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THE
NERVOUS SY8TE
OF THK
HUMAN BODY.
I/)NDON.
ruiN i r.:) liV riioMAS davi'son, \viirri;i' ;ii vKS.
THE
NERVOUS SYSTEM
OF THE
HUMAN BODY.
EMBRACING
THE PAPERS DELIVERED TO THE ROYAL SOCIETY ON THE
SUBJECT OF THE NERVES.
BY CHARLES BELL, F.R.S.
^;^^^3\TY OF Ma^
LIBRARY'
f»und»d 1813
^OF_M
LONDON :
PUBLISHED BY LONGMAN, REES, ORME, BROWN, AND GREEN, PATERNOSTER-ROW
AND J. TAYLOR, UPPER GOWER-STREET.
1830.
16530
Cord til
TO
THE KING.
Sire,
When the exultation, into which the Nation had been
carried by the triumphs of your Majesty's arms, had subsided,
it was seen that your Majesty, comprehending justly what
belonged to the reign of a great Prince, had not been un-
mindful that " Peace has her victories no less than war."
Thus have the times, under your Majesty's auspices, been
as remarkable for the progress of science, the accessions to
literature, and the embellishments of architecture and the arts,
as for great naval and military achievements.
Your Majesty's sense of the importance of the cultivation
of the sciences to the state is evinced by the honours placed
by your Majesty at the disposal of learned societies. May I
be permitted to express how much gratification these honours
VI
afford, and how well they are suited to fulfil your Majesty's
gracious intention of exciting emulation, and rewarding exer-
tion in the pursuit of knowledge.
The permission to inscribe this volume to your Majesty,
demands the gratitude of
Your Majesty's
humble and devoted subject,
CHARLES BELL.
PREFACE.
The account of the nervous system given in this volume
was originally presented to the Royal Society in six papers, which
will be found in their Transactions from the years 1821 to 18:29.
Four of these papers were republished under the title of The
Exposition of the Nervous System ; and some time after an
Appendix was given to the public, containing cases in illustration.
In the period immediately preceding the publication of
these papers in the Philosophical Transactions, there was a
singular indifference to the study of the nerves ; and an opinion
very generally prevailed, that as the notions of the ancients had
descended to us uncontroverted and unimproved, the subject
was entirely exhausted. The hypothesis that a nervous fluid was
derived from the brain, and transmitted by nervous tubes, was
deemed consistent with anatomical demonstration, and there
was no hope of improvement.
IMost of the points of anatomy which have directed my
inquiries had been noticed by Dr. Alexander Monro, in his
work on the Nervous System. It was he who discovered that
the ganglions of the spinal nerves were formed on the posterior
roots, and that the anterior roots passed the ganglions. Santorini
vm PREFACE.
and AVrisberg observed the two roots of the fifth pair of nerves.
Procliaska and Soemmerring noticed the resemblance between
the spinal nerves and the fifth pair, and they said, why should
the fifth nerve of the brain, after the manner of the nerves of
the spine, have an anterior root passing by the ganglion, and
entering the third division of the nerve*?
I do not believe that this approach to the knowledge of
the true anatomy of the nervous system, made by these celebrated
men, will at all diminish the reader's satisfaction on perusing this
volume. He will see that the efforts of those who followed them
* Although the course of my Investigations has not been directed by the sug-
gestions of anatomists, yet it is curious to observe how much importance may be now
given to passages which heretofore had httle interest attached to them.
Prochaska concludes his essay on the Structure of the Nerves with this remark-
able passage : " Quis rationem dabit : quare nam nervorum funiculi tam in sua
crassitie quam in miris suis plexibus ac concatenationibus per totum suum decursum
ludant ? Quare radices anteriores nervorum spinalium ganglia spinalia insalutata
transeant, et quare nam sola" posteriores radices ganglia spinalia trannare cogantur ?
Et cur radices nervorum spinalium anteriores ramosa; in medullam spinalem inse-
runter, aut, si mavis, ex ea medulla oriuntur, dum interim posteriores radices funi-
culos teretes non ramosos complectuntur ? Quare omnium cerebri nervorum solum
(juintum par post ortum suum, more nervorum spinalium, ganglion semilunare dictum
facere debet, sub quo peculiaris funiculorum fasciculus ad tertium quinti paris ramum,
maxillarem inferiorem dictum, properat insalutato ganglio semikmari ad siniilitudinem
radicum antcriorum nervorum spinalium ? Et plura alia in structura nervorum
occurrenlia proponi possent, quorum ratio sufficiens reddi nondum potest : attamen
utrum unquam reddi poterit, desperandum esse minime videtur, verum liceat interim
ea lactari spe, (juam tritum proverbium {dabit dies quod liora ncgat) baud raro non
vanam fuisse ostendit.^" — Procha.shi, de Stmc. Ncrv. 1779.
S(Enimcrring, when discussing what were the probable uses of the ganglions,
says, " Qua2 causa est, cur in radice posteriore tantum nervorum spinalium ganglia
inveniuntur, minime autem in priore. An priore nervorum spina? medulla? radice, et
niinori quinti nervorum paris poitioni novo hoc virium augmento non opus est ?"
— Swmmen-ing; de Corp. Hum. Fob. Tom. iv.
PREFACE. IX
were still undirected by any principle, and that the multiplicity
of anatomical facts which continued to be discovered by the
anatomists of Europe only added to the intricacy of the subject.
Paletta described the anterior root of the fifth nerve, and
tracing it to the muscles of the jaw, conceived it therefore to be
a muscular nerve*. But did this observation diminish the in-
tricacy of the nervous system, or add to it ? For example, Paletta,
after the discovery of these branches of the fifth pair to the
muscles of the jaw, and just as one would expect that he was
about to expound the truth, adds, that for the other branches of
the fifth nerve he does not know what to make of them ! So
that he who really knew the detail of this part of anatomy most
perfectly, was most confused.
It will appear in the text, that after struggling with the
difficulties in the demonstration of the nerves of the body for
many successive years, I had recourse to their origins to find
out their uses. I first took a view of the spinal nerves in all
their course, and observed their exact resemblance to each other
in every particular. I then by experiment proved that their
roots had different powers, and that they really were what their
anatomy had indicated to me, double nerves. Strengthened in
my conviction that the anatomy, if properly pursued, would
bring symmetry out of confusion, I set about the examination
of the nerves of the encephalon, and found that the fifth nerve
of the brain was the only one which could bestow upon the
* He saw the branches crotophiticus and buccinatorius, which he considered
to be voluntary nerves, and to be the cause of trismus.
b
X PREFACE.
head, that which was given to the body through the spinal
nerves. I then selected the nerves of the face for experiment, to
demonstrate to others what I had convinced myself of, by anatomy.
Had I commenced with experiments, they would have misled
me ; I should have supposed the fifth nerve to have been the
nerve of sensibihty, and the portio dura the nerve of motion.
All I wished was to make a sufficient impression on those who
had resigned all hope of a definite issue to the investigations of
nerves. I had before determined that the fifth was a double
nerve, a nerve of motion as well as a nerve of sensation ; and
that the portio dura of the seventh was more than a muscular
nerve, that it belonged to the respiratory system, and that
this was the reason of its running apart from the fifth.
Facts connected with this subject multiply every day, and
now, owing to the knowledge of the general system, its arrange-
ment, and the functions of the different roots, they assume an
order, instead of adding to the former confusion. To show how
little the grand features of the nervous system were known,
and how necessary system was to the comprehension of details,
I shall add some further illustrations. It had been asserted by
our English physician, Johnstone, that ganglions were for the
purpose of cutting off sensation. Monro on the contrary con-
ceived that they did not cut off sensation, for they were attached
to nerves which he knew to be muscular nerves ! " That gangha,"
he says, " do not serve to render motions independent of our
will, as an ingenious author (viz. Johnstone) has supposed, is
evident, without observing more than that all the branches of
PREFACE. 3a
the fifth pair, and the posterior half of all the spinal nerves of
the voluntary muscles, pass through ganglia*." If I had only
ascertained that this M^as not true, and that no motor nerve
from the head to the heel passes through a ganglion, the observa-
tion should have been received with more show of interest.
The celebrated Scarpa dwells with great minuteness on the
ganglions of the spinal nerves and the double origins of the
nerves, and he puts the question — why should the posterior
root have a ganglion? " Is the posterior root," says he, " a
proper and peculiar kind of nerve, belonging exclusively to the
spinal marrow, whilst the anterior root is a cerebral nerve ?"
Thus we see that notwithstanding the knowledge of minute
anatomy, the observation standing in this shape carries no force
with it, and leaves the system doubly confounded. The elegant
plates of the nerves of the throat and thorax by this author,
and the cases in illustration of the affections of the ninth
nerve, have proved the highest source of satisfaction and
improvement to me. And yet these nerves, as represented
by ^icarpa, may convince the reader, as the class dissection was
wont to impress me, that our notions received from the ancients
were quite inapplicable and unsatisfactory.
What better proof can be afforded of the utter confusion
which prevailed than the explanation of Soemmerring, — that many
small nerves were equivalent to one larger, and that this was the
reason of there being three nerves given to the tongue; or that
of Monro, that there were two nerves given to the face, lest by
* Monro's Plates of the Nerves, page 55.
b2
Xll PREFACE.
the accidental division of one, the face should be deprived of
nervous power altogether? This was the authority for the
surgeon making so free with the nerves of the face in the case of
tic douloureux. He divided them, confiding in the opinion that
if one nerve of the face were cut, the remaining nerve would
bestow both sense and motion, though in a diminished degree.
Such, then, was the state of opinions previous to the first paper
given by me to the Royal Society ; nor is it surprising that
whilst these contradictory notions prevailed, our physicians
should look upon the nervous system with despair of finding any
satisfactory result to direct their practice. The practical benefit
to be derived from these investigations is, not only that the
physician shall discover distinct systems of nerves to be the
seat of disease, but he shall acquire new powers of dis-
criminating symptoms, as 1 hope may be shown by the cases in
the Ajopendix,
Immediately after the publication of these papers, attempts
were made both in France and at home to deprive me of what-
ever merit was attached to them. From the indifference so
long evinced to such investigations before these communications
to the Royal Society, I conceived that I should have been per-
mitted in a slow, temperate, and scientific manner, to have
stated the whole of my observations to that learned body.
This, however, became difficult, not only from the attempts
made to anticipate my conclusions, but also because in the
further prosecution of the subject it became necessary to
introduce medical cases. The present mode of publication
admits of those professional illustrations which appear to dis-
PREFACE. Xiu
advantage in the philosophical transactions, which should be
open to general science only.
It was owing to a mere accident that my opponents did not
succeed, by the mere reiteration of assertions, in these attempts,
which would have been attended with this disadvantage to
science — that as they hastened to anticipate my conclusions,
before they themselves comprehended the system, or knew on
what secure foundation and long experience it rested, they had
"almost thrown the whole subject into doubt, and into worse
confusion than had prevailed before. Whilst one gentleman
summed up his conclusion by supposing that the fifth pair of
nerves was the nerve of sensation to the face, and the seventh a
voluntary nerve ; another physiologist had, in addition to my
observation of the fifth being a double nerve, added that it
was the nerve of all the senses !
These mistakes arose from undervaluing the subject, and
mistaking the method of investigation, conceiving that it was
possible without a careful examination of functions, by an ex-
periment merely, to come to the right conclusion. As soon
as the principle was ascertained that nerves had different
functions according to the divisions of the brain and spinal
raarrow, from which they took their origin, all the rest followed
of course ; it required only to study the functions of the organs
and the nerves supplying them, to prove which nerve ministered
to each distinct function. Had any physiologist meant to assist
me in this part of the investigation, good sense, which so often
answers the same end with right feeling, should have dictated an
acknowledgment of the principle on which he was proceeding.
XIV PREFACE.
It was fortunate that after having been engaged in the
investigation of the nervous system for some years, and finding
interminable labour before me, I thought of taking the opinion
of my friends, and of exposing my notions to their criticism, lest
I should uselessly expend all my leisure on an unprofitable sub-
ject. It was with this purpose that I printed a little work in
1811, which I entitled, ^^ An Idea of a new Anatomy of the Brain,
submitted for the Observation of the author's Friends."
I do not know that I could introduce the subject with a
more appropriate preface, after twenty years' familiarity with the
investigation, than is in that little work. The following passage
will show how early and how uniformly I have held the same
language, and how happily my anticipations have been ful-
filled.
" The prevailing doctrine of the anatomical schools is, that
the whole brain is a common sensorium; that the extremities of
the nerves are organized so that each is fitted to receive a
peculiar impression; or that they are distinguished from each
other only by delicacy of structure, and by a corresponding
delicacy of sensation; that the nerve of the eye, for example,
differs from the nerves of touch only in the degree of its sensi-
bility. It is imagined that impressions, thus differing in kind,
are carried along the nerves to the sensorium, and presented to
the mind; and that the mind, by the same nerves which receive
sensation, sends out the mandate of the will to the moving
parts of the body.
" It is further imagined that there is a set of nerves, called
vital nerves, which are less strictly connected with the sen-
PREFACE. xy
sorium, or which have upon them, knots cutting off the course of
sensation, and thereby excluding the vital motions from the
government of the will.
"This appears sufficiently simple and consistent, until we
begin to examine anatomically the structure of the brain and
the course of the nerves ; then all is confusion : the divisions and
subdivisions of the brain, the circuitous course of nerves, their
intricate connexions, their separation and reunion, are puzzling
in the last degree, and are, indeed, considered as things in-
scrutable. Thus it is, that he who knows the parts the best is
most in a maze ; and he who knows least of anatomy sees least
inconsistency in the commonly received opinion.
" In opposition to these opinions I have to offer reasons for
believing, that the cerebrum and cerebellum are different in
function as in form ; that the parts of the cerebrum have dif-
ferent functions, and that the nerves which we trace in the body
are not single nerves possessing various powers, but bundles of
different nerves, whose filaments are united for the convenience
of distribution, but which are distinct in office, as they are in
origin, from the brain :
" That the external organs of the senses have the matter of
the nerves adapted to receive certain impressions, while the
corresponding organs of the brain are put in activity by the
external excitement ; that the idea or perception is according to
the part of the brain to which the nerve is attached ; and that
each organ has a certain limited number of changes to be wrought
upon it by the external impression :
XVI PREFACE.
" That the nerves of sense, the nerves of motion, and the
vital nerves, are distinct through their whole course, though
they seem sometimes united in one bundle ; and that they
depend for their attributes on the organs of the brain, to which
they are severally attached.
" The view which I have to present will serve to show why
there are divisions and many distinct parts in the brain ; why
some nerves are simple in their origin and distribution, and
others intricate beyond description. It will explain the ap-
parently accidental connexion between the twigs of nerves ; it
will do away the difficulty of conceiving how sensation and
vohtion should be the operation of the same nerve at the
same moment ; it will show how a nerve may lose one property
and retain another ; and it will give an interest to the labours of
the anatomist in tracing the nerves."
1 have to add, that, after making several experiments on the
cerebrum and cerebellum, I laid the question of their functions
entirely aside, and confined myself to the investigation of the
spinal marrow and the nerves; a subject which I found more
within my power, and which forms the substance of the present
volume.
So much has been said about a French physiologist an-
ticipating my observations, that I will here transcribe frcm the
little work quoted above, my opinions of the functions of the
spinal marrow, and the distinct offices of the anterior and
posterior roots of the spinal nerves in 1811.
" In thinking of this subject, it is natural to expect that we
PREFACE. xvii
should be able to put the matter to proof by experiment. But
how is this to be accomplished, since any experiment direct upon
the brain itself must be difficult, if not impossible ? I took this
view of the subject ; the inedulla spinalis has a central division,
and also a distinction into anterior and posterior fasciculi corre-
sponding with the anterior and posterior portions of the brain.
" Further, we can trace down the crura of the cerebrum into
the anterior fasciculus of the spinal marrow, and the crura of the
cerebellum into the posterior fasciculus. I thought that here
I might have an opportunity of touching the cerebellum, as it
were, through the posterior portion of the spinal marrow, and
the cerebrum by the anterior portion ; to this end I made ex-
periments, which, though they were not conclusive, encouraged
me in the view I had taken.
" I found that injury done to the anterior portion of the
spinal marrow convulsed the animal more certainly than injury
to the posterior portion ; but I found it difficult to make the
experiment without injuring both portions.
" Next, considering that the spinal nerves have a double root,
and being of opinion that the properties of the nerves are derived
from their connexions with the parts of the brain, I thought that
I had an opportunity of putting my opinion to the test of expe-
riment, and of proving at the same time that nerves of different
endowments were in the same cord and held together by the
same sheath.
" On laying bare the roots of the spinal nerves, I found that
I could cut across the posterior fasciculus of nerves which took
c
XVlll PREFACE.
its origin from the posterior portion of the spinal marrow
without convulsing the muscles of the back; but that on touch-
ing the anterior fasciculus with the point of the knife, the mus-
cles of the back were immediately convulsed.
" Such were my reasons for concluding that the cerebrum and
cerebellum were parts distinct in function, and that every nerve
possessing a double function obtained that by having a double
root. I now saw the meaning of the double connexion of the
nerves with the spinal marrow; and also the cause of that seem-
ing intricacy in the connexions of nerves throughout their course,
which were not double at their origins.
" The spinal nerves being double, and having their roots in
the spinal marrow, of which a portion comes from the cerebrum,
and a portion from the cerebellum, they convey the attributes of
both grand divisions of the brain to every part, and therefore the
distribution of such nerves is simple, one nerve supplying its
destined part. But the nerves which come directly from the
brain come from parts of the brain which vary in operation ; and
in order to bestow different qualities on the parts to which the
nerves are distributed, two or more nerves must be united in
their course, or at their final destination. Hence it is that the
first nerve must have branches of the fifth united with it :
hence the portio dura of the seventh pervades every where the
bones of the cranium, to unite with the extended branches of the
fifth : hence the union of the third and fifth in the orbit : hence
the ninth and fifth are both sent to the tongue : hence it is, in
short, that no part is sufficiently supplied by one single nerve.
PREFACE. XIX
unless that nerve be a nerve of the spinal marrow, and have a
double root, a connexion (however remotely) with both the cere-
brum and cerebellum.
" Such nerves as are single in their origin from the spinal
marrow will be found either to unite in their course with some
other nerve, or to be such as are acknowledged to be peculiar in
their operation.
" The eighth nerve is from the portion of the medulla ob-
longata* which belongs to the cerebellum; the ninth nerve
comes from the portion which belongs to the cerebrum : the
former is a nerve of the class called vital nerves, controlling
secretly the operation of the body; the latter is the motor nerve
of the tongue, and is an instrument of volition. Now the con-
nexions formed by the eighth nerve in its course to the viscera
are endless : it seems no where sufficient for the entire purpose
of a nerve, for every where it is accompanied by others : and the
ninth passes to the tongue, which is already profusely supplied
by the fifth.
" Understanding the origin of the nerves in the brain to be
the source of their powers, we look upon the connexions formed
betwixt distant nerves, and upon the combination of nerves in
their passage, with some interest ; but without this the whole is
an unmeaning tissue. Seeing the seeming irregularity in one
subject, we say it is accident ; but finding that the connexions
never vary, we say only that it is strange, until we come to un-
derstand the necessity of nerves being combined in order to
* " The medulla oblongata is only the commencement of the spinal marrow."
c 2
\
XX PREFACE.
bestow distinct qualities on the parts to which they are sent.
From the crura cerebri, or its prolongation in the anterior fasci-
cuh of the spinal marrow, go off the nerves of motion. But with
these nerves of motion, which are passing outward, there are
nerves going inwards ; nerves from the surfaces of the body ;
nerves of touch ; and nerves of peculiar sensibiUty, having their
seat in the body or viscera. It is not improbable that the tracts of
cineritious matter which we observe in the course of the medul-
lary matter of the brain are the seat of such peculiar sensibilities ;
the organs of certain powers which seem resident in the
body." In this extract there is much which has been rejected
from the present volume, as inconsistent with mature reflection,
or incapable of proof; yet the principle which has guided me
is distinctly announced.
When the first paper was written for the Koyal Society, the
facts to be collected from books, or ascertained by what occurred
in practice, were so few, and yet so important, that they were
admitted into the body of the dissertation. But in the time
that has elapsed since the first publication of these papers, cases
have so multiplied upon me, and have been so liberally com-
municated, that they cannot now be given to the pul^lic as
part of the original essays, without overloading the subject and
introducing intricacy. Besides, these cases being now illustrated
by a better knowledge of the anatomy, they assume a new im-
portance. Formerly the symptoms, which are both regular and
of easy ex])lanation, were thought to be irregular and accidental.
They were classed as nervous symptoms, which was anotlier way
PREFACE. XXI
of saying that the physician was not expected to investigate or
explain them. For these reasons the cases are in this edition
thrown into an appendix, and occasional comments upon them
enable the reader to enter upon some new inquiries without
distracting his attention from the study of the body of the work.
Whatever may be thought of the course of reasoning
pursued in this volume, the facts admit of no contradiction :
and perhaps, hereafter, curiosity may be excited to know in what
manner they were first received. The gratification in the inquiry
has been very great : the reception by the profession has been
the reverse of what I expected. The early announcement of
my occupations failed to draw one encouraging sentence from
medical men. When the publication of these papers by the
Royal Society made it impossible to overlook them altogether,
the interest they excited drew countenance on those who
opposed them, or who pretended to have anticipated them. To
myself this has ceased to be of consequence ; but I confess, I
regret to leave those young men who have honourably and
zealously assisted me in these inquiries*, in the delusive hope of
labouring to the gratification of their own profession — the plea-
sure arising from the pursuit of natural knowledge, and the
society of men of science, must be their sufficient reward.
* I am indebted to a pupil for this note.
The following was the order of communications to the public, on those investiga-
tions of the Nervous System, which were carried on openly in Mr. Bell's theatre, and
taught in his lectures.
The " Idea of a new Anatomy of the Brain," &c., was printed in 1811.
miYERSITY OFMERYLEUD
INTRODUCTION.
FIEST PART.
I.
When the nerves of the human body are fully displayed,
by a dissection pursued for two or three months on the body
preserved in spirits, there appears inextricable confusion. The
same irregularity is visible on the perusal of good engravings of
the nervous system, such as those of the celebrated Scarpa, the
most distinguished anatomist of our time. But if two or more
bodies shovdd be dissected with the same patience and dexterity,
we find that if we lift a thread of nerve, and observe its connexion
in one body, the second and the third bodies will have a similar
thread, with just such connexions as in the first. If we trace
one, two, or three nerves distributed to one organ in the first
body, just so many nerves, and in the same order, will be found
in the second and the third bodies. If we pick out a small
ganglion in the one, it seems like a thing of chance until we
find a similar ganglion, in the precise same spot, with exactly
the same twigs of connexion, in all the bodies. In all the
dissections we make, there are the same joinings and branchings
B
2 INTRODUCTION.
of the same number of nerves ; and we perceive the exactness of
resemblance just in proportion to the care with which the
preparations are made. No thinking person can avoid coming
to the right conclusion here. At first this intricate net-work
seems accidental ; there appears neither arrangement nor system :
but when the anatomist finds a perfect resemblance in all those
bodies ; when the minute twig discovered at Pavia or Berlin is
as surely found by the anatomist in London as the astronomer
abroad traces in the heavens the discoveries of Herschel; there
can be no longer a doubt of the nerves being distributed with
regularity and system.
II.
The term irregular may be applicable to arteries and veins,
because it signifies not whether a part be supplied by this or
that branch of the aortic system ; arterial blood will be supplied,
whether it comes from the right hand branch or the left. But
the seeming irregularities of the nervous system ought not to be
considered as such; the error is in our mode of proceeding;
either the dissection has not been minutely prosecuted, or we
have thought that mere contact was a union of the branches of
the nerves. It will be proved that the property dispensed
through them results altogether from the source from which
the nerve is derived, and that one nerve cannot supply the
office of another. There is no such thing as a nerve deviating
or being wanting, (an occurrence frequent in the vascular
system), without the loss of some essential faculty.
INTRODUCTION. 3
III.
From the age of Galen, or perhaps from that of Herophilus
and Erasistratus, down to the present time, the hypothesis has
been maintained with httle variation, that the brain presides
over the body through the spinal marrow and the nerves. A
fluid was supposed to be secreted from the brain, and transmitted
through the nerves, which were supposed to be tubes ; this fluid
was universally distributed to the moving and sensible parts
of the frame, and through the agency of this fluid all the
phenomena of life were presumed to be carried on. This
notion is easily conceived, and corresponds with the language
of the learned and unlearned. But it is utterly at variance
with anatomy ; for if the brain is the common source of this
fluid, where is the necessity for the double and triple set of
nerves given to one organ, and what is the explanation of the
intricate connexions formed amongst the nerves? If this
supposed nervous fluid were equal to all the phenomena exhibited
in the nervous system, if there were one kind of influence pre-
vailing, we should have expected to find the nerves diverging
regularly from the brain to all parts of the body. But this is
by no means the case.
IV.
A critic, with no unfriendly intent, has attempted to show
that my opinions are nothing more than those of Galen. I
should have been proud to be able to say, that I had re-
conciled the theories of the ancients with the more perfect
B 2
4 INTRODUCTION.
knowledge of modern anatomists; but I fear it is not so. The
division of nerves arising from the brain into those of sensation
and motion, or into hard and soft nerves, proposed by Galen,
implies no more than that he understood that there were nerves
appropriated to the organs of the senses, and nerves for the
governance of the muscles. Neither does the idea of Galen,
that the ganglion was given to a nerve when strong motory
powers were required, savour much of the distinction now
discovered. Galen supposed motion and sensation to be the
properties of the same nerve, but considered motion to be
active and sensation passive, and it was possible, he thought,
that there might be nervous power sufficient for sensation,
though not for motion. Thus he explained how it happened
that sensation remained when motion was lost. And the same
idea has been entertained by some more modern authorities.
Vesalius resisted the authority of Galen on many points,
but he adopted with little variation both his description of the
anatomy of the brain and nerves, and his opinions on the nervous
system. According to him the vital spirits were elaborated in
the brain, and transmitted from the ventricles of the brain into
the spinal marrow and the roots of the nerves, and so sent over
the body. Willis indeed gave an arrangement of the system,
adapted to the appearance presented on dissection, and he enter-
tained many ingenious conjectures on the uses of the parts of the
brain ; but still that organ was with him the sole qfftciua spiritimmy
the source of that subtle spirit which was distilled through the
nerves. And if Willis be found engaged in an inquiry whether
there be a vital and animal spirit, or a sensorial and motor spirit.
INTRODUCTION. 5
it is hypothetically, and neither founded strictly on anatomy nor
on experiment. All these questions are touched on by Haller,
where in the end he concludes — But I know not a nerve which
has sensation without also producing motion ; the nerve which
gives feeling to the finger is that which moves the muscles; and
the fifth nerve of the brain branches to the papillae of the
tongue, and also to the muscles. It is therefore certain that
Haller, who had traced the opinions of authors with the utmost
diligence, gathered nothing from the ancients. The confusion
in his mind, as well as in the minds of our most learned phy-
sicians and commentators, declared the necessity of having re-
course to the volume of nature itself.
V.
Dr. Baillie left his account of the nervous system to be
published after his death. In that publication we have a per-
sj^icuous detail of the system which I have alluded to : and these
were the doctrines he taught with universal approbation in the
school of Windmill-street. Mr. Wilson, my immediate pre-
decessor and colleague, in the same school, did not deviate from
that system in the slightest particular. Such then was the system
followed universally, and taught by my colleague, and in my
own school.
If men look upon the same object in one unvarying aspect,
they will probably receive a similar impression, and describe what
they see in nearly the same words. The error throughout has been
in tracing the nerves from the brain, and taking the instance of
the human body, that is, the highest and most complicated form as
6 . INTRO DUCTIOK
the foundation of the system, instead of tracing the nerves through
the changes they exhibit in different animals, in correspondence
with the formation of these animals, or the organs they possess.
When it was discovered that the lower creatures move and
shrink from injury, and yet possess no nerves, it was not to be
supposed that such creatures had no nervous matter in their
composition. Such a supposition would have drawn us into
the difficulty of being forced to admit that the ways of nature
were not uniform — that sensation and motion were in one creature
endowments of the nervous system, whilst in another a different
mode of action was in operation. This consideration forces on us
the belief that the nerves which appear in creatures that have
distinct organs, or muscles that require to be combined in
operation, are introduced to combine parts which singly, and
as insulated parts, are already (in these lower animals) in
possession of vital power. That power is no doubt possessed
through the operation of the same diffused nervous matter in all
animals, from the simplest up to man.
VI.
When this is understood, a material difficulty in our
investigation is removed ; we obtain a clew to the increasing
complication of nerves seen in animals as we ascend in the scale
of existence. The lowest condition of the nervous system is in
animals which are not symmetrical in form, and which have im-
perfect organs of motion. In such animals an irregular central
ganglion, with an attached nerve, is all which is perceived. But
if a creature possess regular organs of progression, and con-
INTRODUCTION. 7
sequently an arrangement of many muscles to produce a com-
bined operation, we shall find an orderly provision of nerves.
The foot of the gastropoda is known to have little rough points,
which lay hold on a surface ; each of these points has its regular
muscle, and each muscle has its nerve; so that a central chain
or a Cauda equina of diverging filaments may be seen.
But if such an insect as the scarabaiis nasicornis, for
example, be dissected before and after its metamorphosis, a
singular change in the nervous system will be observed to cor-
respond with the change in its organs of motion. The chain of
ganglia and diverging nerves, which were appropriated to the
numerous muscles of its foot, disappear, and the system appro-
priate to the winged insect takes their place.
VII.
What we see accompanying the change of structure in the
same insect, examined before and after it takes wing, may be
seen more satisfactorily by comparing one animal with another
which differs in organization; for example, as new organs of
sense are bestowed in the ascending scale of animals, new nerves
and new ganglions are given ; and as new or more perfect organs
of motion are bestowed, we still perceive the increasing number
and magnitude of the nervous cords.
VIIL
The idea so naturally inculcated by this manner of surveying
the nervous system, in its gradual development from the less
perfect to the more complicated animal, has been perverted by
8 INTRODUCTION
the influence of the celebrated Bichat. His influence has been
very extensive on the continent, and his behef was, that the
chain of gangUonic nerves, seen in the worm or the leech, was
the same with that which is called the sympathetic system in
man and the higher order of animals.
We must speak of Bichat with the respect which is due to
a man of genius ; he possessed ingenuity, industry, and eloquence.
It was this eloquence, united to an indifference for the au-
thorities in anatomy, and the extraordinary condition of Europe
at the time of his publication, that overpowered the physiologists
of the continent, and by which misconceptions were entertained
as to the relative importance of the parts of the nervous system.
Nothing it appears would suit the time (the commencement of
the French revolution) but the entire overthrow of former sys-
tems, and the substitution of a new theory. It was the pleasure
of Bichat to divide the nerves into two distinct systems, instead
of the one uniform system of the ancients, in which the nerves
were supposed to proceed from the sensorium, as a grand centre,
and from that to derive their powers. One of his nervous systems
he conceived to have its centre in the brain, consisting of the
nerves destined to receive impressions, and of the nerves which
convey the influence of the will to the muscular system. The
other had many centres. The power of this last system emanated
from the ganglions, which he observed largely scattered among
the viscera ; and each ganglion he conceived, with the authorities
above, though he was far from acknowledging such authorities,
to be a distinct source of nervous influence, whilst a relation
was preserved between them by connecting nerves. The first
INTRODUCTION. 9
was, according to this author, the nervous system of the animal
life, having one centre in the brain, to which sensation is pro-
pagated, and from which motion proceeds; whilst the second
system was for organic life, had many distinct centres, and many
functions relating to the operations of the animal economy, over
which the mind had no power.
This bold invention was supported by many curious in-
stances, and its author exhibited much knowledge, as well as
ingenuity: but it was anatomically incorrect, and nothing more
clearly evinced the wrong methods of study prevailing on the
continent, than the acquiescence and approbation with which
this system was received there. Two errors pervaded the whole,
which ought not, for an instant, to have been left undetected.
The first was in screening from himself what he could not be
ignorant of — that the cerebral nerves also have ganglions; that
thirty-one pairs of large ganglions, in regular order, and carefully
protected, like important or^ns, are to be found in the nerves
of the head and spine. This at once should have caused the
rejection of the name of ganglionic system of nerves, given to
his nerves of organic life. But his error was not merely the
misapplication of a name: there was misconception and radical
error throughout the whole system. Although Bichat's gan-
glionic system was presented with the aspect of novelty, there
was, in truth, no actual discovery. Anatomists had already
convinced themselves that the sixth nerve was not the root of
this sympathetic nerve; that a filament so small could not be
the trunk of that system which, expanding into larger branches,
and furnished with numerous ganglions, was seen to pervade the
c
10 INTRODUCTION.
whole viscera, and to connect itself with every nerve of the
body. The opinion had been propagated that it was a system
of visceral nerves extending every where, and not depending
upon the encephalon.
But the most remarkable misconception of Bichat was, in
imagining that he saw, in the ganglionic system, or the sympa-
thetic system of man, the development of that series of nerves
which is seen in the lower creatures: thus considering those
nerves which, in them, give sensation and volition, to be the
same system which, in the human body, even by his own
showing, give no token of being either the organ of sensation or
of voluntary motion.
IX.
Since Ave have touched upon this subject, I may here state
what is known of the sympathetic nerves. AVlien I began study,
it was usual to demonstrate this nerve as a nerve of the brain,
descending more directly from the sixth and the second division
of the fifth nerves — to trace it through the carotid foramen, down
the neck with the ncrviis vagus, and so on to its divisions to the
heart, and then as intercostal to the viscera. This term, inter-
costal, sufficiently marked its connexions; it was so called from
the frequency of its connexions with the intercostal nerves, viz.
the spinal nerves which take their course between the ribs.
X.
It being acknowledged that nerves were the only bonds by
which the sympathies of distant parts were to be accounted for,
INTRODUCTION. 11
and physicians observing the connexions between the different
parts, the emotion expressed in the face, the affection of the
organs of sense, that blushing proceeds from the influence of
passion on the body, and even such connexions as sneezing from
tickhng the nose: all these were accounted for by sympathy
through this nerve ; and hence, for distinction, it was called the
sympathetic nerve. The experiments detailed in this volume
will clear away that mass of error in which physiologists were
involved. But I am now the more bound to state our obligations
to Bichat, having shown how far, in some respects, he w^as
incorrect. To him we owe the important fact, that there is no
sensibility in the branches of the sympathetic nerve, nor in the
ganglions formed in its progress. These parts may be cut and
pinched in the living body without producing pain, and they
move no muscular apparatus, as far as we at present perceive.
XL
The functions of this system are known only by negatives :
we have ascertained that they have nothing to do with volition,
nor with sensation, nor with respiration, nor with expression,
nor with sound and speech.
We are left therefore to the conjecture, that the sympathetic
nerve, or the ganglionic system of nerves, according to Bichat,
are for those thousand secret operations of a living body which
may be called constitutional. Circulation, secretion, and ab-
sorption, are operations which simultaneously affect the entire
frame. Constitutional peculiarities, fever, and general derange-
ment of health, must, we conceive, belong to this system of nerves.
c 2
12 INTRODUCTION.
And we call it system ; for it is curious to observe, that by the
progress of anatomy this lesson has become easy. Painfully,
and with a stretch of memory, we were formerly endeavouring
to recoUect the relations and connexions of the sympathetic
nerve, but now we know that it is extended universally ; that its
relations to the nerves of the head are not more remarkable
(when looked upon free of hypothesis) than its branches to the
nerves of the extremities ; that it extends to all the internal
viscera. It is universally distributed to all parts of the body ;
and in this is its peculiarity.
XII.
As to the origin of the sympathetic nerve, we cannot
assign it a commencement. It has a twig from each nerve of the
spinal marrow^ ; but these are very small nerves, compared with
the mass of nervous matter seen in the centre of the viscera of
the abdomen.
The semilunar ganglion and the solar plexus being parts
of this system, and the branches of nerves extending and
diminishing from this region, give countenance to the idea that
we have here the centre of the sympathetic system.
This conjecture is countenanced by the fact, that these
viscera of the abdomen perform functions the most independent
of the will, and over which the mind has no control. Indeed,
it appears to be one of the happiest provisions that these func-
tions of vital importance are withdrawn from the governance of
the mind. No part of the human body is altogether independent.
When, by circuitous influence, the mind does operate on the
INTRODUCTION. 13
vital functions, we know what disturbance is produced ; which
is enough to show with what beneficial effects the relations
are made remote.
Here the investigations of Dr. Wilson Phihp become of
great interest, as distinguishing between the sensorial powers,
the functions of nerves in connexion with the sensorium, and
those vital operations belonging to constitutional functions.
But even these, highly as we must prize them, must be revised
under a more accurate knowledge of the different nerves and
distinct ganglions, than prevailed at the commencement of his
inquiries.
SECOND PART.
BEING
A FURTHER EXPOSITION OF THE SYSTEM OF THE NERVES.
A DESIRE having been expressed to see a simple and con-
nected view of the system of the nerves, the following account
was drawn up for this purpose*. Something of this kind had
become necessary in addition to the papers published in the
Philosophical Transactions : for although those dissertations
explain some of the remarkable facts brought out in the course
of the investigation, they do not convey an idea of the system
as I have conceived it ; nor display its chief excellence, which
is its simplicity, and the order which has been introduced into
the demonstration of the nerves.
My conceptions of this matter arose by inference from the
anatomical structure; so that the few experiments which have
been made were directed only to the verification of the funda-
mental principles on which the system is established.
In France, where it has been attempted to deprive me
of the originality of these discoveries, experiments without
* Written as introductory to the first edition.
INTRODUCTION. 15
number and without mercy have been made on living animals ;
not under the direction of anatomical knowledge, nor by what
I should consider to be the right method of induction, but
prosecuted with cruelty and indifference, in hope to catch at
some of the accidental facts of a system which, it is evident,
the experimenters did not fully comprehend.
The view which I have taken of the nerves has not been
the result of hasty and premature conjecture, but of patient
investigation. From the first year of my delivering lectures,
my demonstrations of the brain were given in a manner not
then common ; and to this peculiarity in the manner in which
I looked on the connexions of the brain, I trace the origin of
opinions different from those hitherto entertained. By the time
I began to lecture in Windmill-street, I was enabled to follow,
in my demonstrations of the nerves, an arrangement which has
given a new interest to the subject, and which, by imperceptible
degrees and improvements from year to year, during every
succeeding course of demonstration, has at length developed
the comprehensive system which I have now to present to the
reader.
The steps by which I have cautiously advanced have been
observed only by my older and more diligent pupils ; who,
becoming interested in the subject, have returned, during
successive years, when it was under consideration, to heai'
how I continued to prosecute it. They have seen the system
gradually developed, and have heard me announcing the deside-
rata as the inquiry proceeded, and explaining the difficulties ;
16 INTRODUCTIOX.
and they have seen how the points which were in one season
the most obscure have, by dihgent investigation, become those
of the very highest interest in succeeding courses.
In the view which I have taken of the nerves of the human
body, there are, besides the nerves of vision, smell, and hearing,
four systems combined into a whole. Nerves entirely different
in function extend through the frame ; first, those of sensation ;
secondly, those of voluntary motion ; thirdly, those of respira-
tory motion ; and lastly, nerves constituting the sympathetic
system, which from their being deficient in the qualities that
distinguish the three others, seem to unite the body into a
whole, in the performance of the functions of nutrition, growth,
and decay, and whatever is directly necessary to animal exist-
ence. Of these, the two first are bound together through their
whole course ; the third are partially joined to the two former ;
and the last are the most irregular of all.
I.
A nerve, as we see it taking its course in the human body,
is a dense white cord : the density is entirely owing to the
membranous coverings of the nerve. There are three which
correspond with the coverings of the brain, and indeed which
may be traced from them. What corresponds with the pia
mater is a delicate and vascular membrane, which forms minute
sheaths or tubes, in which the proper matter of the nerve is
contained.
INTRODUCTION.
17
II.
These nerves are sometimes separate; sometimes bound
together ; but they do not, in any case, interfere with or partake
of each other's influence *.
If we take up a nerve to examine it, we find that it consists
of distinct filaments ; but there is nothing in these filaments to
distinguish them from each other, or to declare their offices.
One filament may be for the purpose of sensation; another for
muscular motion ; a third for combining the muscles in the act
of respiration. But the subserviency of any of all these
filaments to its proper office must be discovered by following it
out, and observing its relations, and especially its origin in the
brain and spinal marrow. In their substance there is nothing
particular. They all seem equally to contain a soft pulpy matter
enveloped in cellular membrane or pia mater, and so surrounded
with a tube of this membrane as to present a continuous track
of pulpy nervous matter, from the nearest extremity in the
brain to the extremity which ends in a muscle or in the skin.
* A. represents a nerve with its sheath or neurilema; B. a single filament
dissected out.
18 INTRODUCTION.
III.
Previous to the observations which I have made, such a
nerve as I have described was supposed to have all its threads
alike ; they were supposed to be branches from the same root,
and all capable of exciting a muscle or conveying a sensation.
IV.
The key to the system will be found in the simple pro-
position, that each filament or track of nervous matter has its
pecuhar endowment, independently of the others which are
bound up along with it ; and that it continues to have the same
endowment throughout its whole length. If we select a fila-
ment of a nerve, (for example, one of those in the compound
nerve represented above), and if its office be to convey sensation,
that power shall belong to it in all its course wherever it can be
traced: and wherever, in the whole course of that filament,
whether it be in the foot, leg, thigh, spine, or brain, it may be
bruised, or pricked, or injured in any way, sensation and not
motion will result ; and the perception arising from the im-
pression will be referred to that part of the skin where the
remote extremity of the filament is distributed.
V.
As the matter of the nerve is every where the same, and
the apparent difference is only in the manner in which the fine
cellular membrane forms the envelope, (it being soft where the
nerve is protected, hard and cordlike where it is exposed or
INTRODUCTION. 19
subject to pressure;) I have been desirous of having some term
or terms which might be apphcable to the same tract of matter
through its different stages, whether traced in one direction or
the other.
Where certain whitish streaks of nervous matter are dis-
coverable in the substance of the brain, we may still use the
term Tractus as being already an anatomical term.
Where, in any part, the line of a nerve is not merely
discoverable by its colour, or the direction of its texture, but
when it is raised, and exhibits an external convexity in form of
a cord, the term Column or Rod may be used.
Where they emerge in distinct threads, Funiculi has seemed
to me a proper term ; and where these funiculi are projected in
combination, 1 use the word Fascis. Although we must keep
the term Nerve, yet it is, as we may say, an abused term. Let
us only distinguish betwixt a simple and a compound nerve.
VI.
A simple nerve is where the threads or funiculi which form
its root arise in a line or sequence from the brain or spinal
marrow. A compound nerve is where the threads forming the
roots arise in double rows, and each row from a different column
or tract of nervous matter; for example, the Ninth ISTerve (ix.
plate 4) is simple; a Spinal Nerve (plate 3) is compound.
VII.
A Nerve, then, is a cord composed of nervous matter and
cellular substance; the nervous matter is in distinct funicuh, and
D 2
20 INTRODUCTION.
these funiculi are bound together in their course to the point
of distribution, although they may possess properties quite
dissimilar.
If we were successfully to trace a nervous cord, (we shall
suppose from a muscle of the fore-arm), it would be found a
simple filament, thread, or funiculus. We should first trace it
into a compound nerve; perhaps the ulnar nerve; which we call
compound, because there are in it filaments of motion and
filaments of sensation bound together. At the root of the
axillary nerve we should trace it into the composition of a fasci.s,
where it forms the anterior root of a spinal nerve (as C, plate 3).
Being further traced, it would merge in the anterior column
of the spinal marrow ; and traced into the base of the brain, it
might be followed as a tractus, a streak of matter distinguish-
able from the surrounding substance, until it was seen to
disperse and lose itself in the cineritious matter of the cere-
brum. In all this extent, however combined or bound up, it
constitutes one organ, and ministers to one function, the direc-
tion of the activity of a muscle of the hand or finger.
And so if we trace other funiculi or filaments, whether
they be for the purpose of sensation or of motion, each retains
its office from one extremity to the other; nor is there any
communication between them, or any interchange of powers,
further than that a minute filament may be found combined
with filaments of a different kind, affording a new property, not
to the nerve thus constituted, but to the part which receives
them in their final distribution.
INTRODUCTION. 21
VIII.
Wherever we trace nerves of motion we find that, before
entering the muscles, they interchange branches, and form an
intricate mass of nerves, or what is termed a plexus. The plexus
is intricate in proportion to the number of the muscles to be
supplied, and the variety of combinations into which the
muscles enter. The filaments of nerves which go to the skin
regularly diverge to their destination. The nerves on the face,
and those on the side of the neck, form plexus; but the grand
plexus are near the origins of the nerves of the upper and lower
extremity. And from the fin of a fish to the arm of a man the
plexus increases in complexity in proportion to the variety or
extent of motions to be performed in the extremity.
Muscles are arranged and combined together, not by any
connexion between themselves, but between the nerves going to
them ; a plexus is that network formed by the interchange of the
filaments of nerves before they penetrate to the muscles. It
is through the connexions formed in the plexus that some
muscles are combined into a class, so that they act, as it were,
by one impulse; and it is by the same means that others are
arranged as their opponents. All the varieties of combinations
are formed in the plexus, and there the curious relations are
established which exist between the contraction of one class and
the relaxation of the other.
THIRD PART.
OF THE SPINAL MARROW.
I.
Taking the spinal marrow as a whole, its offices are of a
double order. First, in relation to the brain. Secondly, as
having powers emanating from itself, or independent of the
brain.
II.
Through the spinal marrow columns extend from the grand
subdivisions of the brain, which are intermediate between the
sensorium, the nerves of the body, and the extremities. It is
for this reason that we look with so much interest on those
columns which give origin to the two roots of the spinal nerves,
since they propagate influences directly in connexion with the
operations of the mind : such as sensation and voHtion.
III.
It is not determined whether the ceneritious matter visible
in the section of the spinal marrow belongs to the columns
which have reference to the brain, or are distinct organs and
new sources of power.
INTRODUCTION. 23
IV.
The spinal marrow is peculiar to the vertebral animals.
It will suffice for superficial observers to say, that it must be so,
because the spine is necessary to conceal and protect the
marrow : but there is much more than this in the established
relationship ; the spine formed by vertebrae is necessary to such
a constitution of the thorax as shall be capable of the motion of
respiration ; and the spinal marrow is equally necessary to that
form and distribution of the nervous system which is required
for associating and combining the muscles of respiration. With-
out the machinery of the spine and ribs, the thorax and abdomen
could not rise and fall in respiration ; and without the spinal
marrow, that arrangement of nerves would be wanting which is
necessary to regulate the motions of the trunk in respiration.
Thus the spinal marrow, the spine and ribs, and the muscles
of respiration, are essential to each other ; as constituting the
several parts of a grand design subservient to respiration.
V.
Each lateral portion of the spinal marrow contains three
tracts or columns ; one for voluntary motion, one for sensation,
and one for the act of respiration ; this is quite obvious
at the upper part or medulla oblongata; with respect to
the lower part of the spinal marrow, the reasoning is more
hypothetical or analogical. There the motor roots and the
sensitive roots arise in the same manner as at the upper part :
and as the common nerves of the spinal marrow certainly
24 INTRODUCTION.
possess a power over the abdominal muscles, controlling them
in the act of respiration, it is not an unwarrantable supposition,
that the respiratory column descends along the spinal marrow,
constituting a part of it, and bestowing power upon the spinal
nerves. So that the spinal marrow comprehends in all six rods,
intimately bound together, but distinct in office ; and the
capital of this compound column is the medulla oblongata.
These six columns of the spinal marrow are discoverable
on looking to the upper part of that body ; but no doubt these
grander columns contain within them subdivisions. Thus, if we
lift up the medulla spinalis from the cerebellum, and look to it
on the back part, we shall see more numerous cords, the offices
of which will one day be discovered.
VI.
This view of the constitution of the spinal marrow led me
to institute experiments, which were followed by the discovery
of the distinct functions performed by the several roots of the
spinal nerves ; but without stating these experiments or their
results, we shall proceed with the general view.
VII.
The anterior column of each lateral division of the spinal
marrow is for motion ; the posterior column is for sensation ;
and the middle one is for respiration. The two former extend
up into the brain, and are dispersed or lost in it; for their
functions stand related to the sensorium : but the latter stops
short in the medulla oblongata, being in function independent
INTRODUCTION. 25
of reason, and capable of its office independently of the brain,
or when separated from it.
VIII.
It is the introduction of the middle column of the three,
viz. that for respiration, which constitutes the spinal marrow, as
distinct from the long central nerve of the animals without
vertebrae, and which is attended with the necessity for that form
of the trunk which admits of the respiratory motions.
IX.
In animals which do not breathe by an uniform and general
motion of their bodies, there is no spinal marrow, but only a
long compound and ganglionic nerve, extending through the
body for the purpose of sensation and motion. This cord in
those creatures does not actuate the animal machine with
alternate dilatation and contraction. There may be a motion
of some part which admits and expels air from a cavity, or
agitates the water, and which motion is subservient to oxygena-
tion of the blood ; and there may be a nerve supplied to that
apparatus with sensibility and power suited to the function
thus to be performed, and resembling our par vagum in office ;
but there is no regular and corresponding distribution of a
respiratory system of nerves to both sides of the body, nor any
arrangement of bones and muscles, for a general and regular
motion of the frame like that which takes place in vertebral
animals, and which is necessary to their mode of existence.
£
26 IXTRODUCTIOX.
X.
An injury to the brain, sufficient to destroy sensation and
volition, leaves the spinal marrow in possession of its function,
and commanding the actions of respiration.
XI.
The experiments of Le Gallois, in which he cut down the
brain to the medulla oblongata, exhibit the respiration continued
when the brain is removed. The observations of Mr. Lawrence
and others shew that the acephalous child lives and breathes*
without a brain, if the medulla oblongata be formed and perfect.
XII.
Injury to the spinal marrow low in the neck, cutting off
the sensation and voluntary motions of the body, leaves the body
in possession of the power of respiration.
XIII.
These facts exhibit the importance of the spinal marrow to
the act of breathing, and point to the upper part of the column,
the medulla oblongata, as particularly the seat of this power.
But a difficult question remains. The act of respiration in
man, and in general in the higher animals, is not subservient to
the circulation of the blood, and to the general economy merely.
The machinery of respiration becomes a grand power, under the
* See Appendix.
INTRODUCTION. 27
command of the will, and efficient in crying, speaking, smelling,
&c. It will be difficult to determine how the power of respira-
tion, residing in the spinal marrow, and independent of the
brain in its primary and most important office, is brought to
be subservient to the will. Is it by a prolongation of the
appropriate column of the spinal marrow up into the brain, or
is it by the junction of cerebral and voluntary nerves with the
respiratory nerves of the medulla oblongata ?
XIV.
From this digression we return to the spinal marrow, to
inquire what are its comparative functions. In animals having
a simple line of nerves with ganglions, as in the earth-worm, the
anterior ganghons, although the smaller ones, have a control
over the rest of the body. If such a creature be divided,
the anterior part will preserve its concatenated motion, and
move away ; the posterior half will remain writhing, as if suffer-
ing, but its motions want aim, and it remains in the same spot.
Cold-blooded animals will live without the brain. Birds whose
heads were cut off, Le Gallois says, walked, seemed to feel pain,
and moved their feet towards the part. Flourens goes further,
since he says that a bird deprived of the cerebral lobes dressed
its feathers, and ran and leaped.
Although I trust very little to these observations, it must
be conceded that in the lower creatures the brain does not
possess all that influence, either on the movements of the frame
or on the life itself, that it does in man, and in the higher animals ;
E 2
28 INTRODUCTION.
and that it becomes more and more important in proportion
as the animals rise in the scale of intelligence.
The question must therefore be asked, how far does the
spinal marrow retain the offices of the gangUonic system of the
vermes for example ? how far is it independent of the brain ?
and what is the mode and the degree of relation between the
brain and spinal marrow ? Such appears to me to be the course
of study which is to improve the knowledge of the nervous
system. Experimenters have gone much too far, into subjects
of extreme delicacy, and to the discussion of w hich their know-
ledge is not competent, until these leading questions be satis-
factorily answered. This conviction has at least influenced me
in restricting me to the functions of the nerves, in distinction
to speculations on the influence of the brain.
FOURTH PART.
OF THE NERVES WHICH ARISE FROM THE SPINAL MARROW.
—COMPARISON WITH THE NERVES OF THE ENCEPHALON.
I.
The first conception which I entertained of the true
arrangement of the nerves arose from a comparison of the
nerves which take their origin from the brain with those which
arise from the spinal marrow. The perfect regularity of the
latter, contrasted with the very great irregularity of the former,
naturally led to an inquiry into the cause of this difference. I
said, if the endowment of a nerve depend on the relation of its
roots to the columns of the spinal marrow and base of the brain,
then must the observation of their roots indicate to us their
true distinctions and their different uses.
II.
The spinal nerves are perfectly regular in origin and dis-
tribution, and are thirty on each side*. Each nerve has two
* The tenth nerve of the head, as enumerated by Willis, and called suboccipital
from its situation, is in constitution a spinal nerve; /. e, it has a double root and a
ganglion on its posterior root. Its distribution is similar to the spinal nerves, and
quite unlike those of the encephalon, with the exception of the fifth.
30 INTRODUCTION.
distinct series of roots coming out in packets or fasces, one from
the posterior column, and one from the anterior column, of the
spinal marrow.
III.
The posterior fascis is formed of funiculi, (see plates 3 and
8, fig. 2) which come out with remarkable abruptness from the
column ; and their roots form a very regular row or series along
the sides of the spinal marrow. They seem at once to burst
out from the confinement of the arachnoid coat. These funiculi,
converging towards the foramen of the sheath of the spinal
marrow, and being collected together, form a ganglion. This
ganglion is not seen within the sheath of the spinal marrow;
its seat is in the part where the fascis is surrounded and united
to the sheath, and just before this root of the nerve joins the
anterior one to constitute a spinal nerve.
IV.
The funiculi of the anterior roots of these nerves gather
their minute origins with more irregularity than the posterior;
and from a wider surface.
V.
The thirty nerves thus formed of two distinct fascicuh, are
suited to perform all the common offices of the trunk and limbs.
Is it, then, by that combination of properties which they acquire
through their double roots, that they are capable of performing
their offices? And is this the cause of their simphcity of
INTRODUCTION. 31
arrangement in their course through the body, as contrasted
with the nerves of the head? Again, what cerebral nerves, in
their distribution to the head and face, correspond in office with
the spinal nerves? On the solution of these questions will
depend our knowledge of the whole nervous system .
VI.
It was necessary to know in the first place, whether the
phenomena exhibited on injuring the separate roots of the
spinal nerves corresponded with what was suggested by their
anatomy. After delaying long on account of the unpleasant
nature of the operation, I opened the spinal canal of a rabbit,
and cut the posterior roots of the nerves of the lower extremity ;
the creature still crawled, but I was deterred from repeating the
experiment by the protracted cruelty of the dissection. I re-
flected, that an experiment would be satisfactory, if done on an
animal recently knocked down and insensible; that whilst I
experimented on a living animal, there might be a trembling or
action excited in the muscles by touching a sensitive nerve,
which motion it would be difficult to distinguish from that
produced more immediately through the influence of the motor
nerves. A rabbit was struck behind the ear, so as to deprive
it of sensibility by the concussion, and I then exposed the spinal
marrow. On irritating the posterior roots of the nerve, I could
perceive no motion consequent in any part of the muscular
frame; but on irritating the anterior roots of the nerve, at each
touch of the forceps there was a corresponding motion of the
32 INTRODUCTION.
muscles to which the nerve was distributed. Every touch of
the probe, or needle, on the threads of this root, was attended
with a muscular motion as distinct as the motion produced by
touching the keys of a harpsichord. These experiments satisfied
me that the different roots and different columns from whence
those roots arose were devoted to distinct offices, and that the
notions drawn from the anatomy were correct.
