cloth that has been dipped into water at 30° (pro-
bably centigrade, 86° Fahr.), is applied to the left limb, the patient
has a feeling of burning, which makes him cry out. When the
cloth has been dipped into water at the low temperature of the
room, the patient has a very acute feeling of cold.

On the right limb the wet cloth does not give either a sensation
of warmth or cold, or of dampness or dryness, although he feels
he is touched. The tickling of the right foot is not felt as tickling,
but only as a contact. On the left foot tickling is exceedingly
painful.

Gradually this patient became more and more able to move the
right limb, and partly also the left limb. The hyperesthesia dimi-
nished, particularly in the upper parts of the left limb ; but the right
limb became, for a time, unable to feel the contact of a hand, and if
pricked there was a sensation, but the patient did not know its
place. On the 20th of February, a slough was found on the right
side of the sacrum ; the patient had not felt anything there. In
April, voluntary movements had returned in the two limbs, but
sensibility was still deficient in the right one. On the 15th of June,
the patient could walk with the help of a cane, and he left the hos-
pital, not having yet, however, recovered entirely the power of feel*
ing, in his right limb.

Three years afterwards the patient was seen again, and he stated
then that he was quite well, and that he could walk without diffi-
culty or fatigue; but a year later, having walked a distance of
many leagues, he found a large schar, produced, he said, by the
friction of his pants on his right knee; he had felt no pain, and
was surprised when he found this wound. Although sensibility
was still deficient in this limb, all its movements were executed



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DECUSSATION OF SENSITIVE FIBBES. 99

freely, and without fatigue. (Vigu&s, in Moniteur des Efipitaux, Sept
3, 1856, p. 888.)

This important case, so carefully reported by my friend, M.
Yignde, has not the sanction of a post-mortem examination, but it
is so mnch in accordance with the results of experiments in animals
that we have thought there could be no objection to our giving it
as a proof of the exactitude of our views. There are several
points that are certain, or almost certain: in the first place, the
sword entered the cord by its posterior surface; in the second
place, its direction was oblique from behind forwards, and from the
right to the left. These two facts being acknowledged, if we re-
member that the point was eight millimetres large, and that it pene-
trated transversely — i. e n its edges being on a line perpendicular to
the longitudinal axis of the cord — we are enabled to judge of the
injury inflicted to the cord. Let us first admit the old theory, that
the posterior column of the right side transmits the sensitive im-
pressions of the right side of the body, and that the left anterior
column transmits the orders of the will to the muscles of the left
side of the body. Now let ns suppose a section of the right poste-
rior column and the left anterior column : there would have been
then just what occurred in this case, loss of movement particularly
in the left limb, and loss of sensibility in the right limb alone.
But I will remark that such an injury was impossible with such a
sword. Had the left anterior column been entirely, or almost en-
tirely divided at the same time with the right posterior column, the
left posterior column would also necessarily have been cut across,
the sword having at its point almost the same diameter as the whole
spinal cord ; and had the left posterior column been divided, the
left limb, according to the theory just exposed, would have lost its
sensibility, and would not have been hyperaesthetic as it has been.
We must therefore put aside the supposition which we have made.
Now, if we take any of the theories that have been proposed con-
cerning the transmission of the orders of the will to muscles, or of
the sensitive impressions to the brain, through the spinal cord, we
find that, except ours, they are all unable to explain the facts of
this case. We think that the point of the sword entered the cord
by only one of its edges (the right one), dividing entirely the left pos-
terior column, and a part of the right one, and also almost the whole
of the gray matter and of the lateral column on the left side, and
a part of the anterior column of the same side, leaving the gray
matter and the anterolateral column of the right side uninjured,



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100 THE CENTRAL NERVOUS SYSTEM.

except by the pressure upon them by the blood which most have
been effused on the withdrawal of the sword. In this way we can
explain the rapid return of voluntary movements in the right limb,
by the absorption of the blood ; and we explain, 1st, the loss of
sensibility and the persistence for years of a degree of anaesthesia
in the right limb, by the section of almost the whole of the gray
matter in the left side; 2d, the hyperesthesia, by the peculiar in-
fluence we have found that a section (complete or incomplete) of a
lateral half of the cord possesses on the sensitive nerves originat-
ing from the same side of the cord below the injured part ; 8d, the
more complete diminution of movements in the left than in the
right limb, by the injury to the gray matter and anterior column
of that side, and in a measure also to the left column of the same
side.
There was no autopsy, also, in the two following cases.

Case 33. — A man fell on his back, from a height of twenty feet
After having recovered his consciousness, he discovered that the
whole left side of his body, from the shoulder down to the foot,
was paralyzed of movement, but that there was not the slightest
diminution of sensibility, and that the right side of the body, in
which the movements were free, was completely deprived of sensi-
bility.

Three months after this accident the patient was in the following
state : When a needle or a lancet was introduced in the right limbs,
the muscles of which obeyed the action of the will, there was no
pain felt. The reverse existed in the left side, where sensibility
was morbidly increased. The muscles of the right side were pro-
minent, strong, and in good state of nutrition, and not paralyzed ;
while those on the left side were emaciated, and incapable of any
voluntary movement The temperature of the right side was one



Online LibraryCharles-Edouard Brown-SéquardCourse of lectures on the physiology and pathology of the central nervous system : delivered at the Royal College of Surgeons of England in May, 1858 → online text (page 11 of 29)