VII.
The anterior roots of the spinal nerves, and the anterior
column of the spinal marrow, being thus shown to have a power
over the muscular system, the next step of the inquiry was
distinctly indicated. If I pursue the track of the anterior
column of the spinal marrow up into the brain, shall I find the
nerves which arise from it to be muscular nerves? An anatomist
will at once answer, that only muscular nerves arise in this line.
Pursuing this method we see the anterior root of the
spinal nerve, arising from this column. We trace the column
up into the corpus pyramidale, and find there the origin of the
ninth nerve. We see that this nerve has only one series of
roots, corresponding with the anterior roots of the spinal nerves,
and that these roots come from the tract us motor ins, and we
cannot forget that this nerve is entirely devoted to the muscles
of the tongue; that it is the motor of the tongue, and has
nothing to do with the sensibility of that organ.
Following up the corpus pyramidale, we find issuing from
it the sixth nerve, a muscular nerve of the eye. Still following
INTRODUCTION. 33
up the tractus motorius through the pons Varolii, we come to the
roots of the third nerve, the motor nerve of the eye. Thus all
the nerves arising in this line from the Crus Cerebri to the Cauda
Equina are jnuscular nerves.
VIII.
On finding this confirmation of the opinion, that the
anterior column of the spinal marrow and the anterior roots of
the spinal nerves were for motion, the conclusion presented
itself that the posterior column and posterior roots were for
sensibility. But here a difficulty arose. An opinion prevailed
that ganglions were intended to cut off sensation; and every
one of these nerves, which I supposed were the instruments of
sensation, have ganglions on their roots.
Some very decided experiment was necessary to overturn
this dogma. I selected two nerves of the encephalon ; the fifth,
which had a ganglion, and the seventh, which had no ganglion.
On cutting across the nerve of the fifth pair on the face of an
ass, it was found that the sensibility of the parts to which it was
distributed was entirely destroyed. On cutting across the nerve
of the seventh pair on the side of the face of an ass, the
sensibiUty was not in the slightest degree diminished.
By pursuing the inquiry, it was found that a ganglionic
nerve is the sole organ of sensation in the head and face: gan-
glions were therefore no hinderance to sensation; and thus my
opinion was confirmed, that the ganglionic roots of the spinal
nerves were the fasces or funiculi for sensation.
34 INTRODUCTION.
It now became obvious why the third, sixth, and ninth
nerves of the encephalon were single nerves in their roots, as
contrasted with the spinal nerves ; for if the fifth nerve bestowed
sensibility universally on the head and face and all the parts
contained, there was no necessity, so to speak, for the third,
sixth, and ninth, having the posterior or ganglionic root.
IX.
Pursuing the subject, and still directed by the anatomy,
the next matter of inquiry was to ascertain how far the fifth
nerve of the encephalon corresponded with the spinal nerves.
It was discovered that the fifth nerve bestowed sensibility on all
the cavities and surfaces of the head and face. It was also
observed, that where the sensibility of the integuments remained
after the division of the fifth nerve, it was only to the extent of
surface supplied by the nerves of the spine. Where certain
fibrils of the spinal nerve extended upon the integuments of the
side of the jaw, they were equivalent in office to those of the
fifth nerve. In short, in regard to their property of bestowing
sensibility, the fifth and the spinal nerves were identified.
But was the fifth nerve in other essential circumstances
similar to the spinal nerves? On recurring to the anatomy, and
comparing the fifth nerve of the encephalon with a spinal nerve,
the resemblance, both in man and brutes, was very remarkable.
In plate VII,!iig. 1 and 2, we recognise corresponding parts in the
spinal nerve and in the fifth nerve. In both nerves we see the
double roots; the anterior root passing the ganglion, and the
INTRODUCTION. 35
posterior root falling into it or forming it*. On following back
the anterior root of the fifth nerve, we may perceive that it
comes out between the funes of the pons varolii, and, apparently,
from the crus of the cerebrum.
Observing that there was a portion of the fifth nerve, which
did not enter the ganglion of that nerve, and being assured of
this fact by the concurring testimony of anatomists, I conceived
that the fifth nerve was in fact the uppermost nerve of the
spine; or to speak more correctly, the most anterior of the
double nerves common to man and animals, of those nerves
which order the voluntary motions, and which at the same time
bestow sensibility, in its extended sense, on the frame of the
body.
This opinion was confirmed by experiment. The nerve
of the fifth pair w^as exposed at its root, in an ass, the moment
the animal was killed; and on irritating the nerve, the muscles
of the jaw acted, and the jaw closed with a snap. On dividing
the root of the nerve in a living animal, the jaw fell relaxed.
Thus its functions are no longer matter of doubt: it is at
once a muscular nerve and a nerve of sensibility. And thus
the opinion is confirmed, that the fifth nerve is to the head,
what the spinal nerves are to the other parts of the body, in
respect to sensation and volition.
* It is curious to notice the uses which were ascribed to this grand ganglion.
Vieussens supposed that it strengthened the nerve; others that it was the bond of
sympathy and the source of expression in the countenance: "Et affectuum animi
indicia in faciei partibus depingere adjuvet." — Hirsch. Sandifort Thes. Dissert,
p. 491.
F 2
36 INTRODUCTION.
X.
But here a very important circumstance must be noticed.
The origin of the fifth nerve being distant from the termination
of the column of the spinal marrow for respiration, it receives
no roots from it. How then are the features to be moved in
sympathy with the lungs, and with the respiratory actions of
the breast, neck, and throat? We shall find presently that this
is effected through the portio dura of the seventh, and that this
is the reason of the very distinct origin and different course of
the two nerves.
I have now only to add, that these facts and experiments
have been followed up by others to the satisfaction of all Europe.
The opinion has been confirmed that the anterior roots of the
spinal nerves bestow the power of muscular motion; and the
posterior roots sensibility. When the anterior roots of the nerves
of the leg are cut in experiment, the animal loses all power over
the leg, although the limb still continues sensible. But if, on
the other hand, the posterior roots be cut, the power of motion
continues, although the sensibility is destroyed. When the
posterior column of the spinal marrow is irritated, the animal
evinces sensibility to pain; but no apparent effect is produced
when the anterior column is touched.
INTRODUCTION. 37
OF THE SYMMETKICAL SYSTEM OF NERVES.
EXPLANATION OF THE PLAN, PLATE I.
I SHALL now proceed, by reference to the adjoined plate 1,
to explain the symmetrical system of nerves. We see thirty-
one nerves similar in origin and constitution, ranging with
perfect order, and going forth to the head, body, and limbs in
regular succession; and in their essential attributes, common to
every class of animals, from the creeping thing* up to man.
When we contemplate the dissection which we have made
of the nerves of the face, neck, and chest, and are lost in the
confusion of the Hid, IVth, Vth, Vlth, Vllth, Vlllth, and
IXth of the branches of the Cervical Nerves, and of the Sym-
pathetic— of the Diaphragmatic, Spinal Accessory, and Inferior
External Respiratory Nerves — we shall be prepared to see the
advantages of the plans which are annexed. The reader will
soon discover that the system, of which these plans may give him
* This will be condemned as a term not systematic, but it is strictly correct. It
is the necessity of a correspondence in the motions of the body and feet which, if we
may so express it, calls for symmetry in the distribution of the nervous system. When
a creature has no feet, or substitute for them, there is no symmetrical system of nerves.
If we were to consider the necessity of correspondence in the motions of the hands
and feet, as well as in the four quarters of brutes, that each foot does not move by
itself, but, on the contrary, that there is a combination of motion betwixt the limbs
in walking, ambling, trotting, galloping, &c., we should see that the muscular system
must be united by a longitudinal cord and uniformity of branches going out laterally.
38 INTRODUCTION.
some idea, is not only an improvement in the knowledge of the
structure and functions of animal bodies, but is of the greatest
use in practical anatomy, in facilitating the acquisition of the
knowledge of the Nerves.
The arrangement is this : — There is an obvious division of
the medulla spinalis into anterior and posterior columns : every
regular nerve has two roots, one from the anterior of these
columns, the other from the posterior: and they have all
ganglions of a particular structure upon the posterior root.
Such are the Vth pair ; the Suboccipital ; the seven Cervical ; the
twelve Dorsal ; the five Lumbar ; and the five Sacral ; viz.,
thirty-one pairs of perfect, regular, or double nerves in the
human body*. These are laid down in the first plan. They
are common to all animals, from the worm up to man ; and are
for the purposes of common sensation and motion, or acts of
volition ; they run out laterally to the regular divisions of the
body, and never take a course longitudinal to the body.
For the sake of distinction and arrangement, the remaining
nerves are called irregular nerves. These are distinguished
by having only a single fasciculus, or single root ; that is, a root
from one column. They are sinqjle in their origin ; irregular in
their distribution ; and deficient in that symmetry which clia-
* There can be no doubt of the accurate resemblance of the fifth to these other
thirty nerves; although it may be difficult to trace the roots of the nerve to the
prolonged columns from which the spinal nerves come. This is a subject which I
mean to prosecute. The last author on this subject is very distinct in tracing the
sensitive root of the fifth to the column from which the posterior roots of the spinal
nerves arise ; and the motor root he represents coming from between the fibres of the
pons varolii, as if it arose from the tract leading to the crus cerebri. See Icones
Atnaomica? Neurologicse, Fasc. i. Tab. xxviii. xxxi, Langenbeck. Gottingae.
INTRODUCTION. 39
racterizes the first class. They are superadded to the original
class, and correspond to the number and complication of the
superadded organs. Of these there are — the Illd, IVth, and
Vlth to the eye; the Vllth to the face; the IXth to the
tongue ; the Glosso-Fharyngeal to the tongue and pharynx ;
the Nervus Vagus to the larynx, heart, lungs, and stomach ; the
Spinal Accessory to the muscles of the shoulder ; the Phrenic to
the diaphragm ; the External Hespiratory to the outside of the
chest. These (with the exception of the two last which are un-
distinguishable at their roots) have single roots, that is, funiculi
coming from one column ; and are thus distinguishable from the
fifth nerve of the head, and the thirty nerves of the spine.
If we inquire into the seeming confusion in this second
class, or class of irregular nerves, we shall perceive that it is owing
principally to the complication of the superadded apparatus of
respiration, and to the variety of offices which this apparatus has
to perform in the higher animals.
We may even now observe that, in the apparently regular
system of Willis, there was in fact great confusion. Since the
nerves, the most opposite in use, were arranged together ; and,
indeed, whilst such a system remained undisturbed, our know-
ledge of the nerves could not be advanced.
A A^
B B ^ Spinal Marrow.
C C^
1 1 Branches of the Vth pair, or Trigeminus, which arise from the union of the
crura cerebri and crura cerebelli in two distinct roots, on the posterior of which a
ganglion is seen, like the ganglion of the spinal nerves. The branches of the Vth
40 INTRODUCTION.
nerve are universally distributed to the head and face ; but the anterior root goes
only to the third division.
2 2 Branches of the Suboccipital Nerves, which have double origins and
ganglions on the posterior roots.
3 3 The branches of the four inferior Cervical Nerves and of the first Dorsal,
forming the Axillary Plexus : the origins of these nerves are similar to those of the
Vth and the Suboccipital.
4 4 4 4 Branches of the Dorsal Nerves, which also arise in the same manner.
5 5 The Lumbar Nerves.
6 6 The Sacral Nerves.
OF THE IRKEGULAK NERVES.
EXPLANATION OF THE PLAN, PLATE II.
The third, fourth, sixth, and ninth nerves, I have classed
with the irregular nerves, as not having the double root and
ganglion which characterise the thirty-one enumerated as re-
gular ; and surely it must be a satisfactory thing to notice why
these nerves have only single roots, and are deficient in the
sensitive root; it is because the parts to which these nerves are
distributed are supplied by the fifth, the source of sensibility.
So that if the proofs were not already sufficient, both from
anatomy and experiment, of the correctness of our arrangement,
this circumstance would be almost conclusive, that no nerve
which goes to a part supplied by the fifth has a sensitive root.
Now as to those irregular nerves, that is to say, nerves with
single roots, which belong to respiration.
The observation of the frame of man or of brutes, and
especially the review of it in a state of high activity, or under
the influence of passion, will convince us that the motions
dependent on respiration extend almost over the whole body,
while they more directly affect the trunk, neck, and face. We
may perceive, also, that during the involuntary action of respira-
tion the same muscles are in operation as in the voluntary
actions. This is evident not only in breathing, but also in
coughing, sneezing, crying, laughing, speaking, swallowing, and
6
42 INTRODUCTION.
vomiting ; for all these are states or conditions of the respiratory
nerves and muscles. In every effort but that of simple volun-
tary motion, the respiratory organs become the agents ; and
even in violent voluntary efforts, or the long continuance of
exercise, the instinctive motions chime in with the voluntary
motions, and the activity of the frame becomes general.
Under the class of respiratory motions we have to distinguish
two kinds : first, the involuntary, or instinctive ; secondly, those
which accompany an act of volition. We are unconscious of
that state of alternation of activity and rest which characterises
the instinctive act of breathing in sleep ; and this condition of
activity of the respiratory organs we know, by experiment, is
independent of the brain. But, on the other hand, we see that
the act of respiration is sometimes an act of volition, intended
to accomplish some other operation, as that of smelling or speak-
ing. I apprehend that it is this compound operation of the
organs of breathing which introduces a certain degree of com-
plexity into the system of respiratory nerves. A concurrence
of the nerves of distinct systems will be found necessary to
actions which at first sight appear to be very simple acts of
the will.
To make this evident, before proceeding further, I shall
give an example of the necessity of this combination of different
powers. Let us observe, in the act of eating and swallowing,
the combination of the three powers of sensation, voluntary
muscular activity, and the act of the respiratory muscles.
If we cut the division of the fifth nerve which goes to the
lips of an ass, we deprive the lips of sensibility: so that when the
INTRODUCTION. 43
animal presses the lips to the ground, and against the oats lying
there, he does not feel them ; and consequently he makes no
effort to gather them. If, on the other hand, we cut the
seventh nerve where it goes to the lips, the animal feels the oats,
but he can make no effort to gather them, the power of muscular
motion being cut off by the division of the nerve. Thus we
perceive that in feeding, just as in gathering any thing with the
hand, the feeling directs the effort; and two properties of the
nervous system are necessary to a very simple action.
In drinking, the fluid is sucked in by the breath, and when
the mouth is full we swallow. The water is felt ; the lips are
moulded into the right form by volition, and the muscles of
inspiration combine to draw in the fluid. In the act of swallow-
ing, the liquid would descend into the windpipe were there not
a combination of the muscles of respiration with the apparatus
of deglutition to prevent it ; nor could the fluid or the solid
morsel pass along the oesophagus through the diaphragm without
a similar coincidence of activity and relaxation between parts
animated by different systems of nerves.
In speaking, it is still more obvious that the act of respira-
tion must become voluntary, in order to push out the breath
in combination with the contractions of the larynx, tongue,
and lips, for producing sound, and more especially articulate
language.
The respiratory system must be exercised under an in-
stinctive and involuntary impulse, as in breathing during sleep
and insensibility. But it must, at certain times, be associated
with voluntary actions. Ey foreseeing this difficulty, we shall
G 2
44 INTRODUCTION.
avoid the danger of pushing the investigation of the anatomy
too far ; or of throwing a doubt over important discoveries by
attempting too much*.
After the investigation of the regular system of nerves of
sensation and voluntary motion, the question that had so long
occupied me, viz. — what is the explanation of the excessive
intricacy of the nerves of the face, jaws, throat, and breast?
became of easy solution. These nerves are agents of distinct
powers ; and they combine the muscles in subserviency to
different functions.
As far as regard motion and sensation, the original and
symmetrical nerves appear sufficient for the concatenation of
the muscles. By them creatures feel pain, move and with-
draw themselves from injury ; they have sensation, and pursue
their objects of desire. But these nerves are not capable of
(that is to say, were not designed for) the vital act of respiration,
far less for smelling, speaking, singing, laughing, in which
several acts the respiratory system is brought into activity.
As animals rise in the scale of beings, new organs are
bestowed upon them. And as new organs and new functions
are superadded to the original constitution of the frame, new
nerves are given also, with new sensibilities, and new powers of
activity.
* There is a question remaining, What is the connexion between the encephalon
and the spinal marrow: does tlie combination of voluntary muscles in walking or
running result from an arrangement in the spinal mari'ow? The combination of
the muscles in respiration obviously does. Whence then arises the power exercised
by volition over these combinations? This is a subject touched upon in the third
paper.
INTRODUCTION.
45
In the act of respiration we see a succession of regular
motions extending over a great part of the animal machinery ;
we perceive that this is a new species of activity, and that
this new energy must be derived from a source different from
the locomotive powers. Looking to the simultaneous motions
of the abdomen, thorax, neck, throat, lips, and nostrils, in
breathing, it is obvious, in the first place, that they must be
animated by nerves partaking of similar powers ; and that these
nerves must have a centre somewhere, so that they may be
simultaneously and equally excited, and give a uniform impulse
to the muscles of respiration.
A B C D are respiratory nerves, arising in a regular series of roots.
A Portio Dura.
B Glosso-pharyngeal .
C Par Vagum.
D Spinal Accessory.
In the line from E to F arc the regular series of roots of the common muscular
nerves.
46 INTRODUCTION.
The reader will now understand the course of my reflections,
when I observed that there were certain nerves arising from a
distinct column of the spinal marrow, not only different from
the spinal nerves in being simple in their roots, but unlike
either of the two roots of the spinal nerves; and that they
had their origin in a row or regular series. After the course
of the inquiry which I have described, it was natural to suppose
that these nerves must have a distinct function, and what so
probable as that pointed out by their course and distribution?
viz. — that they were connected with the offices of respiration.
Observing that the Spinal Accessory nerve, the Par Vagum, the
Glosso-Pharyngeal nerve, and the Portio Dura of the seventh,
arose in a distinct tract and in sequences, as in this outline, I
conceived that they offered themselves as fair subjects for ex-
periment, and that that would determine whether or not these
four nerves connected the remote parts to which they were
distributed in the act of respiration ?
The consideration of the course of the Par Vagum gave
countenance to this idea, and the comparative anatomy of the
nerve confirmed it. Again, on comparing the experiments that
had been made from time to time on this nerve, all conspired to
show that its use was to combine the proper organs of respira-
tion ; while the other nerves were intended to draw the exterior
apparatus of muscles into sympathy with the heart and lungs.
In this inquiry it was natural to ask why the Spinal
Accessory of authors arose from the spinal marrow in the
neck? why it ascended into the head, to join itself with the par
INTRODUCTION. 47
vagum, instead of following the direct and short route to its
destination in the muscles of the neck and shoulder, like the
spinal nerves? The reason is this — The act of respiration
being necessarily joined to the actions of the lips, tongue, larynx,
and pharynx, and not in simple respiration only, but in speaking,
swallowing, &c., it becomes necessary that the muscles of the
neck and shoulders should be joined to those of the tongue,
and larynx. For this purpose the spinal accessory, instead
of going out directly through the vertebra, ascends and inter-
changes filaments with the eighth, ninth, glosso-pharyngeal, &c.
I divided its branches in the living animal, and by that means
certain muscles of the neck were cut off from partaking in the
act of breathing, while they retained their office under the other
nerves; that is, they remained under the direction of the will
when they had ceased to be influenced in respiration.
Directed in the next place to the Portio Dura, I wished to
answer the question, Why does the nerve which supplies certain
muscles of the face take an origin and a course different from
the Fifth Nerve destined to the same parts? Guided by these
considerations in my experiments, by inference I concluded,
that on cutting across this nerve all the motions of the face con-
nected with respiration ceased ; and that it had the origin we see,
and took its course with the respiratory nerves, because it was
necessary for the association of the muscles of the nostrils, cheek,
and lips, with the other muscles used in breathing, speaking, &c.
For this reason it was associated with the root of the Eighth
Pair instead of with the Fifth.
48 INTRODUCTION.
The inquiry into the functions of the branches of the
Portio Dura which go to the eye-Uds, led me to make observa-
tions on the motions of the eye-ball; and finally directed me
to the Fourth Nerve to account for the sympathetic motions of
the eye-ball in combination with the other parts moved in the
excited state of respiration.
I must frankly own that this is the weak part of my system.
There is a connexion in the functions of the nerves, but I cannot
as yet satisfactorily trace back the origin of the Fourth Nerve
to the respiratory column, although we may see that it comes
in the due direction. This intricate subject is discussed in the
paper the last but one in this volume.
Nothing can better prove the importance of the principles
laid down in the beginning of this exposition than the explana-
tion which it offers of the seeming intricacy of the nerves of the
orbit and of the whole head and face; and the variety of curious
facts which it brings to light.
It appears, then, that there are four nerves coming out of a
tract or column of the spinal marrow, from which neither the
nerves of sensation nor of common voluntary motion take their
departure. Experiment further proves, that these nerves excite
motions dependent on the act of respiration. There can be no
hesitation or doubt that as far as the neck, throat, face, and eyes
depend on, or are related to the actions of respiration, it is
through these nerves that they are so associated.
I have been always desirous of stating, that the absolute
proofs stop here, and that the rest is hypothesis. I imagine
INTRODUCTION. 49
that the same column or tract which gives origin to the fourth,
seventh, glosso-pharyngeal, par vagum, and spinal accessory
nerves is continued downward along the lateral parts of the
spinal marrow, and that it affords roots to the spinal nerves,
constituting them respiratory nerves as well as nerves of motion
and sensation; and that it especially supplies the roots of the
diaphragmatic nerve, and the external respiratory nerve.
But this I cannot now demonstrate, and hardly hope to do.
We see in the medulla oblongata three distinct columns, from
each of which arise the roots of nerves possessed of distinct
properties; a little further down we see no distinct respiratory
nerves arising, whilst the motor and sensitive roots continue to
take their origin in regular lines to the termination of the
spinal marrow. It is more than probable that the respiratory
column continues its course downward between the motor and
sensitive columns, and bestows power on the compound spinal
nerves.
The spinal nerves are adequate to the gentle and uniform
motions of respiration, but not to the violent associated actions
of respiration. Thus when a creature cries, or a man speaks or
sings, the muscular effort is not in the muscles of the thorax
only, and directed by the intercostal nerves; but the shoulders
are raised and the thorax expanded by the influence of the spinal
accessory nerve, and the external respiratory nerve; the larynx
is excited by the branches of the par vagum called laryngeal;
the cheeks, lips, and nostrils, are directed by the portio dura.
It appears, then, that it is the distance and the irregular
H
INTRODUCTION.
position of the eye, nostril, mouth, throat and larynx, and
muscles of the neck, which require these diverging and ap-
parently irregular nerves to connect them with the act of
respiration, and without which they would have possessed no
more attributes than the nerves of the limbs; that is to say,
sensibility and volition. But being accessories in violent excite-
ment of respiration, they become the organs of expression in
the motions of the countenance and chest and the sounds of the
voice, and combine the instruments of articulate language.
EXPLANATION OF PLATE II.
A Cavity of the skull.
B Medulla Oblongata.
C C Spinal marrow.
D Tongue.
E Larynx.
F Bronchia.
G Heart.
H Stomach.
1 Diaphragm.
The third, sixth, and ninth nerves are not lettered, but only the following
respiratory nerves.
Ill Par vaguni, arising by a single set of roots, and passing to the larvnx, the
lungs, heart, and stomach.
2 2 Superior laryngeal branches of the par vagum.
S Recurrent or inferior larjiigeal of the par vaguni.
4 Pulmonic plexus of the par vagum.
5 Cardiac plexus of the par vagum.
(i Gastric plexus or corda ventriculi of the par vagum.
7 Fourth nerve, a nerve of this system to the eye.
8 Respiratory nerve or portio dura to the muscles of the face, arising by a
single root.
9 Branches of the glosso-pharyngeal.
10 Origins of the superior external respiratory or spinal accessory nerve.
INTRODUCTION. 51
11 Branches of the last nerve to the muscles of the shoulder.
12 12 12 Internal respiratory, or the phrenic to the diaphragm. The origins
of this nerve may be seen to pass much higher up than they are generally described.
13 Inferior external respiratory to the serratus magnus.
It was said that we understand the use of all the intricate
nerves of the body, with the exception of the sixth. The sixth
nerve stands connected with another system of nerves altogether;
I mean the system hitherto called the sympathetic, or sometimes
the ganglionic, system of nerves ; and of this system we know so
little, that it cannot be matter of surprise if we reason ignorantly
on the connexion of the sixth with it.
On reviewing the whole nerves of the human body, the
sensitive, motor, and respiratory systems combined, surely these
views come strongly recommended. They present a series of
facts unexampled for their number and importance. Such, for
instance, as — 1st, The distinct functions of the nerves of the
face; 2d, The fact that all sensibility in the head and face
depends solely on the fifth nerve; Sd, That the motions of the
jaw depend on one of the roots of this nerve; 4th, The singular
circumstance, that the common sensibility of the whole frame
results from a series of ganglionic nerves extending the whole
length of the spinal marrow ; 5th, That the voluntary motions
result from nerves arising in one line from the crura cerebri to
the Cauda equina, and having no ganglions upon them; 6th,
That the act of respiration in the face, nostrils, throat, &c.
results from a series of nerves differing from the common
nerves; and last of all — 7th, It will not be said that I have left
the question unresolved with which I set out, viz., the cause of
II 2
52 IXTRODUCTIOX.
the intricacy of the nerves of the face, neck, and chest, since
it has been shown that the same part, as for example the tongue,
has different nerves suited to its different functions; and that
the intricacy arises from the interweaving of the branches of
different systems.
If there were no facts ascertained by experiment and the
occurrences in practice, to give proof of the correctness of the
views which I have presented, the simpHcity of arrangement
should be sufficient to recommend them.
I shall now lay before my reader the papers which I pre-
sented to the Royal Society on these subjects.
i
ON THE NERVES;
GIVING
A VIEW OF THEIR STRUCTURE AND ARRANGEMENT,
WITH THE ACCOUNT OF SOME EXPERIMENTS
ILLUSTRATIVE OF THEIR FUNCTIONS.
From the Philosophical Transactions, 1821.
ON THE NERVES, &c.
[Read before the Royal Society, July 12, 1821.]
During the general advancement of science which has
lately taken place in this country, observations have been
gradually accumulating in the school of Windmill-street, vv^hich
prove that the department of anatomy has not been stationary.
The nervous system, hitherto the most unsatisfactory part of
the studies of the physiologist, has assumed a new character.
The intricacies of that system have been unravelled, and the
peculiar structure and functions of the individual nerves ascer-
tained; so that the absolute confusion in which this subject
was involved has disappeared, and the natural and simple order
has been discovered.
In proceeding to give some account of these new observa-
tions, the author of this paper had conceived, that it would be
more suitable to the scientific body he had to address, to lay
the subject before them in the precise manner in which it first
presented itself to his inquiries, and to detail his observations
and experiments in the succession in which they were made;
but he has been persuaded by some of the members of this
society to change that form, and to present the subject in the
56 ON THE NERVES OF THE HEAD.
manner which he has been accustomed to in teaching these
doctrines; and they were pleased to say, that in this way a
new subject would be more readily comprehended*.
Intricacij of the Nervous Si/ stem.
Anatomists have of late, not only in this country, but also
in Germany and Italy, made great improvement in the minute
dissection and display of the nerves; but whilst the doctrines
hitherto received prevail, the discovery of new branches of
nerves, and new ganglions, only involve the subject in deeper
obscurity. Whilst the nerves are supposed to proceed from
one great centre, to have the same structure and functions, and
to be all sensible, and all of them to convey what has been
vaguely called nervous power, these discoveries of new nerves
and ganglions are worse than useless; they increase the intricacy,
and repel inquiry. The endless confusion of the subject induces
the physician, instead of taking the nervous system as the secure
ground of his practice, to dismiss it from his course of study,
as a subject presenting too great irregularity for legitimate
investigation or reliance.
When the physiologist sees two distinct nerves, spreading
their branches to every part of the face (as in the Plate of these
nerves), three nerves from different sources given to the tongue.
* I believed that general attention to these subjects could not be raised by the
account of a system founded on anatomy, and on the minute distinctions in the origins
of the nerves. I thought that it required the announcement of some distinct and
remarkable facts.
ON THE NERVES OF THE HEAD, 57
four to the throat, and nerves in most perplexing intricacy to
the neck; when he finds one nerve with numerous gangUons or
knots upon it, and another without them ; when, in short, after
a minute dissection of the nervous system, he finds a mesh, or
network, spreading everywhere, it is not surprising that the
seeming intricacy and confusion should make him, in despair,
resign inquiry. But the author being forced, in the course of
his duty, to go minutely over the demonstration of the nerves,
year after year, without allowing himself to resign the subject
merely on account of its intricacy, and finding the facts which
he had to explain in his demonstrations of the anatomy quite
inconsistent with the received opinions, he has gradually, after
much study, been enabled to decipher and to read that language,
of which the character had hitherto been imperfectly known.
And now even the youngest students are brought to comprehend
so much of the subject, that the idea of chance or accident, or
real confusion among these numerous branches, is entirely dis-
missed; and what remains unexplained has, by the success of
our past inquiries, become a subject of peculiar interest, from
the conviction, that attention to the minute anatomy, under the
guidance of cautious and fair induction, will, sooner or later, lead
to a comprehension of the whole system.
Statement of the object of the paper.
The author means to limit his present inquiry to the nerves
of respiration. But according to his conception of this matter,
these nerves form a system of great extent, comprehending all
I
58 0^ THE NERVES OF THE HEAD.
the nerves which serve to combine the muscles employed in the act of
breathing and speaking.
The first point of inquiry naturally is, how many of the
muscles are combined in the act of respiration? and the second
question, by what means are these muscles, which are seated apart
from each other, and many of them capable of performing distinct
offices, combined together in respiration? It may sound oddly
to speak of the respiratory nerve of the face, of the neck, and of
the shoulder; and it may be necessary to give an illustration of
the sense in which the term is intended to be employed. When
a post-horse has run its stage, and the circulation is hurried and
the respiration excited, what is his condition ? Does he breathe
with his ribs only ; with the muscles which raise and depress the
chest? No. The flanks are in violent action ; the neck as well
as the chest are in powerful excitement; the nostrils as well as
the throat keep time with the motion of the chest. So if a man
be excited by exercise or passion, or by whatever accelerates
the pulse, the respiratory action is extended and increased;
instead of the gentle and scarcely perceptible motion of the
chest, as in common breathing, the shoulders are raised at each
inspiration, the muscles of the throat and neck are violently
drawn, and the lips and nostrils move in time with the
general action ; if he does not breathe through the mouth, the
nostrils expand, and fall in time with the rising and falling of
the chest ; and that apparatus of cartilages and muscles of the
nose (which are as curious as the mechanism of the chest, and
are for expanding these air tubes), are as regularly in action
as the levator and depressor muscles of the ribs.
ON THE NERVES OF THE HEAD. 59
It is quite obvious, that some hundred muscles thus em-
ployed in the act of breathing, or in the common actions of
coughing, sneezing, speaking, and singing, cannot be associated
without cords of connexion or affinity, which combine them in
the performance of these actions : the nerves which serve this
purpose, I call respiratory nerves.
The nerves of the animal frame are complex, in proportion to the
-variety of functions which the parts have to maintain.
When we minutely and carefully examine the nerves of
the human body, and compare them with those of other animals,
a very singular coincidence is observed between the number of
organs, the compound nature of their functions, and the number
of nerves which are transmitted to them. No organ which
possesses only one property or endowment has more than one
nerve, however exquisite the sense or action may be ; but if two
nerves, coming from different sources, are directed to one part,
this is a sign of a double function performed by it. If a part, or
organ, have many distinct nerves, we may be certain that,
instead of having a mere accumulation of nervous power, it
possesses distinct powers, or enters into different combinations,
in proportion to the number of its nerves. The knowledge of
this circumstance gives new interest to the investigation of this
part of anatomy.
Thus, in reviewing the comparative anatomy of the nerves
of the mouth, we shall find, that in creatures which do not
breathe, the mouth having only one function to perform, one
i2
60 ON THE NERVES OF THE HEAD.
nerve is sufficient. In certain animals, where the face and
nostrils have no complexity of relations, these parts have only a
single nerve. If the throat has no complexity of organization,
it has no variety of nerves. But on the other hand, when the
anatomist employs weeks to dissect and disentangle the nerves
of the tongue, throat, and palate, in the human subject, he finds
at length, that he has exhibited the branches of five different
trunks of nerves ; and there is no clue to the labyrinth, until he
considers the multiplied offices of the mouth in man ; that it is
a pneumatic as much as a manducatory organ ; that it is the
organ of the voice and of speech, as of taste and exquisite
feeling. It would, indeed, be matter of surprise, if the same
nerve served for the action of gnawing and feeding in the
lower animals of simple structure, and also for the governance
of those complicated operations, which serve to interpret the
wants and sentiments of man.
Such are the views which naturally arise, from an acquaint-
ance with the nerves of the human body ; but a comparison of
them, with those of the lower classes of animals, enables us to
establish a more lucid order; and that not in an arbitrary
manner, but perfectly according to nature.
The nerves may be divided into two parts, or systems ; the one simple
and uniform, the other irregular and complex, in proportion to
the complexity of organization.
When the nerves of the face, mouth, throat, and neck of
the human subject are minutely displayed, it seems impracticable
ON THE NERVES OF THE HEAD. 61
to reduce the numerous nerves which cross and entwine with
each other to two distinct classes ; yet nothing is more certain
than that this may be done, and by an easy and natural method.
The principle which is to guide us, is obtained by ascertain-
ing what parts of the organization of an animal are necessary to
life and motion ; what organs are superadded as the animal
advances in the scale of existence, and are necessary to higher
and more complex enjoyments and actions.
Where an animal is endowed with mere sensation and
locomotion, where there is no central organ of circulation, and
no organ of respiration but what is generally diffused over the
frame, the nerves are extremely simple ; they consist of two
cords running in the length of the body, with branches going
off laterally to the several divisions of the frame. And here no
intricacy is to be seen, no double supply of nerves is to be
observed, but each portion of the frame has an equal supply ;
and the central line of connexion is sufficient to combine the
actions of the muscles, and to give them the concatenation
necessary to locomotion.
There is the same uniform and symmetrical system of
nerves in the human body as in the leech or worm ; although
obscured by a variety of superadded nerves. These addi-
tional nerves belong to organs, which, tracing the orders of
animals upwards, are observed to accumulate gradually until
we arrive at the complication of the human frame. These
nerves, additional and superadded to the original system, do not
destroy, but only obscure that system ; and accordingly, when
62 ON THE NERVES OF THE HEAD.
we separate certain nerves, the original system of simple con-
stitution is presented even in the human body.
The nerves of the spine, the tenth or sub-occipital nerve,
and the fifth or trigeminus of the system of Willis, constitute
this original and symmetrical system*. All these nerves agree
* The following note is from a paper by Mr. Shaw. To those who have
interested themselves in these discoveries, during their progress, I need not say how
much I am obliged to him, and with what ability he has advocated my opinions.
Often I have felt satisfied with ascertaining the facts, when he has excited me to
further inquiry, and to shape them for the public.
" Comparison between the Fifth and the Spinal Nerves.
" 1 . That the head and face, having many parts in every respect similar to the
neck, trunk, and limbs, must have corresponding nerves.
" 2. That the manner in which the spinal nerves and the fifth arise by double
origins, is very similar.
" 3. That the ganglion on the root of the fifth nerve, has a strict resemblance
to the ganglions at the origin of the spinal nerves.
" 4. That the manner in which the branches of the fifth are distributed, and
those of the spinal nerves, is the same.
" And, lastly, with reference to the anatomy, we find that the same kind of
connexion exists between the fifth and the sympathetic, as between the latter and
the spinal nerves. In their morbid affections, the similarity also holds good : thus,
in the common cases of hemiplegia, the spinal nerves and the branches of the fifth
are similarly affected. In this disease, the voluntary power over the limbs, and the
sensibility of the side affected, are generally destroyed ; while in some cases the
voluntary power is lost, and the sensibility continues unimpaired, or vice versa.
This variety also occurs on the face ; for the jaw will drop, and there will be all the
marks of paralysis, while the sensibility of the skin and the sense of taste continue
entire.
" In experiments on the nerves of the spine and on the fifth, we meet with the
same results. If, as in the operation, which is now frequently performed on the
nerves of the horse's foot, we cut a spinal nerve after the branches are given oft' to
the muscles moving the part, we shall destroy only the sensibility of that part; but,
if we cut the nerve nearer to the brain, we shall not only destroy the sensibility, but
ON THE NERVES OF THE HEAD. 63
in these essential circumstances ; they have all double origins ;
they have all ganglions on one of their roots ; they go out
laterally to certain divisions of the body ; they do not interfere
to unite the divisions of the frame ; they are all muscular nerves,
ordering the voluntary motions of the frame; they are all
exquisitely sensible ; and the source of the common sensibility
of the surfaces of the body : when accurately represented on
paper, they are seen to pervade every part ; no part is without
them ; and yet they are symmetrical and simple as the nerves of
the lower animals. See Plate I.
If the nerves be exposed in a living animal, those of this
class exhibit the highest degree of sensibility ; while, on the
contrary, nerves not of this original class or system are com-
paratively so httle sensible, as to be immediately distinguished ;
in so much that the quiescence of the animal suggests a doubt,
whether they be sensible in any degree whatever. If the fifth
nerve^ and the portio dura of the seventh, be both exposed on the
also the power of motion. The same happens in experiments on the fifth; for, if
we cut a branch which is distributed principally to the skin of the lips, we shall
destroy the sensibility of the part, but impair the power of mastication only in a
slight degree ; but if we divide the nerve furtlier back, then we shall not only destroy
the sensibility of the skin, as in the first experiment, but also cut off' the power by
which the jaws are moved. I cut a branch of the fifth upon the face ; the sensibility
of the corresponding side of the lip was destroyed, but little paralysis ensued. T
cut the nerve nearer the brain, and at a point previous to its having given off the
branches to the muscles ; then the jaw fell, and the muscles of that side were power-
less. I varied the experiment, by irritating the nerve where it lies in the spheno-
palatine fissure, immediately after an animal was killed ; the jaws then came together
with much force, indeed, so as to nip my assistant's finger severely. This last
experiment may be compared with the very common one of galvanizing the nerves
which pass from the spinal marrow, to supply the muscles of the extremities,"
64 ON THE NERVES OF THE HEAD.
face of a living animal, there will not remain the slightest doubt
in the mind of the experimenter which of these nerves bestows
sensibility. If the nerve of this original class be divided, the
skin and common substance are deprived of sensibility ; but if a
nerve not of this class be divided, it in no measure deprives the
parts of their sensibility to external impression.
More particularly of the respiratory nerves.
The nerves which connect the internal organs of respiration
with the sensibilities of remote parts, and with the respiratory
muscles, are distinguished from those of which we have been
speaking by many circumstances. They do not arise by double
roots ; they have no ganglions on their origins ; they come off
from the medulla oblongata and the upper part of the spinal
marrow ; and from this origin, they diverge to those several
remote parts of the frame, which are combined in the motion of
respiration. These are the nerves which give the appearance
of confusion to the dissection, because they cross the others, and
go to parts already plentifully supplied from the other system.
The following are the nerves to be enumerated as respiratory
nerves, according to their functions.
1. Far vagiDJi, VIII. g. g *, the eighth of Willis, the pnenmo-
gastric nerve of the modern F rench physiologists. This nerve goes
off from the common origin of the respiratory nerves, the lateral
* These letters have reference to plate 4.
ON THE NERVES OF THE HEAD. 65
part of the medulla oblongata: it takes its course to the larynx,
the lungs, the heart, and stomach. It associates these organs
together, which are at the same time supplied with nerves from
other sources. Comparative anatomy would lead us to infer that
this nerve is not essential to the stomach, as it does not exist
but where there are heart and lungs to associate with a muscular
apparatus of respiration. That the stomach must be associated
with the muscular apparatus of respiration, as well as the lungs,
is obvious, from the consideration of what takes place in vomit-
ing and hiccough, which are actions of the respiratory muscles
excited by irritation of the stomach.
2. Respiratory nerve of the face, (VII. plate 4. A. plate 6.)
being that which is called portio dura of the seventh. This nerve,
like the last, goes off from the lateral part of the medulla oblongata,
and, escaping through the temporal bone, spreads wide to the
face. All those motions of the nostril, lips, or face generally,
which accord with the motions of the chest in respiration,
depend solely on this nerve. By the division of this nerve, the
face is deprived of its consent with the lungs, and all ex-
pression of emotion. This part of the inquiry will be found
very interesting.
3. Superior respnratory nerve of the trunk, (h. plate 4. C.
plate 6.) being that which is called spinal accessory. This nerve
has exceedingly puzzled anatomists, from the singular course
which it pursues. It arises from the superior part of the spinal
marrow, in a line with the roots of the other respiratory nerves.
K
^6 ON THE NERVES OF THE HEAD.
Instead of going directly out between the vertebra?, as the
regular spinal nerves do, it passes up into the skull, comes out
through the skull with the par vagum, and, descending upon the
neck, goes to the muscles of the shoulder. In this course it
supplies muscles, which are already profusely supplied by the
regular system of nerves.
This nerve controls the operations of the muscles of the
neck and shoulder in their office as respiratory muscles, when,
by Hfting the shoulders, they take the load from the chest, and
fix the farther extremities of the muscles of inspiration seated
on the thorax, so as to give them greater power over the ribs.
When it was cut across in an experiment, the muscles of the
shoulder ceased to co-operate as respiratory muscles, but
remained capable of voluntary actions.
4. Great internal respiratory nei've, E. The phrenic or dia-
phragmatic, of authors. (See plates 2, 6, and 9.) This is the only
nerve of the system which has been known as a respiratory nerve.
Its origin, course, and destination, are so familiar to every one,
that I shall not say anything more of it here. But there is
another nerve, which has a remarkable resemblance to it, and
which, from circumstances akeady noticed, has been entirely
overlooked. This is,
5. The external respiratory nerve. (See plates 2 and 9.)
This has a similar origin with the preceding nerve. It comes
out from the cervical vertebrae, and is connected with the
})hrenic nerve. It runs down the neck, crosses the cervical and
ON THE NERVES OF THE HEAD. 67
axillary nerves, passes through the axilla, and arrives on the
outside of the ribs, to supply the serratus magnus anticus, which,
it is scarcely necessary to observe, is a muscle already supplied by
nerves coming out between the ribs, from the system of regular
nerves.
These four last-mentioned nerves govern the muscles of
the face, neck, shoulders, and chest, in the actions of excited
respiration, and are absolutely necessary to speech and expression.
But there are other nerves of the same class, which go to the
tongue, throat, and windpipe, no less essential to complete the
act of respiration. These are the glosso-pharyngeal nerve, and
the branches of the par vagum to the superior and inferior larynx*.
We proceed to examine these nerves in detail; and, first.
Of the 7ierves of the face, in which it is shown that the two sets of
nerves, hitherto supposed to be similar, dijfer in structure, sen-
sibility , and function f .
It is in the face that we have the best opportunity of
observing the subservience of the nerves to the uses of the parts,
and of ascertaining the truth of the preceding doctrines. The
human countenance performs many functions possessed by the
lower creatures: in it we have combined the organs of mastica-
tion, of breathing, of natural voice and speech, and of expression.
Here also are seen signs of emotions, over which we have but a
* It will be seen that, in the further investigation of this subject, the fourth nerve
was discovered to be connected with this system. — See the paper on the Nerves of
the Orbit.
f This subject is illustrated by plate G. which represents the nerves of the face.
K 2
68 ON THE NERVES OF THE HEAD.
very limited or imperfect control: the face serves for the lowest
animal enjoyment, and partakes of the highest and most refined
emotions. Happily for our present object, the nerves, which in
other parts of the frame are bound together for the convenience
of distribution to remote parts, are here distinct, and run apart
from each other until they meet at their extremities. They take
different courses through the bones of the head, and come out
upon the face, to be exposed in a manner which courts inquiry.
The nerves of the face are, first, the trigeminus, or the fifth
of WilHs, and that familiarly called the portio dura of the seventh,
but which, in this paper, will be called the respiratory nerve of
the face.
Of the trigeminus, orffth pair.
In all animals that have a stomach, with palpi or tentacula
to embrace their food, the rudiments of this nerve may be per-
ceived; and always in the vermes, that part of their nervous
system is most easily discerned, which surrounds the oesophagus
near the mouth. If a feeler of any kind project from the head
of an animal, be it the antenna of the lobster or the trunk of an
elephant, it is a branch of this nerve, which supplies sensibility
to the member*. But this is only if it be a simple organ of
* The branches of the fifth pair enter the roots df the whiskers of the cat kind,
these being feelers, and requiring branches of the sensitive nerve. The following is
from a paper by Mr. Shaw: —
" In the cat, and in the hare, the branches of the fifth pass not only to the
muscles, but also into the whiskers ; while the branches of the facial respiratory nerve
go past the hairs, and enter into the muscles, moving the tip of the nostril. It is
rather difficult to demonstrate the nerves ffoing; into the bulbs of the hairs in these
ON THE NERVES OF THE HEAD. 69
feeling, and is not in its office connected with respiration. The
trunk of the elephant is not a simple feeler, it is a tube through
which it respires, and therefore it has another nerve.
From the nerve that comes off from the anterior ganglion
of the leech, and which supplies its mouth, we may trace up
through the gradations of animals a nerve of taste and manduca-
tion, until we arrive at the complete distribution of the fifth, or
trigeminus in man. (See plate 6. in which there are its three
grand divisions to the face.) Here in the highest link, as in the
lowest, the nerve is subservient to the same functions. It is the
nerve of taste, and of the salivary glands; of the muscles of the
jaws, and of common sensibility. This nerve comes off from the
base of the brain in so peculiar a situation, that it alone, of all
the nerves of the head, receives roots both from the column
of sensibility and of motion. A ganglion is formed upon
it near its origin, though some of its filaments pass on with-
out entering into the ganghon. Before passing out of the
skull, the nerve splits into three great divisions, which are
sent to the face, jaws, and tongue. Its branches go minutely
into the skin, and enter into all the muscles, and they are
especially profuse to the lips*.
smaller animals, but it is easily done in the phoca. A preparation illustrative of this
fact was shown to me some years ago in Amsterdam, by Professor Vrolich; and in
the first number of the Journal de Physiologic Expcrimcntale, by M. Mao-endie,
there is an account of " les Nerfs qui se portent aux Moustaches du Phoque," by M.
Andral. This fact of anatomy, which has been denied by some, is farther demonstrated
by the dissection of those animals whicli have tufts of hair or whiskers over the eye.
In the American squirrel, I have traced the branches of the first division of the fifth
into the bulbs of the hairs over its eyebrow.""
* We refer the reader to the next paper and the explanation of the plates for
the more minute anatoniy of this nerve.
70 ON THE NERVES OF THE HEAD.
Of the respiratorij nerve of the face, being that zchich is called
portio dura of the seventh^.
This nerve does not exist, except where there is a necessity
for some consent of motions to be established between the face
and the respiratory organs ; and the reason of its circuitous and
prolonged course is, that it may associate with the other nerves
of respiration. In fishes, this nerve, instead of being distributed
forward to the face, passes backward to the muscles of the gills.
In fact, there is, properly, no portio dura of the seventh in fishes,
the nerve resembling it being a branch of the par vagum. A
short description of this nerve in the human body will be
necessary to our inquiry.
The respiratory nerve of the face arises from the superior
and lateral part of the medulla oblongata, close to the nodus cerebri,
and exactly where the crus cerebelli joins the medulla oblongata.
The other respiratory nerves, which form so distinguished a part
of the nervous system, arise in a line with the roots of this nerve.
The nerve, passing into the internal auditory foramen, is
here embraced by \\\e portio mollis; but it separates from it, and
is received into an appropriate canal of the temporal bone. A
little farther on, and while within the temporal bone, two cords
of communication are formed with the branches of the fifth
nerve, or trigeminus. One of these is called Vidian nerve, and
the other corda tympani. By these communications, nerves go
in both directions; branches of the seventh are sent to the
* Portio dura nervi acustici. Sympatheticus parvus by Winslow, Faciale by
Vicq. d'Azyr. ,
ON THE NERVES OF THE HEAD. 71
muscles at the back of the palate; while branches of the fifth
nerve (and also of tlie sympathetic nerve) are brought into the
interior of the ear.
By the second of these communications, the corda tympani,
[which joins the lingual branch of the fifth, just where that
nerve is passing by the side of the levator and circumjiexns palatiij
the branches of this respiratory nerve have access to the velum
palati and its muscles.
The respiratory nerve of the face, emerging through the
stylomastoid foramen, divides into many branches, and these
diverging, spread to all the side of the face. Let it be recollected,
however, that it is here joined by branches of the third division
of the fifth nerve*. The respiratory nerve having escaped from
the temporal bone, divides : first, a branch is sent to the muscles
of the outward ear; another is sent, under the angle of the jaw,
to the muscles of the throat. The principal nerve then passes
through the parotid gland, and comes upon the face. Here the
branches continue to scatter, to go upwards upon the temple
and downwards upon the side of the neck, forming on the neck
a superficial plexus. The principal branches, however, go for-
ward to the muscles of the forehead and eyelids; a branch
called superior facial is sent to the muscles of the cheek and the
side of the nose; while an inferior facial branch is given to the
angle of the mouth, and the muscles which concentrate there.
In this extensive distribution, the nerve penetrates to all
the muscles of the face ; muscles, supplied also with the branches
of the fifth pair.
* See plate 7.
72 ON THE NERVES OF THE HEAD.
The descending or inferior divisions, which go under the
lower jaw, and to the superficial muscles of the throat and neck,
are connected with branches of the spinal nerves, and with the
respiratory nerves, as may be seen in plate 6.
The proportion of the facial respiratory nerve to the fifth,
is greater in man than in any other animal. If we descend to
the next link in the chain of beings (the monkey), we shall find
the proportion of it to be much diminished, and that of the fifth
increased. The distribution of the nerve is more complicated
in the monkey than in the dog, its intricacy being apparently in
proportion to the number of the muscles of expression. From
the lion, the dog, and cat, we descend to the horse, ass, and cow:
in these animals there is a marked difference in the distribution
of the nerve, from that of either the monkey or the dog; for,
excepting a few branches, which pass to the muscles of the
external ear, and to the eyelid, the whole of the respiratory
nerve is confined to the muscles of the nostrils and side of the
mouth, while in the carnivorous tribes it is spread in great pro-
fusion over the cheeks and side of the neck.
There are, however, some varieties in the classes of grami-
nivor<ius animals. In the gazelle, sheep, and deer, the distribu-
tion of the nerve is still more simple than in the horse; while in
the camel it is more profuse, and is, in this respect, intermediate
between that of the carnivorous and the graminivorous animals.
The expression of the enraged camel is sufficiently ferocious; and
the manner in which he shows his tusks, when dying, is very
similar to that of a carnivorous creature.
If we were barely to consider this distribution of the portio
ON THE NERVES OF THE HEAD. 73
dura of the seventh, unbiassed by theory or opinion, we should
be forced to conclude, that it is not alone sufficient to supply
any one part with nervous power, for every one of its branches
is joined by divisions of the fifth. The question then naturally
arises, whether these nerves perform the same function ? whether
they furnish a double supply of the same property or endow-
ment, as so many of our best authorities have supposed? or do
they perform different offices? Having taken all the assistance
that the knowledge of the human structure and comparative
anatomy affords, we are prepared to decide the matter by
experiment.
Experiments on the nerves of the face, with a view of ascertaining
the uses of the portio dura.
If an ass be thrown, and its nostrils confined for a few
seconds, so as to make it pant and forcibly dilate the nostrils at
each inspiration, and if the portio dura be now divided on one
side of the head, the motion of the nostril of the same side will
instantly cease, while the other nostril will continue to expand
and contract in unison with the motions of the chest.
On the division of the nerve, the animal will give no sign
of pain ; or in no degree equal to what results from dividing the
fifth nerve *.
If an ass be tied and thrown, and the superior maxillary
* In plate 7, branches of the fifth or sensitive nerve are seen to join and incor-
porate with the portio dura, so that the nerve, when cut anterior to this junction, must
exhibit signs of sensibihty.
74 ON THE NERVES OF THE HEAD.
branch of the fifth nerve exposed, touching this nerve gives
acute pain. When it is divided, no change takes place in
the motion of the nostril; the cartilages continue to expand
regularly in time with the other parts which combine in the act
of respiration. If the same branch of the fifth be divided on
the opposite side, and the animal let loose, he will not pick up
his corn: the power of elevating and projecting the lip, as in
gathering food, appears lost. He will press the mouth against
the ground, and at length lick the oats from the ground with
his tongue. In my first experiments the loss of motion of the
lips in eating was so obvious, that it was thought a useless
cruelty to cut the other branches of the fifth*.
The experiment of cutting the respiratory nerve of the
face, or portio dura, gave so little pain, that it was several times
repeated on the ass and dog, and uniformly with the same effect.
The side of the face remained at rest and placid, during the
highest excitement of the other parts of the respiratory organs.
When the ass, on which the respiratory nerve of the face
had been cut, was killed by bleeding, an unexpected opportunity
was offered of ascertaining its influence, by the negation of its
powers on the side of the face where it was cut across.
When an animal becomes insensible from loss of blood, the
impression at the heart extends its influence in violent con-
vulsions over all the muscles of respiration; not only is the air
drawn into the chest with sudden and powerful effort, but at
* The cases in the Appendix prove in a more agreeable way the fact, that when
the facial branches of the fifth pair of nerves are cut, insensibility results without loss
of motion. See No. LI., Appendix.
ON THE NERVES OF THE HEAD. 75
the same instant the muscles of the mouth, nostrils, and eye-lids,
and all the side of the face, are in a violent state of spasm. In
the ass, where the respiratory nerve of the face had been cut,
the most remarkable contrast was exhibited in the two sides of
its face; for whilst the one side was in universal and powerful
contraction, the other, where the nerve was divided, remained
quite placid*.
From these facts we are entitled to conclude, that the portio
dura of the seventh is the respiratory nerve of the face; that
the motions of the lips, the nostrils, and the velum palati, are
governed by its influence, when the muscles of these parts are
in associated action with the other organs of respiration. We
cannot fail to acknowledge the necessity of this relation. These
passages to the lungs are membranous tubes, moved by muscles,
which serve to expand and widen them, so that the air may
freely enter into the lungs. It is obvious that, to produce this
expansion, these muscles must have a consent with the other
muscles of respiration, and move simultaneously with them;
and this is effected through the respiratory nerve of the face-f-.
It shall be proved in the sequel, that the throat, neck, shoulders,
and chest, have similar nerves to this, similar in distribution and
♦ Read the case of Paralysis of the Face, No. VII. Appendix, where the expression
of a woman in labour was confined to one side. A frightful expression of countenance
was produced by the same cause in a patient dying. — See Case XXXIX.
t In Case No. X. in the Appendix, the defect from paralysis of the nostril is
apparent. The same is shown in the detail of Daniel Quick's Case, No. III. A
more curious example is presented in No. VI., where it is seen, that if the patient lay
with the nostril of the sound side pressed against the pillow, he was under the necessity
of actually holding the paralytic nostril open with his fingers, in order to breathe freely.
L 2
76 ON THE NERVES OF THE HEAD.
function ; and that these unite all the extended apparatus of
breathing and speaking.
The actions of sneezing and coughing are entirely confined
to the influence of the respiratory nerves. When carbonate of
ammonia was put to the nostrils of the ass whose respiratory
nerve had been cut, that side of the nose and face, where the
nerves were entire, was curled up with the peculiar expression
of sneezing ; but on the other side, where the nerve was divided,
the face remained quite relaxed, although the branches of the
fifth pair and the sympathetic were entire. The respiratory nerve
of one side of the face of a dog being cut, the same effect was
produced ; the action of sneezing was entirely confined to one
side of the face.
These last experiments show, that the peculiar expression
in sneezing results from an effect on the respiratory nerves, and
that the muscles of the face are drawn into sympathy solely by
the influence of the respiratory nerve of the face. It will appear
that the property of receiving impression is not actually lost by
the division of this facial muscular nerve, but the corresponding
expression is quite destroyed*.
There is no part of the nervous system where the anatomy
has been more negligently consulted in forming our physiological
opinions, than in what regards the office of the sympathetic
nerve. The connexions of this nerve, or rather system of nerves,
being universal, it has been supposed that it was the cord
* See Daniel Quick's Case, Appendix.
ON THE NERVES OF THE HEAD. 77
through which the relations of the eye, nose, face, throat,
diaphragm, &c., were estabHshed, and especially in expression;
whereas the combination is effected solely through those nerves
which, from their grand or leading function, I have called the
respiratory nerves. The sympathetic nerve was left entire when
the respiratory portio dura was cut, yet no sympathy pervaded
the features. The sympathetic nerve is therefore not the source
of that sympathy which produces expression.
It has been presumed, that the act of smiling is peculiar
to the human countenance, and that in no other creature
can there arise that state of enjoyment which produces this
distinguishing character of the human face, the affection of
benevolence, or the enjoyment of the ridiculous. But every
one must have observed how near the approach is to this
expression in a dog, when he fawns on his master, and leaps and
twists his body and wags his tail, while at the same time he
turns out the edge of the lips as like a laugh as his organs can
express. When the respiratory nerve on one side of the dog's
head was cut across, there was no longer this motion of the lips,
although it was still observable on the other side, where the
nerve was entire.
On cutting the respiratory nerve on one side of the face of
a monkey, the very peculiar activity of his features on that side
ceased altogether. The timid motions of his eye-lids and eye-
brows were lost, and he could not wink on that side; and his
lips were drawn to the other side, like a paralytic drunkard,
whenever he showed his teeth in rage. Considering these facts,
the conclusion is inevitable, that the motions of the lips, nostrils
78 ON THE NERVES OF THE HEAD,
and eye-lids, and forehead, in expression, have nothing to do
with the fifth pair of nerves, nor with the nervi molles, branches
of the sympathetic nerve, which accompany the blood-vessels of
the face.
In the Appendix we have proofs equal to experiments, that
in the human face the actions of the muscles which produce
smiling and laughing are a consequence of the influence of this
respiratory nerve. A man had the trunk of the respiratory
nerve of the face injured by a suppuration which took place
anterior to the ear, and through which the nerve passed in its
course to the face. It was observed, that in smiling and laughing,
his mouth was drawn in a very remarkable manner to the
opposite side. The attempt to whistle was attended with a
ludicrous distortion of the lips: when he took snuff" and sneezed,
the side where the suppuration had affected the nerve remained
placid, while the opposite side exhibited the usual distortion.
Thus it appears, that whenever the action of any of the
muscles of the face is associated with the act of breathing, it is
performed through the operation of this respiratory nerve, or
jjortio dura. I cut a tumour from before the ear of a coachman:
a branch of the nerve which goes to the angle of the mouth was
divided. Some time after, he returned to thank me for ridding
him of a formidable disease, but complained that he could not
whistle to his horses*.
Thus it appears that the portio clin^a of the seventh nerve
* Of this we have now abundant proofs: — see the cases in the Appendix. The
only subject of surprise is that these circumstances should have been so long un-
observed.
ON THE NERVES OF THE HEAD. 79
is the principal muscular nerve of the face ; that it supplies the
muscles of the cheek, the lips, the nostrils, and the eye-lids;
that is, that it is the nerve which orders all those actions which
have even the remotest connexion with the act of respiration. It
is possible that those relations may not be apparent at first, but
in the prosecution of this subject we shall discover the reasons of
those links by which the respiratory organs are combined with
the actions of the features.
Of the functions of the Trigeminus^ or fifth nerve.
As soon as the proper distinctions in the functions of these
facial nerves are made, facts multiply upon us. We have seen
that when the fifth nerve, the nerve of mastication and sensation,
was cut in an ass, the animal could no longer gather his food.
It was found, that on cutting the infra-orbitary branch of the
fifth nerve on the left side, and iheportio dura,ox respiratory nerve,
on the right side of an ass, the sensibility to pain on the right
side, where the portio dura of the seventh nerve was cut, remained
entire, while that of the left side was completely destroyed by
the division of the fifth. It was also apparent in this experiment,
as in the others, that there was the most marked difference in
the sufferings of the animal, when these nerves were cut across.
The cutting of the fifth nerve gave pain in a degree corresponding
with our notions of the sensibiUty of nerves; but in cutting
the portio dura, it was not evident that the animal suffered pain
at all.
Independently of the difference of sensibility in these nerves,
80 ON THE NERVES OF THE HEAD.
there was exhibited, in all these experiments, a wide distinction
in their powers of exciting the muscles. The slightest touch on
the portio dura, or respiratory nerve, convulsed the muscles of
the face, whilst the animal gave no sign of pain. By means of
the branches of the fifth nerve, it was not possible to excite the
muscles, if the trunk of the nerve were divided; that is to say, if
the communication with the sensorium were cut off.
I divided the branch of the fifth pair, which goes to the
forehead, in a man, at his urgent request, on account of the tic
douloureux: there followed no paralysis of the muscles of the
eye-brow: but in an individual where an ulcer and abscess seated
anterior to the tube of the ear affected the superior branch of
the respiratory nerve, the eye-brow fell low, and did not follow
the other when the features were animated by discourse or
emotion*.
Facts multiply upon us daily, if our attention be kept awake
by a knowledge of the anatomy of these nerves. I had a patient
in whom there was loss of sensibility in the side of the face
and tongue from disease of the fifth, while the motions of the
features remained. The case is detailed in the Appendix, No.
LVI. page cxii., and in the next paper f.
Thus experiments and occurrences in practice leave no
doubt as to the distinct offices of the two nerves of the face ;
and that the fifth nerve is the sole cause or source of the com-
mon sensibility of the head and face.
* This is more particularly illustrated by the division of the fifth nerve — see
No. L. of the Appendix.
•f- See also the case of division of the suborbitary nerve, in No. LI. of the Appendix.
ON THE NERVES OF THE HEAD. 81
The following circumstance occurred to a very learned and
ingenious gentleman. Suffering under the pangs of toothache,
he took the sudden resolution of having his tooth drawn, and by
an inexperienced hand : a grinder of the lower jaw was extracted.
On putting a tumbler of water to his lips, he said. Why have
you given me a broken glass? he found presently that the
glass was entire, but that he had lost the sensation of one half
of his lower lip. He thought that he put half a glass to his lips,
because the lip had been deprived of sensation in one half of its
extent. He retained the power of moving the lip, but not of
feeling in it : and now, after some years, he does not know
when a portion of food, or a drop, hangs on that side of
the lip, although there be not the slightest impediment in its
motions.
This circumstance is explained on reference to the plate,
for there is a branch of the fifth nerve called mandibido-labralis,
coming through the jaw, to be given to the lip. This nerve was
undoubtedly hurt where it takes its course in the jaw under the
roots of the teeth, and the consequence was the loss of sensation
in the one half of the lip which is suppHed by it. It is equally
important in this investigation to notice, that although the
sensibility of the lip was destroyed by the injury of the branch
of the fifth, the motion of the lip remained entire through the
operation of the portio dura.
In the above statement there are some facts regarding the
feeding of the animals which are of difficult explanation, until
we consider what is necessary to the simple act of feeding.
"When a horse gathers the oats from the hand or from the
M
82 ON THE NERVES OF THE HEAD.
ground, he must feel the food, which is the office of the
branches of the fifth ; he must move his hps under the direction
of that feehng, or he cannot gather it. It was accordingly
discovered by experiment, that whether the seventh or the
fifth were cut, if the operation were done on both sides of the
face, the creature was deprived of the power of feeding, but
from different causes ; for in the first experiment it was owing
to the loss of motion, and in the second to the loss of sensation.
I am unable to decide whether or not the muscular branches
of the fifth nerve go exclusively to the muscles of the jaws, and
not at all to those of the cheeks. I have found in an individual,
that, when the cheeks and lips were twisted by paralysis, he
possessed the power of holding with his lips in a manner that
indicated a power independent of the seventh. Now this might
be a defect of one of the endowments of the seventh whilst
another remained, or it might have been owing to a branch of
the fifth going forwards to the buccinator. We shall not discuss
this here, as it is the subject of the second paper*.
* Mr. Shaw in a paper on this subject says, " In the case of a little girl, the
consequence of disease of the right portio dura is very striking. When she laughs
heartily, the right cheek and the same side of the mouth are unmoved, while the
muscles of the left side are convulsed with laughter.
" If told to laugh with the right side, she raises the angle of the mouth, but by
an action which is evidently regulated by the fifth pair. This attempt to laugh
gives a peculiarly droll expression to her face."" But before we decide on this matter,
we must determine whether even the j^oiiio dura of the seventh nerve may
not lose one faculty and retain another. I suspect that the influence of passion, as
tills of smiling or laughing, is lost in consequence of affections that do not destroy
the entire })()wer of the nerve.
" I have observed in one patient the motions of theeyehds lost, while those of the
cheek remained ; in another the motions of the cheek lost, while those of the eyelids
ON THE NERVES OF THE HEAD. 83
It will be asked, why a nerve called respiratory should go
to the ear and the eye ? First, let us inquire, does it belong to
the frame of animal bodies that there shall be in them indications
of passion ? If it be admitted that this is the case, we here learn
in addition, that as the portio dura is the nerve of respiration,
so is it the grand nerve of expression, not only in man, but in
brutes also. All that excitement seen in a dog's head, in his eyes
and ears when fighting, disappears, if this nerve be cut. The
respiratory nerve being cut across in a terrier, the side of the
face was deprived of all expression, whether he was made to
crouch, or to face an opponent and snarl. When another dog
was brought near, and he began to snarl and expose his teeth,
the face, which was balanced before, became twisted to one side,
to that side where the nerve was entire ; and the eyelids being,
in this state of excitement, very differently affected, presented a
sinister and ludicrous expression.
On cutting the respiratory nerve of the face in the carnivorous
animals, it did not appear that the action of feeding was left so
entire as in the graminivorous animals. This gave me reason
to reflect on the different natures of the two classes. The beast
of prey procures his food under the influence of a blood-thirsty
appetite, and suffers a universal excitement; he holds and rends
his prey ; and especially in the larger animals of this class, the
action of feeding is accompanied with horrific sounds of enjoy-
ment; in short, with a highly excited state of the organs of
respiration. In the graminivorous animals, the act of feed-
were entire. These symptoms still tend to show that one function of the portio dura
may be lost without the other."
M 2
84 ON THE NERVES OF THE HEAD.
ing is a simple and unimpassioned exercise of the organs of
mastication.
The author hopes that these experiments will be deemed
conclusive ; yet it is a pleasanter mode of investigation to have
recourse to comparative anatomy. There is only one additional
instance of this kind that he will offer. It has been already
stated that when a feeler, or antenna, is examined, if it be simply
for sensation, one nerve only runs along it. It was suggested to
him, that if this theory were true, the trunk of the elephant
being hollow, and connected with respiration, it should have
two nerves ; whereas, in the observations of Cuvier, it was stated
to have only one ; but on examination, it was found that large
branches, nearly equal in size, of the portio dura and of the fifth
took their course along the trunk *.
* Mr. Shaw had an opportunity of dissecting the trunk of an elephant. He
says, " From the great power which the elephant has over its trunk I Avas certain
that there must be large nerves running to it, similar to those which supply the
fingers in man ; but as the proboscis forms an important part of the respiratory
system of this animal, I thought in the dissection of it there would be the most
distinct proof of the accuracy or fallacy of Mr. Bt4rs opinions on the subject of the
portio dui'ti.
" The trunk was found to be supplied not only by branches of the fifth pair, as
described by Cuvier, but also by a very large branch from the portio dura of the
seventh pair.
" The portio dura in this elephant was found emerging from the parotid gland,
as in other mammalia. It gave off some descending branches to the neck, but
passed from behind the jaw to the proboscis, almost as an entire nerve, and of the
size of the sciatic nerve in man : in its course it only gave some small brandies
to the muscles of the eye, to those of the ear, and to a small muscle which corresponds
with the platysma. Before it passed into the substance of the proboscis, it united
with the second division of the fifth pair, which comes forward from the infra-orbital
liole, in two large branches. Tiie two nerves being then closely united, passed
between the layers of the muscles, which form the greater mass of the trunk. The
ON THE NERVES OF THE HEAD. 85
SOME FURTHER REMARKS ON THE DISEASES OF THE NERVES
OF THE FACE.
Were we to inquire no further, and to rest contented with
the inference, that the two sets of nerves distributed to the face
have distinct functions ; even this must prove useful both to the
surgeon and physician. To the surgeon it must be useful in
performing operations on the face, as well as in observing the
symptoms of disease. If we have to plan an incision on the face,
we must take especial care to avoid cutting the branches of the
seventh nerve, for if it be divided, there will be paralysis of the
muscles supplied by that nerve. Whereas, if we divide the fifth
nerve, though there may be more pain during the operation, and
a defect of sensibility following it, no unseemly distortion will be
produced. To produce paralysis as a consequence of an opera-
tion which was meant to remove deformity, is an unfortunate
mistake ; but even worse consequences may result from an
ignorance of the distinct nature of these nerves : if, trusting to
the eyelids being supplied by the branches of the fifth nerve, a
surgeon, in opening an abscess or cutting out a tumour, should
cut the division of the seventh which goes to the eyelids, the
portio dura became quickly diminished in size, as it gave off its branches in great
profusion to the muscles: but the fifth was continued down, as a very large nerve,
to nearly the extremity of the trunk ; in this respect resembling the nerves to the
fingers in man. On making sections of the proboscis, near its extremity, a great
number of these nerves were seen in its substance.
" A few branches of the portio dura ran to the valvular apparatus in the upper
part of the trunk ; but this peculiar structure was supplied principally by a branch
from the fifth pair, which winded round under the orbit."
86 ON THE NERVES OF THE HEAD.
consequence would be very unfortunate. The eyelids thence-
forward would stand apart, the eye would be permanently un-
covered, and the cornea become opaque, and the vision of the
eye be lost.
By a knowledge of the distinct functions of the nerves of the
face, combined with a knowledge of their roots or origins in the
brain, we become better able to comprehend symptoms when
they are consequent on disease in the bones, or in the base of
the brain, or result from injury to the skull or brain, as in the
case of gun-shot wounds *.
To the physician the facts ascertained in this paper must
also be important : he will be better able to distinguish between
that paralysis which proceeds from the brain, and that partial
affection of the muscles of the face, when, from a less alarming
cause, they have lost the controlling influence of the respiratory
nerve. How often have I seen an inflamed gland affecting a
branch o£ the pot^tio dura mistaken for a disease in the brain itself,
because it was not known that, although the fifth nerve was free,
the pressure on the seventh nerve was sufficient to paralyze the
muscles of the side of the facef. That the disease of the bone
at one time affects the fifth nerve, producing excessive pain of
the face without paralysis ; and that it, at another time, affects
the seventh nerve, inducing paralysis without pain, are now
phenomena accounted for.
* In the Appendix, Nos. 3. 4-0. 42. sufficiently prove the consequences of
cutting across the portio dura, and that the surgeons must avoid dividing this
nerve.
f In the Appendix, the cases Nos. 1, 2. 7, 8. 32. 34. 38. 41. 45. 52. 56. show
the importance of this fact.
ON THE NERVES OF THE HEAD. 87
It is very frequent for young people to have what is vulgarly
called a blight ; by which is meant, a slight palsy of the muscles
on one side of the face, and which the physician knows is not
formidable. Inflammation of glands seated behind the angle of
the jaw will sometimes produce this : before these observations,
it would have been said, that paralysis could not be so produced,
because the parts are plentifully supplied by the branches of the
fifth nerve. The occurrence is stated at p. 4. 34. 62. of the
Appendix. All such affections of the respiratory nerve will now
be more easily detected, even in their most equivocal state: the
patient has a command over the muscles of the face, he can close
the lips, and the features are duly balanced ; but the shghtest
smile is immediately attended with distortion, and in laughing
and crying the paralysis becomes quite distinct.
The fact appears to be, that the respiratory motions of the
face produced by the influence of this nerve are subject to de-
rangement from slight causes ; by causes which do not influence
the general nervous system, nor even the other functions of the
seventh nerve. We shall see in the third paper, that this
character belongs to other branches of the same system in
their distribution to the trunk.
The knowledge of the sources of expression teaches us to
be more minute observers. The author had lately to watch the
breathing of an infant which had been several times restored
from a state of insensibility. At length the general powers fell
low, without any returning fit; insensibihty and loss of motion
stole over the frame; all but the actions excited by the respira-
88 ox THE NERVES OF THE HEAD.
tory nerves ceased; then each act of respiration was attended
with a twitching of the muscles of the ala nasi, and of that
muscle of the cheek which makes the dimple in smiling. It
was then evident that the child could not recover, that all but
the system of respiratory nerves had lost their powers, and the
consideration that these are the last to die showed too plainly
that actual death approached.
There are conditions of the lungs, when the patient is in
great danger, and yet the inflammation is not marked by the
usual signs of pain and difficult motion of the chest. We shall
see nothing but the twitching of those muscles of the face, which
are animated by the respiratory nerve. We see a certain un-
usual dilatation of the nostrils, and a constrained motion of the
hps, which, with the change of voice, is just sufficient to give
alarm, and indicate the patient's condition. This is a state of
the lungs very often produced after severe accidents, as gun-shot
wounds, and after great surgical operations.
A patient being in extreme danger, however debilitated, we
leave him in the conviction that death does not yet approach;
but when the respiratory organs are agitated, then the act of
dying has commenced.
These circumstances are stated to prove, that the subject
of expression is not foreign to medical studies; and certainly, by
attention to the action of the muscles of the face, we shall find
the views drawn here from the anatomy farther countenanced.
We learn that smiling is an affection of the nerve of respiration
on the muscles of the face, and that when laughter shakes the
ON THE NERVES OF THE HEAD. 89
sides, it is only an extended and more convulsive action of the
muscles, produced by the same class of nerves. When to the
paleness and coldness and inanimation of grief, there is added
the convulsive sob and the catching of the throat, and the
twitching of the lips and nostrils, we discover the same class of
nerves to be affected, which, in crying, are only more obviously
in operation, producing more violent contractions.
CONCLUSION.
When the account of the nerves of the throat, neck, and
chest, shall be laid before the Society, as those of the face have
now been, and when a comparison shall be made of the varieties
in nerves corresponding with the changes in the mechanism of
respiration in different animals, a juster estimate may be formed
of the importance of these observations. Then the same distinc-
tions of structure and function, which are made manifest in the
nerves of the face, will be observed in nerves which take an
extensive course through the body. We shall be able to di-
stinguish and separate the nerves of respiration, amidst the
apparent intricacy of the general system. By cutting across
these nerves of respiration, we shall find it possible successively
to stop the motions of the several parts, which unite in the act
of respiration; not only to stop the motion of the diaphragm,
but the motions of the side, of the shoulder, of the larynx or the
pharynx, by cutting their respective respiratory nerves. When
this is done, they will be left in the exercise of their other
90 ON THE NERVES OF THE HEAD.
functions through their other nerves, and still alive to other
excitements, and capable of performing the voluntary motions,
though dead to the influence of the heart and lungs.
By thus distinguishing the nerves of respiration, and as it
were separating them from the others, we reduce the remaining
part of the nervous system to comparative simplicity. The
seeming intricacy in the branching of the nerves, their con-
vergence to certain organs from different origins, their re-union
and divergence, instead of being a source of confusion, become a
subject of the highest interest. The re-union and crossing of
nerves we now ascertain to be for the purpose of associating the
muscles into different classes, for combining them in subserviency
to different organs, and placing them under the guidance of a
sensibility more certain in its operation than the will.
And now it may be once more asked, why is the portio
dura, the muscular nerve of the face, separated from the sensitive
fifth pair? Is it an accidental circumstance? No, certainly: it
is a dangerous principle to admit chance in a matter of this
kind: it cannot be an accident, which directs a distribution so
uniform through all the varieties of animals which breathe. It
is ordered for the ends so often hinted at in these papers — that
the organs in the face may be associated with those of the neck,
larynx, pharynx, &c. The nerve separates from the fifth, and
joins the glosso-pharyngeal and laryngeal, and the roots of the
phrenic, that all the parts supplied by these may be joined
together, and that a sympathy may exist among those parts
which would remain disjoined were there no other nerves than
the regular and symmetrical nerves of the spinal marrow.
ON THE NERVES OF THE HEAD. 91
A VIEW OF THE NERVES OF THE HEAD.
EXPLANATION OF PLATE VI.
In this plate the two distinct classes of nerves which go to
the face are represented ; the one to bestow sensibility, and the
other motion, and particularly the motions of speaking and ex-
pression, that is, the actions connected with the respiratory
organs.
The nerves on the side of the neck are also represented.
These I have discovered to be double nerves, performing two
functions: they control the muscular frame, and bestow sensi-
bility on the skin. Besides these regular spinal nerves, which
are for the common endowments, the nerves of the throat are
represented. These latter nerves are the chords of sympathy
which connect the motions of the neck and throat with the
motions of the nostrils and lips; not merely in swallowing and
during excited respiration, but in the expression of passion, &c.
A. The respiratory nerve of the face, or, according to authors, the portio dura
of the seventh nerve.
a. Branches ascending to the temple and side of the head.
b. Branches which supply the eye-lids.
c. Branches going to the muscles which move the nostrils.
d. Branches going down upon the side of the neck and throat.
e. Superficial cervical plexus.
N 2
92 ON THE NERVES OF THE HEAD.
ff. Connexions formed with the cervical nerves.
g. A nerve to the muscles on the back of the ear.
B. The eighth nerve, par vagum, or grand respiratory nerve.
C. The superior respiratory nerve, or spinal accessory nerve.
D. Ninth nerve, or lingualis.
E. Diaphragmatic or phrenic nerve.
F. Sympathetic nerve.
G. Laryngeal nerve.
H. Recurrent laryngeal nerve.
T. Glosso-pharyngeal nerve.
I. Frontal nerve: a branch of the fifth.
II. Superior maxillary nerve: a branch of the fifth.
III. Mandibulo-labralis : a branch of the fifth.
IV. Temporal branches of the third division of the fifth.
V. Ramus buccinalis-labialis : a branch of the third division of the fifth, pro-
longed from the motor root.
VI. VII. VIII. IX. Spinal nerves.
ON THE NERVES OF THE FACE.
[Fro^ the Philosophical Transactions.— Read May 28, 1829.]
I HAVE to beg the indulgence of the Society to some
minute details of anatomy, for the sake of those deductions
which can be attained by no other means: and that a zeal for
its cultivation may be preserved among us. There is an obvious
practical benefit derived from anatomy, but the public do not
comprehend its importance as a science. It is to the Koyal
Society that those who prosecute this science must look for
countenance in their slow and painful investigations.
Nine years ago, at the request of our late President, I sub-
mitted to the Society a paper on the Nervous System; in which
I arranged the nerves strictly according to the anatomy, and
illustrated the principles of the arrangement, by exhibiting the
different functions of the Nerves of the Face. On presenting a
second paper on the same part of the nervous system after so
considerable a lapse of time, there will be some novelty both in
the facts and in the illustrations; yet I have more gratification
in showing that after the most minute inquiries in different
countries, my positions drawn from the anatomy have been
I
94 ON THE NERVES OF THE FACE.
admitted, and my reasoning on the experiments, with one ex-
ception, found to be correct. Confident in the accuracy of my
deductions from the anatomy of the fifth nerve, I had attributed
to one of its branches a function which belongs to another
branch of the same nerve. The subject will form a part of the
present paper.
After the announcement of the facts in my first paper,
the inquiry became interesting from its application to medical
practice. I must take another opportunity of thanking those
gentlemen who have so liberally afforded additional proofs of
the truth of my principles. I must restrict myself in referring
to them here, since I am desirous that the Society's Transactions
should contain only the philosophical part of the inquiry.
The system of Willis, of which we have an elegant account
in the posthumous works of Dr. Eaillie, prevailed universally in
the schools when I entered on these inquiries. In opposition
to that system I demonstrated that the nerves hitherto supposed
to possess the same powers, consisted of filaments having dif-
ferent roots, and performing different functions. I found myself
embarked in this investigation, from observing the course which
the nerves took in their distribution through the body. Con-
ceiving that the devious course and re-union of the nerves were
for a purpose, I sought in their origins for the cause of their
seeming irregularity. It was discovered that the roots of the
nerves arose from distinct columns of nervous matter, and that
on these columns depended their different properties. Those
which were called the common nerves, that is, the nerves which
ON THE NERVES OF THE FACE. 95
arise from the spinal marrow, thirty in number, were found to
consist each of two nerves derived from distinct columns, one
for sensation and one for motion. In the further pursuit of this
subject, there was reason to conclude that the spinal marrow
contained not only the columns for bestowing sensation and
motion, but also another column, the office of which was to com-
bine the actions of respiration. I then drew the attention of
the Society to the course of the fifth nerve of the brain according
to Willis. I showed that it had the same double root as the spinal
nerves, that it had a ganglion, and that part of the nerve
passed free of the ganglion; and that from all these points of
resemblance, it was to be considered as the anterior or superior
of the spinal nerves, of that system which is called symmetrical,
and which ministers to the same functions in all classes of
animals, bestowing sensibility and the locomotive powers, but
deficient in those filaments which command the respiratory
motions. I am particular in restating this, because from time
to time it has been reported that I had abandoned my original
opinions; whereas every thing has tended to confirm them.
From the general view of the nervous system, I drew
attention to the superadded or irregular nerves. Having shown
that the original or symmetrical system of nerves, of which the
fifth was one, had no power over the motions of respiration, and
that tlie human countenance in all its motions, with the exceji-
tion of mastication, bore relation to the actions of respiration,
it was therefore required that another nerve besides the fifth
should be sent to the face. Having shown also that the roots
of the fifth nerve were distant from that column of nervous
96 ON THE NERVES OF THE FACE.
matter which gives origin to the nerves of the respiratory
system, and that it could not therefore minister to the motions
of the face which are connected with respiration; and that
another nerve, the portio dura, having its root in common with
the nerves of respiration, took its course to the face — the subject
was prepared for experiment.
By experiments on the nerves of the face these three things
were proved: — First, that the sensibility of the head and face
depended on the fifth pair of nerves: secondly, that the muscular
branches of the fifth were for mastication: and in the third
place, it was proved that the portio dura of the seventh, or
respiratory nerve of the face, controlled the motions of the
features, performing all those motions, voluntary or involuntary,
which are necessarily connected with respiration; — such as
breathing, sucking, swallowing, and speaking, with all the
varieties of expression.
Reserving the details, I shall now state shortly the oc-
currences which I have witnessed since the publication of that
paper; as they afford convincing proofs of the correctness of
these opinions.
The first instance was in a man shot with a pistol ball,
which entered the car and tore across the portio dura at its root.
All motion on the same side of the face from that time ceased;
but he continued in possession of the sensibility of the integu-
ments of that side of the face.
The next instance was in a man wounded by the horn of
an ox. The point of the horn entered under the angle of the
jaw, and came out before the ear, tearing across the portio dura.
ON THE NERVES OF THE FACE. 97
He remains now a singular proof of the effects of the loss of
function in the muscles of the face by this nerve being divided.
The forehead of the corresponding side is without motion, the
eye-lids remain open, the nostril has no motion in breathing,
and the mouth is drawn to the opposite side. The muscles of
the face by long disuse are degenerated, and the integuments
of the wounded side of the face are become like a membrane
stretched over the skull. They have lost their firmness, and
the flesh under them is wasted, with the exception of certain
muscles ; the reason of which will be understood on perusing the
anatomical description in the present paper. In this man the
sensibility of the face is perfect. The same nerve (portio dura)
has been divided in the extirpation of a tumour from before the
ear, and the immediate effect has been horrible distortion of the
face by the prevalence of the muscles of the opposite side, but
without the loss of sensibility; and that distortion is unhappily
increased when a pleasurable emotion should be reflected in the
countenance.
These facts are so distinct, that I cannot presume to detain
the Society with the instances of the lesser defects which I have
witnessed from the more partial injuries or temporary diseases
of the nerve; — such as distortion of the features produced by
glands pressing on this nerve, paralysis from suppurations in the
ear affecting the nerve in its passage, or temporary derangement
disturbing one or more of its functions.
As to the fifth nerve, the facts are equally impressive, and
correspond with our former experiments and opinions. By a
small sacculated tumour affecting the roots of this nerve, the
o
98 ON THE NERVES OF THE FACE.
sensibility was destroyed in all the parts supplied by its widely
extended branches ; that is, in all the side of the head and face
and the side of the tongue, whilst the motion of the face re-
mained. Two circumstances affecting this nerve have occurred
with most curious coincidence in the symptoms. By the draw-
ing of a tooth from the lower jaw, the nerve which comes out
upon the chin to supply one half of the lip was injured, and
exactly this half of the lip was rendered insensible. When the
patient put his mouth to a tumbler he thought they had given
him a broken glass ! Precisely the same thing occurred from the
division of that branch of the fifth nerve, which goes to one half
of the upper lip. A gentleman falling, a sharp point entered his
cheek and divided the infra-orbitary nerve : the effect was loss
of sensation without loss of motion, in that half of the upper lip
to which the nerve is distributed. The remarkable circum-
stance was, that this individual made the same remark when the
cup was put to his lip ; — that they had given him a broken one !
The part of the cup which was placed in contact with the in-
sensible portion of the lip appeared to him to be broken off.
I have had two or three instances before me of disease affect-
ing the ophthalmic branch of the fifth nerve, and producing
total insensibility of the eye and eye- lids, without loss of vision ;
whilst the eye-lids continued to be closed and the eye-brow to
be moved by the influence of the portio dura of the seventh
nerve.
Such are a few of the facts which have been reaped from a
patient reliance on the correctness of my first deductions, and I
would now urge them in proof of the importance of reasoning
ON THE NERVES OF THE FACE. 99
upon the anatomy. All these nerves have been repeatedly
divided, by almost every surgeon of eminence in the three king-
doms. Although some have performed the operation of dividing
the nerves frequently, and one eminent gentleman had done it
six times on the face of the same man, all these operations have
been performed without giving rise to the suspicion that these
nerves bestowed different properties. Even now, so slow is the
progress of improvement, it is stated by a surgeon that he will
not hesitate to cut the portio dura in the case of tic douloureux.
My duty is performed when I give publicity to the facts which
prove that horrible distortion of the whole countenance, the loss
of distinct articulation, the loss of expression, the loss of motion
of the eye-lids, and consequent inflammation of the eye, must
follow such an operation.
Much has been said in favour of experiments when made by
men who are positively without any expectation of the result,
or, as they affirm, are unbiassed. The only instances of this that
I can allow, are when the surgeon cuts the nerves of the face in
a surgical operation. In such operations as these for tic doulou-
reux, he is indeed unbiassed; and we have seen the result, that
after fifty years of such experience we remained quite ignorant
of the distinctions in these nerves. But, on the other hand, when
attention is roused to inquiry by anatomy, facts are obtained of
the utmost importance both to the knowledge of disease and to
the safe practice of surgery.
o 2
4^^
100
ON THE NERVES OF THE FACE.
Of the Motor or Manducatory portion of the fifth nerve.
The fifth nerve is usually called Trigeminus, from piercing
the skull in three grand divisions. But when it has been shown
that it is composed of two distinct roots having different func-
tions, the accidental circumstance of its divisions passing through
the bones yields in importance to another inquiry, How is the
muscular portion of the nerve distributed?
Since the pubHcation of my first paper this inquiry has
assumed importance; although the principal facts of the anatomy
were known to Wrisberg, Santorini, Paletta, Prochaska, and
Soemmerring. But in no author is the anatomy of the motor
portion of the nerve traced with sufficient minuteness, or regard
to the distinct uses of the muscular and sensitive divisions.
The motor division of the fifth nerve passes under the
Gasserian ganglion, and free of it. It is not seen when we look
from above, as in the plates of IMonro, When the nerve is
turned up and dissected, this portion is seen to form about a
fifth part of the whole nerve. It is tied to the larger portion
before advancing to the ganglion, by filaments which have been
sometimes taken for nerves.
Having passed the ganghon, it attaches itself slightly to
the superior maxillary nerve, but this is apparently a mem-
branous connexion only*. The nerve itself joins the third
* Gerardi, commenting on Santorini, says that the anterior root (the motor) does
give filaments to the superior maxillary division of the fifth. Prochaoka (de
iStructura Nervorum) gives two views, tab. ii. fig. v. vi., which represent an actual
ON THE NERVES OF THE FACE. 101
grand division after passing the foramen ovale. At this point
the muscular and sensitive portions of the nerves are matted
together, and form a mass which between the fingers feels like a
knot*. There is, however, no red and fleshy-like matter inter-
posed here, as in the Gasserian ganglion of the trunk of the nerve.
But the filaments of both portions of the nerve are here so com-
plexly and intimately combined, that all the branches which go
off after this union are compound nerves, and have motor fila-
ments in their composition.
It is, however, equally obvious that the gustatory division
of the nerve which descends from this mass has not the muscular
portion given to it in that abundance which those branches have
which take their course to the muscles of the jaws. The man-
dibulo-labralis, which also descends from this plexus, lies nearer
the motor portion, and has a more distinct addition given to it
than the gustatory nerve.
This motor or muscular portion which we are tracing sends
off no branch either in its course under the great ganglion, or
after passing it about half an inch. But when it has arrived at
the point of union with the ganglionic portion, the filaments be-
come interwoven; and from this place the nerves are compound,
and go off diverging to their destinations. First, there are sent
off nerves to the temporal, masseter, and pterygoid, muscles, also
to the buccinator muscle. The temporal muscle receives a
union of the anterior root and the superior maxillary nerve. In the plate, however,
the twigs seem rather to go from the ganglionic into the motor division.
* Santorini says, it is a plexus like a ganglion, " in plexum vere ganghoformem
mutatur.'"
102 ON THE NERVES OF THE FACE.
large and appropriate nerve. The nerve to the masseter passes
between the coronoid and condyloid processes of the lower jaw-
bone; but before going into the muscle it sends branches to the
temporal muscle. The pterygoid muscles have each their appro-
priate nerves coming directly from this plexus.
Ramus Buccinalis Lahialis.
This is a remarkable branch, which arises from the same
source, and goes to the cheek and lips. This nerve where it Hes
on the external pterygoid muscle sends one more branch to the
temporal muscle; it then divides, one branch enters the buc-
cinator muscle, and another is prolonged forwards. The division
to the buccinator muscle is tortuous, which is no doubt a pro-
vision for its being undisturbed by the free motion of the cheek ;
its minute branches may be traced until lost among the muscular
fibres, whilst others penetrate to the lining of the cheek. The
prolonged branch is the labial division ; it runs nearer the alveolar
processes of the lower jaw, and becomes so superficial as to
admit a union with the portio dura: from thence, passing under
the facial artery, it may be traced into the triangularis or depressor
anguli oris, the levator labiorum communis, and the lateral por-
tion of the orbicularis oris.
In the distribution of the buccinalis lahialis to the muscles
of the mouth, it is joined, as I have said, by branches of the
portio dura ; and nothing is more striking than the manner in
which this latter nerve passes over the masseter, a muscle of the
jaw, to be profusely given to the muscles of the lips.
ON THE NERVES OF THE FACE. 103
There is one more branch important to the physiology of
the fifth nerve. At the root of the mandibulo-labrahs (where it
is sent off from the junction of the muscular and ganglionic
portions) a small nerve takes its origin. This branch runs
parallel to the greater nerve till it enters the foramen in the
lower jaw ; here it seems to enter, but does not ; it takes a course
on the inside of the jaw to arrive at its final destination, the
mylo-hyoideus and the anterior belly of the digastricus, that is, to
those muscles which open the mouth by drawing down the jaw.
We may for a moment interrupt our particular inquiry, to
notice that all muscular nerves, and consequently the muscular
divisions of the fifth nerve, form a plexus. The plexus, formed
by the motor and ganglionic divisions of the fifth nerve before
they diverge to the muscles of the lower jaw, corresponds with
the plexus formed on the nerves sent to other classes of muscles.
Even that branch of the third division of the fifth nerve which
comes out before the ear joins the portio dura in a plexus*;
and this is the reason of that sensibility evinced in the facial
nerve in making experiments upon it.
The form of the fifth nerve, and its resemblance to the
spinal nerves, had struck some of the best continental anatomists.
But as they had made no distinctions in the functions of the
roots of the spinal nerves, so neither did they imagine any dif-
ference in the roots of the fifth nerve, and therefore no con-
sequence resulted from having observed this resemblance. This
part of the anatomy, together with the whole minute relations
of the nerves, was a dead letter, and led to no inference.
* See the adjoined plate.
104 ON THE NERVES OF THE FACE.
But now resuming the course I have hitherto followed, the
anatomy of the fifth nerve points to curious results. We see
that the motor division of this nerve goes first to the muscles
which close the jaw and give it the lateral or grinding motions.
Secondly, we see that it is distributed to the muscles of the
cheek, which place the morsel under the operation of the teeth ;
and thirdly, we find it going to the muscles which open the
jaws.
We proceed to the second method of proof, by experiment.
Does the fifth nerve move the jaw ? is it indeed the manducatory
nerve as suggested by the anatomy ? Let the following experi-
ments determine the fact.
EXPERIMENT I,
The root of the fifth nerve being exposed in an ass and
irritated, the jaws closed with a snap.
EXPERIMENT II.
The fifth pair being divided in an ass, the jaw fell relaxed
and powerless.
If we consider the action of mastication, we shall see what
the consequence would be, were there no accordance between
the motions of the lower jaw and the cheeks. Conceiving that
there must be such an accordance, and contemplating the roots
of the fifth pair and their distinct functions, I had imagined that
this office was performed by the branches of the second division
of the fifth. But finding that the connexion between the motor
ON THE NERVES OF THE FACE. 105
root and the superior maxillary nerve proved to be only by
cellular texture, and considering the affirmation of M. Magendie
and those who followed him, that the infra-orbitary branch had
no influence upon the lips, I prosecuted with more interest the
Kamus BuccinaUs Labialis. And nobody, I presume, will doubt
that the distribution of this division confirms the notions drawn
from the anatomy of the trunk, — not only that the fifth nerve is
the manducatory nerve as it belongs to the muscles of the jaws,
but also that it is distributed to the muscles of the cheek and
hps to bring them into correspondence with the motions of the
jaws. Let us take in illustration the articulation of the bones.
In the joints, the muscles are attached to the capsular membrane
in such a manner as to draw it from between the bones and adapt
it to the degree of flexion of the joint. If the cheek were a
passive membrane like the capsule of a joint, it would have
required some such mechanical connexion with the jaw or its
muscles, as might have drawn it from, between the teeth in the
motions of mastication. But being a muscular part, to bring it
into just relation with the motions of the teeth, it must have an
accordance through nerves, and act in sympathy ; — relax when
the jaws are apart, and contract when they are closed. I think
therefore we may perceive why a branch of the motor nerv-e of
the muscles of the jaws sends a division to the muscles of the
cheek and to the angle of the mouth.
By such a process of reasoning we see also why a branch of
the same nerve should prolong its course under the chin to the
muscles which are opponents to those which close the jaw.
In short, the motor portion of the fifth nerve sends no twigs
p
106 ON THE NERVES OF THE FACE.
with the ophthalmic division, nor with the superior maxillary
nerve, but only with the lower maxillary nerve. To the muscles of
the lower jaw alone which are in action during mastication, and
to the muscles necessarily associated in that action, the man-
ducatory nerve is distributed.
It remains only that we observe what takes place in man,
and compare the circumstances with experiments on brutes.
I was consulted in the case of a lady with an uncommon
disease in the side of the head : the description of her condition
puzzled me very much ; there was so much said of tumours with
pulsation on the head and face. But when I saw and examined
her, the mystery disappeared ; she had powerful spasms of the
temporal and masseter muscles, which rose and swelled, under
the excitement of a disease of the cheek, and with a pressure of
the jaws so powerful as to displace the teeth. During this
violent spasm of the muscles supplied by the fifth nerve, the
motions of the features were free and unconstrained under the
influence of the portio dura of the seventh nerve.
I have the precise counter-part to this morbid condition of
the muscles of mastication in the case of a poor man now
under my care. He has a disease affecting the fifth nerve of
the left side, attended with the loss of sensibility of the side of
the face and of the surfaces of the eye. In him there is no
motion of the muscles of the jaw of the affected side. In
chewing, the action is only on the right side of the head; the
masseter muscle and temporal muscle of the left side do not rise
or bulge out as in their natural actions; but his command over
his features is perfect through the operation of the portio dura.
ON THE NERVES OF THE FACE. 107
It appears, therefore, that the disease of the fifth nerve, which
has destroyed the sensibihty on one side of the face, has caused
a loss of motion in the muscles of the jaw on the same side.
A more frequent occurrence establishing the distinction of
motions influenced by the fifth and seventh nerves, is presented
in the case of paralysis of the portio dura; for then all the muscles
waste but those supplied by the fifth. In the case referred to,
of the man wounded by the horn of an ox, in whom the portio
dura was torn, and who had the skin of his forehead, side of the
nose, cheek and lips, deprived of all fleshiness and substance,
and in fact wasted to mere skin, the muscles of the jaw were
entire and prominent; and on introducing the finger into the
mouth and making him imitate the motions of mastication, a
weak contraction could be felt in the cheek*.
These facts close the evidence of the fifth nerve being a
double nerve; not only the nerve of sensibility to the head and
face, but a muscular nerve to the muscles of the jaws, active in
mastication, and otherwise useful in all animals whose jaws are
prehensile and used as hands. This curious fact, originally drawn
from the anatomy and now confirmed by it, had nearly been
obscured by experiment; since the external branches of the
fifth nerve, those most exposed to the experimenter, are not
muscular.
I am bound to acknowledge here the correction by M. Ma-
gendie, in regard to the office of the suborbital division of this
* How often a question has occurred as to this motion in the cheeks, may be seen
on referring to cases, p. 123, Exposition, &c. and p. 57, Appendix, first edition.
r 2
108 ON THE NERVES OF THE FACE.
nerve, since it has given occasion to the revisal of the ana-
tomy*.
We were involved in great confusion by the discovery of
new branches of nerves and of gangUons, through which we had
no guide, until we formed a correct arrangement of the whole
system. It is satisfactory to find that the ideas first suggested
by a comparison between the roots of the nerves and their
complex distribution in the face and neck are correct, when
tried by a minute investigation of the internal nerves of the
head; and that the conclusions drawn from the anatomy are
confirmed both by experiment and by a knowledge of the effects
of injuries and of disease in the human frame.
Additional Note. — As the most important fact in this
paper is that ascertained by experiments on the fifth nerve, I am
bound to say by whom they were made, and for what purpose.
To my late brotlier-in-law, Mr. John Shaw, whom I educated,
I have been indebted through the whole of this inquiry. He
had long been acquainted in the most intimate manner witli my
pursuits. He had repeated my experiments on the roots of the
spinal nerves, confirming the results — that the anterior roots
when irritated caused the muscles to contract, and that the
posterior roots had no such influence.
He assisted me in my experiments on the nerves of the
* M. Magcndie says, " Le resultat que nous avons obtenu s'accorde parfaite-
ment avec celui que nous venons tie rapportcr, a I'exception toutefois de I'influence de
la section de sous-orbitaire sur la mastication, influence qui n'a pas c't6 evidente pour
moi." Journal de Physiologic, 1821.
ON THE NERVES OF THE FACE. 109
face, which were for the purpose of establishing that the fifth
pair resembled the nerves of the spine, and at the same time
proving, what was incomplete from the experiments on the
spinal nerves, that a ganglion on one of the roots of a nerve is
no cause of interruption to sensation, but the sign that it bestows
sensibility; making certain what could be only assumed from
the experiments on the spinal nerves.
But he was acquainted also with my opinions drawn from
the distribution of the nerves in the body contrasted with the
anatomy of their roots. And when the correctness of these
opinions was established by experiment, he let no opportunity
pass of advocating and supporting them. In collecting informa-
tion and making dissections he was ever active, as all the real
students educated with him will testify. It was in the fervour
of his zeal that he went to Paris and explained the arrangement
by which I distinguished the nerves, and repeated my experi-
ments with M. Magendie and others at Charenton near Paris
in 1821.
At this time an idea was thrown out that the fifth nerve
was no more than the sensitive nerve of the face accidentally
separated from the muscular nerve (the portio dura). Per-
ceiving that if this notion prevailed we should be thrown back
into our former state of confusion, and to put the matter beyond
all question, Mr. Shaw performed those experiments which are
contained in this paper — experiments which in the gentleness of
his nature he would have hesitated to make from their severity,
but for their being imperatively called for.
Had Mr. Shaw lived, this subject would have been further
110 GN THE NERVES OF THE FACE.
advanced. Whilst his excellent judgment and indefatigable
exertions aided me in every difficulty, his gratification in wit-
nessing the progress of these inquiries was a reward beyond
what I have now to look for.
EXPLANATION OF PLATE VIL
In this figure the superficial nerves of the face are turned off, and the distribution
of the third chvision of the fifth to the muscles of the jaws and cheek exposed.
A. The vortio dura of the seventh or respiratory nerve of the face coming out
from the stylomastoid foramen ; the principal branches are cut and folded forwards.
B. The trunk of the porlio dura of the seventh, dissected off the face and
pinned out, while it is left at its connexions with the branches of the fifth on the
cheek and lips.
C. The branch of the third division of the fifth nerve, which joins the plexus
of the portio dura before the ear. Some experimenters, ignorant of this junction of
a sensitive nerve with the muscular nerve, have occupied themselves with experiments
to ascertain the degree of sensibility of the portio dura.
D. In this figure the masseter muscle is dissected from the jaw-bone and lifted
up to show D, the branch of the fifth pair of nerves going into the muscle.
E. The Ramus Buccinalis-labialis, that branch of the fifth nerve which goes to
the buccinator, triangularis, levator labiorum, and orbicularis muscles.
F. That branch of the fifth nerve which separating from the mandibulo-labralis
goes to the muscles which depress the lower jaw.
G. The suborbitary nerve, a branch of the fifth nerve.
H. The mandibulo-labralis, a branch of the fifth nerve coming out from the
bone to the muscles and integuments of the lip and chin.
I. A branch of the fifth nerve descending from the orbit.
D, E, F, are muscular branches of the fifth nerve, and are motor nerves.
C, G, H, I, are sensitive branches of the same nerve which join the branches of
the portio dura in its universal distribution ; and although these branches of the fifth
enter the muscles, they possess no power over their motions. B is the portio dura,
which, though taking the same course with the last, is for a different purpose ; while
it is a motor nerve, by its association with the respiratory nerves, it is enabled to
excite those actions of the face and lips which are necessarily connected with the act
of breathing.
ON THE NERVES OF THE FACE. Ill
EXPLANATION OF PLATE VIII.
Fig. 1. Represents the fifth nerve dissected out and seen on its lower surface.
A. The posterior or sensitive root before it forms the ganglion.
B. The Gasserian ganglion.
C. The anterior or motor root of the nerve passing the ganglion.
D. The third or lower maxillary division of the fifth nerve.
E. The motor portion joining the lower maxillary nerve and forming a plexus
with it. From this plexus go off the muscular nerves to the muscles of the jaw, viz.
1 . Temporalis.
2. Massetericus.
3. Buccinalis labialis.
4. Pterygoideus.
5. Mylo-hyoideus.
F. Division which joins the portio dura.
G. Mandibulo-labralis.
H. Gustatory nerve.
I. The chorda tympani.
Fig. 2. This figure represents the ganglion on one of the spinal nerves, to show-
its resemblance to the ganglion of the fifth nerve in every particular.
A. The posterior or sensitive root of the nerve.
B. The ganglion formed upon the posterior root.
C. The anterior or motor root of the nerve; this arises in minute branches
which join to form the larger subdivisions, whilst the posterior root is composed of
simple and abrupt portions. This division joins the sensitive division beyond the
ganglion exactly in the same manner that the motor portion of the fifth joins the
lower maxillary nerve.
Fig. 3. Represents one of the ganglions of the sympathetic nerve to show how
different it is from those on the symmetrical system of nerves. In fig. 1 and 2 the
nerve on entering the ganglion and escaping from it, is separated into branches in a
manner very different from the mode in which the sympathetic nerve joins or forms
its ganghons*.
* Authors who have treated of the anatomy of the ganglions have not distin-
guished between the two classes of ganglions as belonging to the sensitive and
sympathetic systems of nerves.
J
OF THE NERVES
ASSOCIATE THE MUSCLES OF THE CHEST, IN THE
ACTIONS OF BREATHING, SPEAKING, AND
EXPRESSION :
BEING
A CONTLNUATION OF THE PAPER ON THE STRUCTURE AND FUNCTIONS
OF THE NERVES.
From the Philosophical Transactions, 1822.
Q
OF THE NEHVES, &c.
[Read before the Royal Society, May 2, 1822. WitJi Additions*.^
The following paper contains an exposition of the nerves
of respiration ; their peculiarities, drawn from anatomy ; their
distinguishing properties, physiologically considered; and their
morbid conditions. It is a subject of some difficulty, because
the anatomy is intricate ; and this, I suppose, is the reason why
there are some who comprehend the distinctions made in the
S})inal nerves, and the difference in function of the nerves of
the face, but do not venture to hold an opinion on this more
difficult subject. I regret this ; for it is here that we have the
practical benefit arising from a knowledge of the different
systems of nerves. It is the knowledge of the nerves of respira-
tion distributed on the neck, throat, and thorax, that will en-
lighten the physician in distinguishing symptoms of disease.
* I have added mm-e freely to this paper than to the former. I have felt dis-
appointment that so great a subject, so full of interest, and so useful in practice,
should have made so little progress ; and under the idea that there must have been
something obscure in the writing, I have attempted to improve it.
Q 2
116 OF THE NERVES OF RESPIRATION.
OF RESPIRATION.
Of the action of the chest, neck, and face, in respiration ; of the
nerves which combine these parts and control their actions ;
and of the offices performed hy these organs of respiration, in
subservience to other purposes than the conversion of venous
into arterial blood.
The term respiration gives rise to no other idea in the
mind of the physiologist, than of certain chemical changes
wrought in the lungs. What, says a very eminent philosopher,
is the meaning of speaking of the respiratory nerve of the face?
what has the face to do with respiration ? The meaning of apply ing
the term respiratory nerve of the face is, that such a question might
be asked, and that we should be brought to consider the action
of respiration in a better and truer sense, and not as limited to its
influence on the blood ; that we may have our minds opened to
the interesting spectacle which is to be exhibited in this paper ;
and that we may perceive, and learn to appreciate, the marvellous
combination of parts, by which we have breathing, voice, speech,
and expression, besides smelling, coughing, sneezing, vomiting :
in short, such a combination of actions as minister, not only to
the vital act of oxygenation, but to the higher properties of
mind, as well as to a number of lesser actions necessary to our
very existence.
Let us suppose, that nature was as improvident as we may
have conceived her to be ; that the act of dilating and compress-
ing the chest was sufficient to the act of respiration ; how is
OF THE NERVES OF RESPIRATION. 117
the air to find admission through the long, membranous, and
compressible tubes which communicate between the lungs and
the atmosphere ? Just as it does in an apoplectic man ; the
lips would move like valves flapping in the stream of air; the
nostrils would be collapsed when they should be expanded ; the
velum pendulum palati would fall down upon the passage ; the
muscles of the glottis would be relaxed, and, instead of the
variety of sounds and articulate language which result from the
accommodation of these muscles with those of respiration, there
would issue no sound but the snoring, or stertorous breathing,
as in the apoplectic person.
1. Let us examine these points one by one. I have at
present a patient paralytic in one side of the face; when he
draws his breath this nostril is drawn together ; almost shut at
the instant when it should be expanded : and to breathe in excited
respiration he must breathe through liis mouth*.
2. If we are looking into a patient's throat, what do we say
to make him draw up the palate, that we may see into the
fauces ? do we tell him to draw up his uvula ? Even if he knows
what we mean, he has no direct power over the motions of that
part. We tell him to draw his breath, and in this action we see
the uvula and velum retracted, and the passage widened. And
so it happens that, as nature has connected the nostril with the
motion of inspiration, and the orifice of the tube expands ac-
cording to the necessity for inspiring air, in the same manner
the fleshy curtain which hangs in the fauces is furled up during
inspiration througli the moutli.
* See Case VI. in the Appendix, and page xii.
118 OF THE NERVES OF RESPIRATION.
3. At the same time that these motions of the nostril and fauces
take place, the chink of the glottis opens at each inspiration, as
I think was first noticed by Le Gallois, and which I have also
witnessed*. The glottis, pharynx, andnostrils mustexpand in pro-
portion to the call for free inspirations ; and without this our con-
dition would be worse than that of the asthmatic ; we should be
suffocated. It will be presently shown how much further the
sympathies of the act of respiration extend ; but these facts suf-
ficiently evince that there must be a wide-spreading means of con-
nexion between parts that are remote, to provide for freedom in
the simple act of breathing, independently of those accessories, or
those operations performed though the apparatus of respiration for
other objects than the oxygenation of the blood. ^Ve shall take an
illustration from the breathing of a horse. The horse does not
breathe by the mouth, but only through the nostrils; therefore
are those tubes formed of large moveable cartilages, which expand
under the influence of appropriate muscles. When a horse has
run his stage, the motions of his flanks, his sides, his neck, and
nostrils, exhibit a degree of excited action, which corresponds
with the accelerated state of the circulation, and the sweat that
pours down from him. This inflation of his nostril, and the
outstretched position of his head, exhibit the necessity of the
air tube being made free and cajjacious, in proportion to the
* In a rabbit dying under the experiment of dividing tlie spinal marrow below the
roots of the resjnratory nerves, and insensible : whilst the diaphragm and muscles of
the neck and of the nose moved in regular succession : I opened the larynx. At this
time the glottis was supplied by the laryngeal nerve of the left side only. Having
made a section of the cartilages of the larynx, I saw that at each inspiration the
crico-arytenoideus and thyro-arytenoideus muscles drew aside the arytenoid cartilage,
performing a motion exactly corresponding with the dilatation of the nostril ; that
is, expanding the glottis, to enlarge the passage for the more free inspiration.
OF THE NERVES OF RESPIRATION. 119
increased quantity of air drawn in and sent forth in respiration ;
and the exact correspondence of the motion of the nostril with
the sides shows the necessity of nervous cords of connexion
between parts so nearly related in function, although so remotely
situated. Accordingly, if you ask an intelligent jockey what are
the points of a horse for the turf, after speaking of the strength
of the loins, the height of the hind quarters, the shortness of
the bones from the hock to the hoof, he will speak of the large
nostril, the broad full windpipe, and the deep chest; because his
experience has shown him that good lungs are accompanied with
a free and capacious tube for the entrance and egress of the air
in respiration. He sees, what I wish to inculcate, that the
organs of respiration are not confined to the lungs, but extend
to all the parts necessary to the free play of the air through the
passages in excited respiration.
Before I proceed to the formal consideration of this subject,
I shall refer the reader to a comparative view of these nerves.
In page 25, we have traced the nervous system in the lower
animals, and we have seen that the regular ganglionic system of
animals of the lower class is sufficient for motion and sensibility.
But that call which gives occasion to inspiration is quite unlike
pain from external impression, as the act it excites is unlike
voluntary motion. It is an instinctive impulse, powerful in
the moment of birth as at any after period, which calls the re-
spiratory muscles into action ; and the motion it produces is of
that instinctive or automatic kind, which is perfect from the
beginning.
A new sense, and a new concatenation of motions, require
a new nerve, a distinct centre or origin, and a new apparatus of
(I-
I
120 OF THE NERVES OF RESPIRATION.
muscles. While yet in the inferior creatures there was a system
of air tubes carried through the body, there were no muscles of
respiration necessary; but when a creature higher in the scale
is in possession of concentrated organs of respiration, and when
to move these (which are passive in themselves) there are
appropriate muscles given, what will avail those muscles if
there are not also new nerves appropriated to them? They
must be placed under the control of a power which would
have been useless in the animal which had no lungs ; and there
are no other means of relationship between this new power and
these new muscles than by nerves.
We perceive, therefore, how it happens that in tracing
animals upwards from their simplest to their more complex
organization, with each new organ, and with every acquisition
of new muscles, there must be additional nerves appropriated
to them.
A question has been agitated : — Is the act of respiration a
voluntary or involuntary action ? and, strange to say, some have
determined that the action which proceeds so equably during
sleep, that is uninterrupted in the insensibility of apoplexy, that
continues when the head of an animal is crushed, the brain
deeply injured, or the head altogether removed, is an act of
volition, depending upon the impression made on the senso-
rium. Can it be the painful duty of a physician to attend the
bed of a dying person, to see, when all sensibility falls low, how
powerfully the chest and shoulders rise, and the flanks are
drawn, and say that this arises from a more powerful impression
on the sensorium ?
Nothing but a cherished hypothesis, joined to much inge-
A
OF THE NERVES OF RESPIRATION. 121
nuity, could bring a person to this conclusion, against the hourly
and obvious concurrence of facts. The confusion, for such I
presume there is, arises from the real difficulty of accounting
for the respiratory system becoming an instrument under the
influence of the will. We must distinguish that state of the
breathing which corresponds with the state of the pulse, that is
to say, the condition of the system by which the air is drawn
and the pulse beats with exact correspondence, from the effect
of volition on the breathing. We have no power to disturb the
established relation between the circulation and the respiration;
these are conditions of the vital functions too important to be left
to the influence of the mind. The power of volition over the
breathing is of a different kind altogether ; it is occasional or
temporary, and is permitted only so far as becomes necessary to
make the apparatus of respiration subservient to other offices.
We can distend the chest by an effort of the will; and we can
force the air out in bellowing, but in doing so there is an obvious
interference with the respiration through additional voluntary
muscles. Observe in what manner we command the breathing
in this interference, and we shall better comprehend the im-
portance of the class of nerves I am to point out: it is by
closing or opening the air-tubes, by playing, as it were, on the
ventiges, as in fingering a wind-instrument of music.
Thus we can close the glottis by the laryngeal muscles, and
suspend the breathing for a short time. If there be no effort of
the will, we breathe through the mouth and the nose equally;
but we can breathe without smelling, and draw the air
through the mouth without drawing it through the nose, or
R
122 OF THE NERVES OF RESPIRATION.
blow with the nose without the air coming through the mouth ;
and all these are irregular, partial, and temporary interferences
with the act of respiration. When the act of respiration, considered
in its highest office as subservient to the oxygenation of the blood,
is temporarily stopped, an accurate account of this interruption
is kept, and we must pant and breathe hard to make up for the
time lost, or the function being so far obstructed, by this inter-
ference of the will. If all these circumstances be neglected in
our course of reasoning, then to be sure we say that respiration
is a voluntary act, because we can blow out a candle !
Physiologists enter freely on these inquiries, if they forget
the anatomy of the nervous system; but if they were discoursing
over the dissection of the nerves of the neck and thorax, I
apprehend there would be some embarrassment. To us, the
inquiry still shapes itself thus: — What is the meaning of this
extraordinary concourse of nerves to these parts ?
We shall find no clue to the intricacy of the nerves of the
neck and thorax, unless we carefully consider the actions of the
muscles of the neck and chest.
There are two distinct conditions of the respiratory organs.
First — That play of the chest, soft and equable, necessary to
the expansion of the lungs and the inlialation of the atmosphere.
Secoiidhj — A condition of more powerful exertion, in which
another class of muscles comes into action, and the chest rises
high and the breathing is hurried.
The first of these conditions corresponds with the state of
the circulation, in which the lungs act in their primary character,
as the instrument of oxygenating the blood (as the term is still
OF THE NERVES OF RESPIRATION. 123
used). The second is a more animated condition, and has some
other end in the economy : bodily exertion or passion may be the
cause of excitement, or voice and speech may be the purpose of it.
For this second condition, in which a new object is to be
attained, different altogether from the original office of the lungs,
there are provided appropriate muscles and nerves. We must
continue to call these, parts of the apparatus for breathing,
because it is upon the air that they operate ; but they more
properly belong to the actions of speaking, smelling, and ex-
pression— of laughing, sneezing, and vomiting: actions which
are either necessary to safety in the complicated organization,
or by which new and essential powers of action are developed,
distinct from the original office of the lungs.
All these different offices, performed by the organs super-
added to the lungs, must be studied, if we hope to explain why
there is so great a concourse of nerves to the neck and chest.
It is even more necessary to consider the functions of the parts,
with reference to the nerves of the throat, tongue, neck, and
chest, than it is to study the functions performed in the face, to
enable us to detect the distinct offices of the nerves there.
Of the Muscles of the Trunk, which are brought in aid of the
common Respiratory Muscles.
If we look upon the frame of the body for the purpose of
determining which are the muscles best calculated to assist in
the motions of the chest, when there is an increased or excited
action, we shall have little difficulty in distinguishing them, and
R 2
124 OF THE Is-ERVES OF RESPIRATIOX.
we shall have as little hesitation in assigning a use to the nerves
which supply these muscles exclusively.
These muscles, in effect, we see powerfully influenced in
deep inspiration, however excited. They are the mastoid muscle,
the trapezius, the serratus magnus, and the diaphragm. They
operate in a circle, and all would be useless in the act of
respiration were one to be wanting. The serratus magnus, as
every student knows, expands the ribs; but this it does only
when the scapula, to which it is attached, is fixed, and unless
the scapula be fixed this muscle has no operation on the breath-
ing. The trapezius fixes the scapula by drawing it backwards
and upwards. These two muscles must always correspond in
action, in order to expand the chest. Xow let us see how the
trapezius influences the operation of the sterno-cleido-mastoideus.
The mastoid muscle elevates the sternum; but only when the
head is fixed, which is done by the action of the trapezius on
the back of the head and neck. To this train of connexions we
may join the diaphragm itself, since without the action of the
serratus the margins of the thorax would sink in by the action
of the diaphragm, and the force of that muscle be consequently
lost. Let us attend more particularly to the exterior class of
muscles.
1. Sterno-cleido-mastoideus. — This muscle, by its attachment
to the sternum or breast bone, and to the clavicle, raises or
heaves the chest. The usual description of the muscle is to
consider it as a muscle of the head, the lower attachments being
the origins; but when the head is fixed it becomes a muscle to
OF THE NERVES OF RESPIRATION. 125
raise the chest, and its operation is very evident in all excited
states of respiration, in speaking, and still more in singing,
coughing, and sneezing. Eut there is something necessary to
the full effect of this muscle on the chest, for otherwise it will
be a muscle of the head, and not of the chest. This leads us to
the next muscle.
2. The trapezius must fix the head or pull it backwards
before the mastoideiis can act as a respiratory muscle; and how
they are combined we shall presently see. The position of the
head of the asthmatic, during the fit, as well as the posture of
the wounded or the dying, prove the influence of the upper
part of the trapezius in excited respiration : that is to say,
when the shoulders are fixed, this muscle, usually described as a
muscle of the superior extremity, becomes a muscle fixing the
head.
The trapezius has a still more powerful and important in-
fluence in respiration when the action rises above the ordinary
condition, and that is by drawing back the scapula, to give the
necessary eflect to the action of the serratus magnus on the
ribs.
3. The serratus magnus anticus being extended over the
whole side of the chest, and attached in all the extent from the
second to the eighth rib, is very powerful in raising the ribs
and holding out the margins of the chest, which would be
otherwise drawn in by the diaphragm : and to this eflect the
intercostal muscles alone would be insufficient in the high or
excited state of respiration. But it cannot exert this power
126 OF THE NERVES OF RESPIRATIOTs^.
independently of the trapezius, since, without the combination
explained above, its force would be exerted in its more common
office of moving the scapula, and not the ribs. Unless the
scapula be fixed, or pulled back by the trapezius^ the serratiis is
not a muscle of respiration.
In this manner do these three powerful muscles hold
together in their action, combining with the diaphragm to
enlarge the cavity of the chest in all its diameters. These
external muscles do not interfere with the gentle actions of
breathing. But if the apparatus of respiration is to be employed
in any excess of action, in passion, in dying, in speaking, singing,
coughing, yawning, &c. these become powerful instruments. Let
us observe how^ necessary the muscles of the neck are to respira-
tion and circulation.
The Action of the Muscles of the Neck shown to he necessary both
for Hespiration and Circulation.
In the muscles of the neck, we have a subject which has
been entirely overlooked. The admirable work of Albinus, and
the various little works on dissection, have not left the fibre of
a muscle undescribed ; and this accurate anatomy has given rise
to the notion, that the subject of the muscles was complete.
On the contrary, Albinus, Cooper, Innes, kc, give us the mere
rudiments of knowledge : from their description of the origin
and insertion of insolated muscles, we understand nothing of
the combined action of muscles, or their relation to important
OF THE NERVES OF RESPIRATION. 127
functions. In this state of ignorance of muscular action, what
can we comprehend of the nerves distributed on the side of the
neck ? To go fully into this inquiry, we should not only have
to consider the action of respiration, but the principles of
hydrostatics and pneumatics, as they illustrate the eifect of
respiration on the circulation. We must be satisfied with
remarking, that when the sterno-cleido-mastoideus muscle lifts
the sternum and clavicle in inspiration, it takes off pressure from
the great veins of the neck, so that the blood from the head
descends freely at this time ; when the thorax descends again,
these veins are compressed ; and in this manner does the act of
respiration assist the circulation through the head.
The platysma myoides is a muscle of respiration, and acts
in aid of the mastoideus ; not only assisting it in all conditions
of excited respiration, but acting in a more particular manner,
in alternately taking off the pressure from the veins of the neck,
and again compressing them, and urging the blood into the
heart. In short, the muscles of the neck rise at the same time
that the thorax is raised and exj^anded ; and the alternate rising
and falling of the platysma myoides and sterno-cleido-mastoideus
are essential accompaniments of the high or excited act of re-
spiration. It is strange that so important a part of the mechanism
of the frame should have been neglected so long. We notice
it now because it is essential to the knowledge of the nerves of
the neck.
We are thus brought to comprehend the necessity of a
combination being established between these muscles, forming
128 OF THE NERVES OF RESPIRATION.
the exterior layer on the breast, back, and neck. How interest-
ing, then, to find that there are nerves coming from a part of
the medulla oblongata (the precise part which is proved to hold
a control over the actions of respiration), and that these nerves
accumulated in a narrow space at their origins do, in fact, diverge
and expand out on these muscles, and on these muscles only !
With what interest, I say, must we perceive, that these muscles
so commonly combined in action, so necessary to each other, and
which are abundantly supplied with nerves of sensation and voli-
tion, have respiratory nerves in addition distributed to them !
The proofs of the existence of such a class of nerves will
presently appear. But for a moment let us take it for granted,
and let us ask, with what nerves these additional respiratory
nerves should be joined ? We have understood that these
muscles, and these nerves, are bestowed for the purpose of
bringing the respiratory organs in aid of ulterior objects : those
objects are, amongst others, natural sounds, articulate language,
and expression. Eespiration, which is a function originally limited
to the exposure of the circulating blood to the atmosphere, is to
become employed in operations which regard the development
of the powers of the mind itself We have just examined this
superadded apparatus of muscles and nerves, and we comprehend
their object. Is it not, then, with the nose and lips, and fauces
and larynx, that these nerves must be joined ? Accordingly we
find that the nerves going to the diaphragm, larynx, pharynx,
lips, and face, are associated with these, and diverge from the
same source.
OF THE NERVES OF RESPIRATION. 129
Origins of the Respiratory Nerves.
The neryes on which the associated actions of voluntary
and excited respiration depend, arise very nearly together.
Their origins are not in a bundle, or fasciculus, but in a line or
series, and from a distinct column of the spinal marrow. Behind
the corpus olivare, and anterior to that process which descends
from the cerebellum, called sometimes the corpus restiforme, a
convex strip of medullary matter may be observed ; and this
convexity, or fasciculus, or virga, may be traced down the spinal
marrow, between the sulci, which give rise to the anterior and
posterior roots of the spinal nerves.
This portion of medullary matter is narrow above, where
the pons Varolii overhangs it. It expands as it descends ; op-
posite to the lower part of the corpus olivare it has reached its
utmost convexity, after which it contracts a little, and is con-
tinued down the lateral part of the spinal marrow less distinctly
pronounced.
From this tract of medullary matter on the side of the
medulla oblongata, arise in succession, from above downwards,
the portio dura of the seventh nerve ; the glosso-pharyngeus nerve;
the nerve of the par vagum ; the nervus ad par vagum accessorius;
and, as I imagine, the phrenic, and the external respiratory nerves.
A question may be here touched upon, which, however,
does not affect the main reasoning. Does this column of the
medulla oblongata continue down the whole length of the me-
dulla spinalis?
s
130 OF THE NERVES OF RESPIRATION.
It is probable that the branches of the intercostal and
lumbar nerves, which influence the intercostal muscles and the
muscles of the abdomen in the act of respiration, are derived
from the continuation of the same cord or slip of medullary
matter ; and the nerves called phrenic and external respiratory,
though coming out with the cervical nerves, may in all pro-
bability take their origin from the same tract or column of the
spinal marrow.
Before we trace these nerves to their destinations, let us
pay some attention to the part of the spinal column from which
they originate.
It has been stated that I began my researches where M. le
Gallois* left his imperfect. This is not quite correct, since my
inquiries were instituted long before I was acquainted with M. le
Gallois' just celebrity: but I had confirmation of my opinion
by his experiments, and more confidence that I was proceeding
in a proper course. M. le Gallois had said, and the observa-
tion was confirmed in the paper of Mr. Lawrence -]-, that what-
ever part of the brain was wanting in the acephalous child, if
the origin of the eighth pair was entire, the child would respire.
On the other hand, my own experiments, and my experience in
witnessing the effect of injuries of the spine, had taught me that
the spinal marrow injured opposite to the fifth vertebra of the
neck permitted the individual to breathe and live.
* Nous voici done arive au point d'ou M. Charles Bell parti, et ce point est pre-
cisement celui ou mon pere s' etait arete en le signalant k I'attention des physiologistes.
— Eug: Le Gallois.
■}- Medico-Chirurgical Transactions. See also the Appendix.
OF THE NERVES OF RESPIRATION. 131
The principal seat of power which controls the actions of
respiration was thus indicated to be within a very narrow com-
pass ; and the conclusion so far drawn is confirmed by abundant
evidence, that if the part so indicated be crushed, respiration
stops in the instant, and death ensues without even a momentary
struggle.
We have arrived at that point of the inquiry, when, with
some hope of a satisfactory answer, we may require an explana-
tion of the extraordinary intricacy of the nerves of the neck,
throat, and chest.
On the side of the neck we see the portio dura sending
down a division to the exterior cervical plexus; we see joined
in the same superficial distribution of nerves the second,
third, and fourth cervical nerves, the roots of the phrenic, and
the branches of the ninth nerve. Deeper we find the spinal
accessory, the glosso-pharyngeal nerve, the laryngeal and pha-
ryngeal divisions of the eighth and the recurrent, the trunk
of the ninth, and the gustatory of the fifth. Every dissector
deserving the name of student of anatomy has stood astonished
and confounded at this display.
We proceed to unravel this confusion : and for this purpose
we must return to the anatomy of the medulla oblongata, for he
who holds this in his hand has the key to the nervous system.
The nerviis vagus arises by many distinct feet from that
column of nervous matter which is between the motor and sen-
sitive columns, in a manner very different from the roots of the
spinal nerves, and from a point quite distinct from the ninth or
s 2
132 OF THE NERVES OF RESPIRATION.
lingualis. Passing out by the foramen lacerwn in the base of
the cranium, it travels extensively, supplying the pharynx,
larynx, and lungs, and then by the side of the oesophagus passes
into the abdomen, to be given to the stomach principally, and is
ultimately lost in the solar plexus.
By reference to any common book of anatomy, the phrenic
nerve (4, fig. 2, plate 9), will be found to have its great root or
origin from the fourth cervical nerve; and to this is joined
a more slender branch from the third cervical nerve. But,
besides these roots, it has connexions, which of themselves would
mark the relations of the nerve : high in the neck, it is con-
nected with the nei'vus vagus and with the lingualis medius or
ninth, while, at the same time, a branch is given off to the
muscles of the larynx. The trunk of the nerve descends into
the cavity of the thorax, and gives no branches, until, arriving at
the diaphragm, it sends out numerous diverging branches, which
are lost in the substance of that muscle.
It has been long known that irritation of this nerve con-
vulses the diaphragm, and that cutting it across paralyses that
muscle. These facts, with the consideration of its course, prove it
to be a respiratory nerve, and such has been the universal opinion.
But to what purpose should a distinct nerve be sent to the
diaphragm, if the other muscles, seated externally, and which are
associated in action with the diaphragm, and as important to
respiration, were left without a similar tie to unite them with
each other, and with the organs of the voice ?
The inferior external respiratory neixe of the thorax (5, fig. 2,
OF THE NERVES OF RESPIRATION. 133
plate 9) is a counterpart of the internal or phrenic nerve. It
comes out from the fourth and fifth cervical nerves, and often it
is connected with the phrenic. It diverges somewhat from that
nerve, because, instead of descending within the chest, it falls
over the ribs, and descends in a distinct flat trunk upon the
outside of the chest, to be distributed entirely to the serratus
magnus anticus. This muscle has nerves from the spinal marrow,
because it has to combine in the motions of the frame in locomo-
tion. But the long descending nerve is a respiratory nerve ;
which we may know from its origin, course, and destination : in
its origin and course it is like the diaphragmatic nerve ; it passes
across the common spinal nerves without joining them; and in its
destination also it resembles the phrenic, since it is given to a
muscle necessary to full inspiration.
I come now to the spinal accessory nerve (3, fig. 2, plate 9)*,
which is more particularly an object of interest in this paper.
It is called here the superior respiratory nerve of the trunk.
Experiments may take a colour from the preconceived idea, but
the accurate investigation of the structure will not deceive us.
The author, therefore, entreats attention to the anatomy of this
nerve, as leading in the most conclusive manner to a know-
ledge of its functions.
It arises from the cervical portion of the spinal marrow ;
but instead of collecting its branches to go out by the side of
the vertebrae, like the internal and external respiratory nerves,
* Nervus ad par vagum accessorius.
134 OF THE NERVES OF RESPIRATION.
it shoots upwards within the theca of the spinal marrow, enters
the skull, and joins the eighth pair of nerves ; from which it has
its name of accessory. We see the roots of this nerve as far
down as the fourth cervical nerve*. These roots arise neither
from the posterior nor the anterior column of the spinal marrow,
but between the posterior roots of the cervical nerves and the
lis;ameiitum dej2ticulatum, and from the column of medullary matter
above described as the respiratory column. The origins of this
nerve come off in one line, and that line is in the direction of
the roots of the glosso-pharyngeal and par vagum, and of that
nerve which has been proved to be the respiratory nerve of the
face, the portio dura of the seventh. In its ascent the accessory
nerve is attached to the posterior root of the first cervical nerve.
The nerve having ascended through the foramen magnum,
passes out from the skull associated with the nerves constituting
the eighth pair, and in the same sheath with them ; they all go
out through the foramen lacerum, and by the side of the jugular
vein. In this course the accessory nerve divides into two. One
of these divisions joins filaments of the par vagum\ and these
again send nerves to the glosso-pharyngeal nerve (9, plate 2);
and sometimes a branch may be seen going to the lingualis
medius or ninth. The more external division of the accessory
nerve descends behind the jugular vein, and comes forwards and
perforates the mastoid muscle. In its passage through the
muscle it sends off branches which course through its substance ;
* In the ass, its roots are seen to extend much lower down.
OF THE NERVES OF RESPIRATION. 135
and if, as sometimes happens, though rarely, the nerve does not
pass through the muscle, these branches are, notwithstanding,
invariably given to it.
When the nerve has escaped from the back part of the
mastoid muscle, it forms a communication with that branch of
the third cervical nerve which ascends behind the muscle ; and
nearly at the same time it is joined by a branch from the second
cervical nerve. The superior respiratory nerve now descends
upon the neck, and begins to disperse its branches in regular
order to the edge of the trapezius muscle (11, plate 2); four
or five branches take their course to that muscle, separate into
minute subdivisions, and are lost in its substance. One more
considerable division, being the lowest of these, is joined by a
long descending branch of the second cervical nerve. Increased
by this addition, it descends under the trapezius and behind the
clavicle. Following this descending branch, it will be found
exclusively attached to the trapezius. Behind the scapula it is
again joined by branches from the spinal nerves ; and here a sort
of imperfect plexus is formed, from which, divisions of the nerve,
still descending, follow the lower edge of the muscle, and are
finally dispersed among its fibres.
This nerve arises from the same column with the respiratory
nerves ; it takes a most intricate and circuitous passage to form
a junction with nerves which we know belong to that class ;
it sends branches to join the nerves of the tongue and pharynx ;
it sends branches to the larynx in company with the branches of
the par vagum ; it then crosses the great nerves of the neck,
passes under the spinal nerves, goes to no other muscles in its
136 OF THE NERVES OF RESPIRATION.
course, but lavishes all its branches on the mastoid and trapezius
muscles. To an anatomist it is as plainly set forth as if it were
written in our mother-tongue, this is the superior respiratory nerve
of the trunk*.
Comparative View of these Nerves.
If we examine the par vagn?n, the portio dura of the face,
the external thoracic, the diaphrag?natic, and the spinal accessory
nerves, by comparative anatomy, we shall conclude that they are
all respiratory nerves, by their accommodating themselves to the
form and play of the organs of respiration. In fishes, the
respiratory nerve f goes out from the back part of the medulla
oblongata. When it escapes from the skull it becomes remark-
ably enlarged, and then disperses its branches to the branchiae
and the stomach. But from the same nerve go off branches to
the muscles moving the gills and operculum, whilst a division
of the nerve is prolonged under the lateral line of the body to
the tail. It is said that this division sends off no branches, but
this is not correct ; it gives branches in regular succession to the
muscles from the shoulder to the tail. Experiments have been
made upon these nerves, but their detail would lead us too far.
It is scarcely necessary to add, that there are neither phrenic
* Lobstein, in a dissertation on this nerve, finding the difficulty of accounting
for the nervoiis Jinid coming by a double passage to the muscle, concludes, veniet
Jbrsan tcmpus quo ista qnce nunc latent, dies extrnhat et longioris cevi diUgentia.
-|- The nerve which by its subdivision supplies the heart, lungs, and stomach,
•and the muscles of the gills.
OF THE NERVES OF RESPIRATION. 137
nor spinal accessory, nor external thoracic nerves in fishes, the
order of their muscular system not requiring them.
In birds, the structure of the wing, and the absence of the
mastoid muscle, render the spinal accessory nerve unnecessary ;
it is wanting, for the reason, that in the absence of the diaphragm
there is no phrenic nerve. Quadrupeds have the three respira-
tory nerves of the trunk ; but even in them there are variations
in the muscular frame, which illustrate the appropriation of the
nerves. The construction of the neck of the camel is like that
of birds ; there is a succession of short muscles along the side
of the neck, and attached to the vertebrae ; but there is no
long muscle, like the ster)w-cIeido-mastoideus, contributing to the
motion of respiration. There is, accordingly, no spinal accessory
nerve in the neck of this animal.
We have a remarkable example of the manner in which
these nerves vary in their course of distribution, and yet retain
their appropriate functions, in the nerves of the neck of birds.
In them, the bill precludes the necessity of the portio dura
going forward to the nostrils and lips ; the nerve turns back-
wards, and is given to the neck and throat ; and it is particularly
worthy of remark, that the action of raising the feathers of the
neck, as when the game cock is facing his opponent, is taken
away by the cutting of this nerve. If we compare the anatomy
of the facial respiratory nerve, in the various classes of birds, we
shall find its distribution to be analogous to that of the same
nerve in the different tribes of quadrupeds. In the game cock,
a few branches of the nerve pass to the loose skin under the jaw,
which is dilated in crowing, the greater number being distributed
T
138 OF THE NERVES OF RESPIRATION.
on the muscles of the neck, which cause the elevation of the
feathers when he puts himself in an attitude for fighting. Eut
in the duck, which, when enraged, has little or no power of
expression, the same nerve is not larger than a cambric thread,
and passes only to the skin under the jaw.
Tlie Functions of these Nerves farther illustrated.
Before having recourse to experiments on brutes, we may
observe what takes place in our own bodies. By placing the
hand upon the neck, we may be sensible that the mastoid muscle
has two motions. The lower extremity of the muscle is fixed
when we move the head ; but when we use the muscle in
inspiration, the head, and consequently the upper extremity of
the muscle, are fixed. Now, if we endeavour to raise the
sternum through the operation of this muscle, we shall find that
other muscles are, insensibly to us, brought into action, which
have nothing to do with this raising of the sternum. For
example, if we strain to raise the lower extremity of the muscle
we shall unavoidably produce an action of the muscles of the
nostrils ; by which association of actions, we shall discover, that
we are using the mastoideus as a respiratory muscle. If we
reverse the action, and move the upper extremity of the muscle,
other muscles will be drawn into co-operation, but they will be
such as assist in the motion given to the head, and there will be
no accompanying motion of the nostril or throat. We may vary
the operation in another way. In snuffing or smelling, if we
place the fingers on the portions of the mastoid muscles which
OF THE NERVES OF RESPIRATION. 139
are attached to the sternum, we shall find every little motion of
the nostrils accompanied with corresponding actions of the
sternal portions of the muscles in the neck. These facts prove
that the mastoideus muscle is subject to two distinct states of
association ; one in which the muscles of respiration are in
action, another in which the muscles moving the head are in
action.
When a man suffers fracture of the spine at the sixth
cervical vertebrae, and the marrow is crushed, he continues to
breathe by the influence of the three nerves which arise above
the injured portion. He inspires with force; but he cannot
perform expiration by muscular effort, it is only by the elasticity
and gravitation of the parts that the breath is propelled. He can
yawn, for that is an action of drawing the breath ; but he cannot
sneeze, for that is an action of expelhng the breath. But this
is a subject so curious in itself, and which has hitherto been so
little considered, that I shall reserve it for a distinct dissertation.
A man having a complete hemiplegia, the side of his face
relaxed, the arm hanging down powerless, and the leg dragged
in walking, we were curious to know if the influence pervaded
all the nerves of the side, or only the regular or voluntary nerves.
Some trouble was taken to make him heave up the shoulder of
the debilitated side, but to no purpose. He could only do it
by bending the spine to the other side, and as it were weighing
up the paralytic shoulder. Eut on setting him fairly in front,
and asking him to make a full inspiration, both shoulders were
elevated at the same time that both the nostrils were in motion.
The respiratory nerve of the face, and the superior respiratory
T 2
140 OF THE NERVES OF RESPIRATION.
nerve, were entire in their office; and, although the regular
system of nerves refused acting, the sterno-mastoideus and the
trapezius partook of their share in the act of respiration. Seeing
that the mastoid muscle has two sets of nerves, that one of these
is of the class of voluntary nerves, and the other of respiratory
nerves, are we not borne out in concluding, that when the head
is moved, being a voluntary act strictly, it is performed through
the common class of voluntary nerves ? that when the chest is
raised, it is an act of respiration, and is effected through those
nerves which control the muscles in respiration * ?
This conclusion is confirmed by the following experiment.
In the ass there are two muscles which take the office of the
mastoid muscle ; one is inserted into the jaw, which we may call
sterno-maxillaris, and the other into the vertebrae, viz. sterno-
vertebralis. To these the superior respiratory nerve (or spinal
accessory) is distributed in its passage to the trapezius. These
muscles are at the same time supplied with numerous nerves
directly from the spinal marrow. If we expose the superior
respiratory nerve, and then induce excited respiration, so as to
bring these muscles into powerful action in combination with
the other muscles of respiration, and if, while this action is per-
formed, we divide the nerve, the motion ceases, and the muscle
remains relaxed until the animal brings it into action as a
voluntary muscle.
An ass being thrown, its phrenic nerves were divided, on
which a remarkable heaving of the chest took place. It rose
* See the Appendix, page cxxxviii.
OF THE NERVES OF RESPIRATION. 141
higher, and the margins of the chest were more expanded at
each inspiration. There was no particular excitement of the
muscles of the neck, shoulder, or throat, at this time ; so that to
excite the actions of these muscles it was necessary to compress
the nostrils. When they began to act with more violence,
keeping time with the actions of the other muscles of respiration,
the superior respiratory nerve was divided ; immediately the
action ceased in the muscles attached to the sternum of the side
where the nerve was divided, while the corresponding muscles of
the other side continued their actions.
After dividing the spinal marrow between the vertebrae of
the neck, and those of the back, respiration is continued by the
diaphragm : which experiment, as it is often mentioned by
physiologists, the author has not thought it necessary to repeat,
but only to institute the following experiment on an ass. The
phrenic nerves being first divided, and then the spinal marrow
cut across at the bottom of the cervical vertebree, respiration was
stopped in the chest ; but there continued a catching and strong
action at regular intervals in the muscles of the nostrils, face,
and side of the neck. The main part of the apparatus of respira-
tion was stopped, but these accessory muscles remained animated,
and making ineffectual endeavours to perform the respiration.
When apparent death had taken place, the ass was so far
re-animated by artificial breathing, that the act of respiration
recommenced ; these muscles on the face and neck were restored
to activity, and became subject to regular and succcessive con-
tractions, as in excited respiration, whilst the chest remained
at rest. These actions continued for a short time, and then
ceased ; but upon artificial respiration being again produced, the
142 OF THE NERVES OF RESPIRATION.
same results followed. This was repeated several times, the
animal remaining insensible during these experiments, and inca-
pable of voluntary motion.
Thus it is proved, that the common muscles of respiration
being cut off from the influence of respiration, and the chest and
diaphragm at rest, the muscles of the face and neck remained in
action, not in voluntary action, nor in convulsions of pain, but
subject to the influence of respiration, and acting in regular
successive impulses.
Upon stimulating the nerves after the death of this animal,
it was observed, that the class of respiratory nerves retained their
power of exciting their respective muscles into action, long after
the other nerves had ceased to exert any power ; they were
evidently of that class which retain their life the longest.
I may add, that I performed these experiments long since,
and I have not repeated them, resting my conviction of the
accuracy of my opinion, that these are respiratory nerves, on
other grounds.
I have now to make a short statement of facts. Where
the phenomena have not been observed by myself, they are from
the highest authorities, and the experiments were made without
reference to the views now presented to the reader.
The division of the portio dura of the seventh nerve stops
the motions of the nostril and of the lips, &c.
The division of the recurrent branch of the par vagmn de-
stroys the voice*.
The division of the laryngeal branch of the par vagiim stops
* Sectis ambobus nervis recurrentibus vox perit. — Arnemann, Soemmerring;
Morgagni.
OF THE NERVES OF RESPIRATION. 143
the consent of motion between the muscles of the glottis and the
muscles of the chest*.
The injury or compression of the par vagum produces dif-
ficulty of breathing -)-.
The cutting of the phrenic nerve stops the motion of the
diaphragm.
The division of the spinal accessory nerve stops the respira-
tory motion of the mastoid and trapezius muscles.
Thus we complete the knowledge of the circle of actions
which result from the respiratory nerves, and which are necessary
to breathing ; and we cut oif the respiratory organs by the di-
vision of the irregular nerves, although we leave the regular
nerves perfect. The regular nerves, those common to all animals,
do not minister to these actions of respiration in the face, throat,
and neck.
The medulla oblongata and spinalis are composed of columns
of nervous matter, and from the different powers of the nerves,
as they arise from the one or other of these columns, it is proved
that they possess distinct properties. In animals that breathe by
ribs and a numerous class of muscles, and which animals have a
spinal marrow, w^e see that a column of nervous matter is em-
braced between the anterior and posterior virgce of that body,
and that this portion may be traced downwards between the
* Le Gallois.
j- Vinculo compressis nervis vagis oriuntur in bestiis spirandi difficultas, surditas,
vomitiis, corruptio ciborum in ventriculo. — Soemmerring, Holler, Brim de Ligatuiis
Nervorum.
144 OF THE NERVES OF RESPIRATION.
roots of the spinal nerves. From the upper part of this column,
where it begins in the inedulla oblongata, the several nerves pro-
ceed which have been just described, and on the influence of
which, it has been proved, the motions of respiration principally
depend. It is not an extravagant conclusion to say farther,
that the power of the regular series of intercostal and lumbar
nerves, as far as they regulate the respiratory actions, proceeds
from the connexions of the roots of these nerves with this column,
which is continued downwards, and which can throughout be
distinguished from the rest of the spinal marrow.
We are now enabled to distinguish the influence of the
spinal marrow, and its regular succession of nerves, from those
which have been traced in these papers. The first are essential
to the act of respiration ; without them the others are unequal
to the task. But on the other hand, although the regular suc-
cession of spinal nerves be equal to the raising and depressing
the thorax, they are not equal to the full heaving of the chest in
animated exertion of the voice. They are not competent to
the performance of the motions of the glottis, pharynx, lips, and
nostrils, which several parts are necessarily influenced in excited
respiration, as well as in the acts of smelling, coughing, sneezing,
and speaking : for these, the co-operation of the whole extended
class of respiratory nei*ves is required.
TsTow we comprehend the difference between the effects of
injuring the medulla oblongata, and cutting the par vagum. In
bruising the first, we at once destroy the motions of the nostrils,
larynx, pharynx, glottis, the neck, shoulders, and diaphragm ;
OF THE NERVES OF RESPIRATION. 145
who will doubt, that, if nerves going to all these parts were
simultaneously divided, immediate death would result * ?
Of the Seat of that Power which controls the Respiratory Motions.
The perfect sympathy which combines the muscles in the act
of respiration — muscles seated in parts of the body remote from
each other — would imply some common centre from which the
power emanates. If our inquiry be directed by the anatomy, we
shall not be long of discovering the seat of this influence. It
is not in the brain, because animals breathe when both cerebrum
and cerebellum are removed. It cannot be in all the spinal
marrow, because if the spinal marrow be divided three fingers'
breadth from the upper part of the column, the person breathes
through the nerves which arise above the division, although not
at all by those which arise below. On the other hand, it is
familiarly known, that if the medulla oblongata be crushed, all
actions connected with breathing cease in the instant. Here,
then, must be the seat of that power which controls the motions
of the nostril, pharynx, fauces, larynx, diaphragm, and shoulders,
* These respiratory nerves of the thorax, the diaphragmatic, the spinal accessory,
and the external thoracic nerve, are all nerves oiinspiration. The act of inspiration is
provided for in a more especial manner than the act of expiration. It requires more
muscular effort, and is more essential to life. Inspiration is the first act of resuscitated
life, the last of exhausted nature, and for this reason the muscles of inspiration are
large and powerful, and the nerves in a double order ; for not only do the lateral
branches of the spinal marrow influence the act of inspiration, but these additional
respiratory nerves descend from the upper part of the spinal marrow to the chest, as
an additional and especial provision, guarding life.
U
146 OF THE NERVES OF RESPIRATION.
by that class of nerves which we have pointed out as diverging
from this point, and have called respiratory.
Some modern inquirers have thought to extricate them-
selves from the difficulties of their subject, by ingeniously
arguing that respiration is a voluntary action — that is, that a
painful impression attends the cessation of breathing ; that the
impression is conveyed to the sensorium, and from the sensorium
the will acts to make us draw breath. If we say that this action
goes on in sleep, so, they will tell us, an irksome posture makes
us turn in bed while asleep; but I know not how they explain
the respiration in apoplexy, far less how it can be supposed pos-
sible that respiration proceeds from a sensorial impression, when
it is known from undoubted authority that an animal continues
to breathe after both cerebrum and cerebellum have been dug
out of its skull.
We, therefore, confidently return to our position, that the
medulla oblongata is the seat of that power which gives motion
to the parts in respiration. But, are we deceived when we draw
breath under the sensation of oppression in the chest ? The belief
is very natural that the condition of the heart and lungs draws
after it the action of the muscles in inspiration. Is this belief
consistent with the following facts? — The spinal marrow is
divided below the medulla oblongata; the animal continues to
breathe : the two nerves of the par vagum are divided ; the
nostril continues to move, the animal gasps, the chink of the
glottis opens and closes, the larynx is drawn down, the diaphragm
acts ; all these actions are simultaneous ; they follow in regular
OF THE NERVES OF RESPIRATION. 147
succession as in common breathing, and in this condition the
animal will live some time. Here there can be no communica-
tion of sensations from the heart and lungs ; all the nerves are cut
but those which go out from the medulla oblongata to the parts
moving. The conclusion, therefore, I must presume to be, that
in the lateral portion of the medulla oblongata, from which the
several respiratory nerves go off, there is seated a power which,
passing out through these diverging nerves, combines the remote
organs.
I know not how further to avoid the conclusion that the
regular succession of actions in respiration is directly consequent
upon the influence of this part of the nervous system*. It is
incomprehensible, certainly, but not more so than the effect of
volition: whilst the brain presides over the various voluntary
movements, controlling an infinite variety of combinations of
muscles in the familiar actions of the body and limbs, this por-
tion has a power of influencing certain muscles ; but with this dif-
ference— that the arrangement of muscles in their action is always
the same, and the action after regular periods of intermission.
It will be objected to these conclusions, that the brain has
a certain influence over the action of respiration. I must con-
fess that this subject is obscure or difficult ; but even in regard
* I may here add a conjecture on the provision for securing the circulation through
a part so vital as the medulla oblongata. The vertebral arteries are supposed to run
in the canal of the cervical vertebrae to secure the circulation in the brain, in the event
of compression on the carotids; but considering the command which this part of the
medullary column exercises over the respiration, and that it is more vital than the
brain, may it not be a principal object of the very peculiar course of the vertebral
arteries, to supj)ly the organ of respiratory motion free from the casualties which
influence the supply of blood to parts of less consequence to life ?
U 2
148 OF THE NETIVES OF RESPIRATION.
to the voluntary motions of the body, they are not directly from
the brain. That relation of nervous matter which makes the four
quarters of an animal move in a succession suited for progression ;
and that combination of muscles called flexors and extensors,
which is necessary to every movement of the limbs, result from
an organization in the body : these relations are not established
in the brain, although the brain has power over them. In the
same manner those relations of muscles, which are necessary to
the act of breathing, are established in the medulla oblongata,
and nervous cords connected with it, although the brain receives
impressions through the medulla oblongata of the condition of
the respiratory organs, and the will exercises a certain control
over them.
If the nerves of a limb which is separated from the body be
excited, the muscles will not all become immediately rigid; there
will be an action of the limb — the hind leg of the horse will seem
to kick. This arises from the association of the muscles in the
limb through the nerves, and from their being combined in
classes. So in exciting the spinal marrow in the entire animal,
there is a certain combination in the movements of the four
extremities. Thus the malefactor, after apparent death, under
the excitement of the galvanic influence, will spring, gape, and
stare. These are so many instances showing that the system of
voluntary nerves in the body is arranged with a view to com-
binations, and the exercise of the relative classes of muscles pro-
duce action in the limbs. The excitement does not produce a
tetanic and fixed condition of all the muscles equally; on the
contrary, certain relations between them are preserved, and
OF THE NERVES OF RESPIRATION. 149
motion of the body and limbs is the effect ; and these combina-
tions in action are shown to exist even if the head be separated
from the body. When we look to the action of respiration, and
make similar experiments on the respiratory nerves, they will be
seen to act according to their peculiar nature or endowment.
As the muscles of the limb were combined in the former instance,
so the muscles of respiration, however remotely situated, are
now combined into one simultaneous action ; and whereas in
the former one motion followed each successive application
of the stimulus, in the present instance the respiration being
once excited continues in a regulated succession of actions, but
more and more feebly, until it again stops altogether. Here,
then, we perceive, first, that there is a combination between the
muscles formed in the body, and independent of the brain ; and,
secondly, we perceive that there is a peculiarity in the nature of
the power exercised upon the muscles, according as they are
muscles of volition or muscles of respiration.
The muscles of volition form one system of combined parts,
the muscles of respiration form another system altogether ; the
difference between them is, that in the latter there is a distinct
source of influence, which will both preserve the muscles com-
bined together, and cause them to act in a regular succession.
There is no more difficulty, I repeat, in conceiving that the mind
operates through the nervous system dedicated to respiration,
than that it has a power over the infinite variety of combinations
of the voluntary muscles ; combinations which these experiments
show are established in the frame of the body, and not in the
brain.
150 OF THE NERVES OF RESPIRATIOK.
On the Actions of Hespiration in those who hate suffered Fracture
of the Spine at the lower Cervical VertebrcB.
When the spinal marrow is crushed at the upper part of
the spine, the man dies instantly ; but if the spinal marrow be
crushed opposite to the lower part of the neck, although the
injury be such as to deprive him of all sense and all voluntary
motion of the parts below, he continues to breathe.
It has been stated by our first authorities, that a man in
these circumstances breathes by his diaphragm, in consequence
of the phrenic nerve, which supplies that muscle, taking its origin
from the spinal marrow above the part injured. But the ob-
servations have been inaccurately made which have led to this
opinion. I shall first show how untenable such a supposition is,
and then detail the phenomena which attend the fracture of the
spine at this part ; and, finally, show that other nerves, besides
the phrenic, descend from the same source to supply the exterior
muscles of the chest, and that it is in a great measure through
their influence that the act of respiration is continued.
The diaphragm is that muscular septum which divides the
thorax and abdomen, and by the descent of which the depth of
the cavities of the chest is increased in inspiration. When it
has acted and descended, and the air is admitted into the lungs,
that air is again expelled by the re-action of the abdominal mus-
cles. These muscles compress the viscera, and, by pushing them
up, raise the relaxed diaphragm, preparing it for another effort
of inspiration. Is it not obvious, that, if the power of the
OF THE NERVES OF RESPIRATION. 151
diaphragm remain entire, and the power of the abdominal mus-
cles be lost, the respiration must stop ? It would be so, were
it not that there are other muscles and other nerves no less
important than the diaphragm and the phrenic nerves, and which
physiologists have not contemplated.
In the first part of this paper it is shown that the sterno-
cleido-mastoideus, the trapezius, and the serratus magniis, are
muscles calculated, by their combined operation, to raise the
chest with great force, and to perform inspiration. It is also
shown that the nerves there described as the superior and the
external respiratory nerves take their course exclusively to those
muscles which act upon the chest, and that what the phrenic
nerves are to the diaphragm, these are to the three great ex-
terior muscles. Were it not the action of these external muscles
which raise and extend the borders of the chest, the diaphragm
would exhaust its effort in drawing in the ribs, and expiration
would be the consequence of the action of a muscle of inspira-
tion. Further, when it ceased to act, the ribs would exert their
elasticity, and dilate the chest*. It is also shown in this paper,
that as all these nerves take their origins from the same part of
the spinal marrow, they are consequently in the same circum-
stances as to fracture of the spinal tube. When the spine is
fractured at the lower cervical vertebrae, these nerves escape
injury, and continue to animate the muscles exterior to the ribs,
as well as the diaphragm.
The great importance of these exterior nerves and muscles
* See Appendix, Nos. LIX., LX., LXI., LXIL, LXIII., LXIV., LXV.,
LXVI.
152 OF THE NERVES OF RESPIRATION.
to the continuance of life will be proved by the cases of fracture
of the spine. I have purposely omitted all the detail of practice,
and have taken the symptoms purely in a physiological view, and
as if it were an experiment, instead of a most afflicting accident
to a fellow creature.
In these narratives we have the account of the symptoms
which accompany fracture of the cervical vertebrae, and which
have hitherto been negligently considered. It appeared to me
very distinctly, that, in the case first described, No. LIX., the
man had the power of drawing his breath by muscular exertion,
and that the expulsion of the breath was not a muscular effort, but
occasioned entirely by the elasticity of the ribs and the gravita-
tion of the parts forcibly raised by the action of the muscles.
This was evident in the total want of the power to exert the
abdominal muscles, or to compress or depress the chest beyond
what was produced by the elasticity of the ribs ; in the necessity
of raising the chest at the utterance of each word ; in the perfect
power of yawning, which is a gradual and powerful act of in-
spiration ; in the want of the power of sneezing or blowing the
nose, which is a sudden call of the muscles of expiration into
action.
The strongest reason of all for maintaining this view of the
use of these nerves, which I have called respiratory, is, that
respiration and the activity of the muscles of the chest did
actually continue after the functions of the spinal marrow were
destroyed by violence done to the tube, and that there is no
other explanation of the fact than this, that those nerves which
take their origin from the medulla oblongata and upper part of
OF THE NERVES OF RESPIRATION. 153
the spinal marrow, and which descend upon the neck and chest,
did continue to animate the sterno-cleido mastoideus and the
trapezius, and the muscles of the throat, in the act of inspiration.
We have only further to recollect, that it was not the forcible,
occasional, and voluntary motions of respiration that were thus
preserved, but that by the same means, viz., by the superior, the
external, and the phrenic nerves, the play of the chest in
respiration during sleep was continued : these are therefore
respiratory nerves, for if they had been voluntary, their function
would have ceased when the patient fell asleep.
In the second case, No. LX., it is clearly proved, both by
the symptoms and the dissection of the bones, that the fracture
must have affected the roots of the phrenic nerves ; and we are
at liberty to conclude, that the difference of symptoms, in com-
paring it with the first case, as well as the shorter period of his
sufferings, were owing to this cause.
The breathing was very different, and is described by our
house surgeon in a manner to produce conviction. His breathing
was like sighing; and at each inspiration his head was drawn
between his shoulders ; that is to say, by the loss of the ac-
tion of the diaphragm the action was thrown on the muscles
exercised through the spinal accessory nerve: and this is con-
firmed by what is said of the want of motion in the viscera of
the abdomen; for, as it was proved in the first case, at each
contraction of the diaphragm the viscera of the abdomen were
propelled outward.
The want or defect of action in the diaphragm, and the
act of breathing being circumscribed to the muscles of the
154 OF THE NERVES OF RESPIRATION.
neck and shoulders, were undoubtedly the cause of the patient
sinking so soon.
In the cases Nos. LXI., LXII., LXIIL, LXIV., LXV., it
appears, that the spinal marrow being injured so high up as to
destroy the roots of all the respiratory nerves, the death was
sudden, as in pithing an animal.
I must next direct the reader's attention to the very
interesting case of disease of the spine, No. LXVI., in which
these observations are confirmed.
When we have ascertained these facts, certain queries are
naturally suggested. Why should these respiratory nerves,
which descend from above upon the thorax, go only to muscles
which assist in raising and expanding the chest ? Why should
the act of inspiration be secured by a double provision of nerves,
viz., those which come out from the sides of the spine, and those
which descend from the neck, when the act of expiration is
provided for solely through the former ?
I would offer these reasons : —
First, The act of drawing the breath is the more difficult,
and requires greater force ; the act of expiration is comparatively
easy, being assisted by the weight of the parts incumbent on the
ribs, as well as the resiliency or elasticity of the ribs themselves.
Second, The act of inspiration is the active state; the
condition of expiration is a state of rest.
Third, The inspiration is necessary to Hfe, and must be
guarded with more care, and performed with more force, than
the expiration. In suffocating, the agony is in elevating the
chest and drawing the breath. On the approacli of death the
OF THE NERVES OF RESPIRATION. 155
inspiration becomes more laboured, that is, the exterior muscles
are in violent action ; but the act of expiration is an interval of
rest.
Fourth, We can blow through a membranous and soft
tube, but we cannot inhale by it, for it collapses by the pressure
of the atmosphere the moment the attempt is made to draw the
air through it. In forcing out the breath, there is no impedi-
ment, although the tubes are soft and pliant; but in drawing in
the breath, the sides of the tube must be expanded by consent
of many muscles.
Fifth, These nerves, which govern the muscles of inspiration,
are linked more intimately by sympathy with the state of cir-
culation and respiration ; for we see in disease, as in experiments
on animals, that when the powers of Hfe have run low, the
sympathy is still exerted with such sudden catching of the
muscles of inspiration, and with an effort so powerful and
unexpected, as to startle, while the expiration is soft and without
effort. We perceive the same sympathy causing the same
sudden and powerful inspirations, and marking the presence of
life, when a person is recovering from fainting, or from sus-
pended animation, from whatever cause ; as drowning, haemor-
rhage, &c. The sudden inspiration is always the first of the
renewed actions of life, as it is the last in exhausted nature.
This corresponds with the experiments made on animals.
When the sensibility is exhausted in the common spinal nerves
from the ebbing of life, the respiratory nerves on the neck and
side of the chest are still capable of exciting the muscles to
renewed vibrations ; they are the last to die.
x2
156 OF THE NERVES OF RESPIRATION.
These considerations exhibit the importance of the act of
inspiration over that of expiration, and prove the necessity for
these exterior nerves of respiration.
We have seen by experiments, that the respiratory nerves
are distinguished from the other nerves by retaining their
power longer; that they are alive to impression, and can be
made to produce convulsions in the muscles they supply, after
the other nerves are dead to the application of stimuli. In
disease, during the oppression of the mental faculties, and on
the approach of death, we witness these nerves, and the muscles
put into operation by them, continuing their functions, when in
other respects the body is dead. This circumstance, so famihar
to the medical observer, might have led to the conclusion to
which we have arrived, more laboriously, through anatomical
investigations ; that there are a great many muscles extended
over the body, and which perform the common offices under the
will, that are occasionally drawn into combination with the
muscles of respiration, and are held in relation to the vital
functions by a distinct system of nerves, and that these nerves
have a centre and a source of power different from that of the
voluntary nerves*.
CONCLUSION.
When we survey the full extent of the respiratory system
of nerves, we are prepared to comprehend its importance to the
* See Appendix, Nos. LXVI., LXVII,, LXXVII.
OF THE NERVES OF RESPIRATION. 137
continuance of life. The infant born without a brain can
breathe if the origins of these nerves be entire*. Deep wounds
of the brain, though eventually fatal, are not necessarily or
instantly so. The man wounded in the spine, below the origins
of the nerves which we have traced, drags on existence for a few
days ; but a bruise on the part of the medulla oblongata, from
which these nerves take their departure, is death in the instant :
a breath is not drawn again.
Now since we find that many respiratory nerves depart
from the same centre, and go out to all the parts of the muscular
frame which move in respiration, we can better comprehend
how injury of the medulla oblongata suppresses at once the act
of respiration in the nostrils, throat, and windpipe, as well as
the action of the muscles both without and within the chest;
even the expression in the agony of dying is, by the injury of
the roots of all these nerves, suddenly interrupted, and actual
death follows quickly, owing to the cessation of the respiratory
functions.
The next thing that strikes us in the vital character of these
nerves, called respiratory, is, that as they form a system belonging
to the heart, lungs, stomach, larynx, throat, and the whole
exterior association of muscles of respiration, and are essential
to life, they must be influenced in all mortal affections ; and in
fact, death cannot take place whilst this division of the nervous
system is unchanged or unaffected. On the contrary, the injury
* See Appendix, No. LXVIII.
158 OF THE NERVES OF RESPIRATION.
to their roots is attended with immediate death, and the change
takes place with appalling suddenness.
On the contrary, if other parts of the body are injured by
disease or accident, death comes slowly from the rising of
inflammation, or the extension of the influence gradually over
the system ; at length the respiratory system partakes of the
influence, the chest rises higher and more frequently, an alarm-
ing symptom, when there is reason to fear approaching dis-
solution ; the throat is then afi^ected ; the whole apparatus of
respiration is violently agitated ; the chest, neck, lips, cheeks,
and eyelids are wrought with terrible convulsions ; the breathing
is about to stop ; the action returns with sudden and startUng
effort, and then ceases, the patient dying in the state of expira-
tion, the muscles of inspiration being incapable of renewing
the effort.
If it be important to know the approach of danger, and to
distinguish nervous agitation from the formidable symptoms of
approaching dissolution, it is necessary to know the causes of
these symptoms, otherwise the physician is no better than the
nurse.
In sleep the offices of the regular nerves are resigned, but
the irregular nerves remain in play; such is also the case in
apoplexy, and on the approach of death. Were the same in-
fluence to spread over all the nerves on the approach of sleep,
death would be the consequence. This consideration gives us
interest in the statement made by a patient, No. LXXVII. of
the Appendix, where we find that the pulse began to beat slow
OF THE NERVES OF RESPIRATION. 159
and weak, and the respiration to be interrupted at the moment
of dropping asleep ; the struggle of death, in fact, awoke him !
The physiological and pathological observations connected
with the demonstrations of the par vagum, are among the most
interesting in physiology ; but they make no part of the author's
particular views. Let it only be recollected that the nervus
vagus is the nerve of the pharynx, larynx, lungs, and stomach,
and that derangement in any one of these organs most singularly
disorders the functions of the others. And that we are to
consider the stomach to be fully as much tied to the re-
spiratory muscles as the lungs themselves; instance the act of
vomiting. The stomach, indeed, as being the part most liable
to derangement from the irregularities in our mode of life,
and from having reflected upon it almost every disorder to
which the system is subject, is the most frequent source of
nervous symptoms. Although these respiratory nerves be justly
accounted the most vital and important, their more serious
morbid conditions are often mimicked by symptoms which have
their cause no deeper than derangement of stomach.
Men capable of investigating by a just mode of observation
and of induction will, I hope, apply themselves to this class of
diseases. Hitherto the disorderly demonstrations of anatomy
have rendered this department of pathology far from satis-
factory.
160 OF THE NERVES OF RESPIRATION.
Paralytic and Convulsive Affections of the Respiratojy Nerves.
As these nerves belong to a distinct system, and have a
different origin from the nerves of sensibiUty and common mus-
cular motion, so it is fair to presume that they will occasionally
be affected by disease, when the others are left in a natural and
healthy condition. But if the natural distinctions of the nerves
be negligently considered, the affections of the respiratory nerves
must remain obscured. The portio dura, or respiratory nerve
of the face, is very subject to derangement, producing partial
paralysis, or frequent and spasmodic twitchings of the face. The
most common defect proceeding from this cause is a rapid and
twinkling motion of the eye-lid of one side. Sometimes Me find
the whole of one side of the face subject to contractions, by
which the features are drawn towards the ear. This condition
of nerves, and consequent spasmodic muscular contractions,
sometimes extend to the neck : then we see the head suddenly
twitched sidewise, at the same moment that the mouth is drawn
aside. This is a great deformity; for while the individual is
animated, and speaking with exertion, he gives those sudden
startling motions, opening his mouth and turning it to his
shoulder, as if he were catching flies. The neck is twisted, the
head bent down, and the mouth turned laterally and opened.
These motions must now be attributed to the influence of the
respiratory nerves of the face and neck.
But the same class of nerves, in their distribution to the
chest, are hable to similar derangement. It is not very un-
OF THE NERVES OF RESPIRATION. l6l
common to find the shoulder of a young person falling low, and
the appearance of distortion produced by a paralysis of that part
of the trapezius muscle which supports the shoulder, and which
is supplied by the spinal accessory nerve. This affection forms
a parallel with the paralysis of the eye-lid and the cheek ; and
there are not wanting examples of spasmodic affection of the
thorax resembling those which I have just noticed on the side
of the face and neck. From inattention to the source and
nature of the complaint, the cases in the Appendix are, perhaps,
the first which are recorded*.
Now we perceive that these nerves of respiration, so peculiar
in relation and function, are differently influenced by disease from
the other divisions of the nervous system. We know that their
functions are left entire when the voluntary nerves have ceased
to act, and that they are sometimes strangely disordered, while
the mind is entire in all its offices, and the voluntary operations
perfect. In tetanus the voluntary nerves are under influence,
and the voluntary motions locked up in convulsions ; in hydro-
phobia, on the contrary, the respiratory system is affected ; and
hence the convulsions of the throat, the paroxysms of suffocation,
the speechless agony, and the excess of expression in the whole
frame, while the voluntary motions are free.
The frequency of sudden death, where no corresponding
appearances are exhibited in the brain or heart, leads us to con-
sider more attentively the only part of the system through which
* See Appendix, Nos. LXXI., LXXIL, LXXIIL, LXXIV., LXXV.,
LXXVL, LXXVIIL, LXXIX., LXXX., LXXXI.
162 OF THE NERVES OF RESPIRATION.
life can be directly extinguished. In angina pectoris, we witness
the agony of suffering in this system when the patient survives ;
and when he dies suddenly we can imagine it to proceed from
an influence extending over these nerves, and interrupting the
vital operations. We have seen that a branch of this system
may suddenly cease to operate on the corresponding muscles,
and that in this way the side of the face may be deprived of all
participation in the act of respiration, and all expression be lost.
What would result from a more universal defect in the actions
of this class of nerves, but sudden death ?
The stomach, supplied with the great central nerve of this
system, exhibits the most powerful influence on these extended
nerves ; a blow on the stomach " doubles up" the bruiser, and
occasions that gasping and crowing which sufficiently indicates
the course of the injury ; a little more severe, and the blow is
instantly fatal. A man broken on the wheel suffers dreadful
blows, and his bones are broken, but life endures; the coup dc
grace is the blow on the stomach.
The position of the asthmatic shows how this system is
affected; whether directly or indirectly, it is not our present
business to inquire. He stands stooping forward, resting his
arms so as to throw the muscles of the chest into operation
upon the ribs. The position of the head and the rigidity of the
muscles of the neck, the action of the mastoid muscle, and of the
cutaneous muscle, visible in the retraction of the cheeks and
mouth, and the inflation of the nostrils, carry us back in review
of the nerves and muscles of respiration.
OF THE NERVES OF RESPIRATION. l63
Some additional Notes on the Nerves of Respiration.
It will now, perhaps, be acknowledged, that the methods of
physiologists, in accounting for the combination of parts in the
actions of respiration, were very imperfect, or rather altogether
erroneous. To account for the convulsion of the diaphragm in
sneezing, they were constrained to go a far way about : first,
connecting the roots of the phrenic with the sympathetic nerve ;
bestowing sensibility on the latter, which it does not possess ;
then, following a remote connexion between it and the nerves of
the nose ; then again, counting the relations between the facial
nerve and the third of the neck : they satisfied themselves that
they had explained the manner in which the diaphragm became
convulsed upon irritating the membrane of the nose. Another
misconception w^as ingrafted on the first ; they spoke of these
actions as convulsive and irregular, which are amongst the most
admirable provisions for the protection of life. As to the act of
sneezing, like coughing, it is a consequence of an irritation of the
fifth pair in the membrane of the nose, whence the whole muscles
of respiration are brought into action. That there is nothing
accidental, nor of the nature of convulsion, is shown by the
admirable adjustment of the muscles to the object. A body
irritating the glottis will call into simultaneous action the mus-
cles of respiration, so as to throw out the air with a force capable
of removing the offending body. But if the irritation be on the
membrane of the nose, the stream of air is directed differently,
and, by the action of sneezing, the irritating particles are removed
Y 2
164 OF THE NERVES OF RESPIRATION.
from these surfaces. By the consideration of how many Httle
muscles require adjustment to produce this change in the direc-
tion of the stream of air, we may know, that the action is in-
stinctive, ordered with the utmost accuracy, and very different
from convulsion.
Of Smelling^ as influenced hy the Portio Dura of the Seventh
Nerve.
In these papers I hope it will be found that 1 have gone
deliberately and diligently about my investigation. It will, I
hope, be acknowledged that I have studied the functions of the
parts to which the nerves are sent, before I made my experi-
ments or drew my conclusions. Even in the exercise of the
sense of smelling, parts are employed which do not, at first, seem
necessary. For the highest enjoyment or exercise of the sense
of smelling, the stream of air must be inhaled through the
nostrils, changed in its direction and increased in force. In
breathing through the nose, the air is carried directly backward.
If the nostrils are expanded in anxious or hurried respiration,
the passage is enlarged, and made more direct. But, perhaps,
the reader is not aware that in each nostril there are two circular
openings, the innermost something more than half an inch within
the other. This interior circle expands, and becomes lower when
the breath is forcibly drawn into the lungs ; but in the act of
smelling it is much diminished and elevated. The change in
the form and relation of the exterior and internal nostril is pro-
duced by the action of the muscles on the cartilages ; and the
OF THE NERVES OF RESPIRATION. 165
effect of the change is to increase the force of the stream of air,
and to direct it up towards the seat of the sense of smelUng. In
common breathing some part of the effluvia afloat in the atmo-
sphere reaches the seat of the sense ; but fully to exercise the
sense it is necessary to concentrate and direct the stream of air,
as I have described.
It will now be comprehended how the destruction of the
portio dura, or respiratory nerve of the face, affects the organ of
smelling; for if by the injury of that nerve the motion of the
muscles of the nostrils be lost, the breath may be drawn into the
lungs through the relaxed passage ; but it will not be drawn
forcibly up towards the seat of the olfactory nerve, nor will the
air brush over the surface on which the proper nerve of sense is
expanded.
A man being paralytic on one side of the face by the loss of
power in the portio dura, he was made to smell ammonia : it did
not affect the paralytic side, because it was forcibly inhaled into
the cells of the nose only on the side where the nostril was
moveable. On trying the experiment on a dog, in which the
portio dura of one side had been cut, the same thing was mani-
fested ; he snuffed it up with the sound side, and showed the
natural consequence of the irritation of the membrane ; while he
was not similarly affected when the bottle was put to the para-
lytic nostril. This fact is further illustrated in cases in the
Appendix*.
Unless I had attended to the structure and function of the
part, on witnessing these phenomena, I might have conceived
* See page xii.
166 OF THE NERVES OF RESPIRATION.
that the seventh nerve was the nerve of smeUing, Hke a noted
French physiologist, who concluded too hastily that he had dis-
covered the nerves of vision and of smelling in the fifth nerve.
I allude to certain experiments lately performed in London
by a distinguished visiter, which afford a proof of the utter im-
possibility of reasoning correctly on these subjects without the
knowledge of the anatomy. The olfactory nerve was destroyed,
and ammonia put to the nostrils of the animal, and when the
creature sneezed it was a coup dc theatre! Then the gentlemen
congratulated themselves that it was discovered that the first
pair of nerves was of no use !
The sensibility of the schneiderian membrane results from
the fifth nerve : it was this common sensibility which was
here excited by the ammonia. Now we ask, why does the
membrane possess this sensibility, and why is the sensibility
joined to the actions of the respiratory system ? Because these
passages must be guarded as the larynx is guarded. When any
thing offensive is lodged there, it must be removed, and the
means nature employs is to drive the air by an instinctive action
of the respiratory organs, violently and suddenly, through the
nostrils. But what has this to do with smelling? As well
might we destroy the olfactory nerve, and wonder that the
creature experimented on still coughed when the larynx was
tickled.
We have some observations on this subject in Mr. Shaw's
paper already quoted. " The effect upon the nostril is the most
obvious symptom, when the nerve is cut in the ass. If after
having cut the right nerve (portio dura), we hold the nostril for
a short time, so as to prevent the animal from breathing, he will,
OF THE NERVES OF RESPIRATION. 167
when freed, begin to snort, but with the left nostril only. If we
hold carbonate of ammonia to the paralysed nostril, he will not
be affected ; but if it be held to the other, he will snuff it up,
and then curl the nostril, and have an expression in the whole
of that side of the face, as if he were going to sneeze, while the
right side will remain quite unmoved."
The rationale of this is worth attention ; by the neglect of
it some physiologists and experimenters have appeared to much
disadvantage. We repeat that the act of smelling is not simply the
act of drawing the breath ; but while the breath is drawn there
is a conformity in the motion of the nostrils, by which the air,
loaded with the effluvia, is directed to the seat of the olfactory
nerve ; that is to say, is made to circulate in the higher parts of the
cavities of the nose, instead of streaming directly backwards into
the posterior nostrils. This was the reason why, on putting the
ammonia to the nostril which was still, the creature was not
excited, although there had been nothing done to injure the
sensibility of that side of the nose. If a man were simply to
draw his breath in taking snuff, the powder would be drawn into
his fauces and lungs ; but to snuff, the point of the nose is drawn
down, and the nostrils contracted, and then, when the air is in-
haled, the snuff rises to the superior cells, and stimulates all the
interior of the nostrils*. Although by this stimulus he sneezes,
the olfactory nerve has nothing to do with it. The luxury is in
the stimulus of the respiratory system through the excitement
of the membrane, not in the odour as enjoyed by the olfactory
nerve. The sensitive branches of the fifth are first excited, then
* See Appendix, No, III., page xii. Nos. LV., LVI., page cxii.
168 OF THE NERVES OF RESPIRATION.
the respiratory system is in a secondary manner affected ; and to
ascertain whether the mode of communication between the fifth
and the respiratory nerves be affected at their roots in the brain,
or at their extremities, is a fair question to be determined by
experiment or reasoning.
These Respiratory Nerves are Organs of Expression.
We may notice another office of these respiratory nerves ;
in smiUng, laughing, and weeping, the influence is solely propa-
gated through them. The face, we have seen, is dead to all
changes of the kind when the nerve of this class which goes to
it is destroyed, whether it be by division of the nerve, or from
its being surrounded with inflammation or suppuration. When
we consider that all the respiratory nerves depart from the
same source, and participate in the same functions, and more
especially when we see the respiratory organs so very distinctly
affected in the conditions of the mind, which give rise to these
affections, it is not too much to suppose, that what is proved in
regard to one of these nerves is true of the whole class, and that
they alone are influenced in laughter. Physiologists who have
not investigated the cause, are yet agreed in describing laughter
to be a condition of the respiratory muscles, where the air is
drawn in rapidly, and thrown out in short spasmodic motions of
these muscles, and crying to be nearly the reverse, the inspiration
being cut by spasmodic actions of the muscles of inspiration. By
these considerations are explained the subrisus which proceeds from
abdominal irritation, and the sardonic retraction of the muscles
of the face produced by wounds of vital parts, and particularly
OF THE NERVES OF RESPIRATION. l69
of the diaphragm. They explain also the successive convulsive
heaving of the shoulders in wounds of the diaphragm.
That a system of nerves, so intimately combined as this is
with the other parts of the general system, should suffer in
hysterical disorders, cannot surprise us ; and admitting that
the irritation reaches to the respiratory system, we perceive
how rapidly the change may be produced, from the convulsions
of laughter to those of crying ; and that in these affections, if
there be a corresponding condition of the mind, it rather follows
than precedes the expression of the frame.
It would have been extraordinary if we had arrived at any
satisfactory theory of expression, before it was known through
what instruments the mind influenced the body during emotion
or passion. But since we know that the division of the re-
spiratory nerve of the face deprives an animal of all expression,
and that the expressive smile of the human face is lost by an
injury of this nerve ; since it is equally apparent, that the con-
vulsions of laughter arise from an influence extended over this
class of nerves ; it comes to be in some sort a duty, in pursuing
this matter, to examine farther into the subject of expression.
We may be at the same time assured that whatever serves to
explain the constant and natural operations of the frame will
also exhibit the symptoms of disease with more precision.
In terror, we can readily conceive why a man stands with
eyes intently fixed on the object of his fears, the eyebrows
elevated, and the eyeballs largely uncovered; or why, with
hesitating and bewildered steps, his eyes are rapidly and wildly
in search of something. In this we only perceive the intent
z
170 OF THE NERVES OF RESPIRATION.
application of his mind to the objects of his apprehension, and
its direct influence on the outward organs. But when we
observe him farther, there is a spasm on his breast : he cannot
breathe freely : the chest remains elevated, and his respiration is
short and rapid: there is a gasping and convulsive motion of
his lips : a tremor on his hollow cheeks : a gulping and catching
of his throat : his heart knocks at his ribs, while yet there is no
force in the circulation, the lips and cheeks being ashy pale.
It is obvious that there is here a reflected influence in
operation. The language and sentiments of every people have
pointed to the heart as the seat of passion, and every individual
must have felt its truth. For though the heart be not in the
proper sense the seat of passion, it is influenced by the conditions
of the mind, and from thence its influence is extended through
the respiratory organs, so as to mount to the throat, lips, and
cheeks, and account for every movement in passion, which
is not explained by the direct influence of the mind upon the
features.
So we shall find, if we attend to the expression of grief, that
the same phenomena are presented ; and we may catalogue them,
as it were, anatomically. Imagine the overwhelming influence
of grief- — the object in the mind has absorbed the powers of the
frame ; the body is no more regarded, the spirits have left it ; it
reclines, and the limbs gravitate, the whole frame is nerveless
and relaxed, and the person scarcely breathes : so far there is no
difficulty in comprehending the effect in the cause. J3ut why,
at intervals, is there a long drawn sigh; why are the neck and
throat convulsed, and whence the quivering and swelling of the
OF THE NERVES OF RESPIRATION. 171
lip ; why the deadly paleness, and the surface earthy cold ; or
why does convulsion spread over the frame like a paroxysm of
suffocation ?
To those 1 address, it is unnecessary to go farther, than to
indicate that the nerves treated of in these papers are the
instruments of expression, from the smile upon the infant's
cheek, to the last agony of life. It is when the strong man is
subdued by this mysterious influence of soul on body, and when
the passions may be truly said to tear the breast, that we have
the most afflicting picture of human frailty, and the most
unequivocal proof, that it is the order of functions which we
have been considering that is then affected. In the first strug-
gles of the infant to draw breath, in the man recovering from a
state of suffocation, and in the agony of passion, when the breast
labours from the influence at the heart, the same system of parts
is affected, the same nerves, the same muscles, and the symptoms
or characters have a strict resemblance.
Having examined the system of nerves and muscles, which
are the agents in respiration, in their fullest extent and in all
their bearings ; having looked at them in their highest state of
complication in the human body ; and having traced them
upwards, from the animals of simple structure, and then by
experiment, and in a manner analytically as well as synthetically,
their relations become obvious. Instead of one respiratory
nerve, the par vagum, the nerve so called, is found to be the
central one of a system of nerves of great extent. Instead of
the relations of the vital organs of circulation and respiration
z 2
172 OF THE NERVES OF RESPIRATION.
depending on some supposed influence of the sympathetic nerve,
they are found to have an appropriate system.
This system of nerves, extricated from the seeming confusion
in which it lay hitherto encumbered, is found to be superadded
to that of mere feehng and agency, attributes common to all
animals. Through it we see, ingrafted as it were, and superadded
to the original nature, higher powers of agency, corresponding
to our condition of mental superiority : these are not the organs
of breathing merely, but of natural and articulate language also,
and adapted to the expression of sentiment, in the workings of
the countenance and of the breast, that is, by signs, as well as by
words. So that the breast becomes the organ of the passions,
and bears the same relation to the development of sentiments,
that the organs of the senses do to the ideas of sense.
OF THE NERVES OF RESPIRATION.
173
EXPLANATION OF PLATE IX.
FIG. 1. IIEI'RESENTS THE MEDULLA SPINALIS.
A. The pons Varolii.
B. B. The anterior medullary columns of the spinal marrow, continued from
the corpora pyramidalia.
C. Corpus olivare.
D. Corpus rest'iforme.
1. The origin of the respiratory nerve of the face.
2. Origin of the glosso-pharyngeal nerve.
3. Origin of the par vagum.
4. Origin of the spinal accessory nerve, or superior respiratory nerve of the
trunk.
FIG. 2. PLAN OF THE KESPIllATOKY NERVES IN THEIR COURSE THROUGH THE
BODY.
A. The sterno-cleido mastoideus muscle.
B. B. The trapezius muscle. It is seen to arise from the back of the head, and
from the spine ; it is inserted into
C. The scapula, and
D. The clavicle.
E. E. The serratus magnus anticus. It is left at its attachment to the ribs,
but cut off from its insertion into the scapula, so as to expose the trapezius and the
spinal accessory nerve.
F. The lower surface of the diaphragm.
G. The upper surface of the diaphragm.
H. The larynx.
The four great muscles (A. B. B. E. E. F. G.) are powerful muscles of
inspiration.
To simpUfy this view, the regular or symmetrical system of nerves is not pre-
sented in this drawing, but only the respiratory nerves. It is the entwining of nerves
of distinct systems which produces the apparent intricacy. If the spinal nerves were
represented crossing these, and the network of the sympathetic superadded to them,
we should have all the seeming confusion of the dissected body.
II
174 OF THE NERVES OF RESPIRATION.
1. Respiratory nerve of the face, or portio dura of autliors.
2. The glosso-pharyngeal nerve.
3. The superior respiratory nerve. It is seen to pass through the sterno-cleido
mastoideus muscle, and to supply it with branches: then to take a course down the
.side of the neck, branching exclusively to the trapezius muscle.
4. The phrenic or diaphragmatic nerve. It is seen coming out from the spine,
and running a direct course to the diaphragm.
3. The external respiratory nerve of the chest. It is like the last nerve in its
origin, but it deviates in its course, passes on the outside of the chest to supply the
powerful respiratory muscle, the serratus magnus E. E.
These three nerves with the par vagum combine the sterno-cleido mastoideus,
the trapezius, the serratus magnus, and the diaphragm, with the lungs, the larynx,
the tongue, and nostrils.
6, 7. The nerve of the par vagum. Coming from the same origin with the
other respiratory nerves, it passes down to the internal organs; but in its passage
gives off these :
8. The superior laryngeal nerve, a branch of the last nerve.
9- The recurrent nerve; a branch also of the par vagum. Where the par
vagum is in the thorax (7) at the same time that it sends off the recurrent (9), it
sends off many small nerves to the heart and the lungs, and then descends in a
plexus on the oesophagus, to the stomach.
ON THE MOTIONS OF THE EYE,
IN ILLUSTKATION OF
THE USES OF THE MUSCLES AND NERVES OF
THE ORBIT.
From the Philosophical Transactions, 182.'}.
11
ON THE MOTIONS OF THE EYE, &c.
[Read before the Royal Society, March 20, 1823.]
The object of this paper is to explain the reason of there
being six nerves distributed to the eye, and consequently crowded
into the narrow space of the orbit.
But before it is possible to assign the uses of these nerves,
we must examine the motions of the eye more minutely than
has hitherto been done, and try to comprehend the offices to be
performed. ]\luch as the eye has been studied, the frame- work
which suspends it, and by which it is moved and protected, has
not received the attention it deserves. Yet this frame-work, or
apparatus, is not less calculated to renew our wonder, than the
properties of the organ itself
It is, therefore, necessary to divide the paper into two parts.
First, to show the uses of the apparatus which is exterior to the
eye-ball ; and then, in the second place, to consider how the nerves
minister to these offices.
A A
178 ON THE MOTIONS OF THE EYE.
PART I.
Of the Muscles and Frame-work which are around the Eye-hall.
Even grave and learned men have eulogized this organ as
the most necessary to intellectual enjoyment, and which ranges
from the observation of the fixed stars, to that of the expression
in the human face*. But this admiration is in part misplaced,
if given to the optic nerve and ball of the eye exclusively ; since
these high endowments belong to the exercise of the w hole eye,
to its exterior apparatus as much as to that nerve which is sensible
to the impressions of light. It is to the muscular apparatus, and
to the conclusions we are enabled to draw from the consciousness
of muscular effort, that we owe that geometrical sense, by which
we become acquainted with the form, and magnitude, and di-
stance of objects. We might as well expect to understand the
uses of a theodolite, or any complicated instrument for observa-
tions, by estimating the optical powers of the glasses, without
considering the quadrant, level, or plumb-line, as expect to learn
the whole powers of the eye by confining our study to the naked
ball. I propose to show, that we must distinguish the motions
of the eye, according to their objects or uses, whether for the
direct purpose of vision, or for the preservation of the organ. I
* Sir Henry Wotton, Dr. Reid, and many others.
ON THE MOTIONS OF THE EYE. 179
shall show that the eye undergoes a revolving motion not
hitherto noticed ; that it is subject to two distinct states, of
rest, and of activity ; and that the different conditions of the
retina are accompanied by appropriate conditions of the sur-
rounding muscles ; that these muscles are to be distinguished
into two natural classes ; and that in sleep, faintness, and insensi-
bility, the eye-ball is given up to the one, and that in watchfulness,
and the full exercise of the organ, it is given up to the influence
of the other class of muscles : and finally, that the consideration
of these natural conditions of the eye explains its changes as
symptomatic of disease, or as expressive of passion.
Motions of the Eye-hall and Eye-lids.
We shall consider the muscles of the eye, first, as necessary
to its preservation ; secondly, as necessary to it as the organ of
sense. We do not reflect on those actions of our frame which
are most admirable in themselves, which minister continually to
our necessities, and perfect the exercise of our organs, until we
be deprived of them : like unnatural children, unconscious or
unmindful of indulgence, we feel only the loss of benefits.
" With much compassion," says the religious philosopher, " as
well as astonishment at the goodness of our loving Creator, have
I considered the sad state of a certain gentleman, who, as to the
rest, was in pretty good health, but only wanted the use of
these two little muscles that serve to lift up the eye-lids, and so
had almost lost the use of his sight, being forced, as long as this
AA 2
180 ON THE MOTIONS OF THE EYE.
defect lasted, to shove up his eye-Uds with his own hands*?" I
have often thought of this saying when I have seen a patient
in all respects in health, but without the power of raising the
eye-lids.
There is a motion of the eye-ball, which, from its rapidity,
has escaped observation. At the instant in which the eye-lids
are closed, the eye-ball makes a movement which raises the
cornea under the upper eye-lid.
If we fix one eye upon an object, and close the other with
the finger in such a manner as to feel the convexity of the
cornea through the eye-lid, when we shut the eye that is open,
we shall feel that the cornea of the other eye is instantly elevated ;
and that it thus rises and falls in sympathy with the eye that is
closed and opened. This change of the position of the eye-ball
takes place during the most rapid winking motions of the eye-
lids. When a dog was deprived of the power of closing the
eye-lids of one eye by the division of the nerve of the eye-lids,
the eye did not cease to turn up when he was threatened, and
when he winked with the eye-lids of the other sidef.
Nearly the same thing I observed in a girl whose eye-lids
were attached to the surrounding skin, owing to a burn ; for the
fore i)art of the eye-ball being completely uncovered, when she
* Paley's Natural Theology.
■f- The experiment of cutting the facial respiratory nerve was performed on a
dog. The following is the note made a few days after the nerve was cut : — The dog
is now quite well, having suffered very little from the operation ; when he fawns, the
riglit side of his face is completely motionless ; (tlie nerve of the right side was cut).
When I threatened to strike him, although there is a tremulous motion expressive of
ON THE MOTIONS OF THE EYE. 181
would have winked, instead of the eye-lids descending, the eye-
balls were turned up, and the cornea was moistened by coming
into contact with the mouths of the lacrymal ducts.
Instead of enforcing this fact, I shall merely refer to the
numerous cases in the Appendix in which this motion is proved
to take place. I ought not, however, to omit stating, that the
fact has been denied, and in very extraordinary terms.
The purpose of this rapid insensible motion of the eye-ball
will be understood on observing the form of the eye-lids and the
place of the lacrymal gland. The margins of the eye-lids are
flat, and when they meet, they touch only at their outer edges,
so that when closed there is a gutter left between them and the
cornea. If the eye-balls were to remain without motion, the
margins of the eye-lids would meet in such a manner on the
surface of the cornea, that a certain portion would be left un-
touched, and the eye would have no power of clearing off what
obscured the vision, at that principal part of the lucid cornea
which is in the very axis of the eye ; and if the tears flowed,
they would be left accumulated on the centre of the cornea, and
winking, instead of clearing the eye, would suff*use it. To avoid
these effects, and to sweep and clear the surface of the cornea,
at the same time that the eye-lids are closed, the eye-ball re-
volves, and the cornea is rapidly elevated under the eye-lid.
fear in all the muscles of the left side of the face, the other is perfectly still : he can-
not even close the eye-lid ; and instead of winking when he expects to be struck, the
eye-ball itself is turned up. When he is excited, there is an expression of alacrity in
all the muscles of the left side of the face, and a brilliancy in the left eye, while the
right is perfectly inanimate. This is shown in an extraordinary degree when he is
fighting with another dog.
182 ON THE MOTIONS OF THE EYE.
Another effect of this motion of the eye-ball is to procure
the discharge from the lacrymal ducts ; for by the simultaneous
ascent of the cornea, and the descent of the upper eye-lid, the
membrane on which the ducts open is stretched, and the effect
is hke the elongation of the nipple, facilitating the discharge of
secretion.
By the double motion, the descent of the eye-lid and the
ascent of the cornea at the same time, the rapidity with which
the eye escapes from injury is increased. Even creatures which
have imperfect eye-lids, as hshes, by possessing this rapid re-
volving motion of the eye, are enabled to avoid injury and clear
off impurities.
I may observe in passing, that there is a provision for the
preservation of the eye, in the manner in which the eye-hds
close, which has not been noticed. While the upper eye-lid falls,
the lower eye-lid is moved towards the nose. This is a part of
that curious provision for collecting offensive particles towards
the inner corner of the eye If the edges of the eye-lids be
marked with black spots, it will be seen that when the eye-lids
are opened and closed, the spot on the upper eye-lid will descend
and rise perpendicularly, while the spot on the lower eye-lid will
play horizontally like a shuttle.
To comprehend certain actions of the muscles of the eye,
we must remember that the caruncle and membrane called semi-
limaris, seated in the inner corner of the eye, are for ridding the
eye of extraneous matter, and are, in fact, for the same purpose
with that apparatus which is more perfect and appropriate in
(juadrupeds, called the haw.
ON THE MOTIONS OF THE EYE. 183
The course of our inquiry makes some observation of these
parts necessary.
In quadrupeds there is a gland for secreting a gkitinous and
adhesive fluid, which is seated on that side of the orbit next the
nose ; it is quite distinct from the lacrymal gland ; it is squeezed
by an apparatus of muscles, and the fluid exudes upon the sur-
face of the third eye-lid. This third eye-lid is a very peculiar
part of the apparatus of preservation. It is a thin cartilage, the
posterior part of which is attached to an elastic body. This body
is lodged in a division or depression of the orbit on the side
towards the nose. When the eye is excited, the eye-ball is made
to press on the elastic body, and to force it out of its recess or
socket ; the consequence of which is the protrusion of the carti-
laginous third eye-lid, or haw, as it is termed, in the horse. By
this mechanism the third eye-lid is made to sweep rapidly over
the surface of the cornea, and by means of the glutinous fluid
with which its surface is bedewed, it attaches and clears away
offensive particles.
In birds, the eye is an exquisitely fine organ, and still more
curiously, and as we might be tempted to say, artificially pro-
tected. The third eye-lid is more perfect ; it is membranous
and broad, and is drawn over the surface of the eye by means of
two muscles which are attached to the back part of the eye-ball,
and by a long round tendon, that makes a course of nearly three
parts of the circumference of the ball. The lacrymal gland is
small, and seated low, but the mucous gland is of great size,
and seated in a cavity deep and large, on the inside of the orbit.
As the third eye-lid is moved by an apparatus which cannot
184 ON THE MOTIONS OF THE EYE.
squeeze the mucous gland at the same time that the eye-Ud is
moved, as in quadrujDeds, the oblique muscles are particularly
provided to draw the eye-ball against the gland, and to force out
the mucus on the surface of the third eye-lid. It flows very
copiously ; and this is probably the reason of the smallness of
the proper lacrymal gland which lies on the opposite side of the
orbit.
We already see two objects attained through the motion of
the eye-lids and eye-ball ; the moistening of the eye with the
clear fluid of the lacrymal gland, and the extraction, or rather the
protrusion, of offensive particles.
There is another division of this subject no less curious : the
different conditions of the eye during the waking and sleeping
state remain to be considered. If we approach a person in
disturbed sleep when the eye-lids are a little apart, we shall not
see the pupil nor the dark part of the eye, as we should were he
awake, for the cornea is turned upwards under the upper eye-lid.
If a person be fainting, as insensibility comes over him the eyes
cease to have speculation ; that is, they want direction, and are
vacant, and presently the white part of the eye is disclosed by
the revolving of the eye-ball upwards. Look to a blind beggar ;
these white balls are not turned up in the fervor of prayer or en-
treaty; it is the natural state of the eye-balls, which are totally
blind, and from the exercise of which the individual has withdrawn
his attention. So it is on the approach of death; for, although
the eye-lids be open, the pupils are in part hid, being turned up
with a seeming agony, which however is the mark of increasing
insensibility. I'hese motions of the eye, which are for the pre-
ON THE MOTIONS OF THE EYE. 185
servatioii of the organ, do not interfere with the vision, they are
performed unconsciously. The motions of the eye-ball for di-
recting the eye to objects are strictly voluntary, and are always
connected with the exercise of the sense of vision.
It will now be admitted that the variety of motions given to
the eye and eye-lids require the complication of muscles which
we find in the orbit ; and it must be obvious to the most casual
observer, that unless these various offices and different conditions
of the eye be considered, it will be in vain to attempt an accurate
classification of the muscles of the orbit, and consequently of the
nerves.
Of the Actions of the Muscles of the Eye, and their natural
Classification.
Muscles of the Eye-lid. Even in the action of these muscles,
although the most exposed and familiar of any, there is some-
thing still to be observed. The eye-ball is held betwixt the
levator palpebra and the orbicularis, the one tending to the pro-
trusion of the eye-ball, the other to compress and restrain it. In
page xxxvi of the Appendix, we may observe the effect of the
paralysis of the orbicularis, that the eye-ball is protruded, and
starts further forward than natural, and that then the eye-lid is
loose or flabby, and can be lifted like a bit of common skin.
In other cases of the Appendix it is shown, that the upper
eye-lid is raised, and the lower eye- lid depressed, by one muscle.
Anatomists have sought for a depressor of the inferior eye-lid,
seeing that it is depressed, but such a muscle has no existence,
B B
186 ON THE MOTIONS OF THE EYE.
and is quite unnecessary. The M. elevator palpebrce superioris
opens wide the eye-lids, depressing the lower eye-lid at the same
time that it elevates the upper one. If we put the finger upon
the lower eye-Hd so as to feel the eye-ball when the eye is shut,
and then open the eye, we shall feel that during this action the
eye-ball is pushed outwards. Now the lower eye-lid is so adapted
as to slip off the convex surface of the ball in this action, and to
be depressed whilst the upper eye-lid is elevated.
The origin of the levator being at A., and the insertion into
the cartilage of the upper eye-lid at B., the effect of the action
of the muscle must be the protrusion of the eye-ball, C, into the
dotted line. By the elevation of the upper eye-lid, the eye starts
forward a little, and the lower eye-lid slips off the lower segment
of the eye-ball. This action of the muscles is happily illustrated
by the case in the Appendix, No. XXI. It is curious to observe
how the eye-ball retreats in its condition of repose, and is pro-
truded when about to be exercised in vision. The high excite-
ment, as in terror, when the eye-balls are largely unclosed, is
attended with an increase of the sphere of vision by the protru-
sion of the eye-balls, a change remarkable both in the ferocious
and timid animals, especially in the latter.
ON THE MOTIONS OF THE EYE. 187
The muscles attached to the eye-ball are in two classes, the
recti and obliqui. The recti muscles are four in number, and
come from the bottom of the orbit, and run a straight course
forwards and outwards ; they embrace the eye-ball, and are in-
serted at four cardinal points into it. The obliqui are two
muscles having a direction backwards and outwards ; they em-
brace the eye-ball, one passing over it obliquely, the other under
it obliquely.
That the recti muscles perform the office of directing the
axis of the eye, turning it round to every point in the sphere of
vision, there are many proofs. In the first place, their origin,
course, and insertion, accurately fit them for this office ; and they
are obviously equal to it, unassisted by other muscles. In the
next place, from man down to the cuttle-fish, the voluntary
motions of the eyes are the same, and the origin, course, and in-
sertion of these muscles are similar, while the other muscles vary
with the change of apparatus which is around the eye.
The oblique muscles of the eye stand contrasted with the
recti in every respect, in number, size, and direction. Yet it is
a received opinion, that they antagonize the recti, and keep the
eye suspended. To this conclusion there are many objections.
1 . In creatures where the eye is socketed on a cup of cartilage
and cannot retract, the oblique muscles are nevertheless present.
2. Where a powerful retractor muscle is bestowed in addition to
the recti muscles to pull the eye-ball back, the oblique muscles
have no additional magnitude given to them to pull the eye-
ball forwards. 3. In matter of fact, the human eye cannot be
retracted by the united action of the recti as we see quadrupeds
B ]J 2
188 ON THE MOTIONS OF THE EYE.
draw in their eyes, for the exertion which we give the recti
pervades the levator palpebrae also, and its action, as we have
just shown, is to protrude the eye, which is an argument against
these muscles being retractors, and therefore against the obliqui
being their opponents, to draw it forward.
As we have just observed, the eye-bail is suspended between
the muscles within the orbit, and the orbicularis palpebrarum
anteriorly ; this is shown by the effect of the paralysis of the
orbicularis, for then the eye-ball is unnaturally protruded (see
the case in the Appendix, No. X.)
To these, other objections, no less strong, may be added.
We have just found that certain very rapid motions are to be
performed by the eye-ball ; now it can be demonstrated, that a
body will be moved in less time by a muscle which is oblique to
the line of motion, than if it lay in the line on which the body
moves. If the oblique muscles were either opponents or coadju-
tors of the recti, there appears no reason why they should be
oblique, but the contrary ; for as the points of their insertion
must move more rapidly than those of the recti, they are un-
suitable. On the other hand, that there may be no difference in
the time of the action and relaxation of the several classes, we
see a reason why one rectus should be opposed by another, and
why there being occasion for one oblique, its antagonist should
also be oblique.
In proportion as a muscle gains velocity by its obliquity, it
loses power ; from the obliquity, therefore, of these muscles be-
lieved to be opposed to the recti, and from there being two of
them to four of the latter, they are disproportioned in strength.
ON THE MOTIONS OF THE EYE. 198
and the disproportion proves that the two classes of muscles are
not antagonists.
By dissection and experiment it can be proved, that the
oblique muscles are antagonists to each, and that they roll the
eye in opposite directions, the superior oblique directing the
pupil downwards and outwards, and the inferior oblique direct-
ing it upwards and inwards. But it is proved that any two of
the recti muscles are equal to the direction of the pupil in the
diagonal between them, and there is no reason why an additional
muscle should be given, to direct the pupil upwards and inwards
more than upwards and outwards, or downwards and inv/ards.
It is evident, then, that the oblique muscles are not for assisting
the recti in directing the eye to objects, or there would have
been four of them, but that they must have some other appro-
priate office. If we proceed farther, it must be by experiment.
Experimental Inquiry into the Action of these Muscles.
I. I divided the superior rectus or attollens in a rabbit, and
felt something like disappointment on observing the eye remain
stationary. Shortly afterwards, on looking to the animal while
it was feeding, I saw the pupil depressed, and that the animal
had no power of raising it.
The explanation I conceive to be this : during the experi-
ment the eye was spasmodically fixed by the general action of
the muscles, and particularly by the powerful retractor, a muscle
peculiar to quadrupeds. But on the spasm relaxing, and when
the eye was restored to the influence of the voluntary muscles,
190 ON THE MOTIONS OF THE EYE.
the recti, the voluntary power of raising the eye being lost by
the division of the superior muscle, the eye was permanently
depressed.
II. On opening the eye-lids and irritating the eye of the
rabbit, in which the superior rectus muscle had been divided,
the eye was turned up; so that though the voluntary motion was
lost by the division of the rectus, the involuntary motion re-
mained by the influence of the obliquus.
III. Wishing to ascertain if the oblique muscles contract
to force the eye-ball laterally towards the nose, I put a fine
thread round the tendon of the superior oblique muscle of a
rabbit, and appended a glass bead to it of a weight to draw out
the tendon a little. On touching the eye with a feather, I had
the pleasure of seeing the bead drawn up. And on repeating
the experiment, the thread was forcibly drawn through my
fingers.
By experiments made carefully in the dead body (having
distended the eye-ball by dropping mercury into it to give it its
full globular figure), I had found that the action of the superior
oblique muscle is to turn the pupil downwards and outwards,
and that the inferior oblique just reverses this motion of the eye.
In the above experiment there is abundance of proof that the
superior oblique muscle acted, and yet the pupil was not turned
downwards and outwards, therefore both oblique muscles must
have been in action. Their combined action draws the eye-ball
towards the nose.
In the violent spasmodic affection of the eye, when it is
painfully irritated, I believe that all the muscles, both of the
ON THE MOTIONS OF THE EYE. 191
eye-ball and eye-lids, are excited. In quadrupeds, I have ascer-
tained that the oblique muscles act when the haw is protruded,
but I have also found that the retractor oculi alone is capable
of forcing forwards the haw.
But quadrupeds having an additional apparatus of muscles
to those of the human eye, are not suited for experiments
intended to illustrate the motions of our eyes. The monkey
has the same muscles of the eye with man.
IV. I cut across the tendon of the superior oblique muscle
of the right eye of a monkey. He was very little disturbed by
this experiment, and turned round his eyes with his charac-
teristic inquiring looks, as if nothing had happened to affect
the eye.
V. I divided the lower oblique muscle of the eye of a
monkey. The eye was not, in any sensible manner, affected ;
the voluntary motions were perfect after the operation.
VI. On holding open the eyes of the monkey, which had
the superior oblique muscle of the right eye divided, and waving
the hand before him, the right eye turned upwards and inwards,
while the other eye had a scarcely perceptible motion in the
same direction. When the right eye was thus turned up, he
seemed to have a difficulty in bringing it down again.
From these experiments it is proved, first, that the division
of the oblique muscles does not in any degree affect the volun-
tary motions by which the eye is directed to objects. Secondly,
that the division of the recti does not prevent the involuntary
motions.
192 ON THE MOTIONS OF THE EYE.
In the third place, we have also seen that in winking to
avoid injury, the oblique muscles were in operation ; and that
the inferior oblique muscle gained in the power of elevating the
eye-ball by the division of the superior oblique, its opponent.
It would appear, that the inferior oblique muscle has a
power of elevating the cornea under the eye-lid, and causing the
eye-ball to revolve many degrees further than the rectus superior
does. For if we hold the eye open and excite it, as with a feather,
the pupil will turn up quite under the upper eye-lid, and this
is an involuntary act ; but if we ask the person to turn the eye
upwards, as in looking to the ceiling, he cannot direct the pupil
beyond the margin of the eye-lid. The fact is obvious enough,
and the rationale also ; for to what end should there be a power
of voluntarily raising the eye-ball in vision, without an accompany-
ing action in the attollens palpebree, and for what purpose should
we have a voluntary power of turning the cornea under the
eye-lid ? It is obvious, that we could not extend the sphere of
vision by this action, and as for the object of moistening the
cornea, that is more effectually performed by the operation of
the inferior obliquus*.
These revolving motions accompanying the winking motions
of the eye-lids are of the utmost consequence to the preservation
of the organ. A case which was some time under my observa-
tion proved this. By a defect of motion, the eye and eye-lids
remained fixed, and the consequence was that the cornea in-
* See Appendix, page xxxv.
ON THE MOTIONS OF THE EYE. 193
flamed and became opaque. Another curious circumstance in
this case was, that when the eye-Uds were closed, the patient
still saw red light through the affected eye, the reason of which
was that the eye-ball did not turn up when the eye-lid was
closed. A case, showing this effect, will be found in the Ap-
pendix, No. XXXVII.
If we close the eyes opposite to the window or before a
candle, and continue to attend to the sensations of the eye, we
shall still see red light coming through the eye-lids ; and we may
observe, at this time, that the convexity of the cornea has not
changed its place ; we may feel it in ourselves, or we may observe
it in our neighbours. But if we make an effort to close the
eye-lids (though they be already shut), we shall be in momentary
darkness, because during the effort the eye-balls are then turned
up. Thus it appears that the dropping of the eye-lid would
make but an imperfect curtain before the eye, and the eye, to
be entirely protected from the light, must have the pupil turned
upwards *.
■
On the two Conditions of the Eye, its State of Rest, and of
Activity.
The eye is subject to two conditions ; a state of rest with
entire oblivion of sensation, and a state of watchfulness, during
which both the optic nerve and the nerve of voluntary motion
* In the case above alluded to, the patient had lost both motion and the common
sensibility of the eye ; the offices of the third and fifth nerve were lost, yet the optic
nerve retained its power, and he could see. — See also No. IX. of the Appendix.
C C
194 ON THE MOTIONS OF THE EYE.
are in activity. When the eye is at rest, as in sleep, or even
when the eye-Uds are shut, the sensation on the retina being
then neglected, the voluntary muscles resign their office, and the
involuntary muscles draw the pupil under the upper eye-hd.
This is the condition of the organ during perfect repose*.
On the other hand, there is an inseparable connexion be-
tween the exercise of the sense of vision and the exercise of the
voluntary muscles of the eye. When an object is seen, we
enjoy two senses ; there is an impression upon the retina ; but
we receive also the idea of position or relation, which it is not
the office of the retina to give. It is by the consciousness of
the degree of effiDrt put upon the voluntary muscles that we
know the relative position of an object to ourselves. The
relation existing between the office of the retina and of the
voluntary muscles may be illustrated in this manner : —
Let the eyes be fixed upon an illuminated object until the
retina be fatigued, and in some measure exhausted by the image,
then closing the eyes, the figure of the object will continue
present to them : and it is quite clear that nothing can change
the place of this impression on the retina. But notwithstanding
that the impression on the retina cannot be changed, the idea
thence arising may. For by an exertion of the voluntary
muscles of the eye-ball, the body seen will appear to change its
place, and it will, to our feeling, assume different positions
according to the muscle which is exercised. If we raise the
pupil, we shall see the body elevated, or if we depress the pupil,
* See Nos. III. and X. of the Appendix.
ON THE MOTIONS OF THE EYE. 195
we shall see the body placed below us ; and all this takes place
while the eye-lids are shut, and when no new impression is
conveyed to the retina. The state of the retina is here as-
sociated with a consciousness of muscular exertion ; and it shows
that vision in its extended sense is a compound operation, the
idea of the position of an object having relation to the activity
of the muscles *.
We may also show, by varying this experiment, that an
agitated state of the muscles, or a state of action where the
muscles are at variance or confused, affects the idea of the image.
If we look on the luminous body so as to make this impression
on the retina, and then cover the face so as to exclude the light,
keeping the eye-lids open, and if we now squint, or distort the
eyes, the image which was vividly impressed upon the retina
instantly disappears as if it were wiped out. Does not this cir-
cumstance take place, because the condition of the muscles thus
unnaturally produced, being incongruous with the exercise of
the retina, disturbs its operation ?
If we move the eye by the voluntary muscles, while this
impression continues on the retina, we shall have the notion of
place or relation raised in the mind ; but if the motion of the
eye-ball be produced by any other cause, by the involuntary
muscles, or by pressure from without, we shall have no corre-
sponding change of sensation.
If we make the impression on the retina in the manner
described, and shut the eyes, the image will not be elevated,
* Read, on this subject, the Essay of Dr. Wells on Single Vision.
C C 2
196 ON THE MOTIONS OF THE EYE.
although the pupils be actually raised, as it is their condition to
be when the eyes are shut, because there is here no sense of
voluntary exertion. If we sit at some distance from a lamp
which has a cover of ground glass, and fix the eye on the centre
of it, and then shut the eye and contemplate the phantom in
the eye ; and if, while the image continues to be present of a
fine blue colour, we press the eye aside with the finger, we shall
not move that phantom or image, although the circle of light
produced by the pressure of the finger against the eye-ball
moves with the motion of the finger.
May not it be accounted for in this manner? the motion
produced in the eye-ball not being performed by the appropriate
organs, the voluntary muscles, it conveys no sensation of change
to the sensorium, and is not associated with the impression on
the retina, so as to affect the idea excited in the mind. It is
owing to the same cause that, when looking on the lamp, by
pressing one eye, we can make two images, and we can make the
one move over the other. But, if we have received the impres-
sion on the retina so as to leave the phantom visible when the
eye-lids are shut, we cannot, by pressing one eye, produce any
such effect. We cannot, by any degree of pressure, make that
image appear to move, but the instant that the eye moves by its
voluntary muscles, the image changes its place; that is, we pro-
duce the two sensations necessary to raise this idea in the mind ;
we have the sensation on the retina combined with the conscious-
ness or sensation of muscular activity.
It has been said, that in this experiment the eye-ball does
not move, which is the reason that the phantom does not seem
ON. THE MOTIONS OF THE EYE. 197
to move. Then how are we to account for that effect of pressing
one eye-ball when the eyes are open? for then we make the
images double, and cause the one to move over the other.
It is very remarkable, that the eye will sometimes be ob-
served to move continually, and yet, to the person having that
defect, the objects viewed will appear at perfect rest. The cases
in the Appendix prove this ; there we find that a young woman
can thread her needle at the time her eyes are in incessant
motion. In this instance, when the eye-lids were held open,
and the girl was made to attempt closing them, the eye-ball
rolled up and remained stationary. All I can offer in explanation
of this is, that she is unconscious of the motion of the eye, and
that the idea of motion or change of place is not indicated.
The subject is very interesting. — See Appendix, Nos. XIII.,
XIV., XV., XVI., XVII.
These experiments and this explanation of the effect of the
associated action of the voluntary muscles of the eye-ball, appear
to me to remove an obscurity in which this subject has been left
by the latest writers. In a most scientific account of the eye
and of optics, lately published, it is said on this question, " We
know nothing more than that the mind residing, as it were, in
every point of the retina, refers the impression made upon it, at
each point, to a direction coinciding with the last portion of the
ray which conveys the impression." The same author says,
" Kepler justly ascribed erect vision from an inverted image to
an operation of the mind, by which it traces the rays back to
the pupil, and thus refers the lower part of the image to the
upper side of the eye." What can be here meant by the mind
198 ON THE MOTIONS OF THE EYE.
following back the ray through the humours of the eye ? It
might as well follow the ray out of the eye, and like the spider
feel along the line. A much greater authority says, we puzzle
ourselves without necessity. " We call that the lower end of
an object which is next the ground." No one can doubt that
the obscurity here is because the author has not given himself
room to illustrate the subject by his known ingenuity. But it
appears to me, that the utmost ingenuity will be at a loss to
devise an explanation of that power by which the eye becomes
acquainted with the position and relation of objects, if the sense
of muscular activity be excluded, which accompanies the motion
of the eve-ball.
Let us consider how minute and delicate the sense of
muscular motion is by which we balance the body, and by which
we judge of the position of the limbs, whether during activity
or rest. Let us consider how imperfect the sense of touch
would be, and how little of what is actually known through the
double office of muscles and nerves would be attained by the
nerve of touch alone, and we shall be prepared to give more
importance to the recti muscles of the eye, in aid of the sense of
vision ; to the offices performed by the frame- work around the
eye-ball, in aid of the instrument itself.
Of the Expression of the Ejje, and of the Actions of the Oblique
Muscles in Disease.
If, as I have alleged, the uses of the oblique muscles of the
eye have been misunderstood, and if, as I hope presently to prove,
ON THE MOTIONS OF THE EYE. 199
the distinctions of the nerves have been neglected, the symptoms
of disease, and the sources of expression in the eye, must remain
to be explained.
During sleep, in oppression of the brain, in faintness, in
debility after fever, in hydrocephalus, and on the approach of
death, the pupils of the eyes are elevated. If we open the eye-
lids of a person during sleep or insensibility, the pupils will be
found elevated. Whatever be the cause of this, it will be found
that it is also the cause of the expression in sickness, and pain,
and exhaustion, whether of body or mind : for then the eye-lids
are relaxed and fallen, and the pupils elevated so as to be half
covered by the upper eye-lid*. This condition of the eye during
its insensible unexercised state we are required to explain.
It is a fact familiar to pathologists, that when debility arises
from affection of the brain, the influence is greatest on those
muscles which are, in their natural condition, most under the
command of the will. We may perceive this in the progressive
stages of debility in the drunkard, when successively the muscles
of the tongue, the eyes, the face, the limbs, become unmanageable;
and, under the same circumstances, the muscles which have a
double office, as those of the chest, lose their voluntary motions,
and retain their involuntary motions, the force of the arms is
gone long before the action of breathing is affected.
If we transfer this principle, and apply it to the muscles of
the eye, we shall have an easy solution of the phenomena above
enumerated. The recti are voluntary muscles, and they suffer
* See the curious case in the Appendix, No. XVIII.
200 ON THE MOTIONS OF THE EYE.
debility before the oblique muscles are touched by the same con-
dition ; and the oblique muscles prevailing, roll the eye.
If it be farther asked, why does the eye roll upwards and
inwards ? we have to recollect, that this is the natural condition
of the eye, its position when the eye-lids are shut and the light
excluded, and the recti at rest, and the obliqui balanced.
The author has to regret that these minute circumstances
regarding the action of the muscles of the eye have led him to
so great a length ; he hopes they are not altogether without
interest in themselves, while the discussion will aiFord him secure
ground for establishing an arrangement of the nerves of the
eye, and will enable him to distinguish them according to their
uses.
SECOND PAKT OF THE PAPER
ON
THE NERVES OF THE ORBIT.
From the Philosophical Transactions.
D D
i
I
SECOND PART OF THE PAPER
ON
THE NERVES OF THE ORBIT.
[Read before the Royal Society, June 19, 1823.]
In these Papers I endeavour, to the utmost of my power, to
distinguish between the facts which I am able to substantiate,
and the hypothesis by which I have been directed in my inquiries.
I hope that the importance of the facts may give some bias in
favour of that mode of reasoning by which they have been dis-
covered, and an additional interest to anatomical studies.
In my endeavour to arrange the nerves of the orbit, I en-
counter, in the first step, ail the difficulties of my subject ; for
although there be only nine nerves properly enumerated as pro-
ceeding from the brain, six of these go to the eye ; the second,
third, fourth, part of the fifth, sixth, and seventh, go into the
orbit, and may be said to be concentrated into a space no larger
than a nut-shell.
In this investigation it is not always possible to give demon-
strative evidence, or to answer opposition by cutting across a
nerve ; here we must proceed on a minute investigation of the
DD 2
204 ON THE NERVES OF THE ORBIT.
anatomy, and by reasoning, rather than by experiment : yet I
shall demonstrate what was stated hypothetically, in a former
paper, that there is a correspondence between the compound
functions of an organ and the nerves transmitted to it.
Of the Function of the Ophthalmicus, a Division of the Fifth
Nerve.
We are, in the first place, to inquire by what nerve the
common endowment of sensibility is bestowed upon the mem-
branes and surfaces of the eye. On recurring to this subject we
are reminded, that the sensibilities of the body differ as much in
kind as in degree ; that the sensation of pain is provided to rouse
our activity, and guard us against violence, or, by means more
direct, to excite instinctive motions, which shall anticipate the
most rapid actions of the will, and serve as a more perfect safe-
guard. The trigeminus, or fifth nerve, bestows upon all the sur-
faces of the head and face, external and internal, that sensibility
which is enjoyed by the rest of the body through the spinal
nerves. But through some of its branches is also bestowed that
distinct sense on certain parts, for the purpose of drawing the
muscles into combination ; as, for example, that fine sensibility
of the surface of the eye to the presence of minute particles,
which at once excites the flow of tears, and draws the muscles
into a combination to expel the offensive matter.
It has been shown in a preceding paper, by experiment, that
on dividing the branch of the fifth nerve which goes to the cheek
and lips, the skin was deprived of sensibility, although in pos-
ON THE NERVES OF THE ORBIT. 205
session of other nerves, and enjoying muscular activity. The same
has been proved in regard to this ophthalmic division ; for if that
branch of it which comes through the orbit and mounts upon
the forehead be divided, the skin will be deprived of sensibility,
while the motion of the eye-brow will remain entire.
These facts are so strong, that when supported by the
symptoms of disease they afford no apology for deep dissection
in the living animal, and authorize the conclusion, that all the
branches of the same division of the nerve resemble each other
in function, and bestow sensibility on the parts within, as well
as on those without.
That the ophthalmic nerve may be deprived of its function,
and the parts supplied by it of their sensibility, we may learn
from the following instance, communicated to me by Mr. Cramp-
ton, of Dublin. To understand the inference from the short
narrative, it is only necessary to remember, that the nerve in
question goes through the orbit, supplying the parts contained in
it, but that it also extends its branches to the angle of the eye,
eye-lids, and forehead. "A few days after the discharge from
the ear had ceased, the eye became entirely insensible to the
touch. This loss of feeling extended to the lining of the eye-
lids, to the skin covering them, and to the skin of the cheek and
forehead, for about an inch surrounding the eye : it did not go
beyond the middle line of the face. When she told me her eye
was dead (as she expressed it), to be certain, I drew my finger
over its surface ; and so far was this from giving her pain, that
she assured me she could not feel that I was touching it at all.
The eye-lids made no effort to close while I was doing this, but
the conjunctiva appeared sensible to the stimulus, as a number
206 ON THE NERVES OF THE ORBIT.
of vessels on the surface of the eye became immediately injected
with blood*."
Here we have an insensibility of the eye itself corresponding
with the insensibility of the skin, which latter part we know^
possesses sensibility through the Jifth nerve ; and we therefore
conclude, that it is the affection of the same nerve near its root,
to which we have to attribute the insensibility of the surfaces of
the eye, as well as of the skin around the eye. We must observe
in this case, as in others of which I have had experience, that
the third nerve remained entire in its functions, and, in some
degree, the optic nerve, during the loss of common sensibility.
It will be shown by case No. LV. of the Appendix, that the
injury of the ophthalmic division of the fifth, at its root, deprived
the eye of sensibility. By experiment it can farther be made
evident, that the sensibility of the eye, enjoyed through the
ophthalmic nerve, does not bestow on the organ directly the
power of combining the muscles, either for the defence of the
eye, or for any other purpose. The impression must be referred
back to the brain, and the muscles be excited by their proper nerves.
In experiment I have not been able to excite the motion of the
eye by irritating the ophthalmic division of the fifth when its root
had been divided |; and in the instance given above, the eye-lids
did not move when the surface of the eye was irritated, because
no sensation was conveyed inward to the sensorium, and con-
sequently no mandate transmitted from it. The young lady
* See the case in the Appendix, No. LII.
f In attempting to excite the muscles of the eye by galvanism sent through the
fifth nerve, the muscles of the jaw were affected.
ON THE NERVES OF THE ORBIT. 207
could see, and could move the eye and eye-lids ; the eye itself
was irritated by touch, as appeared from the rising inflammation;
but by the insensibility of the ophthalmic nerve, a link was lost
in the relation necessary to join the action of the muscles to the
sensibility of the surface.
The three cases in the Appendix, Nos. VIII., XXXVII.,
LIIL, demonstrate the correctness of my conclusion drawn from
the consideration of the anatomy ; for disease at the part where
the ophthalmic nerve is passing forwards entirely took away the
sensibility of the surface of the eye and eye-lids, whilst vision
and the motion of the eye-lids remained. By these cases it is
further shown how curiously the sensibility of the surface of
the eye protects it, and that when that sensibility is destroyed,
although the motions of the eye-lids remain, they are not made
to close the eye, to wash and clear it, and consequently inflamma-
tion and destruction of the organ follow.
Of the Nefves performing the involuntary Motions.
We have just seen that nerves in great profusion come out
upon the eye-lids and forehead, and until these experiments were
made, it was supposed that they directed the motions of the
forehead and eye-lids. But I have found that they have nothing
to do with this function. On the contrary, a very small branch
of the respiratory nerve of the face,, that nerve which comes out
before the ear, controls the motions of the forehead and eve-lids.
If this small nerve be divided, then the motions of the eye-lids
are lost, and they remain open. If, on the contrary, all the
nerves, that is to say, the second, third, fourth, and fiftli, should
II
^08 ON THE NERVES OF THE ORBIT.
be destroyed, and this small twig remain entire, the contractions
of the eye-lids remain perfect* The inquiries instituted in the
first part of this paper give a lively idea of the consequences of
the imperfection arising from the defect of this small branch of
the respiratory nerve; since they show that the eye, being un-
guarded and unwashed, becomes dry by evaporation, inflames,
and the cornea becomes opaque. It is unnecessary to point out
the importance of this fact to the operating surgeon f.
I must, however, draw the reader's attention more par-
ticularly to the effect of the loss of power in the branch of the
portio dura which goes to the eye-lid. The tone and action of
the orbicularis being lost, the eye is protruded, or rather per-
mitted to come forwards by the absence of opposition. This
protrusion of the eye appears so like the effect of disease or of
tumor in the orbit, that surgeons have concluded that the cause
of paralysis externally was pressure in the orbit ; thereby con-
founding themselves, and countenancing errors in regard to the
offices of the nerves.
It has been asked, why should this nerve be called respira-
tory ; and what have the actions of respiration to do with the
eye-lids? The name was given to excite attention to certain
relations, and that the connexions of remote parts might be
noticed and remembered. These connexions are so curious, the
knowledge of them is sometimes so useful, and they are so im-
mediately related to the present subject, that I may be permitted
to explain them.
During the state of excitement of the respiratory organs, a
* See Appendix, Nos. VIII., IX., &c.
t See Appendix, Nos. XXXIII., XLIL, &c.
ON THE NERVES OF THE ORBIT. 209
very extensive consent of the muscular frame is necessary to bind
together and support the textures, that they may bear the strain,
either during violent efforts of the body, or in coughing, sneezing,
&c. We may take the act of sneezing as a familiar example of
the manner in which the eye is guarded during a sudden and
violent act of expiration.
At the instant of this convulsive action of the respiratory
muscles, a violent impulse is communicated to the head along
the column of blood in the vessels of the head and neck. Every
body is sensible of the eye flashing light at this moment ; but
the cause is mistaken, for it is supposed to be the impulse of
blood forced into the eye ; whereas it is the contraction of the
eye-lids to counteract the force of this impulse, and to guard the
delicate texture of the eye. If we tap the eye with the finger
when the eye-lids are closed, we shall be sensible of the sparks of
light. We may produce the same by suddenly and forcibly closing
the eye-lids in the dark ; but in sneezing, the compression is both
more rapid and more forcible, and as the eye-ball receives at
once the impulse through the column of the blood from behind,
and the resistance of the muscle on the fore part, the sparks are
more brilliant. If the eye-lids be held open during the act
of sneezing, no sensation of light will be experienced, because
the contraction of the eye-lids upon the eye-ball is prevented.
Can we believe this action of the muscle of the eye-lids, in com-
bination w ith the action of the respiratory muscles, to be through
an accidental connexion ? Is it not rather a provision to com-
press and support the vascular system of the eye, and to guard it
against the violent rush of blood which attends certain acts of
E E
210 ON THE NERVES OF THE ORBIT.
respiration ? If we open the eye-lids of a child to examine the
eye while it is crying and struggling with passion, by taking off
the natural support from the eye, the blood at the same time
being forced violently into the head by the act of respiration, we
shall see the conjunctiva suddenly fill with blood, and the eye-
lid everted.
The respiratory nerve of the face performs two offices, one
of which is voluntary, as in moving the cheeks and lips in speech ;
and the other involuntary, as in moving the nostrils in breathing
during sleep or insensibility. In like manner, that branch of the
respiratory nerve which is prolonged to the eye-lids performs a
double office, contracting the eye-lids by volition, and also pro-
ducing those involuntary winking motions of the eye-lids which
disperse the tears and preserve the lucid surface clear, whilst it
causes a correspondence in the motions of the eye-hds with the
act of respiration.
But it has been observed, in the first part of this paper,
that the shutting of the eye-lids is not the only part of the act
of preservation, and that the motions of the eye-lids are attended
with a rolling of the eye-ball. How is this relation between the
eye-lids and eye-ball established ? This leads to an examination
of the fourth nerve.
Of the Fourth ISIerve, as performing an Involuntary Motion.
I should, perhaps, not touch upon this subject, because I
cannot demonstrate the truth of my opinions as I have hitherto
done. However, the question is this, why should the fourth
ON THE NERVES OF THE ORBIT. 211
nerve come from a part of the brain so far back compared with
the other nerves ? why should it have a different origin from the
nerve which gives sensibility to the surfaces of the eye, as well
as from that which gives the voluntary motions to the eye ? why
should it take so long a course amongst these common nerves
without exchanging a filament with them ?
The fourth is a fine nerve, which takes its origin from the
brain, at a part remote from all the other nerves which run into
the orbit. It threads the intricacies of the other nerves without
touching the other muscular nerve, and is entirely given to one
muscle, the superior oblique*. We may observe, too, that this
singularity prevails in all animals. What office can this nerve
have in reference to this one muscle ? We now reflect, with in-
creased interest, on the offices of the oblique muscles of the eye,
observing that they perform an insensible rolling of the eye-ball,
and hold it in a state of suspension between them. We have
seen that the effect of dividing the superior oblique was to cause
the eye to roll more forcibly upwards ; and if we suppose that
the influence of the fourth nerve is, on certain occasions, to cause
a relaxation of the muscle to which it goes, the eye-ball must be
then rolled upwards f.
* It receives a twig from the fifth nerve.
■f- The nerves have been considered so generally as instruments for stimulating the
muscles, without any thought of their acting in the opposite capacity, that some additional
illustration may be necessary here. Through the nerves is established the connexion
between the muscles; not only that connexion by which the muscles combine to one ef-
fort, but also that relation between the classes of muscles by which the one relaxes while
the other contracts. I appended a weight to the tendon of an extensor muscle, which
gently stretched it and drew out the muscle; and I found that the contraction of
the opponent flexor was attended with a descent of the weight, which indicated the re-
E E 2
212 ON THE NERVES OF THE ORBIT.
The course of inquiry leads us, in the next place, to observe
the vicinity of the root of this fourth nerve to the origin of the
respiratory nerve of the face, that is, the nerve of the eye-lids, and
we find them arising from nearly the same tract of fibrous sub-
stance. The column of medullary matter which constitutes that
part of the medulla oblongata from which the respiratory nerves
arise, terminates upwards, or at its anterior extremity, just under
the corpora quadrigemina, and there the fourth arises. We have
just seen that there is an intimate relation between the orbicu-
laris muscle and the oblique muscle. Is there also a corre-
spondence between the general act of respiration and the rolling
of the eye ? Led thus to make the experiment, I was gratified
to find it so easy to give the proof. On stopping the nostrils
with the handkerchief, every effort to blow the nose will be
attended by a rapid rising of the cornea under the upper eye-
lid. And on every occasion when the eye-lids suffer contraction
through the agency of the respiratory nerve of the face, as in
sneezing, the eye-ball is rolled upwards. Is this through the
agency of the fourth nerve ?
I might, perhaps, be satisfied with having made the observa-
tion of these two facts ; first, that there is such a combination of
the motions of the eye-ball and eye-lids as I have before noticed ;
and secondly, that the nerves which move the eye-lids, and the
laxation of the extensor. To establish this connexion between two classes of mus-
cles, whether they be grouped together as in the limbs, or scattered widely as the
muscles of respiration, there must be particular and appropriate nerves to form this
double bond, to cause them to conspire in relaxation as well as to combine in con-
traction. If such a relationship be established, through the distribution of nerves,
between the muscles of the eye-lids and the superior oblique muscle of the eye-ball,
the one will relax while the other contracts.
ON THE NERVES OF THE ORBIT. 213
nerve of the obliquus muscle of the eye-ball, are associated at
their roots ; but I should not do full justice to this interesting
subject if I did not attempt something farther. I must confess
that the point of anatomy is still a desideratum. I have not in
a manner satisfactory to myself made out the relation between
the roots of the portio dura and of the fourth nerve.
It is plain that we must consider the nerves and muscles of
the eye-lids in a double capacity, in their voluntary and in-
voluntary actions. In the first, the motions of the eye-lids com-
bine with the whole muscles of the eye-ball, as we may perceive
in the voluntary contractions and squeezing of the eye ; but in
the insensible and invohmtary motions of the eye-lids, there
would be no sympathy with the muscles of the eye-ball, and
therefore no correspondence in the motion of these parts, without
a nerve of the nature of the fourth ; that is, a nerve which
having diverged from the root of the respiratory nerves, takes
its course to the oblique muscle. Does, then, the connexion of
its root declare the office of this nerve ?
The expression of the eye in passion confirms the truth of
this relation being established by a respiratory nerve, and con-
sequently by a nerve of expression. In bodily pain, in agony of
mind, and in all this class of passions, the eyes are raised and
dragged, in conjunction with the changes to which the other
features are subjected, and so in faintness and in death. If it be
asked now, why the fourth nerve goes into the orbit, where there
are so many nerves, why it is so distant in its origin from the
other nerves, and why it sends off no twig or branch, but goes
entirely to one muscle of the eye ? the answer is, to provide for
the insensible and instinctive rolling of the eye-ball ; and to
214 ON THE NERVES OF THE ORBIT.
associate this motion of the eye-ball with the winking motions of
the eye-hds ; to establish a relation between the eye and the
extended respiratory system : all tending to the security or pre-
servation of the organ itself*.
Of the Voluntary Nerves.
The voluntary nerves of the eye are the third and sixth.
The third nerve arises from the crus cerebri ; that track of me-
dullary matter which gives off all the nerves purely of volition.
It is given to the muscles of the eye generally, and to no part
but muscles. For these reasons we retain the name motor oculi,
given by Willis, although his reasons for calling it so were fanciful
and unsatisfactory. The fifth nerve, by its ophthalmic division,
gives branches to the muscles of the eye, but not so profusely as
to the surrounding parts ; and not more than sufficient to give
them sensibility in the degree possessed by muscular substance
generally. Since the branches of the fifth nerve, transmitted to
the muscles of the eye-lids and forehead, do not minister in any
degree to muscular action there, it would be unwarrantable to
suppose that they served the purpose of giving action to the
muscles within the orbit. For these reasons, I conceive the third
nerve to be tliat which gives volition to the muscles of the eye,
and that it is, of all the nerves of the body, the most perfectly
and directly under the power of the will. In No. IX. of the
Appendix we may see how inflammation, involving the roots of
the third pair of nerves, arrested the motions of the eye-ball.
* For the affection of the eye in sleep, see cases in the Appendix, Nos. III.,
VII., X. In dying, No. XX XIX.
ON THE NERVES OF THE ORBIT. 215
The sia:th nerve is called abducens, and ??iotor externus. There
is no obscurity in this nerve with regard to its origin and distri-
bution ; it arises from the same track of medullary matter which
gives rise to the motor nerves, and it is distributed to a voluntary
muscle, the rectus extermis. in this respect it is like a subdivision
of the third, and without doubt it is a voluntary nerve ; but there
is a circumstance in its connexion which I cannot explain. It
receives a gross branch from the great visceral nerve called
Sympathetic. This nerve, ascending through the base of the
skull, unites with the sixth nerve as it is entering the orbit.
Some, having proceeded so far, would be inclined to call this an
accidental connexion, and so leave it ; but similar investigations
for many years have brought me to the conviction that there is
no accident in an animal body ; and comparative anatomy proves
this to be a regular established relation.
Comparative anatomy may, perhaps, assist us here. In
all animals which have the retractor oculi, the sixth nerve is
distributed to that muscle, as well as to the rectus externus.
This would seem to imply that there is something common to
the retractor oculi and the rectus externus. Now as the re-
tractor muscle is always found where there is a haw, as in the
horse, and as its action is known to be for the purpose of pushing
out the haw, and removing irritation from the surface of the eye,
may we not surmise that the rectus externus of the human eye
is well suited to draw the eye-ball towards the inner canthus,
and to produce a similar effect on the caruncle and membrana
semilunaris ? but in thus accounting for a certain peculiarity
in the action of the sixth nerve, we have not a very satisfactory
3
216 ON THE NERVES OF THE ORBIT.
reason why it should be solitary in its origin and course*. I
think this abducens muscle of the eye more subject to de-
rangement than the other recti. Whilst this sheet is beside
me I have been consulted by a patient who complains of
seeing double when he looks towards the right, although his
vision be perfect when his eyes are directed to the left. It is
obvious that the abductor of the right eye is incapable of drawing
the eye-ball beyond a certain degree: when the left eye moves
round beyond this degree, the images of objects begin to separate,
and become more and more apart as the left eye traverses to
the right. An absolute squint, of a particular kind, in which
the pupil is directed to the inner can thus, results from a greater
defect of the external rectus. Does the connexion of the sixth
nerve with the sympathetic account for such derangements ?
I hope I have now, in a considerable degree, unravelled the
intricacy of the nerves of the head, and have assigned to each
nerve its proper office. In our books of anatomy the nerves are
numbered according to the method of Willis; an arrangement
which was made in ignorance of the distinct functions of the
nerves, and merely in correspondence with the order of suc-
cession in which they appear on raising the brain.
The first nerve is provided with a sensibility to effluvia, and
is properly called the olfactory nerve.
The second is the optic nerve, and all impressions upon it
excite only sensations of light.
The third nerve goes to the muscles of the eye solely,
* My young men are engaged in prosecuting the branch of the portio dura which
penetrates the temporal fascia, and goes through the malar bone into the orbit.
ON THE NERVES OF THE ORBIT. 217
and is a voluntary nerve by which the eye is directed to
objects.
The fourth nerve performs the insensible traversing motions
of the eye-ball. It combines the motions of the eye-ball and
eye-lids, and connects the eye with the respiratory system.
The fifth is the universal nerve of sensation to the head and
face, to the skin, to the surfaces of the eye, the cavities of the
nose, the mouth and tongue, and the manducatory nerve.
The sixth nerve is a muscular and voluntary nerve of the eye.
The seventh is the auditory nerve, and the division of it,
called poj'tio dura, is the motor nerve of the face and eye-lids,
the respiratory nerve, and that on which the expression of the
face depends.
The eighth, and the accessory nerve, are respiratory nerves.
The ninth nerve is the motor of the tongue.
The tenth is the first of the spinal nerves ; it has a double
root and a double office ; it is both a muscular and a sensitive
nerve. It supplies the integuments and back of the head, to
which the branches of the fifth do not extend.
In concluding these papers, I hope I may be permitted to
offer a few words in favour of anatomy, as better adapted for
discovery than experiment. The question lies between observa-
tion and experiment, and it may be illustrated by astronomy
and chemistry. In the first, the objects being beyond our
influence, we make observations, not experiments ; and the
science at length attains a state of perfection which raises our
estimate of the human intellect. In the latter, for the most
F F
218 ON THE NERVES OF THE ORBIT.
part, the subjects lie out of the sphere of mutual influence ; they
must be brought together by artifice, and chemistry becomes a
science of experiment. But anatomy is more allied to the
former than to the latter science, inasmuch as things are obvious
to the eyes. In the animal body the parts present distinct
textures, and are laid in a natural and perfect order; it is
necessary only to trace the tubes, or to observe the symmetrical
order of the nervous cords, that we may discover their respective
uses ; the motions, whether of the solid or fluid parts, are so
regular and uniform, that the whole offers a subject for observa-
tion and induction. Anatomy is already looked upon with
prejudice by the thoughtless and ignorant: let not its professors
unnecessarily incur the censures of the humane. Experiments
have never been the means of discovery ; and a survey of what
has been attempted of late years in physiology wiU prove, that
the opening of living animals has done more to perpetuate error
than to confirm the just views taken from the study of anatomy
and natural motions.
In a foreign review of my former papers, the results have
been considered as a further proof in favour of experiments.
They are, on the contrary, deductions from anatomy ; and I have
had recourse to experiments, not to form my own opinions, but
to impress them upon others. It must be my apology, that my
utmost efforts of persuasion were lost, while I urged my state-
ments on the grounds of anatomy alone. I have made few
experiments ; they have been simple, and easily performed ; and
I hope are decisive.
If we turn to the opinions which have been entertained on
ON THE NERVES OF THE ORBIT. 219
the subject of the brain and nerves, we find one theory to have
prevailed from the Greek authors to the time of AVillis, and to
have descended from him, with Httle alteration, to modern
writers. The brain has been supposed to secrete and supply a
nervous fluid, and the nerves to be the conduit-pipes for its
conveyance. In every age the brain has been considered a
common sensorium, and all the nerves to be capable of convey-
ing sensation, unless when they had ganglions. If ganglions in-
tervened, then the nerves were said to be cut off from the brain :
and those so distinguished were called vital nerves, neither
serving the purpose of governing the muscles, nor of conveying
sensation. With all this apparent simpHcity of doctrine, there
never has been presented such a crude heap of errors in the
history of any department of science.
These notions were obviously founded on the mistake, that
the same nerve served different purposes, and that a fluid moved
in the same tube outwards to stimulate the muscles, and inwards
to convey sensation of external impressions. So inconsistent
are those opinions with the structure of the frame, that the
simplest dissection proves them to be false.
So far is it from being true that ganglions cut off* sensation,
that I have ascertained, and proved by experiment, that all the
nerves, without a single exception, which bestow sensibility, from
the top of the head to the toe, have ganglions on their roots ; and
those which have no ganglions are not nerves of sensation, but
are for the purpose of ordering the muscular frame.
The hypothesis, that the nervous fluid streams out from
the great officina along the nerves, has had an unfortunate
F F 2
220 ON THE NERVES OF THE ORBIT,
influence in directing the labours of the experimentalists.
During the last age it kept the pupils of Haller engaged in
inquiries regarding the influence of the nerves: de nutritione
imprimis nervosa ; and de nervorum in arterias imperio : and the
interest of this question has not subsided, but, on the contrary,
has increased among us.
This notion of a fluid moving backwards and forwards in
the tubes of the nerves, equally adapted to produce motion and
sensation, has perpetuated the error, that the different nerves of
sensation are appropriated to their offices by the texture of their
extremities, " that there exists a certain relation between the
softness of the nervous extremities, and the nature of the bodies
which produce an impression on them." On the contrary, every
nerve of sense is limited in its exercise, and can minister to
certain perceptions only. Whatever may be the nature of the
impulse communicated to a nerve, pressure, vibration, heat,
electricity, the perception excited in the mind will have refer-
ence to the organ exercised, not to the impression made upon
it. Fire will not give the sensation of heat to any nerve but
that appropriated to the surface. However delicate the retina
be, it does not feel like the skin. The point which pricks the
skin, being thrust against the retina, will cause a spark of fire or
a flash of light. The tongue enjoys two senses, touch, and
taste ; but by selecting the extremity of a particular nerve, or,
what is the same thing, a particular papilla, we can exercise
either the one or the other sense separately. If we press a
needle against a nerve of touch, we shall feel the sharpness, and
know the part of the tongue in contact with the point ; but if
ON THE NERVES OF THE ORBIT. 221
we touch a nerve of taste, we shall have no perception of form
or of place ; we shall experience a metallic taste.
I would not say that the innovations of the celebrated
Bichat did not bring us a step nearer the truth ; since it was a
great matter to have ascertained that the ganglions and branches
of the sympathetic nerves were positively insensible and in-
capable of bestowing motion, it is always useful when a man
of genius can present familiar subjects in a new view, since it
enlivens and excites inquiry. But I think it will not be denied
that Bichat paid too little regard to the opinions that prevailed ;
often assuming that as a novelty which really was not, and
doing injustice to those who had preceded him. The best
apology for this, perhaps, was the condition of his country at
the time he lived. What had been termed the sympathetic
system of nerves, he called the ganglionic system ; although
they are not more distinguishable by ganglions than the other
nerves, upon which, indeed, the ganglions are remarkable for
their size, number, and regularity. These ganglions must not
be thrown out of the system altogether, merely because they
are contained within the skull and vertebrae; a circumstance
. which should rather mark their importance.
The experiments of M. Le Gallois were of the rudest kind
possible. The spinal marrow was cut across, or destroyed, by
passing skewers into the spinal canal, and the effects were
observed ; as if the spinal marrow were a simple body. Whereas,
by such destruction of its substance, the original ganglions, which
form a series along the spine, must have been hurt ; the tract of
nervous matter which gives rise to the nerves of sensation ; that
also which gives roots to the nerves of voluntary motion ; and
222 . ON THE NERVES OF THE ORBIT.
the lateral column connected with the offices of respiration,
must all have been destroyed by such coarse experiments. It
cannot surprise us that the results were obscure and contradictory.
But I should regret to be thought insensible to the importance
of M. Le Gallois' experiments in regard to the source of the re-
spiratory movements.
The most extravagant departure from all the legitimate
modes of reasoning, although still under the colour of anatomical
investigation, is the system of Dr. Gall. It is sufficient to say,
that without comprehending the grand divisions of the nervous
system, without a notion of the distinct properties of the
individual nerves, or having made any distinction of the columns
of the spinal marrow, without even having ascertained the dif-
ference of cerebrum and cerebellum. Gall proceeded to describe
the brain as composed of many particular and independent
organs, and to assign to each the residence of some special
faculty.
When the popularity of these doctrines is considered, it
may easily be conceived how difficult it has been, during their
successive importations, to keep my pupils to the examples of
our own great countrymen. Surely it is time that the schools
of this kingdom should be distinguished from those of other
countries. Let us continue to build that structure which has
been commenced in the labours of the Monros and Hunters *,
* While printing the last sheets of these papers, I took up Mr, Hunter's
work on the Animal Economy, to consult him on the distribution of the nerves
to the nose. I was as much surprised with the following passage as if I had
never before read it. This work of Mr. Hunter was my earhest acquisition as a me-
dical student, and often perused with deep interest ; T believe I might trace back the
course of my reflections to it, although during the prosecution of this subject it never
ON THE NERVES OF THE ORBIT. 223
and which the undeserved popularity of the continental system
has interrupted.
The whole history of medical literature proves, that no
solid or permanent advantage is to be gained, either to medical
occurred to me that I was indebted to him. I have often hung over the plates of
Monro, certain that there was an arrangement to be discovered which would explain
the seeming confusion of the nervous system, but I was not so sensible of what I owed
to Mr. Hunter. I am happy that I fell so opportunely on this passage, and inex-
pressibly gratified to find a support of some of my opinions in such authority : —
" The nerves being in themselves, perhaps, the most difficult parts of an animal
body to dissect, becomes a reason why we are still unacquainted with many of their
minuter ramifications : yet, if a knowledge of these, together with that of their origin,
union, and re-union, is at all connected with their physiology, the more accurately
they are investigated, the more perfectly will the functions of the nerves be understood.
I have no doubt, if their physiology was sufficiently known, but we should find the
distribution and complication of nerves so immediately connected with their particular
uses, as readily to explain many of those peculiarities for which it is now so difficult
to account. What naturally leads to this opinion is, the origins and number of nerves
being constantly the same ; and particular nerves being invariably destined for particular
parts. The fourth and sixth pair of nerves are remarkable instances of this ; and we
may reasonably conclude, that every part has its particular branch allotted to it ; and
that however complicated the distribution may be, the complication is always regular.
There are some nerves which have a peculiarity in their course, as the recurrent and
chorda tympani ; and others which are appropriated to particular sensations, as those
which go to four of the organs of sense, seeing, hearing, smelling, and tasting ; and
some parts of the body having peculiar sensations (as the stomach and penis), we
may, without impropriety, include the fifth, or sense of feeling. This general
uniformity, in course, connexion, and distribution, will lead us to suppose that there
may be some other purpose to be answered more than mere mechanical convenience ;
for many variations have been described in the dissections of nerves, which I believe
to have arisen from the blunders of the anatomist, rather than from any irregularity
in their number, mode of ramifying, course, distribution, or connexion * with each
* " Here it is to be understood I do not mean lateral connexion ; such as two
branches uniting into one cord and then dividing ; or a branch going to a part,
either single or double, for still it is the same nerve ; or whether a branch unites with
another a little sooner or a little later, for still it is the same branch. Such effects may
arise more from a variety in the shape of the bodies they belong to, than any variety
in the nerves themselves."
224 ON THE NERVES OF THE ORBIT.
or general science, by physiological experiments unconnected
with anatomy. To disregard the anatomy of the nervous
system, or to take it in the gross, and, influenced by a false
analogy, to call life a fluid, and to attempt to direct it along
a cord or a wire, is to transgress all the rules of philosophical
inquiry. Were such a method continued, it would be attended
with the rapid decline of anatomical studies. They would be
considered as imposing restraints on genius, or be rejected as
useless ; and with them pathology, and the other studies which
are the foundations of medical science, would fall into disuse.
other. We observe no such uniformity in vessels carrying fluids ; but find particular
purposes answered by varying their origin and distribution : the pulmonary artery
answers a very different purpose, in the circulation of the blood, from that of the
aorta ; yet both arise from the same source, the heart. The course of the arteries is
such as will convey the blood most conveniently, and, therefore, not so necessary it
should be uniform ; it not being very material to a part by what channel the blood is
conveyed ; though, in particular instances, certain purposes may be answered by a
peculiarity in origin and distribution, as happens in the testicle of quadrupeds. This
t)bservation respecting arteries is likewise applicable to veins, and still more to the
absorbent vessels, in which last, regularity is even less essential than in the veins.
Whoever, therefore, discovers a new artery, vein, or lymphatic, adds little to the
stock of physiological knowledge ; but he who discovers a new nerve, or furnishes a
more accurate description of the distribution of those already known, affords us
information in those points which are most likely to lead to an accurate knowledge of
the nervous system : for if we consider how various are the origins of the nerves,
although all arising from the brain, and how different the circumstances attending
them, we must suppose a variety of uses to arise out of this peculiar structure.
Indeed, if we reflect on the actions arising immediately from the will, and affections
of the mind, we must see that the origin, connexion, and distribution of the nerves
must be exact, as there are parts whose actions immcdiatelv depend upon such
circumstances."
ON THE NERVOUS CIRCLE
WHICH CONNECTS THE
VOLUNTARY MUSCLES WITH THE BRAIN.
From the Philosophical Transactions.
Cr G
ON THE NERVOUS CIRCLE, &c.
[Read before the Royal Society, February 16, 1826.]
In the papers which I have had the honour of addressing
to the Society on the arrangement of the nerves of the human
body, I have proceeded upon a comparison of the nerves of the
spinal marrow with the nerves of the encephalon.
It was shown that the former were compounded of filaments
possessing different powers, and that each nerve, having several
properties or endowments collected within itself, proceeded to
its destination without intricacy.
Unless we had discovered the composition of the roots of
these nerves, we should have continued to suppose that one
nerve was simple in its structure, and yet capable of bestowing
the very different properties of motion and sensation.
But having satisfied myself that the roots of the spinal
nerves had distinct powers, I followed up the columns of the
spinal marrow; and with a knowledge of the composition of
these nerves as a key, I examined the different properties of the
nerves of the encephalon. Here, in the head, the nerves arise
simply, and diverge to their destinations without the close com-
G G 2
228 ON THE NERVOUS CIRCLE.
pact or union which the spinal nerves form ; and accordingly, the
anatomy of these nerves of the brain affords satisfactory proof of
their uses or functions. I am about to show that every muscle
has two nerves, of different properties, supplied to it. This 1
could not have ascertained by examination of the spinal nerves
alone, because of the intimate union of all their fibres; I had
recourse therefore to the nerves of the head. By prosecuting
those inquiries, which led to the distinction of the different
classes of nerves, I hope now to demonstrate — that zrhere nerves
of different functions take their origin apart and run a different
course, two nerves must unite in the muscles, in order to perfect the
relations betz^een the brain and these muscles.
It may be in the recollection of the Society, that my first
paper showed the difference of the nerves of the face; by di-
viding one nerve, sensation was destroyed, whilst motion re-
mained; and by dividing the other, motion was stopped, whilst
sensibility remained entire.
Other parts of the nervous system since that time have
engaged my attention ; and it is only now that I am able to
make full use of the facts announced in my first paper, which
were indeed expected to lead to further improvement of our
knowledge of the animal oeconomy. ^Vhen I distinguished the
two classes of nerves going to the muscles of tlie face, and divided
the motor nerve, and when the muscles were deprived of motion
by this experiment, the natural question suggested itself — of
what use are the nerves that remain entire ?
For a time 1 believed that the fifth nerve, which is the
sensitive nerve of the head and face, did not terminate in the
ON THE NERVOUS CIRCLE. 229
substance of the muscles, but only passed through them to the
skin; and I was the more inclined to this belief on observing
that the muscular parts when exposed in surgical operations did
not possess that exquisite sensibility which the profusion of the
sensitive nerves would imply, or which the skin really possesses.
Still dissection did not authorise that conclusion. I traced
the sensitive nerves into the substance of the muscles: I found
that the fifth pair was distributed more profusely to the muscles
than to the skin; and that, estimating all the nerves given to the
muscles, the greater proportion belonged to the fifth or sensitive
nerve, and the smaller proportion to the seventh or motor nerve.
On referring to the best authorities, as Meckel*, and my
excellent preceptor Monro, the extremities of the fifth were
described by them as going into the muscles ; so that of this fact
there cannot be a doubt.
Having in a former paper demonstrated that the portio dura
of the seventh nerve was the motor of the face, and that it ran
distinct from the sensitive nerve, the fifth, and observing that
they joined at their extremities, or plunged together into the
muscles, I was nevertheless unwilling to draw a conclusion from
a single instance; and therefore cast about for other examples
of the distribution of the muscular nerves. It was easy to
find motor nerves in combination with sensitive nerves, for all
the spinal nerves are thus composed; but we wanted a muscular
nerve clear in its course, to see what alliance it would form in
•Meckel de quinto Pare Nervorum Cerebri.
2S0 ON THE NERVOUS CIRCLE.
its ultimate distribution in the muscle. I found in the lower
maxillary nerve the example I required.
The fifth pair, from which this lower maxillary nerve comes,
as I have elsewhere explained, is a compound nerve; that is to
say, it is composed of a nerve of sensation, and a nerve of motion.
It arises in two roots ; one of these is the muscular nerve, the
other the sensitive nerve: on this last division the Gasserian
ganghon is formed. But we can trace the motor nerve clear of
the ganglion and onward in its course to the muscles of the jaws,
and so it enters the temporal, masseter, pterygoid, and buccinator
muscles.
If all that is necessary to the action of a muscle be a nerve to
excite to contraction, these branches should have been unaccom-
panied ; but, on the contrary, I found that before these motor
nerves entered the several muscles, they were joined by branches
of the nerves which came through the Gasserian ganglion, and
which were sensitive nerves*.
I found the same result on tracing motor nerves into the
orbit, and that the sensitive division of the fifth pair of nerves
was transmitted to the muscles of the eye, although these mus-
cles were supplied by the third, fourth, and sixth nerves.
A circumstance observed on minute dissection remained
unexplained — when motor nerves are proceeding to several mus-
cles they form a plexus ; that is, an interlacement and exchange
of fibres takes place.
• See plate VIII.
ON THE NERVOUS CIRCLE. 231
The muscles have no connexion with each other, they are
combined by the nerves ; but these nerves, instead of passing
betwixt the muscles, interchange their fibres before their dis-
tribution to them, and by this means may combine the muscles
into classes. The question therefore may thus be stated : why
are nerves, whose office it is to convey sensation, profusely given
to muscles in addition to those motor nerves which are given to
excite their motions ? and why do both classes of muscular nerves
form plexuses ?
To solve this question, we must determine whether muscles
have any other purpose to serve than merely to contract under
the impulse of the motor nerves. For if they have a reflective
influence, and if their condition is to be felt or perceived, it will
presently appear that the motor nerves are not suitable inter-
nuncii between them and the sensorium.
I shall first inquire, if it he necessary to the governance of the
muscular frame, that there be a consciousness of the state or degree
of action of the tnuscles ? That we have a sense of the condition
of the muscles, appears from this : that we feel the effects of over
exertion and weariness, and are excruciated by spasms, and feel
the irksomeness of continued position. We possess a power of
weighing in the hand : — what is this but estimating the muscular
force ? We are sensible of the most minute changes of muscular
exertion, by which we know the position of the body and limbs,
when there is no other means of knowledge open to us. If a
rope-dancer measure his steps by the eye, yet on the other
hand a blind man can balance his body. In standing, walking,
and running, every effort of the voluntary power, which gives
232 ON THE NERVOUS CIRCLE.
motion to the body, is directed by a sense of the condition of
the muscles ; and without this sense we could not regulate their
actions.
If it were necessary to enlarge on this subject, it would be
easy to prove that the muscular exertions of the hand, the eye,
the ear, and the tongue, are felt and estimated when we have
perception through these organs of sense ; and that without a
sense of the actions of the muscular frame, a very principal inlet
to knowledge would be cut off.
If it be granted, that there must be a sense of the condition
of the muscle, we have next to show that a motor nerve is not a
conductor towards the brain, and that it cannot perform the
office of a sensitive nerve.
Without attempting to determine the cause, whether de-
pending on the structure of the nervous cord, or the nature or
the source of the fluid contained, a pure or simple nerve has
the influence propagated along it in one direction only, and not
backwards and forwards ; it has no reflected operation or power
retrograde ; it does not both act from and to the sensorium.
Indeed reason without experience would lead us to con-
clude, that whatever may be the state, or the nature of the
activity of a motor nerve during exertion, it supposes an energy
proceeding from the brain towards the muscles, and precludes
the activity of the same nerve in the opposite direction at the
same moment. It does not seem possible therefore that a motor
nerve can be the means of communicating the condition of the
muscles to the brain.
Expose the two nerves of a muscle ; irritate one of them.
ON THE NERVOUS CIRCLE.
and the muscle will act ; irritate the other, and the muscle will
remain at rest. Cut across the nerve which had the power of
exciting the muscle, and stimulate the one which is undivided,
the animal will give indication of pain; but although the nerve
be injured so as to cause universal agitation, the muscle with
which it is directly connected does not move. Both nerves
being cut across, we shall still find that by exciting one nerve
the muscle is made to act, even days after the nerve has been
divided ; but the other nerve has no influence at all.
Anatomy forbids us to hope that the experiment will be
as decisive when we apply the irritants to the extremities of the
divided nerves which are connected with the brain ; for all the
muscular nerves receive more or less minute filaments of sensitive
nerves, and these we can trace into them by the knife, and con-
sequently they will indicate a certain degree of sensibility when
hurt. To expose these nerves near their origins, and before any
filament of a sensitive nerve mingles with them, requires the
operator to cut deep, to break up the bones, and to divide the
blood-vessels. All such experiments are much better omitted;
they never can lead to satisfactory conclusions.
Experience on the human subject most abundantly illus-
trates these facts. For example: — a patient of mine having, by
a tumour pressing the nerves of the orbit, lost the sensibility of
the eye and eye-lids, she retained the motion of the eye-lids by
the portio dura coming round externally and escaping from the
pressure which injured the other nerves. Here the course of
sensibility backwards to the brain was cut off, while the course of
volition forwards was free; she could not tell whether the eye-lid
II II
234 ON THE NERVOUS CIRCLE.
was open or shut, but being asked to shut the eye which was
ah'eady closed, she acted with the orbicular muscle and puckered
the eye-lids. Nay, when the eye was scarified she had no sensa-
tion, and did not wink with the eye-lids. There was no motion
in this case, because the sensitive fifth pair had lost its power,
although she could command the motion by voluntary exertion.
It will further be remarked in the case N^o. VIII. page xxvii.,
that the patient shrunk and winked when a blow was aimed at
the eye, although there was no motion when the eye was touched
with a feather. Here the sensation was conveyed backwards by
the optic nerve, the fifth having lost its power.
In another instance, when the eye was insensible, touching
the eye gave rise to a blush of redness and to inflammation,
because the part was excited, but the muscles were not called
into action. The relations which connect the sensibility of the
eye with the motions of the eye and eye-lid are established in
the roots of the fifth and seventh in the brain ; the loss of func-
tion of the fifth nerve therefore interrupted the circle. Here
too the motor nerve of the eye-lid was perfect, and the eye-lid
readily acted under the influence of the will ; but when the eye-
lid was touched or pricked it communicated no sensation. Is
this insensibility of a motor nerve owing to the course of its in-
fluence being from the brain, and not towards it ? When the
nostril had lost its sensibility from an affection of the fifth pair,
we could not excite sneezing*; when the tongue and cheek had
lost sensibility, the morsel was permitted to remain between the
* See Appendix, Nos. XXX. and LV., page cxii.
ON THE NERVOUS CIRCLE.
235
tongue and the cheek until it was offensive, although the motions
both of the tongue and the cheek were perfect *. All these
phenomena correspond with the experiments on animals j".
Now it appears the muscle has a nerve in addition to the
motor nerve, which being necessary to its perfect function,
equally deserves the name of muscular. This nerve however
has no direct power over the muscle, but circuitously through
the brain, and by exciting sensation it may become a cause of
action .
Between the brain and the muscles there is a circle of nerves ;
one nerve conveys the influence from the brain to the muscle, another
gives the sense of the condition of the muscle to the brain. If the
circle be broken by the division of the motor nerve, motion
ceases ; if it be broken by the division of the other nerve, there
is no longer a sense of the condition of the muscle, and there-
fore no regulation of its activity j.
We have noticed, that there is a plexus formed both on
the nerves which convey the will to the muscles, and on the
nerves which give the sense of the condition of the muscles.
* See Appendix, No. XXXVII.
•j- See further in the Appendix, page civ. See also the case communicated by
Dr. Ley, and No. LXXXVI.
X Thus led to conclude that there is motion in a circle, we nevertheless cannot
adopt the hypothesis of circulating fluids. That a fluid does not proceed from the
brain, we may learn from this ; that on touching the end of a motor nerve which has
been some days separated from the brain, the muscle is excited as when the nerve
was first divided. The property, however it may be defined, is therefore in the
nerve. Our language might perhaps be made more precise if we used terms which
implied the course of nervous influence, whether from or towards the brain ; but it
will be difficult to express this without the aid of hypothesis.
H H 2
236 ON THE NERVOUS CIRCLE.
The reason of this I apprehend to be that the nerves must cor-
respond with the muscles, and consequently with one another.
If the motor nerve has to arrange the action of several muscles
so as to produce a variety of motions, the combinationj must be
formed by the interchange of filaments among the nerves before
they enter the muscles, as there is no connexion between the
muscles themselves. As the various combinations of the muscles
have a relation with the motor nerves, the same relations must
be established by those nerves which convey the impression of
their combinations, and a similar plexus or interchange of fila-
ments therefore characterizes both*.
We have seen that the returning muscular nerves are
associated with the nerves of sensibility to the skin, but they
are probably very distinct in their endowments, since there is a
great difference between conveying the sense of external im-
pressions, and that of muscular action.
In surgical operations the fact is forced upon our attention,
that the pain of cutting the skin is exquisite, compared with
that of cutting the muscles ; but we must remember that pain is
a modification of the endowment of a nerve, serving as a guard
to the surface, and to the deeper parts consequently. This
is further exemplified in the sensibility of the skin to heat ;
whilst, on the contrary, a muscle touched with a hot or cold
sponge during an operation, gives no token of the change of
temperature but by the degree of pain.
* The pupils must be put on the pursuit of some of the points of the anatomy
connected with this subject.
ON THE NERVOUS CIRCLE. 237
Many of the nerves which perform the most deUcate opera-
tions in the economy, are not more sensible to pain than the
common texture of the frame. The lower degree of sensibility
to pain possessed by the muscles, and their insensibihty to heat,
is no argument against their having nerves which are alive to
the most minute changes of action in their fibres.
When the anatomist shall find both the portio dura of the
seventh and the fifth going to the integuments of the head and
face, he may naturally ask, why are there two nerves to the
surface ? and he will probably reflect, that although the principal
office of the nerves of the skin is to convey impression to the
sensorium, yet the influence of the mind is conveyed to the
surface. The condition of the mind in passion, for example, is
as forcibly communicated to the skin as to the muscles them-
selves ; and therefore if a branch of the fifth be necessary to
convey sensation from the surface to the sensorium, the seventh
is necessary to the change of vascular action, and to the
condition of the pores when affected by a cause proceeding
from within, outwards.
I feel a hesitation when I reason upon any other ground
than on the facts of anatomy. Experiments are more apt to
be misinterpreted ; and the very circumstance of a motor and
sensitive nerve being generally combined together, affords a
pregnant source of error.
It is natural to suppose that the galvanic influence might
be brought to bear on this subject ; but I may be permitted to
^^38 ox THE NERVOUS CIRCLE.
suggest to any one who pursues it in this way, that it will be
necessary to distinguish the effects produced by the nerve as a
mere conductor, and when performing its living functions. The
nerve, dead or alive, may convey the galvanic power like a wet
cord ; but if the nerve be in possession of its living property, a
gTeat deal will depend on the direction in which the galvanic
fluid is transmitted. If it be transmitted against the course of
the nervous influence, it will reach the muscles and act feebly,
although the power of the nerve be not in this case exercised
upon the muscles ; but if it be transmitted in the proper course
towards the muscles, the nerve itself will be excited, and its
power propagated so as to produce violent action in the corre-
sponding muscles.
APPENDIX,
CONTAINING
CASES AND LETTERS OF CONSULTATION
ON
NERVOUS DISEASES,
SUBMITTED TO THE AUTHOR
THE PUBLICATION OF HIS PAPERS ON THE FUNCTIONS OF THE NERVES, IN THE
TRANSACTIONS OF THE ROYAL SOCIETY,
ILLUSTRATI\^ OF THE FACTS ANNOUNCED IN THE
PRECEDING PAGES.
CONSULTATIONS AND CASES
ILLUSTRATIVE OF
THE FACTS ANNOUNCED IN THE PRECEDING PAPERS.
The following sheets refer entirely to the nervous system. They contain
notes of cases, and such letters of consultation, as the author conceived
himself at liberty to publish. They confirm and illustrate the opinions
delivered in the preceding papers ; and with other beneficial results he
hopes they will tend to show the importance of anatomy in questions
the most strictly practical.
Systematic authors, possessing the highest talents for investigation of
disease, and great learning, have notwithstanding run into much con-
fusion on the disorders of the nerves. Nor can this surprise any one who
considers the imperfect notions that prevailed on the nervous system : the
obscurity regarding the different systems of the nerves, and the variety of
the functions that were indiscriminately given to the branches from what-
ever root derived.
The author has attempted no system; there are here accurate reports
only. The facts stand isolated and abrupt, because noted at intervals ; it
will be long, he apprehends, before the united labours of the profession
can enable the medical author to arrange the diseases of the nerves, and
to describe them accurately ; we are obviously in a very early stage of
the inquiry.
He has to add that whenever he could receive the testimony of others
he has preferred their words to his own. When an interesting case presented
in the hospital, for example, he has been in the habit of asking an in-
telligent pupil to make a note of it, without informing him of the object of
1)2
IV PARALYTIC AFFECTION
the inquiry. This method of taking evidence, as to matters of fact, may
have produced an irregularity in these notes, which, however, proceeds
from the reverse of carelessness.
The first division of cases will illustrate the first and second papers, in
which it is demonstrated, that the branches of the fifth pair of nerves give
sensibihty to the head and face ; and that the motions of the eye-lids,
cheeks, nostrils, and lips, result from the influence of the Portio dura of
the seventh nerve.
PARALYTIC AFFECTION OF THE FACE *.
Trismus diastrophe, Diastrophe Galeni. Oris tortura paralytica Linncei. Est distorsio
oris versus alterutrum latus^ ob oppositi lateris hemiplegiam, unde musculus zygomaticus et
buccinator lateris sani os ad se trahunt et tractum detinent, paralyseos aut apoplexiae prodromus
aut sequela : eamdem curam exT^ostulans.^Sauvages.
In consultation the following letter was put into my hands :
No. I.
** It is in my power to relieve your mind of much anxiety. My
experience has furnished me with five cases of paralysis of the muscles
of the face of one side, completely local, and in no way connected with
the encephalon. They all did well without general bleeding. Dr. B. and
Dr. S. met me lately in consultation on the case of a lady in the eighth
month of her pregnancy, w^ho suffered this partial paralysis of the muscles
on one side of her face, from the action of mercury on her mouth. The
sore mouth inflaming, a lymphatic gland between the mastoid process and
the angle of the jaw compressed a branch of the seventh pair of nerves.
The muscles of the face on that side were so completely paralysed, that
the cheek was drawn by their antagonists, and the mouth disfigured.
*' Dr. B, and Dr. S. suspected pressure on the brain at the origin of
the fifth pair of nerves. But I took the liberty of stating the discoveries of
* To know the previous state of opinions, and the point from whence we start, read a paper
on this subject, Transactions of the College of Physicians, vol. i.
I
OF THE FACE. v
Mr. Charles Bell, and proved to them by other cases which had fallen
under my notice, that there was no danger, and that the brain was not
implicated.
*' This case, in the course of a fortnight, did well under the use of
mild laxatives, leeches behind the ears, and a small blister."
I owe the following case to the kindness of Dr. Gregory, who has
vouched for the accuracy with which the account of symptoms has been
drawn up by a medical friend. The patient was at the time under Dr.
Gregory's care.
No. II.
Case of Paralysis of the Face.
" John Chapman, aet. 45, foreman to a builder, January, 1827. He
says, for five years past he has not considered himself in a good state of
health. Three years ago, after a few days' illness, he was seized with
paralysis of his lower extremities : he recovered from this attack, and
resumed his occupations. He had an abscess in his right ear, which burst,
and continued to discharge matter : he cannot precisely state when the
disease of his ear commenced. For eighteen months following the attack
of paraplegia, he was subject to fits of the ague; afterwards he was free
from any complaint, except that his ear discharged a thin foetid matter. In
August last, while coughing or sneezing, a substance which he describes
as cylindrical and hollow, about an inch in length, dropped from his right
ear : from this time the discharge ceased. Three weeks after this period,
his wife first observed that his face was distorted to one side. On pre-
senting himself to his medical attendant in the country, he was told that
he was going to have another attack of palsy, and was ordered to be cupped
and blistered, &c. His daughter says, his countenance appears now exactly
in the same condition as when first observed to be distorted.
'* All the muscles of the right side of his face, which are controlled
by the influence of the portio dura, or respiratory nerve of the face, are
completely paralysed. He cannot elevate his eyebrow nor frown ; there
VI PARALYTIC AFFECTION
is a line nearly in the centre of his forehead, dividing the bulging of the
muscles on the left side from the smooth uncontracted state of those on
the right side. He cannot close the eyelids of the right eye ; they remain
always open: when he makes the attempt to close them, we see the eye-ball
rolling upwards. The secretion of tears is very abundant, so as to render
this eye more glistening than the other: he complains of the inconvenience
produced by its continually weeping ; he also attributes a dimness of vision
in the right eye to this cause. From the nature of his occupations, he is
constantly troubled by the dust getting into this eye ; but he has acquired
a readiness of pulling down the eye-lid with his finger, to defend it. His
daughter says, that when she has seen him asleep, only the white of his
eye Vv'as visible.
" His right nostril is collapsed. The muscles of the cheek and mouth
are relaxed and dragged to tlie left side. When he speaks, the cheek flaps
like a blind before an open window, and if he attempt to utter a word with
peculiar emphasis, the air escapes from the corner of his mouth, like the
wliiff of a person smoking. He sometimes experiences a difficulty of
swallowing, at the moment when the morsel is thrown back into the
fauces.
" The sensibility of the right side of his face is natural. When he
clenches his jaws, the masseter muscles can be felt equally hard and con-
tracted on both sides of his face. He can protrude his tongue, and twist
it to either side. He is deaf in the right ear."
^ The peculiarity of the preceding case is paralysis occurring in two
instances in the same patient, but from different causes. It was natural
for the physician in the country, on perceiving paralysis come upon the
face, to suppose it was the precursor of a second attack of paraplegia. But
comparing the symptoms with those of other cases in this Appendix, and
more especially observing the connexion betwixt the discharge from the
ear and the paralysis of the face, the reader will be inclined to believe with
me, that the second attack arose from the affection of the portio dura in
its course through the temporal bone.
OF THE FACE, Vll
No. III.
Clinical Lecture on Partial Paralysis of the Face, delivered hij Mr. Bell,
at the Middlesex Hospital.
Case. — Daniel Quick, set. 70. One of the young gentlemen attending
the hospital brought this old man to show him to Mr. Bell. He had ob-
served him sweeping the streets : one of his eyes was staring wide open,
and red : the cheek on the same side was loose and pendulous, and the
mouth was dragged to one side. His attention being attracted by these
appearances, he was led to question the man as to the cause of them.
Twelve years ago his face was " all right j" but, he said, pointing to
a scar in the angle of the jaw on the left side, ever since he received
a wound in that part, from being tossed by a bullock, his face has
been in the same condition in which it now is. The horn of the animal
had entered his neck just below the ear; he was lifted from the ground,
and when he fell, the blood gushed out, according to his expression, "as
when a sheep is stuck." A surgeon sewed up the wound, and " made a
capital cure of it."
The left side of his face forms a remarkable contrast with the other.
Upon the forehead the skin lies flat and smooth, there being no wrinkles
as on the right side ; and when he frowns, the left eye-brow moves only a
little, by the action of the muscles on the right side dragging it towards
them. The eye remains permanently open: there are none of the common
winking motions: and when he is asked to close the eye forcibly, although
he makes the attempt, there is not the slightest motion observed in the
eye-lids. The lower eye-lid hangs down considerably, so that the con-
junctiva is much exposed ; and there is a fulness in its vessels, apparently
consequent on repeated attacks of inflammation. This eye has been the
source of great distress to him, especially during the summer season, owing
to the dust and the brightness of the sun both injuring it. His wife, he
said, has told him that he never closes this left eye, not even when he is
asleep. In the repeated attempts which he made, although the eye-lids
vm PARALYTIC AFFECTION
did not move, it was always observed that the cornea was tilted upwards,
so as to be completely concealed behind the upper eye-lid. This is a
motion of the eye-ball which Mr. Bell first described in his papers upon
the nerves within the orbit; and he has on former occasions pointed it out
to the pupils at this hospital. Being curious to discover the position of
the eye during sleep, the reporter of this case went to the patient's house.
His wife told him, that what her husband said about his never closing the
left eye was correct, and that it was open even while he was sound asleep.
Being then asked in what direction he appeared to be looking while he was
asleep, whether he fixed his eyes on her ? " No, sir," she said, " that cannot
be, for there is only the white of his eye seen." Being further questioned,
she said, that a small part only of the black of his eye could be perceived,
at the margin of the eye-lid; but she was quite sure he could not see her.
The muscles of the cheek on the left side are wasted, and there appears
to remain nothing but the thin integuments, which hang upon the side of
the face, as if dead, without having any action in them, or wrinkles, as in
the right cheek ; and when he speaks, this cheek is alternately puffed out
and then collapsed, the air first distending it, as it were a bag, and then
escaping at the angle of the mouth.
The left nostril lies flat, and is not at all distended while he draws a
deep breath, or makes the motion of sniffing up.
His whole mouth is drawn to the right side, thus producing most re-
markable distortion of the face. Whatever action there is in the mouth is
altogether owing to the contraction of the muscles on the right side of it ;
the left angle hangs loose, and is quite passive ; and the saliva is allowed
to flow constantly out upon the lower lip on this side.
In regard to sensation, that is wanting only in the integuments over
the cicatrix, and a little way above it, just before the ear. Otherwise, in
all the parts of the head and face, it is quite perfect.
Gentlemen, I have brought this man to you, that you might your-
selves examine him, and be satisfied as to certain facts, which men, high
in science, and respectable in our profession, have denied with a heat and
pertinacity which I can never understand, and which surely ought not to
belong to such an inquiry.
OF THE FACE. IX
For years I had the conviction that the nerves, and especially the
nerves of the face, had distinct functions. I was deterred from announcing
my opinions because I conceived it impossible but that experience and
observation must have long ago ascertained the fact. Yes, gentlemen,
from the dissection, I conceived that the branches of the fifth nerve, and
of the portio dura of the seventh nerve, must have distinct offices. But
then, I said, if it were so, the fact could not be so long concealed; these
nerves are cut by surgeons every day ; they are exposed in wounds ; and
yet I find no surmise to countenance this idea. Were I to refer to my
note books, I could prove to you how anxiously I looked around for some
circumstance to support this opinion ; and although of late years many
such cases as the present have been submitted to me, there was a time
in which I would have given all that I was worth to have such proofs as
you have now before you.
Some will contend about the propriety of making experiments on the
living — none will hesitate to say that it is our duty to observe accurately,
when an accident may be converted into an experiment. This poor man
was tossed by a bull: the horn went in here at the angle of the jaw, and
he hung suspended upon it, until the integuments before the ear giving
way, he dropped. The blood flowed copiously, and he will tell you that he
heard it splashing upon the ground : notwithstanding, he expresses, with
gratitude, that his doctor made a famous cure of it. The point of the horn
had entered behind the upright portion of the jaw, and had hooked up and
torn across the portio dura of the seventh, where it is coming forwards
from the stylo-mastoid foramen. I wish you to direct your whole atten-
tion to the effects of the division of this nerve ; since it is as much of the
nature of an experiment as if you had tied an animal neck and heel, and
had divided the nerve with your scalpel.
You have observed the remarkable distortion of the whole face ; and
that one side is become as it were a dead mass, incapable of motion, or of
expression of any kind j an effect which, heretofore, any medical man
would have supposed could only be produced by the division of all the six
nerves that go to the side of the face; whereas you see the effect has been
produced by the destruction of one only. You observe, by the answers to
my questions, that whilst motion is gone, sensibility remains. And you
c
X PARALYTIC AFFECTION
cannot resist the conviction that the remaining sensibility is owing to the
entireness of the branches of the fifth pair, which come out through the
orbit, and through the upper and lower maxillary bones ; whilst the loss of
motion has resulted from the tearing of the portio dura. Nor is this a
solitary case in this hospital. A patient was brought in who had put a
pistol to his ear; which, strange to say, did not immediately destroy him,
nor at once deprive him of sense; although ultimately he died. The tem-
poral bone was shattered, and the portio dura torn : and the paralysis of
the muscles of the face was as complete as it is here.
[Mr. Bell. — Now, my friend, shut this left eye.
Patient. — No, sir, I cannot do that: my wife says I never shut my
eye.
Mr. Bell. — But make an attempt: close both your eyes, as if you were
going to sleep.
The patient makes the attempt, but still adds, it is needless; "my
wife says I never shut this eye." In the attempt, we observed, that when
the right eye-lids were closed, the left eye-ball was rolled up, so as to be
concealed under the upper eye-lid.]
Mr, Bell continued. — You witness the fact, then, gentlemen, that there
is this very remarkable turning up of the cornea in the attempt to close
the eye-lids; and you comprehend how this takes place : the imperfection is
only in the eye-lids ; and, although the will cannot reach them, owing to the
division of the portio dura, yet the rolling of the eye is performed, because
the nerves to the oblique muscles within the orbit are entire. Before you,
then, there can be no denying this revolving of the eye ; and in future
you will allow no question about it.
If you will take the trouble to inquire, this man will tell you that he
is not at all aware of the eye being turned up ; although he can turn it up
by a voluntary act, and be conscious of it at the same time. This is alto-
gether an instinctive or involuntary action in the eye-ball; and you dp
not observe it merely because it is a part of the protecting action, accom-
panied with the rapid closing of the eye-lid which conceals it. You may,
however, feel it at any time, by putting your finger upon the closed eye-
lid; and then, acting with the eye-lids to close them more firmly, you will
feel the convexity of tlie cornea slip upwards: or, spread out the eye-lid
OF THE FACE. XI
upon a friend's eye with your fingers, until you see the cornea under the
tense skin : then ask him to make the effort to wink, and you will see
the convex body slip up and disappear.
Without going far into this question, I would just observe that this
motion is altogether for the protection of the eye : and you see that there
are two parts of the same action; first, the dropping of the eye-lid, like a
curtain; secondly, the raising of the cornea towards the lachrymal ducts;
by which these ducts are stretched, and a copious secretion bedews the
cornea.
The cutting of the portio dura, or of that branch of it which goes
towards the eye-lids, paralyses the orbicularis palpebrarum, and they there-
fore remain open. This has a very bad effect, by causing inflammation of
the eye; and, in this case, you perceive the effects of this inflammation, in
the eversion of the lower eye-lid, and the redness of the tunica conjunctiva
— the circumstance, indeed, which first attracted our friend's attention to
this man on passing him in the street. But the cornea is still safe ; and
you see how this is : although the eye-lid does not descend, yet the eye
ascends to the eye-lid : and it is wiped, cleaned, and moistened, by this
partial performance of the instinctive act of winking. We have had in this
house a girl in whom the eye-lids of both sides were so adherent to the
eye-brows and cheeks, from a burn, that they were not recognizable from
the common skin. The eye-balls stood out naked ; and although the
horrible and preternatural appearance of the girl, consequent upon the
staring eye-balls, was increased by the red circles of inflammation around
them, yet the cornea were preserved transparent, by their being raised in
the frequent act of winking, and dipped, as it were, at the lachrymal
fountain. In the case before you, although the eye is not altogether de-
stroyed by inflammation, you see the very unpleasant effects produced by
the deprivation of this branch of nerve, in the exposure, inflammation, and
suffusion of the surfaces.
The next thing that is curious is the condition of his eye in sleep.
You find it stated that the cornea goes up during sleep ; for his wife being
asked, if, since the eye-lid remained open, he continued looking at her
when asleep, she answered, "that cannot be, for only the white of the eye
is seen." You have here, then, all but ocular demonstration of what I
c2
xu PARALYTIC AFFECTION
have elsewhere affirmed, that there is a particular position of the eye-ball,
or, in other words, another condition of the muscles of the eye-ball,
peculiar to the state of sleep. Indeed, it must be obvious to you that if,
in this man, the pupil were not covered, and the cornea moistened during
sleep, there would be an incessant irritation upon the eye, from the
entrance of the light, and the evaporation of the moisture from the cornea.
But, however interesting in a philosophical light, this is not practical ; and,
therefore, I am not at liberty to detain you longer upon it in this place.
[Mr. Bell. — Now, my friend, let us see you take a snuff: (the patient
put the pinch to the right nostril). But why do you not snuff with the
left side?
Patient. — Because it does not go high enough to let me feel it.
Mr. Bell. — Can you breathe through that left nostril?
Patient. — My wife says I cannot.
A bottle of carbonate of ammonia being put to this nostril, he said,
■with some emphasis, " I can feel that."]
You see, gentlemen, that this honest fellow bids fair to have domestic
peace: he confides more in his wife's authority than in his own sensations.
But you will have no difficulty in understanding how the destruction of
the portio dura affects the sense of smelling, and destroys, in a great
measure, the gratification of snuffing. The cartilages of the nose form a
very curious structure ; and, you know, are moved by four appropriate
muscles, these muscles being governed by the respiratory nerve of the face
or portio dura. Every violent inspiration is attended with an excitement
of these muscles, and an expansion of the tube : were this wanting, you
see what the effect would be. At the moment of a sudden inspiration,
instead of the tubes for the passage of the air being enlarged proportionally,
they would hang, like this man's nostril, upon the left side, which you see
forms a loose membranous slit ; and be more apt to close and cause a
sniffling, in drawing the breath, than to become inflated to admit the air
freely. In smelling, or in snuffing, there is such an action of these muscles
as produces both a narrowing and a new direction of the lower part of the
tube of the nostril ; by which the air, and whatever that air has suspended
in it, is drawn forcibly upwards to the more sensitive part of the Schnei-
derian membrane. Our friend here finds it a mere waste of snuff to put
OF THE FACE. Xlll
it into this nostril : he tells you it does not go high enough : he can draw
it in, but he cannot make it mount. You perceive, then, that although
the function of the olfactory nerve remains entire, the loss of the portio
dura is attended with a destruction of that apparatus which is made
subservient to the organ of smelling.
[Mr. Bell. — Do you put the morsel into the left side of your
mouth ?
Patient. — Yes, but I wumhle it over to the other side.
He now got a pot of porter, and as he swallowed, there was a flapping
of the paralysed cheek ; he said that he required time, or it would fall out
of his mouth again. Mr. Bell thought he felt a stringy or active condition
of the buccinator, but recommended us to give him a pot some other
day, and ascertain this.
He was now asked if he could laugh ; and, quaintly enough, he an-
swered, '* Yes, when he had got something to laugh at ;" and on this he
exhibited a very singular distortion of countenance : at each cachinnation
his left cheek was puffed out, flapping like a loose sail ; and the forehead
and eye-lids of this side remained perfectly still ; whilst upon the right
side the whole mouth was drawn upwards, the cheeks were strongly
wrinkled, and the eye-lids puckered.]
You know, gentlemen, that I have classed the portio dura of the
seventh pair with the superadded respiratory nerves ; as, besides having
the voluntary power over the muscles of the face, it produces that consent
among them with the organs of respiration, which continues when the
voluntary power is gone. And as this portio dura takes its circuitous
course, for the purpose of associating parts necessary to the act of respira-
tion, for the same reason it must be the nerve of expression ; since the
self-same parts are the organs of expression that are the organs of respira-
tion. Suppose that a filament of the fifth had been the link of connexion
to establish the sympathies among the features of the face (as it was once
supposed that its ganglion was for that purpose), then the nerve of
expression in the face would have been separated from the other parts
of the organs of respiration, and, consequently, from expression. You
witness, however, in this patient, the fact : you see that with the destruc-
tion of this nerve, the expression in laughing is gone from the side of the
xiv PARALYTIC AFFECTION
face. You will, perhaps, take it on my authority, that crying would be all
on one side of the flice too. The neck, shoulders, and chest, would be
equally incapable of agitation in laughter or weeping, if the respective
nerves of this class were divided. Now these are the extremes of ex-
pression ; and all the intermediate gradations, which are the signs of
emotion, are frequently lost.
This subject is not uninteresting to you in practice : for as you find
the portio dura in possession of distinct properties, all of them related to
respiration — breathing, speech, and expression j you will not be surprised
that these functions are occasionally differently affected ; as, for example,
a man will continue to possess the power over the nerve, as the nerve of
speech, and yet he will be incapable of expressing the usual signs in
laughter, or in crying. In short, you find that your patient sometimes
exhibits paralysis of the side of the face only when he smiles or laughs ;
at other times it is not observable. We really have no reason to conclude
that the one property of a nerve requires a finer organization than another.
I would rather suppose that this power of expression is constituted with
a finer relation to the condition of the mind, and of the body ; and, there-
fore, we may suppose is more easily affected by slighter derangements.
No. IV.
Proposal to divide the Poi'tio Dura.
'* Sir, — Having attended your brother's lectures during my studies in
Edinburgh, and read several of the works of both, I am induced to apply
to you in behalf of a very respectable patient, Mr. of this place. He
is a healthy strong man of fifty, who has been affected for nearly twenty
years with an involuntary contraction of the muscles of the side of his face,
drawing up the angle of the mouth, and giving to the palpebral a winking
motion, so remarkable, that it may be seen at a considerable distance.
This hurts his feelings so much, that he has lately come to the determina-
tion of having an operation performed on the nerves of the part affected.
" He has never had any pain during the convulsive actions but once
for two or three days, when it was so severe as to resemble, in many
OF THE FACE. xv
symptoms, the tic douloureux. I am ignorant that the operation has been
ever performed for such an affection. But as the disease has become
much more troublesome, I should think there would be no impropriety in
trying it.
" Should you be enabled to give any encouragement to its perform-
ance, he will proceed to London immediately."
Remark. — In a note on the following page, it will be seen, that a
gentleman came to me to have the branches of the fifth nerve, on one side
of the face, cut, in order to balance the paralytic features of the other. A
singular consequence would have resulted from such an operation. The
patient woidd have been deprived of sensibility on one side of his face, and
of motion on the other!
If the subject of the present consultation had submitted to have the
nerve cut, his eye would have remained open, for the attollens palpehrce
being supplied by the third nerve, and the orhicularis paJpehrarum by the
seventh, the cutting of the latter w^ould have paralysed the eye-lids : they
would have remained open, and the eye would have become inflamed, and
probably opaque. There would have been greater deformity, and blind-
ness also.
How such proposals are made is obvious enough. Surgeons have
been, of late years, cutting the branches of the fifth pair with impunity;
that is to say, no ugly paralysis resulted from these operations.
Answer to the foregoing Letter :
34, Soho-square, May 16-
" Dear Sir, — I am happy you have communicated this case of Mr.
to me, for some serious considerations present themselves, before attempting
to remedy his symptoms by an operation. The nerve affected is the portio
dura of the seventh pair, which comes out before the ear, and spreads from
that over the face. It is very liable to the affections which you describe.
But before dividing it we must consider its functions, which are very im-
portant : through it, we are enabled to close the eye-lids, and through it we
move the lips in speaking. Although we leave the branches of the fifth
pair going to these parts, yet, by the division of this portio dura of the
seventh pair, we deprive them of all motion. The effect upon the eye is
XVI PARALYTIC AFFECTION
very serious : it remains open, and the exposure excites inflammation and
opacity.
" These you will see are strong reasons against cutting across the
nerve. Perhaps you are not aware that the dividing of this portio dura
would not at all diminish the pain, the sensibility of the side of the face
depending altogether upon the fifth pair. I fear, therefore, you must limit
your attempts to relieve your patient to medical treatment. You will find
this twitching to depend a good deal on the state of the digestion. Ano-
dyne liniments rubbed in the course of the nerve, and pressure to limit the
motion of the parts spasmodically affected, I have found attended with
advantage. The pressure, which restrains this spasmodic motion, tends to
break that habit, on which, in a great measure, it at length depends, how-
ever originally produced: and indeed it is this circumstance, the conti-
nuance of the symptoms for twenty years, which forbids me being sanguine
in the expectation of your effecting a cure.
•* Charles Bell."
No. V.
Proposal to divide the hranches of the Fifth Pair,
A gentleman, in the vigour of life, came into my room to consult
me, having the most remarkable distortion of countenance I had ever seen.
He proceeded to state to me what he conceived to be the cause of this
paralytic affection of one side of his face : he had been knocked down by a
blow upon the ear, and had remained a whole night insensible, with bleeding
from the ear, from which time his features had been thus drawn to the
opposite side. I thought I should give him comfort by stating to him
that this was a paralysis attributable to the injury of the bone, and that, as
it had not proceeded from an apoplectic tendency, thei"e was no danger of
a future attack or of increase of the paralysis. But this was not what he
expected from me ; he had consulted my brother, then at Rome, who
had proposed to cure him by an operation.
1 was quite at a loss to conceive what operation his ingenuity had
contrived to relieve so remarkable a deformity. Tiie gentleman men-
tioned that it had been intended to make three small incisions on different
OF THE FACE. xvii
parts of his face, so as to restore the balance of his features : and he was
obviously disappointed in finding me less intelligent, or less able than he
had expected, and we parted.
On reflecting on the conversation of this gentleman, it occurred to
me, that my brother, believing that the paralysis had arisen from an injury
of the fifth nerve, had proposed to restore the features to an equilibrium
by dividing the branches of the same nerve on the opposite side ; trusting,
no doubt, to the features being still animated by the seventh pair of nerves.
A singular consequence would have resulted from such an operation. The
features would have remained drawn to the same side as before, and he
would have been deprived of all sensibility of that side ! If it was designed
to have cut the portio dura of the side contracted, a more unhappy con-
sequence would have resulted; for he could never afterwards have spoken,
or even have kept his lips to his teeth, or retained the saliva. The fea-
tures of both sides would have fallen in relaxation, the eye would have
remained uncovered, and he would have lost his sight by the inflammation
and opacity consequent on its continual exposure !
It must, indeed, appear a singular circumstance now, that so many
surgeons were cutting the branches of the fifth pair of nerves for the tic
douloureux, without being led to inquire more particularly into the
functions of the several nerves of the face. We see how nearly my brother's
ingenuity was leading him wrong, from having often cut the fifth pair
without producing horrible distortion. And I believe that the very same
mistake led a gentleman to say that I had not cut the frontal branch of the
fifth pair of nerves on the face of a nobleman, when in fact I had only cut
that branch and had not interfered with the branches of the portio dura,
and, consequently, had produced no effect on the muscles of the eye-brow.
All these circumstances, I hope, tend to enforce the importance of
anatomy.
I find the following observation in a review of a former edition of this
work : — " It would appear that Mr. Bell has not consulted Dr. Darwin's
Zoonomia: for we find there a striking illustration of his opinion. A gen-
tleman having tic douloureux was under the care of three eminent prac-
titioners. Dr. Darwin, Mr. Cruickshanks, and Mr. Thomas. Nine incisions
(together with some smaller ones) were made on the left side of his face :
d
xviil PARALYTIC AFFECTION
every nerve of that side of the face, including the branches of the fifth
pair and of the seventh, were divided; yet there is not one word concerning
the defect of sensation or of motion. The patient set out for Leicester-
shire perfectly restored."
No. VI.
Paralysis of the Face,
*' My dear Sir, — Being informed by Mr. Alexander Shaw, that you
were desirous of having some notes which I had taken of a case of partial
paralysis of the face, I beg leave to transmit them to you.
" S. Nicholas, set. 35, a sailor. — He has been ill for upwards of three
years, with various scrofulous affections. Two years ago, he first noticed
that he was deaf in his left ear. Subsequently there has been a discharge
from it. About nine months ago, abscesses formed in various parts of his
body, one of which broke just betwixt the mastoid process and the angle of
the jaw of the left side. The cicatrix is still painful to the touch. Shortly
after the formation of the abscess, it was remarked that the left side of the
face was paralysed, and the eye-lids of the same side stood open, and could
not be closed by any mental effort directed immediately to them *.
" He says that a portion of that side, viz. the fleshy part of the cheek,
feels puffy, although he adds, he is conscious that this is not really the
case. The left ala nasi is also paralysed, for if he lies on the right side
with his head pressed against the pillow, he is obliged to pull the left nostril
open with his fingers in order to breathe freely.
" He also says, that he feels as if he had no power to hold any thing
with the soutid side of his mouth. It is certain that he always applies the
mug, in drinking, to tlie paralysed side.
" He can chew equally well on both sides. And the sensation of
touch is equally acute in all parts of his face. The eye-ball of the left or
paralysed side is also sensible to touch and to other stimuli. The motions
of the eye-ball were examined by Mr. North of Seymour-street, by Dr.
* It may be worth remarking, that Nicholas always keeps the lids of the left eye closed
by his hand, to keep it warm, as he says.
OF THE FACE.
XIX
Stewart, Mr. Griffiths, and by myself, and it was evident to all of us, that
whenever the patient attempts to close his eyes, the left eye-ball is turned
up. When the right eye-ball was examined by forcibly separating the lids
of that side, it was always found in the same position as the left. I
remain, dear Sir, your obliged,
" R. Ferguson.
" Feb. 21, 1825.
" 5, Baker-street, Portman-square."
We have, in the foregoing letter, a simple and very clear statement of
a common case. For the case is very common, although the observers are
not always masters of the subject like Dr. Ferguson.
The ratmiale is obvious enough. The portio dura is involved in the
stool of an abscess ; and it has partaken of the inflammation. Just as the
spinal marrow being involved in the inflammation of the diseased vertebral
column will cause paralysis of the lower extremities, so here the muscles of
the face corresponding with the portio dura, lose their power.
The reader will observe, that the patient " ca?i chew equalhj well on
both sides" I have noticed such circumstances before, that although the
individual could not hold his pipe with the lips, he could turn the morsel,
which led me to reflect on the muscular branches of the fifth pair sent to
the buccinator muscle, and the levator and depressor anguli oris.
Motion of the Eye.
In the preceding letter, as well as in several which follow, notice is
taken of the rolling of the eye-ball. I have explained the necessity of a
connexion between the motion of the eye-lids and the motions of the eye-
ball itself; and I have shown that the connexion between the muscles of
the eye-lids and eye-ball is established at the roots of the seventh and fourth
nerves. I may be permitted to express my surprise that there has been
any doubt upon this subject : it is so easy to prove that when the eye-lids
close, the eye-ball rolls up.
In reference to the last letter, it is distinctly stated, that when the
eye-lid stood open from paralysis, the eye-ball turned up at every effort to
close the eyes. Systematic authors call this want of power to close the
d2
XX PARALYTIC AFFECTION
eyelid, Strabismus lagophthalmos ; Viie de lihre, from the vulgar notion
that the hare sleeps with her eyes open.
Sauvages says, that this aiFection is classed with strabismus ; but on
what principle, he adds, authors have failed to inform us. I believe it is
owing to the eye-ball being seen turned up, which is conceived to be part
of the disease ; but this is a natural action, which, from the eye-lids being
apart, is visible, and appears symptomatic of disease.
On every occasion where the immobility of the eye-lids has given me
the opportunity of observing the motions of the eye-ball, it has rolled
upwards, as I have described during the effort to close the eye. I have
many times pointed out the circumstance to the pupils going round the
hospital.
Dr. Brewster, in his Journal, denies that the eye-ball revolves. Tliere
can, however, be no doubt of the fact. My reader must perceive the object
of the first paper on the motions of the eye, to he, first, to show the different
motions of the eye-ball and eye-lids, and to deduce from that examination
the necessity of two classes of muscles. Secondly, to show that the muscles
are divided into two classes ; that to the motions of the one we are acutely
sensible, while to the operations of the other we are totally insensible ; and
hence to prove that there must be nerves with distinct endowments. Thirdly,
it is shown, that owing to the different sensibilities enjoyed by the organ, and
the distinct classes of muscles, there is a necessity for the six nerves which
go to the eye-ball and eye-lids, and this is the final object of the paper. A
reader of Dr. Brewster's Journal could not guess at the contents of this
paper. I hope the feeling which dictated his observations has subsided.
No. VII.
Case of Partial Paralysis.
" Mary Unwin, now in the twenty-second year of her age, is about
seven months advanced in her second pregnancy: she is of a full habit of
body, and instead of having the usual wasting of the face and sharpness of
features, she has a plumpness and fulness. She has for some time com-
plained of spasms of the lower extremities. Her constipated state of bowels
OF THE FACE. xxi
has required powerful purgatives to relieve her. The head has not been
the seat of any particular affection, though, when the inquiry was repeated,
she observed that there had for some time existed a dulness over the eyes.
— She applied for advice respecting a remarkable affection of the face, on
the 5th of February. On examining the countenance, a singular distortion
of the features is most apparent. The mouth is drawn to the right side,
and the nose evidently inclines in the same direction. She was asked to
put the forehead in action as in frowning, and then was presented the
appearance of wrinkles across the right side of the forehead, whilst the
opposite side was even and perfectly unmoved. In sleep, the right eye-
lids are closed as usual, but the left eye remains uncovered. She appears
to have no power over the muscles, whose office it is to move the eye-lids
of the left side.
" There is little (I think no) difference in the sensibility of the two
sides of the face. There is occasionally a dimness of vision of the left side,
owing probably to the circumstance of the globe of the eye not being
lubricated with the tears, as is the case with the opposite one.
" The patient states that she experiences pain on the left side of her
neck, and at the root of the ear of that sidej but there is no swelling nor
marked evidence of inflammation existing in these parts. On pressing on
the branch of the porfio dura, or, as you have termed it, the respiratory
nerve of the face, especially in the situation of the parotid gland, no un-
easiness is experienced. Tiie iris moves in obedience to the stimuli of
light, and the tongue possesses its natural movement. In fact, there is no
paralysis in any part of the body, excepting in those parts specified above,
and which are supplied with nervous influence by the porfio dura.
" I have been guided in tlie treatment of this case by the improve-
ment which your important discoveries has effected in the pathology of
partial paralysis. Instead of fearing the supervention of pressure on the
brain, I considered the affection as confined entirely to an individual
nerve. Formerly, excessive depletion would have been resorted to here :
I have adopted moderate evacuation, with local stimuli, &c."
This case was sent, with a very polite note, from Mr, Jackson, of
Sheffield. I wrote to him, and this is his answer ; —
xxu PARALYTIC AFFECTION
" Sheffield, April 23, 1825.
" Dear Sir, — Considerable delay has been occasioned in my replying
to your queries respecting the motions of the eye-ball in the case of partial
paralysis of the face, which I had the honour of communicating to you.
When the patient attempts to close the eye-lids, the upper lid of the right
eye obeys the will, whilst the upper lid of the left side remains motionless;
and at the same time the left eye-ball rolls upwards, so as nearly (sometimes
entirely) to conceal the cornea.
" During sleep, the eyes are similarly circumstanced. The right is
closed, and the upper eye-lid on the left side remains as in the state of
ordinary vision, whilst the inferior margin only of the cornea is visible ;
then simulating the appearance, on the paralytic side, of a person in tlie
act of dying.
" During the violent respiratory efforts of labour, the expression and
action of the muscles on the left side of the face were lost; in consequence
of which, the countenance assumed a singularly ludicrous aspect. I am
sorry to add, there appears very little improvement in the state of the
patient.
" It affords me great pleasure in having contributed to establish, by a
rare and important pathological fact, the truth of some part of your dis-
coveries as connected with the physiology of the nervous system.
" I remain,
" Yours very truly,
" Wm. Jackson."
The manner of this letter must convince my reader how well Mr.
Jackson is capable of observing minutely. What I drew from the anatomy
is here distinctly stated — that, in sleep, the eye-ball is given to that state of
perfect rest where the voluntary muscles are relieved from activity, and the
involuntary muscles balanced, and that in this condition the eye is with-
drawn from the light.
The agony, that is to say, the seeming agony, of dying, is very
naturally touched upon. We cannot visit the sick without witnessing the
influence of the obliqui on the expression of the eyes. It is the Strabismus
OF THE FACE. xxiii
patheticus — orantium of Boerhaave. Sauvages says, that the eye is turned
up towards the close of formidable diseases ; " (Strabismus) paulo ante
mortem suj)erve7iit." The vulgar say, that children with water in the head
are looking to their final home, " Vulgo aiunt Jios tenellos suam patriam
respicere :" and on this he adds, wherefore is the superior elevator muscle
of the eye convulsed alone, so that the white of the eye only is visible ?
It passes my understanding : " ratio me latet."
It would indeed be strange if one muscle of a class were thus exerted j
but it is not so. The rectus superior is not convulsed ; for we have seen,
that when that muscle was cut, the eye-ball still turns up, on irritation, by
the influence of the obliqui, and that the progress of debility over the
voluntary muscles of the eye, as over the other muscles of volition, leaves
the obliqui with a relatively greater power, and that it is their operation
which distorts the eye-balls.
No. VIII.
Cases of Affections of the Nerves, with Clinical Remarks.
The three following cases were read from the Case-Book of the
Middlesex Hospital, at Mr. Bell's Lectures, on the 21st and 23d of
January, and were made the subjects of clinical remarks by him. They
show, in a very striking manner, the advantages in the formation of our
diagnosis, derived from the discoveries of the distinct functions of
the nerves of the head. He interspersed the reading of the cases with
remarks, which we put down in the order they were made.
Case I. — Case of Affection of the Nerves of the Head, with Paralysis of the
IMuscles of the Eye.
John Windsor, lately a farrier in the 2d regiment of horse-guards,
came to the Middlesex Hospital in the middle of November, and was
placed under Mr. Bell's care. He has lost the power of elevating the left
eye-lid, so that it covers the eye, as in the case of ptosis : but his chief
suffering arises from a continual and severe pain seated in the left side of
his face.
XXIV PARALYTIC AFFECTIOX
He gives the following history of his illness. He was wounded in the
commencement of the battle of Waterloo, by the bursting of a shell which
he saw coming towards him. He was struck on the left temple and cheek-
bone, and was rendered insensible. He recovered his senses on the second
day, and then found himself in the hospital at Brussels. He was soon re-
stored to health ; but it was some time before he recovered from an in-
flammation of the left eye, which had been injured by the mud being
thrown into it at the time he was wounded. Five years after receiving
this wound, he got a second hurt in the same place, while shoeing a horse:
the animal kicked out, and threw him against a wall ; his scalp was turned
up, and bled profusely. He continued in the regiment, fit for duty, until
about a year and a half ago. Previously to this time he had become subject
to severe headaches and giddiness. He then had an attack of hemiplegia
on the left side. From this he soon recovered ; but there was no abate-
ment of the severe pain in the head to which he was subject. " It all
rested itself," he said, " in the forehead, and in the left cheek." Four
months ago, when the pain was dreadfully severe, so as almost to make
him frantic, he suddenly lost the power of opening his left eye ; the
eye-lid dropped and hung like a curtain over it, thus depriving him of
vision in this eye.
Climcal Remark. — " You will recollect, gentlemen, how the eye-lid
is moved, and by what nerves. The attollens palpebrse superioris arises
along with the recti muscles, and running over the eye-ball and upon the
superior rectus, has its tendon spread into the ciliary cartilage. This
muscle is supplied by a branch of the third nerve. The orbicularis palpe-
brarum shuts the eye-lids, and is supplied by a branch of the portio dura of
the seventh pair, coming round superficially from before the ear. This
falling of the eye-lid, therefore, implies that a disease has affected the third
nerve in its course : the power of winking and corrugating the eye-lids
remaining, implies that the seventh nerve, by its circuitous course, has
escaped that diseased influence."
At the same time it was discovered by the surgeon who attended him
that he squinted ; when his left eye was exposed it was seen fixed, and
OF THE FACE. xxv
looking outwards. It remained in this position for ten or twelve days ;
but afterwards it came gradually to be directed forwards.
" This circumstance would imply, that whilst the muscles of the eye
were paralysed by the pressure on the third nerve, the abducens, or sixth
nerve, had for a time escaped ; but that the disease at length encroached
upon the sixth, and consequently paralysed the rectus externus, and thus
reduced all the muscles of the eye to the same condition."
The upper lid of the left eye completely covers the eye-ball. When
asked to try to raise it, he arches the eye-brow, but produces no effect on
the eye-lid. He can wink, and shut this eye forcibly. When the eye-lid
was raised witli the finger, and he was asked to look around in various
directions, it was found that he had no power of moving this eye either
sideways, or upwards, or downwards ; but, whilst the right eye was re-
volving from one side to the other, this remained perfectly stationary.
When the eye-lids were again held apart, and he was told to wink, still the
eye-ball continued fixed.
" You know the eye-ball is turned up by two different muscles. If
you direct your eye upwards to look at an object, the rectus superior and
attollens palpebree combine together, and both the eye-ball and eye-lid are
raised. If there were not such a combination between these two muscles,
the eye-ball might be turned up by the effort of the rectus, but instead of
seeing by this means, the pupil would be turned under the eye-lid. Again,
when the eye-lids are opened by the fingers, and held apart, and the person
is asked to shut them, you see the eye-ball roll up. Here the rolling up
of the eye-ball, combined with the action of shutting the eye-lids, is not
performed by the same muscle which turns the eye-ball up in vision.
This motion is involuntary, and is performed by the inferior oblique muscle.
But this, as well as all the other motions of the eye, are in this case gone,
which shows that all the nerves of the muscles within the orbit are affected."
Although he has lost the motions of this eye, still he retains vision in
it. This is slightly obscured by a nebula upon one side of the cornea ;
e
XXVI PARALYTIC AFFECTION
but which has been the same ever since he had inflammation of the eye
consequent on the wound received at Waterloo. The pupil of the left eye
is dilated considerably more than that of the right eye, without any irre-
gularity of its shape. Upon a careful examination, not the slightest motion
of the iris could be perceived in the left eye. He can distinguish light
from darkness through the eye-lid. He complained of the candle-light
giving him uneasiness.
" When you simply close the eyes, but are awake to all that is going
on about you, you see the light through the eye-lid: the eye-ball does
not turn up. But when the eye is closed in sleep, the eye-ball does
turn up, the pupil is directed upwards, and the light, coming through the
eye-lid, is a less annoyance. In this case, as in others which I have seen,
the axis of the eye remaining in its usual place, although the eye-lid be
dropped, the patient complains of the light of the candle in the ward.
** You will further observe, in what has been read, that the iris is
insensible to the variations of light. This reminds you, that the relation
established between the retina and iris is not direct, — is not in the organ ;
but the impression must be carried back to the sensorium through the
optic nerve, and return again through the third nerve. Therefore, by the
influence of the third nerve being destroyed, we see why the motion of
the iris should be arrested."
The surface of the eye is quite insensible to touch. When we held
up the eye-lid, and threatened to touch the eye, he drew back and winked
before the finger had touched him ; but when the finger was drawn across
the eye-ball, he did not feel it. This eye is equally bedewed with
moisture as the other. There was not observed to be any increased
flow of tears after touching it. This eye is a little more prominent than
the right one.
"You will observe these circumstances with interest. When he saw
you aiming, as it were, to injure the eye, he winked, because the vision
was perfect, and the motion of the orbicularis palpebrarum remained:
the circle between the retina, brain, and tlie muscle, being entire. But
OF THE FACE. xxvii
this was not the case when you touched the eye. On touching the eye,
the impression should be upon the fifth nerve ; but the fifth having lost
its function, there was no impression carried backwards to the brain, and
of course none was given to the portio dura of the seventh, to bring the
orbicularis into action."
His reason for applying for relief is not so much on account of this
condition of the eye, as that he suffers such excruciating pain in the left
side of his face. His appearance shows how harassed he is with long
continued suffering. The pain extends over all the left half of his face,
and he points to the forehead, the cheek above the angle of the mouth,
the chin, and the side of the tongue and the gums, as the parts principally
affected. It is a dull aching pain; but in the side of the tongue it is
rather of a burning kind. All these parts are much deadened in their
sensibility, but more so in some parts than in others. Thus sensation
seems altogether gone upon the side of the forehead, and we may rub the
surface of the eye with the finger without his feeling it; while, in the
other parts of the face, he can merely, in an imperfect way, distinguish
whether we touch him or no. On tickling the orifice of the left nostril
with a feather, he made no signs of this annoying him; but he started
back and pushed the feather away whenever it was put to the right
one.
" I must remind you, that upon an injury to a nerve any where in its
course, the pain is referred to the extremity of that nerve. If we could
imagine, as is most probable in the present case, that a tumor or abscess
engages the root of the nerve, then there would be pain, not in that part,
but referred to the extremities of the nerve. This, perhaps, accounts for
the pain in the corresponding side of the face and of the tongue. And
you will observe at the same time, that it is quite consistent with this
opinion, that the parts, which are the seat of this morbid pain, should still
be insensible when touched : for the disturbance in the root of the nerve
which causes the false impression of pain in the extremities of it, prevents
the course of sensation being conveyed from the surface towards the
sensorium."
e9,
xxviii PARALYTIC AFFECTION
As it appeared that there was here an affection of the trigeminus, or
fifth pair of nerves on the left side, we were led to examine the condition
of the temporal and masseter muscles. He was directed to open and shut
his mouth, and clinch his teeth firmly together; and while he did this,
the fingers being placed first upon the two temporal muscles, and then
upon the two masseter muscles, the comparative degree of action in them
was observed. It was distinctly perceived by all who examined them,
that while the muscles on the right side bulged out and contracted
naturally, those upon the left side were quiescent. The masseter on
the left side was wasted and flaccid, so that the surface of the jaw-bone
could be easily felt. The corresponding muscle on the right side was
hard and full.
" You will remember, in the demonstration of the fifth pair of nerves,
that it bore an accurate resemblance to the spinal nerves; that the
anterior root passed the ganglion on the posterior root, and went to the
muscles of the jaws; so that this nerve, like the spinal nerves, possesses
a double function. If, therefore, a disease affects the roots of this
nerve, we should expect, what is here stated, that at the same time the
sensibility of the face was diminished, the muscles of the jaws should be
weakened."
The temperature of the skin on both sides of the face appeared to
the touch quite the same. He was ordered to have six leeches applied
every third day behind the left ear; to take a Plummer's pill every night;
his bowels to be kept open with salts and senna ; to rub the back of his
neck with the camphorated mercurial liniment, and the lotion of lead and
opium to be applied to the left side of his face.
Dec. 2ith. — He has attended as an out-patient, and has expressed
himself somewhat relieved by the treatment. But to-day he complains of
being much worse: the pain in the side of his face is more severe; he
has almost entirely lost vision in the left eye, and yet the eye is quite
transparent: this has come on gradually since yesterday, and has not been
attended with flashings of light. He is also deaf in the left car, but tiiis
symptom has been coming on during the last week.
OF THE FACE. xxix
Dec. 29th. — This man was admitted into the hospital on the 24th,
but he left it late on the same night, and returned home. Being visited at
his house, lie said that the patients in the ward had complained of the noises
he made while trying to blow his nose, and therefore he left the hospital.
He has formerly complained of an obstruction to his breathing at the back
part of his nostrils. He sometimes starts up in bed with a sensation as
if he were choking, and makes strong efforts, by sneezing, hacking, and
blowing his nose, to remove something which seems to block up the
posterior nares: he also made use of a bit of wood, which he thrust into
his back nostrils on the left side, and picked away pieces of a substance
resembling glue, tinged with blood.
*' I presume nothing can more convince you of the insensibility of
the surfaces resulting from the disorder of the fifth nerve than this practice
of the poor man. He is tickled with a feather on the right nostril, and
yet on the left he thrusts back a rough stick into the cavities of his nose."
This difficulty of breathing was much aggravated on the day he was
admitted into the hospital.
On the night of the '26th. he was extremely ill; suffering very great
pain in the forehead, having a succession of cold fits, and no sleep. In
the morning his wife was alarmed by finding his face twisted to the
right side; and she immediately went to obtain medical assistance at a
neighbouring dispensary. He was cupped at the back of his head, and
afterwards a large blister was applied.
The muscles on the left side of his face are paralysed. The eye-lid
can now neither be elevated nor shut: it remains in whatever position it is
put by the finger, being like that of a dead person. There is great
redness and turgescence of the conjunctiva, and there is a film, as if it
were dried mucus, covering the greater part of the surface of the eye.
The patient said he had picked some of this off with his nail. He was
cautioned against repeating this, and his wife was instructed to bathe the
eye frequently, and to cover it with its eyelid. When the face became
paralysed the pain was considerably abated, and now he suffers compa-
ratively little from it ; the sensibility to touch is still defective as before.
XXX PARALYTIC AFFECTION
" In these circumstances we have a proof of two properties of the
nerves being necessary to the preservation of the eye. The sensibility to
impression is followed by the winking or closing motion of the eye-lids,
which washes off or otherwise removes the offending body. There was
danger to the organ when its guardian, the sensibility, was destroyed;
but when, at length, the winking motions were lost, and the tension of
the orbicularis muscle, which supports the eye, gone, then a destructive
inflammation very quickly followed. And you have here, in this case, as
you may have also seen lately in a patient in the cancer ward, the very
vsingular phenomenon of a person picking the inflammatory crust from the
surface of the eye.
" I may here make a clumsy comparison to illustrate this subject,
and yet I believe the analogy is perfectly correct: Formerly, in speaking
to you of the fractured spine, with the loss of sensibility in the hips and
the lower extremities, I told you that it was necessary to direct the nurse
to shift the patient a little, from time to time, and to support him with
pillows, put under the loins, hips, and thighs, otherwise your patient
would soon have mortification of the hips. Consider how often you have
shifted your seats since you have taken your places before me this evening
— that irksomeness which makes you change the pressure from one hip
to the other is the guard upon the texture of the part, and if you had
not that uneasiness, you would have worse when you rose up — you would
have actual pain, followed by inflammation. But if a person, who has the
spinal marrow torn across, have no such shifting motions, no little accom-
modation of posture so as to throw the pressure upon different parts, then
you know the consequence is that, being neglected, he has mortification
of the hips or heels. Thus we understand the necessity of pain or un-
easiness, as a continual monitor to us; and we see in the eye what is the
effect of the loss of this sensibility, that it inflames, loses its transparency,
and is finally destroyed."
He can twist his tongue about: he has no numbness nor loss of
motion in his extremities, and his intellect is perfectly clear.
Dec. 31st. — His hearing has now returned to the left ear: the pain
in his face is less.
OF THE FACE. xxxi
Jan. 14th, 1829. — He returned to the hospital to-day. He has now re-
gained the power of motion in the muscles of his face to a certain degree,
but not perfectly: his eye may now be said to be completely lost: the
conjunctiva is of a bright red colour, and the cornea projects like a horn,
being apparently about to slough. The pain which was so severe in the
forehead, is now entirely gone. He complains more of pain in the back
of his head. A seton has been put in the back of his neck.
Jan. 29th. The cornea has sloughed, and a part of the humours, of a
dark pulpy appearance, projects from the centre of the eye: when he
presses the eye, it bleeds. He is much better in other respects.
May. This man progressively improved, and he attributed his
relief to the seton placed in the back of his neck. His eye-ball was found
one morning to be turned inwards, and it remained permanently so. It
became clearer, but he never recovered vision in it. By degrees the sensa-
tion returned to the skin, and the pain in his face entirely ceased. The
action of the muscles of the jaws could again be felt when he chewed.
No. IX.
Case II. — Notes of the Case of a Patient who had Paralysis of the Muscles
within the Orbit.
Geo. Bungay, set. 20, was admitted, under Dr. Macmichael's care,
Nov. 22d. He had symptoms of fever for a week before he presented
himself at the hospital. He complained of getting no rest at night: his
bowels were constipated ; his tongue foul ; the pulse slow and regular ;
he had slight tenderness in the epigastrium ; he suffered no pain in the
head. On the night of the 23d tlie nurse said he wandered a little in the
night. On the following night he had no rest. In the afternoon of the
25th he was seized with delirium j the delirium came on in paroxysms.
After this he fell into a comatose state. He continued in this state until
his death, which happened on the 29th.
When the delirium came on, it was observed that the right eye
remained always closed, while the left eye was opened: he had lost
the power of raising the lid of the right eye. Upon elevating it with
the finger, it was discovered that he had also lost all motion of the
xxxil PARALYTIC AFFECTION
eye-ball : while the left eye revolved from one side to the other, this re-
mained still, and as if he were looking straight forwards. On holding the
eye-lids apart, he resisted with the orbicular muscle, and closed them again
forcibly together.
Dissection. — There was a considerable quantity of serum in tlie
ventricles of the brain. On raising the brain from the basis of the skull,
both the optic nerves, but in particular the right one, were observed to be
more vascular than natural. On dividing these across, and continuing to
turn back the brain, it did not separate easily as usual. There was found
to be a thick deposit of coagulable lymph, straw-coloured, and of the con-
sistence of jelly, which caused the upper part of the pons varolii to adhere
to the dura mater. This was most abundant on the right side of the sella
turcica. All those nerves which passed into the orbit were enveloped in
this deposit: the third pair of nerves was completely embedded in it, and
had a yellowish brown appearance. The corresponding nerves upon the
left side were also affected, but in a slight degree. On examining the roots
of the portio dura of the seventh pair, they were found quite removed
from the disease.
" You will in this case distinguish the symptoms of delirium and coma
from the local affection; and as regards the appearances on dissection, you
will also distinguish the result of the general condition of the brain from
the more local effects upon the base. The effusion into the ventricles of
the brain shows the state of general excitement ; but it is to the coagulable
lymph matting the third, fourth, fifth, and sixth nerves together, that you
must look for an explanation of the symptoms in regard to the condition
of tlie eye. The root of the seventh pair being free from the disease, ex-
plains how the eye-lids retained their winking motions, whilst the eye-ball
was stationary from the disorder affecting the third, fourth, and sixth
nerves.
" If I brought to you my private cases of consultation, you might
suppose that, owing to circumstances, cases of diseased nerves were accu-
mulated ; but you now perceive, in the common practice of an hospital,
how frequent these cases of nervous affection are ; and the interest you
attach to them, proves to me the advantage of an accurate knowledge of
the anatomy in exciting minute attention to symptoms, and satisfactorily
OF THE FACE. xxxiii
explaining them. If you had not known the distinct uses of the fifth and
seventh pairs of nerves, you would have had no gratification in following
these details."
No. X.
Case III. — Case of Partial Paralysis of the Face.
James Delahay, aet. 13, Nov. 26. — Seventeen days ago he fell from a
scaffolding ten feet in height, and was brought to the hospital immediately
after the accident, suffering from the effects of concussion. There was
general tumefaction of the left side of his head, from the jugum to the
vertex, and there was a bruise of the scalp above the ear, marking the place
on which he had fallen. He recovered his senses about an hour after the
accident. His head was shaved, leeches and cold lotions were applied to
it, and he took purgative medicines. At the end of a week he was so far
recovered as to be dismissed from the hospital. He continued in good
health until Sunday last, when he had a severe headache, which went off
in the course of the day. On Monday his friends were alarmed by ob-
serving his face twisted to one side ; they therefore sent him to the
hospital, and he became a patient of Mr. Bell.
The left side of his face is relaxed, and the natural balance of the
features is gone, so that the countenance has a distorted, wry appearance.
" You have so lately had a demonstration of the nerves of the head,
that I need hardly remind you that all the motions of the face, — the mo-
tions of the forehead, of the eye-lids, the nostrils, the expression of the
cheek and lips, both in passion and in speech, result from the influence of
the portio dura of the seventh pair ; and that the muscular branches of the
fifth pair are given to parts internal, and to such as have no direct connexion
with the actions of respiration. The debility or disorder of the portio dura
has the most unhappy consequences upon the countenance : when this
nerve has lost its power, the corresponding side of the face becomes im-
moveable as a mask, or it is drawn to the opposite side by the excited action
of the muscles there. It is important in your practice to observe the dif-
ferent causes of this defect : the slightest, perhaps, is an influence on the
/
XXXIV PARALYTIC AFFECTIOX
surface ; the next is a swelling of a gland, in the course of the nerve,
which presses upon it ; the third is a suppuration within the ear ; the
fourth is a suppuration at the basis of the brain ; and, lastly, the defect
may arise from neither of all these, but from the condition of the brain
itself, and may be in correspondence with the paralysis of the other motor
nerves. In the present case, the boy received a violent injury on the same
side of the head on which the paralysis is ; and we have liad cases in the
hospital where the portio dura was torn by the fracture passing through
the temporal bone * ; but in the present instance this could hardly be the
case — the paralysis would have taken place at once, whereas it has come
on at a later period, and has been accompanied with swellings of the glands
of the neck, and with no defect of hearing on that side.
" When w^e see a person alarmed without cause, and there is no danger
in the case, there is something approaching to the ludicrous in the scene.
A physician paid me a visit who had come up from the country in the mail,
and had fallen asleep in the night-time, with his cheek exposed at the open
window to the east wind. On the morning of his arrival, when preparing to
go abroad, he found, upon looking into his glass, that his face was all twisted.
His alarm gave more expression to one side of his face, and produced more
horrible distortion. Both laughing and crying, you know, depend on the
function of this nerve, but when he came to me he considered it no
laughing matter : I never saw distortion more complete. It was difficult
to comfort him ; but I am happy to add, that the paralysis gradually left
* No. XI. — A man was brought into the hospital who had fallen from a height upon his head.
He recovered from the first shock of the accident ; but he continued in a dull stupified state, com-
jilaining much of headache, for a week, when he became comatose, and died. He had paralysis
of the muscles of the left side of his face. What was chiefly remarkable, there was a constant
flow of clear serum from the left ear, so that the concha was always fuU of it, and the piUow
commonly wet. On dissection there was found a fracture extending across the basis of the skull,
and passing through the petrous portion of the left temporal bone, tearing the seventh pair of
nerves just at its entrance into the meatus auditorius internus. The dura mater was torn where
it passes from the sella turcica to the petrous portion of the temporal bone ; and the cavernous
sinus was found infiltrated with serum. There was a considerable effusion of serum between
the dura mater and the brain. A communication had been formed through the laceration of the
dura mater, and the fissures in the temporal bone, by which this serum had flowed, during life,
first into the cavities of the car, and thence it had escaped outwards through a rupture of the
membrane of the tympanum.
OF THE FACE. XXXV
him, as I told him it would. I have at present a young lady under my
care who has paralysis of the face, and who has received great benefit from
galvanism. And I have lately seen an instance of the same kind ; the
more remarkable only as showing how the want of expression will injure
the finest countenance. I mention these things to remind you of the fre-
quency of the occurrence, and of the necessity of your distinguishing the
slighter cases, where the exterior branches of the nerve are affected, from
those wherein the cause is deeper seated, and more formidable."
The left eye stares widely and unnaturally open, while the right is
only moderately disclosed ; when he makes an attempt to close the eye-
lids, the left remain unmoved ; but the eye-ball is elevated upwards ; and
it is raised to so great an extent, that the pupil is quite concealed beneath
the upper lid, the white of the eye only being exposed. He is unconscious
of the eye-ball thus revolving upwards : the objects around him in the
ward are not seen at all while it takes place. He was told to direct his
eye so as to look as straight above him at the ceiling as he could : when
he did this, it was observed that he could not raise the pupil, by his utmost
efforts, so high, by some degrees, as during the involuntary act. When
turned up in the effort to wink, the cornea rose so as to be presented to-
wards the roof of the bony orbit, and consequently quite concealed by the
eye-lid ; on the other hand, when he looked upwards at the ceiling, more
than one-half of the pupil remained visible. During sleep the eye-lids
remain wide open ; and the pupil is concealed, just as it is observed to be
when he winks. It is remarked that the globe of the eye protrudes con-
siderably more than the other; the conjunctiva is inflamed, and is loaded
with numerous blood-vessels. He says that he suffers pain from this eye
being constantly open, especially when he is sitting before the fire at night.
" I am sure you have listened with interest to the statement of these
facts, which you can yourselves verify; and, first, as to the protrusion of
the eye. Any one ignorant of the functions of the nerves, looking upon
this boy, and observing the defect of the eye-lids, and the protrusion of
the eye, would say that there must be some tumour in the orbit forcing
out tiie eye ; and this they would, no doubt, also consider was the cause
of the debility in the muscle. But by a more correct process of reasoning
/2
XXXvi PARALYTIC AFFECTION
you perceive that the defect is solely in the portio dura of the seventh
pair. The eye-ball is naturally held between the muscles within the orbit,
and the orbicularis muscle without ; but in this case the exterior muscle,
viz. the orbicularis palpebrarum, has not only lost its activity, but its tone ;
and the greatest difference may be perceived between the right and left
eye-lids by pinching them up with the finger and thumb. There is thus
a want of pressure exteriorly, which permits the muscles within the orbit
to press the eye-ball out, and is the reason of the prominence of the eye.
Indeed, this want of support may, in part, conduce to the inflammation and
debility of the eye, which result in those cases where there is a defect of
muscular action.
" I shall direct your attention to one more circumstance only in the
narrative; viz. the difference of the extent of motion when the pupil is
directed upwards by volition, and when it is turned up by the instinctive
and involuntary actions of the muscles. I think I formerly told you that
on cutting the superior rectus in the monkey, the animal lost the power
of directing that eye upwards ; but when the eye was stimulated by the
end of a feather, and the effort to wink or close the eye was produced, the
eye-ball turned up, and the pupil was concealed under tlie eye-lid. Such
an experiment, I think, satisfactorily proves that the superior rectus is the
voluntary muscle, and the inferior oblique the involuntary muscle to turn
up the eye-ball. To suppose that the eye is revolved upwards by the
superior rectus when the eye-lids are closed, would be to make this
muscle act at the same time with the contraction of the attollens palpebrae
superioris, and act also at the moment of its relaxation. Thus, when you look
upwards to the ceiling, you elevate the eye-lid at the same time that you
raise the eye ; you perform the motion of the eye-ball with the superior
rectus, in conjunction with the attollens palpebrai superioris. If there
w^ere not this sympathy between these two muscles, the eye-lid would not
be raised in proportion as the eye-ball was turned up, and no advantage
would be derived from the revolving of the eye-ball, since the pupil
would be turned under the eye-lid. You see, then, there must be a strict
sympathy in the contraction of these two muscles. But we have anotiier
action in the eye-ball to provide for — a rolling upwards of the eye-ball
while the eye-lids are closed, as in winking and in sleep. Now to suppose
that the eye-ball was in this instance also rolled upwards by the rectus,
OF THE FACE. xxxvii
would be to make it act both with the contraction and with the relaxation
of the attollens palpebrs. Thus by reasoning, as by experiment, we come
to the conclusion that the instinctive rolling up of the eye-ball, as in
winking, is not produced by the action of the superior rectus, but by the
inferior oblique muscle.
" In this youth the motions of the eye-ball, in its different conditions,
can be well observed, owing to the eye-lids remaining open : for example,
we ascertain that the eye-ball turns up when the effort is made to close
the eye-lids. With regard to this motion, it is curious to observe that
here, as in many other instances, part only of the action is voluntary
and sensible — viz. the closing of the eye-lids; whilst the other part, the
revolving of the eye-ball, is insensible. We have an opportunity of further
observing, as the narrative proceeds, that in the voluntary direction of the
eye upwards, the action is limited; indeed we may say, what would be
the use of that muscle (which is to direct the axis of the eye in vision)
carrying the centre of the cornea higher than the margin of the orbit, and
under the upper eye-lid? But we do see a reason why the obliquus, in
the involuntary motion of the eye, should carry the cornea much higher
up, since the object is to moisten it at the fountain of the tears, and to
purify it from all irritating matter. Accordingly, when this youth's eye is
irritated, and the involuntary muscle brought into activity, the eye-ball is
revolved so much, that the cornea is quite lost under the eye-lid."
When he is told to frown there is no motion perceived on the left
side of his forehead, but all the expression seems drawn to the right side.
When made to laugh, the features are curled up in the expression of
laughter only on the right side of his face, which presents a singular
contrast with the sad, or rather lifeless appearance of the left or paralysed
side. When a spoon was put into the left angle of his mouth, he could
not grasp it; he said that in eating he put the morsel into the right side.
The left nostril is not dilated in a corresponding degree with the right;
and the difference between them was most distinctly seen when he
attempted to sniff up the air or to breathe hard, for then, whilst the right
nostril expanded more widely, this one became quite collapsed, or shut
up against the air.
xxxvill PARALYTIC AFFECTION
The sensibility of the skin over the whole of the head is perfect, and
the muscles of the jaws act powerfully. He can move his tongue about
in all directions.
There is a greater fulness over the left temple and jugum than over
the right; there is also a blueness of the iqteguments, consequent on the
injury which he received, but he does not even wince if this part be
pressed severely. There is an enlarged gland in the hollow under the
left angle of the jaw, and it gives him pain when pressed. The whole
chain of the glandular concatenatae in the left side of the neck are enlarged
and tender. His hearing is not affected, and there has been no discharge
from the ear.
He says that for some days his head has been drawn towards the right
side ; but this symptom has disappeared, and he can hold his head erect.
Leeches to be applied before the ear; the face to be rubbed with the
camphor liniment; cold lotions to be applied to the side of the
head; and a powder of Calomel gr. iv. Rhei gr. viii. to be taken
twice a week. He was instructed to move the eye-lid with his
finger over the eye frequently, so as to lubricate its surface.
Nov. 29th. — His head is twisted to the right side, and this is the
position in which he said it had formerly been. The head is not merely
inclined to the right, but it is also twisted round, so that the right ear
presents forwards. On examining the sterno-cleido mastoideus muscle
upon the right side, it is found hard and tense, being in a state of tonic
spasm: it is the constant action and rigidity of this muscle which prevents
the head from being moved to the erect position. It gives him no pain.
When he is asked to hold up his head, he throws his head back, but still
the neck is twisted towards the right: he can rotate his head in various
ways to the right side and to the left, yet he is always checked by the
permanent contraction of the sterno-mastoid muscle alone.
Dec. 2d. — This boy has continued in the same state as has been
described above ; but to-day the spasm of the sterno-cleido mastoid
muscle is considerably diminished. He has rubbed the neck with the
camphorated mercurial liniment.
Dec. 5tli. — He can now hold his head erect, and move it easily in
any direction.
OF THE FACE. xxxix
Dec. 20th. — Little change has occurred since the last report. The
contraction of one side of the neck has not returned. He complained at
one time of having some difficulty in swallowing; but nothing could be
observed on inspecting the inside of his throat. His face is now in a great
measure restored to its natural balance, at least it appears so, if we look
at him when his countenance is unmoved ; but when he begins to speak
or to smile, then the distortion is visible. Leeches have been applied in
succession under the angle of the jaw; he has regularly fomented the side
of his face, by holding it over the steams of the poppy fomentation. A
blister is now applied under the ear, he has been taking the infusion of
gentian with the carbonate of soda.
Jan. 13th. — He has continued much in the same condition, but he is
gradually acquiring some more power in the muscles of the face. The
swelling under the angle of the jaw is still of a considerable size.
Mr. Bell here observed that he would not stop to inquire into the
affections of the sterno-cleido mastoideus muscle; but he could assure
them that it was subject in a particular manner to derangements of this
kind; which, indeed, appeared in the cases kept in the hospital book*.
No. XII.
Case of Paralysis of the Voluntary 3Iuscles of the Eye-ball.
(Communicated to the Author.)
" November 24, 1825.
" The master of a small trading vessel applied for advice. The most
prominent and obvious symptom of the case was Ptosis, or paralysis of
the upper eye-lid. Suspecting that there might be a general affection of
the third nerve, or motor nerve, I desired him to look to the ground: he
attempted it, but was utterly unable to accomplish his intention. He
was also told to look upwards, and then inwards: in both which he failed.
*' He could close and wink with the eye-lids when we touched the
cilia, proving that the portio dura, and the branches of the fifth, possessed
their sensibility and power f.
* See the Cases of Spasmodic Affections of the Stemo-cleido-mastoideus muscle.
t See the last paper. On the Nervous Circle, reprinted from the Philosophical Transactions.
xl PARALYTIC AFFECTION
" Now, forcibly separating the eye-lids, and desiring him to close
them, while I still held them open, I could distinctly see the eye-ball
turn upwards, which I supposed to indicate that the fourth nerve still
influenced the trochlearis muscle.
" He had the power of looking outwards, accomplished by the sixth,
which was not included in the paralytic affection. He saw well, save
that the fallen lid interfered with vision. He had been troubled with
this affection nearly a fortnight, attended with slight headache, and some
symptoms of derangement of the stomach and bowels.
♦' Samuel John Stratford."
Ptosis is the term applied by surgical writers to the relaxed eye-lid,
when the person cannot raise the eye-lid so as to disclose the pupil. We
have here nothing to do with those cases, where the inability depends on
disease in the eye-lid itself: but it must be acknowledged, that the
subject of paralysis of the eye-lid was obscure until these observations
were made. We perceive that this ingenious gentleman, when he found
that the patient could not raise his upper eye-lid, reflected that this must
be from paralysis of the levator palpebrae superioris ; that the defect must
in all probability be in the third nerve ; that if so, the motions of the
recti, with the exception of the abducens, must also be imperfect. He
found this to be the case. He then reflected that the instinctive turning
up of the eye-ball depended on other muscles and on other nerves. He
knew that when I had cut the voluntary muscle, the rectus superior,
although the creature could not turn his eye to objects above, yet, tiiat
the instinctive motion of the eye-ball upwards by the ohliqui remained.
He tried, and found that the involuntary turning motion of the eye-ball
was here entire.
We perceive the importance of this observation, since the defect is
proved to be in a cerebral nerve, and therefore to imply an affection of
the brain, and to threaten apoplexy. It stands contrasted with that
inability of closing the eye which results from the affection of another
nerve and of a different system, the system of respiratory nerves, which
are more subject to derangement than the cerebral nerves, and which
offer a less alarming symptom.
OF THE FACE. xli
It is said by surgical writers, that where there is ptosis, the patient,
seeing a little under the eye-lid, soon gets into the habit of squinting.
Squinting is never a hahit, the fact being, that the weakness of the levator
arises from a defect of the nerve common to that muscle, and to all the
voluntary muscles of the eye; and hence the involuntary muscles acquire
a preponderance, or comparative increase of power, and drag the eye-ball.
Practice or experience points out a distinction between the con-
dition of the patient, when the eye-lid has fallen from paralysis, and
when it is spasmodically twitched by the action of the orbicularis. This
last is the periodical ptosis; and do we not perceive that the one is the
formidable affection of the cerebral nerve, and the other the sympathetic
affection of the respiratory nerve?
The following note, which I owe to our ingenious house-surgeon,
Mr. Goss*, refers to a tremulous motion in the muscles of the eye: —
No. XIII.
Incessant Motion of the Eye.
" Joseph Rogers, Z5 years of age, has lost the right eye, and has had
an opacity in the centre of the cornea of the left eye for twenty years.
The left eye has a curious semirotatory and involuntary motion, which is
constant. The rotatory motion is to the extent of about one-fourth the
circumference of the ball. The cornea is nearer the nose than is natural,
forming an imperfect squint. He has not the slightest power in arresting
this motion ; it is that which would be produced by the alternate action
of the obliqui antagonizing each other."
I had put my young friends in the hospital upon investigating this
case. But being a physician's patient, and tliey not knowing my wish,
he was dismissed. When the pupils brought me to visit this man, they
announced it as a case where, notwithstanding the continual motion of
the eye, the patient was insensible to that motion, and saw objects
naturally and at rest.
• Now Surgeon at DawHsh.
xlii PARALYTIC AFFECTION
Was this a defect arising from the disorder of nerves, or an accom-
modated action to the opacity of the centre of the cornea?
No. XIV.
Case communicated hj Mr. Alexander Shaw.
Sophia Walker, ast. 17, has an incessant motion in both her eyes.
The left eye is shrunk j she lost it during infancy, when she had the small-
pox. In the right eye there is a leucomatous spot upon the inner side of
the cornea, nearly opposite the pupil, and to this part the iris adheres, but
she sees objects distinctly with it. The remarkable circumstance is, that
her eyes are not for a moment at rest, and yet this motion does not
disturb her vision. There is a constant tremulous motion in them, which
her mother says has continued since her infancy; it is not so much
upwards and downwards, as in a transverse direction, but it is irregular
in this respect. When she was requested to take her book and read,
she read with perfect ease, and yet there was no cessation of the
motion in her eye. She threaded her needle without any apparent
difficulty, and then showed how she could sew, which was with the usual
nimbleness; she gained her living, indeed, by her needle-work. She also
looked steadily at various objects in the room, but the motion of her eye
continued the same in all these attempts. She was asked to look as far
upwards as her eye could be directed, and in the same manner to strain
her eye in all the various directions, but by no means could the tremulous
motion be arrested. She was not sensible of there being any defect of
this kind in her eye, or at least it did not produce any inconvenience ;
all objects seemed in their natural state either of rest or of motion.
When she looked at herself in the glass, she saw her eye rapidly moving.
In order to ascertain whether any change took place while the eye-ball
was involuntarily rolled upwards, the eye-lids were held apart, and she was
told to wink forcibly: the cornea was elevated, so as almost to be hid, and
during the time that it remained in that position it was quite fixed and
steady. It was next desirable to know whether the eye-ball remained fixed
during sleep. When the eye-lids were gently closed, the eye-ball continued
OF THE FACE. xliii
in a state of motion, and communicated a very distinct quivering to the
eye-lids. This was observed by the mother, and she was then requested
to take an opportunity while her daughter was sleeping to remark whether
this quivering motion continued the same. Three days afterwards I was
informed by the mother that no motion whatever could be observed
either in the eye-lids or the eye itself during sleep.
No. XV.
Note. — A child, about four years old, was brought to the hospital by
the mother, who was a patient. The eyes were observed to roll con-
tinually in all different directions, and without any correspondence. It
appeared, sometimes, that the child merely squinted, but the squint was
continually varying; the motion of the eyes was generally in a transverse
direction, but occasionally they converged, and then again separated.
The child was very short-sighted, and, it was remarked, whenever any
object was brought so close as to attract its attention, that the eyes became
fixed. This wandering of the eye resembled what is seen in congenital
cataract.
No. XVI.
Note. — June 1st. There is at present in the hospital a young
woman who has had cataracts in both her eyes from infancy. She has a
constant rolling of the eyes, a vacillating motion, like the balance wheel
of a watch. She sees a little, and can distinguish a person in the ward;
but notwithstanding the motion of the eyes, the object she distinguishes
is at rest.
June 24th. — The opaque lens of the left eye was pierced and dis-
turbed with the needle, and the capsule burst or torn. This operation
after three weeks was a second time performed: the vision improved, and
the eye became steadier. Some time after I couched the other eye ; the
vision is perfect in that which was first operated upon, and is fast im-
proving in the second. The motions of the eyes have much diminished.
xliv PARALYTIC AFFECTION
No. XVII.
Case communicated bij Mr. North.
Francis Robbins, aet. 19, has been short-sighted from his infancy.
The structure of the eyes appears perfectly natural. The pupils are less
contracted by the application of a strong light than is usual. I have
seen him frequently during the last six or seven years, and have always
observed that the eye-balls are in constant motion, not upwards and
downwards, but laterally. He is of a very nervous temperament, and
upon the slightest excitement this motion of the eyes is considerably
increased, and no effort to look steadily at an object placed before him
has any effect in restraining it. His vision does not deceive him as to
the state of things he looks at: he is sensible when objects are perfectly
at rest, and perceives immediately the true direction of the slightest
motion which is given to them: he can read music with facility, and
plays accurately from the notes rapid passages on the violin. If he is
surrounded by many moving objects his vision becomes confused, and he
forms an erroneous judgment as to their distance from each other, and
from himself. Thus, in the morning early, before the streets are
crowded, he drives a carriage and pair of horses with safety and dexterity,
but he cannot do this in the middle of the day, when, to use his own
expression, " he gets flustered," and is afraid of meeting with accidents.
^ This motion of the eye, without a corresponding idea of change
in the position of the object, is certainly a very curious fact ; yet it admits
of explanation, if the statement which is made in the text be correct.
We observed that vision is a compound operation, that the impression
upon the retina is combined with a certain effort of volition, and that
this volition, directed to the muscles of the eye, is necessary to the idea
of motion or place of the object. If a motion of the eye takes place
without volition, there is a want of that essential circumstance wJiich
indicates place or motion. These patients, therefore, having the motion
of the eye from a different cause than volition, although the impression
of the object moved upon the field of the retina, had simply the sensation
OF THE FACE. xlv
on the retina, without the idea of motion, because there was no muscular
effort.
Of the Eye-lids; as indicating different Affections of the Nerves.
(A Communication of the Author to the IMedical Gazette.)
My attention having been drawn to tlie actions of the muscles of
the eye, I have persuaded myself that there is a strict correspondence
between the retina, as the organ of vision, and the surrounding muscles.
We observe that, when the retina is excited by vision, there is an
attendant excitement of the recti, or voluntary muscles of the eye ; and
that when vision is not exercised, the eye then becomes passive, and is
drawn upwards by the preponderating influence of the obliqui: that,
consequently, there is an established relation between the falling of the
eye-lid and the revolving of the cornea upwards.
It did not occur to me that any thing farther could be done in the
way of experiment, than what is offered in the Philosophical Transactions,
June, 1823; and I concluded that we must wait for the opportunity of
observation in the human eye, to perfect our knowledge of this subject.
It is with this view that I present you with the following cases, to which
my attention is at this moment directed.
The condition of the eye-lid and eye-ball, when carefully observed,
appears to me to give the symptoms of very different affections of the
nervous system. Putting aside the affections which come under the head
of strabismus, we have, in the first place, the eye-lid fallen, from disease
of the eye-lid itself, independent of nervous disorder; secondly, the eye-
lid permanently elevated, and the cornea exposed ( Lagopthalmos : vue
de lihrej, indicating defect in the office of the portio dura; thirdly,
incapacity to raise the eye-lid, attended with total insensibility of tlie
surface of the eye and side of the face, with the power of forcibly closing
the eyes still retained: indicating disorder of the nerves within the orbit,
probably pressure between the origin and distribution of the nerves, the
portio dura being free from disease ; fourthly, amotion in the eye-ball itself
rapidly to and fro (Nystagmus hulhi), independent of any affection of the
eye-lid ; fifthly, we have the eye-lid depressed, and the motion of the eye-
xlvi PARALYTIC AFFECTION
ball remaining ; sixthly, we have the eye-lid depressed, and, at the same
time, the cornea elevated.
It is to these two latter cases that I have to request the attention of
your readers : in the first place, as they imply very different conditions of
the nervous system ; and, being attended with blindness, may be confounded
with affections of the optic nerve or retina.
No. XVIII.
Case of Periodical Blindness, from a Cause not hitherto observed.
The subject of this case is a young lady, twenty-four years of age, of
delicate frame, with great intelligence and expression ; accomplished, and,
as ladies are, studious. She was in the habit of drawing a great deal, and
had painted a miniature a short time before the symptoms I have to
describe commenced. In giving the case, I am assisted by the letter of
her physician, which she presented to me, and which shows that he has
studied the symptoms, having that interest in the case which is so na-
turally excited in a benevolent mind.
In August, 1826, she began to have headaches, which, however, had
not a common character: the pain extended down the side of her face to
the angle of the jaw, and then backwards into the ear, with a sensation of
tightness in the skin of the forehead; and this pain she had first on one
and then on the other side of her face. These pains appeared to her
physician to be " connected with considerable disorder of her stomach
and alimentary canal, increased, if not produced, by too sedentary a habit,
and application to drawing. After a dose of calomel and opium, she took,
in succession, the sulphate of quinine, the extract of henbane, and the
liquor arsenicalis. She had also the blue pill, until her mouth became a
little sore."
The pain had ceased, and a " heavy stupidness," to use her own
expression, prevailed for a few days, when one day, in reading, she found
that she could not see the letters, — they were thrown together and con-
founded. This obscurity of vision was attended with a fluttering in the
eyes, which seemed to her alternately to open and shut with great rapidity:
by turning away from her book and attending to other things, she could
OF THE FACE. xl
Vll
read for some time, when she again looked upon the page. The appH-
cation of leeches relieved these symptoms for a day or two; but the relief
was temporary, and she gradually lost the power of directing her eyes.
From the beginning of this affection of the eyes, the pain ceased in the
head. This " actual blindness came on periodically. It began about ten
o'clock in the morning, and ceased about four ; and, during the blindness,
there was constantly presented a most quick motion of the eye-lids and
eye-balls ; and during the whole of these attacks, she lost all control over
the muscles of the eye-lids and eye-balls. She could partly see, or at least
distinguish light from darkness." Her vision was occasionally restored :
at one time her medical man having made his visit, he was called back as
he was stepping into his carriage, she having at that moment entirely
recovered her sight. Her blindness has of late been permanent. Her
physician looks upon these symptoms as connected with nervous irrita-
bility, and different from genuine amaurosis arising from disease of the
optic nerve or retina. I should have stated that the solution of belladonna
was applied to the eye-lids, by which her medical attendants satisfied them-
selves that there was no cataract. They next ventured upon the galvanic
battery, and were encouraged to proceed in consequence of her being able
to see almost on the first shock, which was given across the eyes. She
found her way out of the room without assistance, and could distinguish
the colour of the ladies' dresses who accompanied her in the carriage.
After this, although a spark of light was excited at each shock of the
battery, her sight did not improve ; and she even lost that degree of vision
which she had enjoyed in the morning and the evening.
This young lady has a pleasant, intelligent manner : but I observed to
her, that she conversed with her ears ! on which she said, " Oh dear, am I
already so bad as that?" understanding perfectly what I meant, — that the
direction of her countenance to those who addressed her was like that of a
blind person. This expresses a fact, at the same time that it may show the
acuteness of her understanding. Her eye-lids are dropped over the eye, but
not with the character of a paralysis : they are in continual motion while she
speaks, being raised and depressed for about the twelfth of an inch ; and never
so far raised as to expose the pupils ; the eye-brows are raised by an in-
xlviii PARALYTIC AFFECTION
effectual attempt to open the eye-lids. She can close the eyes and wink,
powerfully compressing them. The secretion of tears flows plentifully.
There is not the slightest degree of inflammation in the eyes. The con-
cealment of the pupils is not altogether owing to the dropping of the eye-
lids, but to the eye-balls being at the same time rolled upwards : she has
an equal inability of raising the eye-lids and of depressing the eye-balls.
If there be a difficulty of understanding this description, I would say that
there is continually in this young lady that condition of the eye and eye-
lids which the surgeon sees when he is about to examine the eye, or per-
form an operation on it: the cornea is turned up, whilst the eye-lid is forci-
bly drawn down — such is exactly the condition of this young lady's eyes.
The first thing I did was to stretch the eye-lids over the eye-ball, and
keeping her face directed to the window, I inquired, " Do you see red
light ?" " No," said she, " but I see bright yellow light." I had forgot
that when we look through the eye-lids the light is red, but if we stretch
the eye-lids, so as to undo the furrows, we see a brighter yellow light.
This fact was sufficient to show me that the defect of vision was not in the
retina, but arose from a deranged action and want of consent in the muscles
of the eye. I next inclined her face downwards, and forcibly raising the
upper eye-lid, I disclosed a small part of the pupil, the eye-ball being
powerfully rolled upwards : before I did this I said, " Let me try if you
cannot see your surgeon;" and as soon as the pupil was disclosed, she said,
laughing, " I see he has on spectacles." I next asked her to turn her eyes
in different directions ; she could turn them to the right and to the left,
but she jnet with an uncontrollable opposition in rolling them downwards.
To these facts let me only add this consideration : we might imagine that
when the pupil is disclosed, however little, she ought to see distinctly ;
but this cannot be, for the light that then enters, enters obliquely, not in
the line of the axis, and consequently the impression is not made on the
more sensitive central part of the retina. If we are looking to the side of
a room which is hung round about with pictures, we faintly distinguish
the frames of the pictures lateral to our position, the light from these
objects falling upon a part of the retina which is less sensible. It is not,
therefore, any morbid insensibility of the retina which renders this young
OF THE FACE. xlix
lady blind, but the fact that she cannot even for a moment direct her eye
to the object, and consequently cannot receive the impression in the central
portion of the retina, which is alone capable of distinct vision.
I expressed my opinion that this was an instance of that irregtdar
muscular action which depends on some remote irritation, and is not re-
ferable to organic disease, either of the brain or nerves, and that I saw no
reason why we should not hope for sudden restoration of sight.
Dec. 21th. — On conversing with the family again, I find that the
above statement is correct. She, however, adds, *' I wonder, considering
the many questions you put to me yesterday, that I forgot a circumstance
which is, perhaps, important; that I have pain extending round the head
as if it were bound by a hoop. This is not continual, but is excited by
the motion of a carriage or by noise. I have also," said she, *' a whizzing
noise in my ears, especially when I awake in the morning."
My first idea was to excite the viscera of the abdomen by emetics,
and to follow these up by opiates.
January 3d. — During the operation of the first emetic her eyes
opened, and she saw for a short time. On the second operation her eyes
remained open for ten minutes. The opiates being then administered, on
the first morning when she awoke she saw perfectly, but after a short in-
terval she was again blind. This morning she met me with a still better
account, — that she saw during all the time of breakfast, and had played a
new song from the book. But what was most agreeable took place during
my visit, for whilst I was writing my prescription, she called with interest
to me to look at her ! and, to my surprise, her eyes were open and steadily
fixed upon me, her countenance was wholly changed, and I need not say
improved ; I thought that her sister had slipped into her seat. Her sight
continued perfect whilst I remained in the house.
January 27th. — This happened twice afterwards, her eyes remaining
open for the space of an hour. This was not altogether chance, but de-
pended upon the high excitement of her mind whilst I conversed with her,
she having the greatest confidence in my power to relieve her. I increased
the dose of opium by giving her a pill at night and a draught of 35 drops
of laudanum in the morning. It had the effect of opening her eyes for a
longer period, that is, for an hour and a half or two hours ; but it became
h
i'!; PARALYTIC AFFECTION
oppressive to her, and I accordingly left it off. Fearing, during our bad
weather, that the opiates and the confinement might affect her liealth, I
gave her bark, and substituted the local application of opium for the opiate
draughts, and with the most remarkable effect. A blister was applied to
the temple, and a lotion of opium ordered to wash it with. The effect was
almost immediate, but still it was temporary; however, with this advan-
tage, that she could see when she chose, for by going up and bathing her
temples with the simple opium lotion, she could come down stairs seeing
perfectly for twenty minutes or half an hour.
February 2d. — To-day I had a pleasant scene with this young lady,
for she met me, saying, with her usual cheerful manner, " I have got
a way of restoring my sight as well as you, for there is a part of my temple,
which, when I press with the point of my finger, my eye-lids are instantly
opened." She put this in practice. Feeling for the little pit before her
ear, and above the jugum, and pressing pretty firmly there, the eye-lids
went up with a rapidity and effect as if she had touched the spring of a
Venetian blind, and they remained open as long as she kept her finger
there. She proceeded to inform me that she had found this accidentally,
and that when she pressed both temples the relief was more complete, but
that pressing on one side was sufficient to open both eyes, of which she
made demonstration to me. I conceived at first that she had pressed upon
some branch of the fifth nerve, for I could conceive nothing more likely
to produce an influence upon the nervous system of the head ; but when I
pressed upon the divisions of the fifth pair on the forehead, and on the
jaw bones, it had no effect. It next occurred to me that it was by
pressing on the artery; to ascertain which, I stopped the pulsation of the
carotid by pressing in the neck. Whilst feeling for this, she said, " I
know that there is a part of the neck which has the same effect, but I
cannot find it again." When I put the point of my thumb under the angle
of the jaw, and pressed the carotid against the vertebra?, the effect was
perfect, thereby proving that it was caused by some influence of the cir-
culation over the nervous system of the head.
Some days afterwards, at my visit, she told me, that, on pressing at
the pit of the stomach, the same effect was produced as on pressing the
temple. Tliis I found to be the case ; for, on pressing down the cartilages
OF THE FACE.
li
over the left hypochondriac region, so as to press the cardiac portion of the
stomach, the eye opened, and it remained open whilst I pressed. Being
now more and more convinced that this affection of the eye depended
on some very slight irritation, and she being in high spirits, I satisfied
myself with putting her on the plan of tonics, such as steel, and a mild
purgative, and permitted her to go into company. She enjoyed one night
at the play, but returned from it with a severe headache, fell into bad
health and bad spirits; no pinching any where could raise the eye-lids, and
we were all full of disappointment. Dr. Babington was called into con-
sultation : he prescribed pills of the cuprum ammoniatum. After eight
days, her friends being alarmed with the increasing weakness and want of
appetite, I once more changed the treatment to a draught of quinine and a
pill of calomel, with the compound aloetic pill. She is at this moment ob-
viously benefited by this : she has recovered her spirits, and, by opening
the eye-lids of one eye, the other eye is disclosed also ; and in a moderate
degree she can enjoy her reading and drawing.
I remember no other instance like this, except one in the Medical
Museum, in which the patient, a female, saw perfectly well in the morning
till ten o'clock. When it " turned often" it seemed to her as if her eyes
were covered with a cloud : and this darkening of her sight was preceded
by convulsive motions in the integuments of her forehead. She was re-
lieved by opium, but relapsed in consequence of some misfortune attended
with low spirits.
We see how apt the practitioner would be to suppose this some
singular affection of the optic nerve : a species of amaurosis contrasted
with nyctylopia, since it seems inexplicable at first that the patient should
see in the morning, become blind at ten o'clock, and remain so till four.
There is a reflection, however, calculated to give comfort — as the symptoms
vary, so must the cause also vary : and this proves that it is not organic ;
for if the cause were organic derangement, the symptoms would be per-
manent.
h9,
lii PARALYTIC AFFECTION
No. XIX.
Blindness from drojoping of the Eije-lid: and imperfect motion in the
Eye-hall.
A boy, about 1 1 years of age, was brought to me a twelvemonth ago.
He was of a scrofulous habit, had a pale and sickly look, and had disease
in his knee-joint. When the complaint which I have to describe com-
menced, it was in this manner. He came from school, and said to his
mother, " The boys tell me I squint, is that true ?" adding, " I saw two
masters in the school, and two of every thing."
The boy is intelligent, docile, and (his mother says) acute. His
countenance is very peculiar, from his eye-lids having fallen, and his eye-
brows being elevated and arched. He cannot see without throwing back
his head, and looking under his eye-lids, in the manner of a person who
is trying to see from under a green shade. The reason of this is, that if
he keeps his head in the usual position, he can only see the ground at his
feet, but by throwing back his head, without changing the relative position
either of his eyes or eye-lids, he is then enabled to see any thing on the
same level with himself. He has a little more power over the left eye-lid
than the right, but it is clear that he has not complete power over either
of them. He raises the left eye-lid with his finger, and then says he sees
his mother distinctly. Although he cannot raise the eye-lids, lie can shut
them firmly; winking, if the eye be irritated. In the attempt to open the
eyes, he wrinkles the forehead, and arches the eye-brows, but only draws
the skin of the eye-lids smooth, without raising the margins of them.
His mother sa^^s, that when he saw double, she observed his eyes
were both turned to the right side ; objects, however, do not now appear
double. In the beginning, as now, there was a twitching of the face, and
a drawing of the mouth a very little to the left side.
On attending more particularly to the motions of the eye-balls, the
left eye is observed to move in a lively manner, but perhaps not to the
full extent, and the right is more fixed ; but when I close tlie left, and lift
the eye-lids of the right, and place my face opposite to the pupil of the
right eye, he sees me perfectly. Although he sees the liglit when I open
OF THE FACE. liU
either the right or the left eye, yet the iris of the left only is moveable.
The pupil of the right is dilated.
This boy's health declined in the course of a few months. He first
complained of pain in his right arm, and across his nails. He became
subject to headaches, and flushing of the face; he had a wasting of the
muscles of the thumb, and soon after an obvious withering of the whole
arm. Before his death he became quite paralytic, and finally the paralysis
extended over his body generally. Yet it was remarkable that when he
slept, the left arm was always elevated above his head, and altliough his
mother put it down twenty times under the clothes, in a very short time
she found it again stretched above his head. He remained sensible until
two days before his death. He said he was quite willing to die ; and that
as his surgeon had paid him greater attention than any person during his
whole life, he hoped his mother would let him examine his body if he
desired it.
The dissection of the brain exhibited all the common appearances of
acute hydroceplialus : in the ventricles there were about ten ounces of
fluid; the substance of the brain was exceedingly soft, so that it tore, and
became flocculent in the water of the ventricles. On the base of the brain
coagulable lymph was exuded, and it bound the roots of all the nerves,
from the olfactory down to the nhith. The fifth was the most entire; the
third of the right side was hardly discoverable amongst the coagulable
lymph, from its having degenerated and acquired transparency. There
were several scrofulous tubercles in different parts of the cerebellum and
nodus cerebri,
Altliough there be a certain resemblance in the symptoms of these
two cases, yet a careful observer will distinguish a nervous affection, pro-
ceeding from organic injury, in the one case, from tliat which is, in the
other, purely spasmodic. In the boy, there was no part of the functions
of the eye and eye-lids perfect but that which belonged to the portio dura
of the seventh pair of nerves, that nerve which takes its course circuitously
to the eye-lids by the ear and the side of the face; on the contrary, the
functions of those nerves which came througli the bottom of the orbit were
more or less injured. I would be inclined to attribute the first train of
symptoms to the condition of the base of the brain; no doubt, the state of
the boy ultimately was referable to the hydrocephalic condition of the brain.
liv PARALYTIC AFFECTION
And now let me mark the difference of the symptoms in the lady's
case. The disorder did not come on gradually, nor was it permanent at
first ; it came on like a sudden spasm, and as suddenly disappeared. "We
have next to observe that it is a morbid condition, mimicking a natural
state of the eye ; for the action of the eye is here the same as when a
candle is held to a sleepy eye ; it is the condition of the muscles of the
eye, when the organ is excessively irritated. It may, therefore, be de-
scribed as a natural action become permanent ; such a condition, then, as
is consistent with the idea of irritation upon the nervous system : it does
not imply any actual defect, as in the other instance, where the eye-Hd,
instead of being tremblingly alive, hung motionless, and the eye-ball, in-
stead of being turned up with a strength that implies spasm, was simply
limited in its play, or altogether motionless.
No. XX.
Inability to close the Eye-lids,
In the preceding part of the paper I have mentioned the condition of
the eye, in which it appears ever watchful ; the eye-lids do not close upon
it even in sleep, and it has been called oculus leporinus, from the vulgar
notion that the hare sleeps with its eyes open. I have a young lady now
under my care, in whom this condition of the eye was presented, in the
early stage of the complaint, and it still in some degree remains. The detail
of the case may be interesting to your readers. A very few years ago it
would have appeared to me of the utmost consequence for understanding
the functions of the portio dura and the fifth pair of nerves ; even now its
interest is only diminished to me from its frequent occurrence.
This lady, 22 years of age, was attacked six years ago with scarlet
fever and sore throat. Inflammation appears to have been communicated
through the Eustachian tubes to the interior of the temporal bones. On
the left side, the inflammation went on to suppuration : tlie mastoid pro-
cess became carious, and portions of bone were discharged through an
ulcer behind the ear. A small bone, the form of which she cannot de-
scribe, was discharged also from the tube of the ear. During the progress
of this inflammation, she never experienced any diminution of sensibility
in the face ; but a very unpleasant consequence attended this disease of
OF THE FACE. IV
the temporal bone, she became paralytic on all the left side of the face.
During the violence of the attack she could not close the left eye. At this
period, too, she felt pain in the collar-bone of the same side, and such a
degree of difficulty of moving the shoulder-joint, that she describes it by
saying it was like a rusty hinge. At present she is dull of hearing in both
ears, more particularly in the left : her face is a little twisted to the right
side ; which becomes quite a distortion when she speaks, and especially
when she smiles. The eye-lids of the left eye have recovered in a con-
siderable degree, but still she cannot bring the margins of the eye-lids
close together, and in attempting to shut them, the white part of the eye-
ball is seen, as the cornea is turned up.
In this case all my efforts are directed to relieve the scrofulous action
which has been set up in the tympanum. On the second visit I found that
the use of stimulating fomentations to the ear, liniments behind the ear,
and warm gargles, had the effect of removing the remaining paralysis of
the eye-lids.
This case is important, 1st, as showing the office of the portio dura of
the seventh pair of nerves; from its being affected in its course through
the temporal bone, and depriving the corresponding side of the face of
motion, without in any degree depriving it of sensation : 2dly, we see how
the inflammation has been propagated from the throat into both ears ; and
we cannot but reflect on the unhappy consequences which would have re-
sulted had the inflammation in the right ear gone on to suppuration ; for
then the muscular power of the lips, cheeks, and eye-lids would have been
lost on both sides, and the consequences need not be described*: 3dly, we
are directed by the affection of the nerves to the condition of the temporal
bone ; and it cannot escape observation that the temporal bone is a bone
of the cranium, in contact with the brain ; and there is danger of that
affection of the brain which by the old pathologists was called vomica
cerebri. The circumstances of pain and debility in the arm during the
violence of the inflammation sufficiently point out the danger of her con-
dition at that time, and that it should still be our principal object to prevent
any accession of inflammation in the temporal bone, and to preserve the
discharge free.
; * See the case below of the patient who was in the Hotel Dieu, under M, Depuytren.
Ivi PARALYTIC AFFECTION
No. XXI.
Case illustrathe of the action of the Levator PaJpehrce Superioris.
I am tempted to describe the condition of a patient now under my
care, because it exhibits a succession of those phenomena which we seek
to explain. He presented himself to me in the hospital with a distinct
squint, the left eye being distorted from the object. On the eye-lid of
the right eye there was a deep venereal ulcer: the man was in danger
of losing this eye, and required prompt assistance, but before he could
be brought under the influence of mercury, the inflamed sore became
deeper and the cornea opaque. The superior rectus muscle being, as I
suppose, injured by the increasing depth of the sore, the pupil became
permanently depressed. The sight of the right eye being now lost, the
left eye came into use; it was directed with precision to objects, he had
no difficulty in using it, and it daily became stronger.
After a few weeks, medicine having had its influence, the sore on the
upper eye-lid of the right eye healed; the inflammation and opacity of the
eye gradually diminished, the light became again visible to him ; first it
was yellow, and then a deep pur})le. And now the muscles resumed their
influence, and the eye was restored to parallel motion with the other,
so as considerably to embarrass the vision. But the inflammation of the
upper eye-lid had been so great, as to diminish its mobility; and what
appeared most extraordinary, the lower eye-lid assumed the office of the
upper one, and a very unusual degree of motion was remarked in it. It
was depressed when he attempted to open the eye, and elevated and
drawn towards the nose when he closed the eye. The upper eye-lid was
not only stiff, but diminished in breadth ; so that notwithstanding the
remarkable elevation of the lower eye-lid, their margins could not be
brought together, and we could perceive the motion of the eye-ball; in
his attempt to close the eye w^e constantly saw the pupil elevated, and the
white part of the eye exposed.
I shall now attempt the ex])lanation of these phenomena.
The impression u])on the left eye had been weak from infancy, and
the retina being unexercised, the recti, or voluntary muscles, wanted their
OF THE FACE.
1
Vll
excitement, and were deficient in activity; the involuntary muscles
therefore prevailed, and the pupil was turned upwards and inwards, and
consequently removed from the axis of the other eye. But when that
other eye became obscured, the left eye being the only inlet to sensation,
the attention became directed to the impression on the retina, the
voluntary muscles were excited to activity, and they brought the eye to
bear upon objects. This eye improved daily, because the natural exercise
of a part is its stimulus to perfection, both in function and in growth.
When the right eye became transparent, and the light was admitted, the
voluntary muscles of that eye partook of their natural stimulus, and com-
menced that effort in search of the object, which in the course of a few
days brought the eye to its proper axis, and both eyes to parallelism.
The next thing that attracts our attention in this short narrative is
the revolving of the eye-ball. It has been explained in a former part of
the work, that when the eye-lids are shut, the recti, or voluntary
muscles, resign their office, the inferior oblique muscle gains power, and
the eye-ball traverses so as to raise the pupil. It will not have escaped
observation, that the pupil of this eye was depressed, and could not be
elevated by a voluntary act for the purpose of vision, owing, as we have
supposed, to tlie injury of the rectus attollens, at the same time that it
was thus raised involuntarily, in the attempt to shut the eye -, a proof that
this insensible motion is performed by the lower oblique muscle, and not
by the superior rectus muscle.
The circumstance of the lower eye-lid assuming the functions of the
upper one, and moving like the lower eye-lid of a bird, reminds me of an
omission in the account of authors. They have sought for a depressor of
the inferior eye-lid, which has no existence, and is quite unnecessary; for
the motion of the 31. attollens palpehrce superioris opens wide the eye-lids,
and depresses the lower eye-lid, at the same time that it elevates the
upper eye-lid. If we put the finger on the lower eye-lid when the eye is
shut, and then open the eye, we shall feel that during this action the eye-
ball is pushed outwards ; and we may observe, that the lower eye-lid is so
adapted as to slip off the convex surface of the ball, and is consequently
depressed. The reason of this is, that the muscle which raises the upper
eye-lid passes over a considerable part of the upper and back part of the
Iviii PARALYTIC AFFECTION
eye-ball, and the origin and insertion of the muscle being under the
highest convexity of the ball, that body must be pressed forwards in
proportion to the resistance of the upper eye-lid to rise. In the pre-
ceding case the upper eye-lid being stiff and unyielding, both the origin
and the insertion of the elevator j)cilpehrcB became fixed points; con-
sequently, the action of the muscle fell entirely on the eye-ball itself,
whereby it was forced downwards and forwards in an unusual manner,
and so depressed the lower eye-lid to an unusual degree. Thus the
muscle became a depressor of the inferior eye-lid, instead of an elevator
of the upper eye-lid! The motion of elevation in the lower eye-lid was
of course performed by an increased action of the lower portion of the
orbicularis palpebrarum.
No. XXII.
Extract from Mr. Skald's Paper on Partial Paralysis, in the Medico-
Chirurgical Transactions.
" A good example of complete paralysis of the levator palpebral, and
of loss of power in the pupil, without any affection of the retina, occurred
last winter; and I was fortunate enough to have an opportunity of
examining the body after death. A young woman had a fungous tumour
under the jaw; the cheek of the same side was paralytic: the upper eye-
lid of the same side had fallen ; but when the eye-lid was raised, the
patient could see distinctly, although the pupil was fully dilated and
immoveable. Upon dissection, it was found that the tumour had ex-
tended into the lateral part of the orbit ; the fourth nerve ran over the
tumour, the third was in the substance of it, but the ophthalmic division
of the fifth pair was the nerve most destroyed; the sixth was partially
affected. The tumour did not reach as far as the optic nerve. Since all
the nerves of the orbit, except the optic, were included in the disease, we
cannot draw any further conclusion from this case, than that the motions
of the iris do not altogether depend upon the state of the optic nerve.
The voluntary power which some individuals possess over the motions of
the iris will perhaps be considered as in some degree supporting the view
OF THE FACE. lix
which I have taken. The members of the Society are, no doubt, aware,
that one of their most distinguished associates has tiiis voluntary power
over the motion of his iris. Upon an occasion in which the gentleman I
allude to, was so kind as to show me to what an extent he could exercise
this power, I thought I could perceive that the exertion which attended
the attempt had some effect upon the motions of the upper eye-lid."
The following shows the dependance of the action of the muscles of
the eye on the sensibility of the retina.
No. XXIII.
Case of Strabismus with Affection of the Eye-lid,
Cromer, March 11, 1829.
" Sir, — I feel much obliged by the favour of the letters I received from
you; beneath you will see the remarks I have been able to make on the
case, and I shall always be happy to contribute such others as it may be in
my power to supply.
** I am, Sir,
" Yours most respectfully,
" C. S. Earle.
"In Wortley, the falling of the eye-lid is not the whole cause of one
eye only being used at the same time. The foci of the eyes are not alike,
the focus of the right (viz. the sound eye) being the common distance,
while that of the left is several inches more. When the right eye is
directed to any object, the left eye-lid falls, but it can be elevated at will,
though not completely so; when it is thus elevated the eye-ball is turned
upwards and outwards, and is then not under the influence of the
voluntary muscles ; but if the right eye-lid is closed, the left eye-lid can
not only be elevated, but the eye-ball will resume its proper position ; it
cannot, however, be turned in the slightest degree further towards the
nose; it can be directed downwards, but then the eye-lid follows it, and
half closes it; when an effort is made to move it upwards, it inclines
i <2
Ix PARALYTIC AFFECTION
slightly outwards at the same time; it perfectly retains the power of
being directed outwards.
" The right eye can be turned in any direction by the voluntary
muscles.
" When he looks at an object with the left eye he drops the right eye-
lid, but after a short time he can elevate it again, without altering the
position of the left eye ; the right eye, however, will be found precisely in
the same state as the left is in, when the right eye is used (viz. turned
upwards and outwards, and not under the influence of the voluntary
muscles until the left eye is either closed or directed from the object).
" If the finger is applied to the left eye-lid while it is closed, and an
effort is made to shut the right eye, the eye-ball can be distinctly felt
rolling upwards and outwards.
" He is not troubled with seeing red or yellow light through the
closed eye-lid.
" The power of sensation, and also of expression (except so far as I
have noticed), is perfect on each side of the face."
No. XXIV.
Case of Partial Paralysis.
*' Mary Brown, aet. 15, a pale and emaciated girl, was in the phy-
sicians' ward for an obstinate constipation of the bowels, and for some
symptoms of paralysis.
" We learn, that when four years old she fell and struck the back of
her head; she was stunned by the blow, and remained insensible for a
short time. She was for two days sleepy and lethargic, when it was
observed that the left side of the body was completely paralysed; this
paralysis continued for fifteen months, without any amendment taking
place. After this period she improved slowly, and at the end of another
twelvemonth she was so far recovered as to be able to walk; the disease
tlien remained stationary, and no alteration appears to have taken place
up to the present time.
" She is in a very feeble condition: the paralysis seems now to be
OF THE FACE. Ixi
confined to the left side of the face, with the exception, however, of the
left arm, which is much weaker than the right. There is not only a
want of power in the muscles of the left arm, but the sensibility of the
extremity is evidently impaired, for she is unable to perform those actions
which require the combination of the delicate sense of touch, and the
finely-regulated action of the muscles. She cannot pick up a pin.
" The sensibility of the left side of the face is but little affected. The
parts supplied by the portio dura on this side have lost all their motion;
the mouth and right ala of the nose are dragged towards the right side.
She is unable to move the left side of her face, even in the sliahtest
degree. When she smiles, this side is void of all expression, and is in
strong contrast with the opposite side. She says that the food is apt to
lodge on this side of the mouth, betwixt the cheek and the gums. The
inability to close this eye-lid affords us a good opportunity for observing
the motion of the eye-ball in the act of winking. Every time that she
winks, the uncovered eye-ball of the left side is turned up, and as quickly
descends again. This motion of the eye-ball is performed with extreme
velocity, but at the same time is so obvious and demonstrable, that the
most careless observer could not overlook it. In order to see the same
motion of the eye-ball performed more slowly, she was desired to attempt
to close her eye-lids; when it was observed that the eye-ball was turned
up in the same manner, and remained so until she again unclosed the
eye-lid of the right side. The senses of taste and hearing on this side are
impaired; the sight is dim, but she sees the whole of an object. The
tendency to constipation of tiie bowels was coeval with the paralysis, and,
no doubt, depended upon it." From the House-Surgeon's Case-Book.
This is one of the cases where the brain has been so influenced as to
affect the whole nerves, both of sensation and volition, of one side. As to
the fact of the rolUng of the eye, it is conclusive.
The following note was drawn out by one of my pupils : —
Ixii PARALYTIC AFFECTION
No. XXV.
Case of Partial Paralysis of the Face.
" During the last course of lectures in Windmill Street, while Mr.
Bell was giving his lectures on the nervous system, a gentleman, who
had been a pupil of another school of anatomy, came to consult him on
his own case. His face was distorted, the muscles being completely
paralysed on one side ; he retained the sensibility equally on both
sides. He presented the exact case, which we had heard described at
lecture as an affection of the portio dura of the seventh pair of nerves.
" We observed the eye-ball of the side affected. When he winked,
the eye-ball revolved upwards and inwards, and there was no doubt or
difficulty in observing this movement, as the eye-lids remained wide open
at the time when the eye-lids of the other side contracted.
" He ascribed the origin of this affection to having imprudently sat
without his coat reading at an open window, after being fatigued and
heated with a long ride. This paralysis of the face, and a stiffness of the
neck, attacked him nearly at the same time.
I ** We (the students present) showed him the dissection of the nerves
of the face, which had been prepared for lecture. He examined it with
great interest, and the explanation of his case was apparently new to
him."
I have lost the other notes on this case.
If the reader will turn to authors upon the diseases of the eye, under
the head of Lagoj^hthalmia, he will see how much practitioners are mis-
taken in applying the remedies to the eye-lids in this disease, when the
cause may be in the temporal bone, or the glands near the angle of the
jaw, or some remote nervous irritation. Oculists, as Richter, for example,
when the eye-lids do not close, recommend rubbing the eye-lids once or
twice a day with a drop or two of fennel oil, frictions upon the eye-lids
with the tinctura cantharidis, blisters near or immediately upon the
eye-lids, the application of cold water to the eye by means of compresses
wet very often in the course of the day, &c.
OF THE FACE. Ixiii
No. XXVI.
Case of Paralysis of the Face.
"January 2, 1827, Daniel Stalder accompanied his wife, who had a
paralytic stroke, to the Middlesex Hospital. It was observed that the left
side of his face was much distorted, and there was great wasting of the
muscles. He was examined by Mr. Bell, before the pupils of the hospital,
and it proved to be a case of paralysis of the portio dura. The two sides
of his forehead presented a very striking contrast: the right side was
furrowed with deep wrinkles, which were more strongly marked when he
frowned; and a large fold of the skin was prolonged down upon the same
side of his nose, which marked the descending slip of the occipito frontalis
muscle. The left side of his forehead was perfectly smooth, the skin
appearing to be stretched tightly over the bone, and there was no motion
of the integuments in the act of knitting or elevating his eye-brows. His
left eye-lids were quite motionless. When he was desired to wink, this eye
remained open, and the cornea was elevated so as to be quite hid under
the upper eye-lid. This eye appeared a little duller than the other, yet
he says he never had any disease in it. He cannot see so clearly with it
as with the other eye. The left nostril is collapsed, and has not that
fulness which the right possesses. He seems to retain some power of
acting with his cheeks, as in whistling there is a slight quivering ob-
served. Although his lips are dragged to the right side, they do not
appear to be totally deprived of muscular power: he can grasp the point
of the little finger pretty firmly when it is introduced into the left angle
of his mouth. The muscles of the neck are perfect: the fibres of the
platysma myoides start out when he puts it into action. The skin has
its natural degree of sensation. He states that he has had this aifection
since he was a child. He has had no deafness; nor any disease which he
can remember to have preceded this distortion of his countenance."
I have introduced this case, because the patient is at this time about
the Middlesex Hospital, and can be seen as affording an instance of the
effect of early paralysis in the seventh nerve.
Ixiv PARALYTIC AFFECTION
On one point the following case is unsatisfactory, and, therefore, I
am bound to give it: —
No. XXVII.
Partial Pa?'alysis.
*' I take the liberty to transmit to you this case, as it is curious, and
bears strongly on the physiological doctrines taught by Mr. Charles Bell.
If you are acquainted with him, or could obtain his opinion on it, I should
feel much gratified, and greatly obliged to you.
*' I am. Sir,
" Your obedient Servant,
" J. "Webster.
" Ramsgatej 22d August.
" A healthy male child, four months old, of a plethoric habit, w^as
very restless during the night of the 11th of August; a dose of calomel
and scammony had been given him the day before, and the mother supposed
the restlessness was owing to this circumstance. She observed, however,
that when he cried, his face was drawn forcibly to the left side. 12th.
The aperient was repeated. 13th. On a careful examination there is
nothing remarkable behind the ear or about the angle of the jaw, and the
child allows the parts to be handled without shrinking. There is an
evident puffiness above and below the zygoma. With the exception of
the eye, the features on this side of the face of this lively laughing little
fellow are quite without expression. When he laughs, the muscles of
expression on the left side are thrown into considerable action, and when
he cries, (from the loss of all antagonising power,) into the most dis-
agreeable distortion, the right eye remaining wide open ; the orbicularis
palpebrarum, the corrugator supercilii, as well as the rest of the muscles
on this side, remaining quite relaxed. The nose is drawn to the opposite
side."
The communication describes the remedies and their effects, and
then proceeds : —
OF THE FACE. Ixv
" When he is made to wink, the left eye-lid moves with rapidity,
whilst the right is quite stationary. The occipifo frontalis partakes also
of paralysis; for when the child looks earnestly at any object, the eye-
brow and skin of the forehead on the left side are drawn upwards, but on
the right there is no corresponding motion. During sleep, the aifected eye
is only partly closed. The sense of feeling is alike on both sides of the
face.'*
In writing to Mr. Webster, I requested to know the condition of the
eye-ball; the answer was not satisfactory.
" October 6, 1826.
** The right side continues relaxed and flabby, so as to give to the
cheek the appearance of being larger than the other. The upper lip, on the
affected side, overhangs the lower. If the child's attention is fixed, and
the hands are suddenly clapped together before the face, the left eye-hds
move rapidly, and the right upper eye-lid in part falls and recedes with a
trembling irw^tion, but the eye-ball is not moved. When the child sleeps,
the aperture formed by the want of approximation of the lower eye-lid to
the upper, crosses about the middle of the cornea ; so that the direction of
the eye-ball is that of a person looking downwards. On raising the eye-lid
with the finger, so as not to disturb the child, and holding a strong light
suddenly before him, the eye-ball is pulled downwards and outwards."
The letter concludes with an apology for not answering my letter
sooner, " owing to the almost constant habit of the child nestling his face
in the pillow, as it were to avoid the annoyance from light which the open
eye is exposed to."
This is the only instance in which observation is at variance with my
statement, that the eye-ball revolves upwards when the eye is threatened.
It is not necessary to carry the proofs further. In the following in-
stance, extracted from a long and circumstantial case, the same effects are
seen which result from the paralysis of the portio dura of the seventh
nerve.
Ixvi PARALYTIC AFFECTION
No. XXVIII.
" Masters, aet. 27. — His friends first remarked the distortion of
the face. One eye was more disclosed than the other. The eye-lid of the
left side did not move when the other was winking. This eye was not-
withstanding clear, because the inferior part of it was covered by the lower
eye-lid, whilst the upper part was moistened, during the act of winking,
by revolving upwards under the upper eye-lid. When he was asked to
blow his nose, the eye turned suddenly upwards under the eye-lid."
No. XXIX.
Paralysis of the Face from injury ofilie temporal hone.
I received from Mr. Perry, of Great James Street, a note, giving me
the account of a child who fell from a swing, and had paralysis of the
face. He was stunned, and bled from the right ear, and was deaf in that
ear. Three weeks after, the child became paralytic on the right side of
the face, with great distortion of the features. After a judicious anti-
phlogistic treatment, without effect, the paralysis disappeared under the
influence of mercury.
This is not a solitary instance of paralysis of the face from injury of
the temporal bone. It will be readily admitted, that whilst it was believed
that the five branches of the fifth pair of nerves, distributed to the face,
were muscular nerves, or nerves of voluntary motion, such a distortion as
this could not have been attributed to its real cause, the injury of the
portio dura in its course through the bone, but, on the contrary, to the
injury of the brain itself. This case, therefore, affords another proof of
the practical benefit to be derived from knowing the distinction in the
functions of the fifth and the seventh nerves.
OF THE FACE. Ixvii
No. XXX.
Disease of the Face.
Eliza Smith. — The following is one of the cases which is demonstrative
of the distinct functions of the seventh and fifth nerves.
" The disease from which this woman suffers has been supposed to be
that sometimes called Noli me tangere, and in its more aggravated form,
Ltupus. The nose was destroyed by a slow process of ulceration, which
opened the cavities of the face, so that we could look into the oethmoid
and maxillary cells. At this stage an ointment was used which had the
happiest effect wherever it could be applied, and she appeared nearly well.
But a small speck of ulceration remained upon the os planum, deep in the
cavity : it could not be arrested. The disease in that way got into the
orbit.
" The eye-ball became now protruded from the socket, with tension
of the eye-ball and tumefaction of the conjunctiva, attended with excru-
ciating pain. At length the eye-ball became so much pushed out, that the
eye-lids could not meet ; the cornea was continually exposed, and became
opaque." (And now the symptoms began to bear on our present subject.)
" The sensibility of the surface of the eye, though in a state of ulceration,
was lost. She could press her finger upon the eye. The forehead of
the same side, the lip, the cheek, and side of the nose, were deprived of
sensibility ; at this time she could move the eye-lids, although she could
not close them from the bulk of the eye, and she had the motion of the
cheek and lips.
" When the eye and temple were perfectly insensible, and when, as she
herself said, she could pick off the scales from the surface of the eye without
feeling at all, she was tortured with most excruciating pain seated in these
very parts ; that is to say, referred to these parts."
But on the 28th December there is a note of this patient's case, which
describes the swelling to have extended to the temple, the eye to have
k 2
Ixviii PARALYTIC AFFECTION
fallen, and where there was insensibility before, she could not bear the
touch of a soft sponge.
** She for some time previous to this, complained of a drumming and
a weary pain in her right ear ; and now she cannot knit her brows, or
move the eye-lid, and when she speaks or blows there is a stillness in all
that side of the face."
This case requires little comment. The swelling of the parts within
the orbit, compressing the fifth nerve, caused insensibility of the part of the
face to which these branches were distributed without affecting the motion.
When the tension and swelling subsided, there was returning sensibility ;
but more than this, the inflammation affecting the nerves in their passage
through the orbit gave the sensation of excruciating pain, perceived as if
in the face. An inflammation of a nerve does not give perception of pain
in the proper seat of the disease, but in the part to which the extremity of
the nerve is distvibuted.
Whilst the sensibility of the face was recovering (by the diminution
of pressure on the nerves in the orbit), the motion of the features was
arrested. But previous to this the ear became affected, by which it is
implied that the seventh nerve had become compressed, or engaged in the
progress of the swelling.
I shall add here some familiar instances and cases to show the im-
portance of the knowledge of the nerves of the face in the investigation of
disease.
No. XXXI.
*' J. Richardson, October, 1820. On first looking at this man, there
does not appear to be any thing unusual in the state of his face ; but the
moment he speaks or smiles, the mouth is drawn to the left side. When
he laughs, the distortion is increased ; and when he sneezes, the difference
between the two sides is quite extraordinary.
" On holding ammonia to his nose, it was observed that he could not
inhale freely with the right nostril ; and, on examining the state of the
OF THE FACE. Ixix
muscles, when the act of sneezing was excited by the ammonia snuffed up
by the left nostril, it was found, that not only those of the right side of the
nose and mouth, but also of the eye-lids, were passive, while all the muscles
of the left side were in full action. When he blew, or attempted to whistle,
the air escaped by the right angle of the mouth, the right buccinator not
at all corresponding in action with the muscle of the left side, nor with
that of the muscles of the chest and neck, by which the air was expelled.
The sensibility of the paralysed cheek was equal to that of the other side,
and he could close his jaws with equal force on both sides."
The early history of the case, according to the account given by the
patient's friends, was this :
" He was seized with a severe pain under the ear, and in a short time
became so delirious, and his face so distorted, that the people in whose
house he lodged, supposing him to be mad from brain fever, carried him
to the parish work-house. There he lay until his friends discovered him,
and brought him into the hospital. It was then found, that the frenzy
which had led the people of the lodging-house to suppose that he was mad,
was only a high state of delirium, in consequence of a severe attack of
cynanche parotidea. Indeed the inflammation had run so high, that an
abscess formed and burst under the ear. When the swelling subsided the
degree of paralysis was very observable."
The delirium and the paralysis of the face naturally led the medical
gentlemen who first saw this patient to suppose that the symptoms were
caused by an affection of the brain. Luckily, the treatment generally fol-
lowed in cases of phrenitis was best adapted for the particular affection
which had caused both the delirium and the paralysis. The portio dura
being engaged in the inflammation under the ear was the true cause of the
paralysis.
For the next case I am indebted to a physician in Worcester :
Ixx PARALYTIC AFFECTION
No. XXXII.
" Worcester, July 25, 1824.
" Dear Sir, — My acquaintance with the nature of your late researches
upon the functions of the nerves induces me to send you the following
case :
" A young gentleman, aged 14, residing in the village of Kempsey,
in this county, was observed by his family to have the expression of his
countenance much altered. As long as the features were quiet, nothing
unusual was observable in the countenance ; but as soon as any passion
was excited, the expression of the face was so different to what was natural
to him, that his brothers and others of the family complained of his ' making
faces at them.' He, in fact, smiled, laughed, or frowned only upon the
left side of his face, the muscles of the right side remaining inactive; and,
as they passively yielded to the contraction of the muscles of the left side,
the countenanccj of course, was much distorted whenever these were called
into action. He lost the power of whistling, and, for the same reason, of
blowing, and was unable to close his right eye. The sensibility of the
right side was as perfect as that of the left. He was quite unconscious of
any change in himself, and was not at all aware of the distortion of his coun-
tenance when he smiled, &c. This affection did not occur suddenly, but
seemed gradually to increase, and became so evident in the course of a
week, as to induce the father of the young man to send for his apothe-
cary, Mr. Bick, of Kempsey. When Mr. B. saw him he found the symptoms
as above stated; but upon examining the right side of the face more mi-
nutely, he discovered a fulness immediately beneath the right ear, produced
by a hard, fixed, and indolent tumour, lying between the ramus of the
lower jaw and the mastoid process of the temporal bone.
" He ordered him some aperient medicine, and directed the tumour
to be rubbed with camphorated oil. In a fortnight the tumoiu' disappeared,
and with it, gradually, the paralysis of the muscles of that side of the face.
It is a fortnight since Mr. Bick first saw him, and he has now recovered
every power, excepting that of blowing or whistling. I saw him several
times during the progress of his cure. It appears to me that the portio
OF THE FACE. Ixxi
dura of the seventh pair was, in this case, injured by the pressure of an
enlarged gland soon after its emergence from the stylo-mastoid foramen,
and that upon the removal of the pressure its functions were restored.
" I remain, dear Sir,
" Your obedient servant,
" Jonas Malden, M.D."
The danger to which the eye is exposed by paralysis of the portio
dura, or by any operation on the face, in which its functions are not
attended to, is well illustrated by the following case: —
No. XXXIIL
*' This poor man, about nineteen years ago, was attacked by a severe
pain accompanied with discharge from the right ear. After a paroxysm
severer than usual, he found, on getting up one morning, that the right
side of his face was paralytic. His present condition, and the description
which he gives of the progress of the symptoms, prove that the same results
followed this paralysis, as in the instances already related. But what this
poor fellow particularly laments is, that since the day he was first attacked,
he has not been able to close his right eye ; and well he may regret this,
for the constant exposure of the eye to the light and dust has been the
cause of many attacks of inflammation, and, consequently, of opacity of the
cornea, so that the vision is now entirely lost. This, I fear, will often
occur in similar cases, for I have observed that the eye has always become
inflamed in those animals in which the portio dura has been cut. It is
worthy of remark, that the inflammation has been more severe in the dog
and in the ass than in the monkey. One great source of the increase of
the inflammation is the purulent secretion from the conjunctiva; this the
monkey wiped away with his hand ; but it lodged between the eye-lids of
the dog and of the ass, so as to form an additional source of irritation."
The ultimate effects of the loss of power over the muscles of the face,
in consequence of an affection of the portio dura, are shown in the fol-
lowing extract : —
Ixxii PARALYTIC AFFECTION
*• A most remarkable appearance in the face of Garrity is the wasting
of all those muscles of the face which are subservient to respiration and
expression. His cheek is so thin that when he speaks it flaps about as if
it were only skin, and the corrugator supercilii and occipito-frontalis, which
are principally muscles of expression, are so wasted, that we might, at first
sight, suppose they had been removed by operation, and that now the
bones were only covered by skin. There can be little doubt that the
wasting of these muscles has been in consequence of their long inactivity ;
since the masseter and temporalis muscles of the same side, which retain
their office, are not at all diminished in size, being as large as those of the
opposite side."
A curious example of a contrary effect produced on the growth of the
muscles of respiration and expression, by an injury of the portio dura, was
afforded in an experiment made upon a young dog. After the nerve was
cut he was taught to snarl whenever a stick was held out to him ; this
being often repeated, the muscles of the side upon which the nerve was
entire became very strong, while those on the paralysed side rather dimi-
nished than increased as the dog grew older. In a few months the one
side of the face was much lai'ger than the other. Every day we see similar
results following palsy of the muscles of the limbs.
Many instances will now occur to my reader of cases where tlie para-
lysis of the face, consequent on a local affection of the portio dura, has
been mistaken for an attack of apoplexy, and the patient treated accord-
ingly. In one case the patient, after having undergone the discipline of
bleeding, purging, and starving, and after having had his head shaved and
blistered, was suddenly cured by the bursting of an abscess in his ear.
No. XXXIV.
♦' In another gentleman, the disease commenced with a violent pain
below the ear, and in a short time one side of his face became paralysed.
For this paralytic affection he consulted many eminent men. The first plan
of treatment was bleeding, blistering, and starving, the disease being sup-
posed to have its origin in the brain ; but as he got rather worse than
OF THE FACE. Ixxiii
better under this treatment, he was put upon a course of mercury, which
was carried to such an extent, that he lost several of his teeth. After he
recovered from the bad effects of the mercury, he was recommended to
attend only to the state of his digestive organs. But the blue pill had no
effect upon the distortion. The last advice which this gentleman received
was to wear an issue in his neck ; with this, however, he has not complied,
as he feared it would, like some of the other remedies, have the effect of
rendering him more uncomfortable."
A great many cases, somewhat similar, have been presented to me by
my pupils; I will add only three other instances, two of which are from
papers by Mr. Shaw.
The first regards a patient who had suffered an attack of common
apoplexy; it may be offered in example of that train of symptoms which is
consequent on an affection of the original or symmetrical system of nerves,
and as distinguishable from those which follow an affection of the super-
added class. The second is of a man, in whom both the portio dura and
the fifth had been injured by a blow; and the third is of a patient in whom
both these nerves seem to have been affected by a disease within the skull.
No. XXXV.
"J. Cooper. — This man's general appearance is completely that of an
old paralytic, but the distortion of his face is more remarkable than usual,
in consequence of the right or paralysed side being marked with a red blotch.
" The arm and leg of the same side are nearly powerless, his intellects
are much impaired, and his memory gone. The history of his case was
given very clearly by his wife. According to her account, her husband was,
for the first time, attacked with apoplexy about seven years ago; from this
attack he gradually recovered, but at the end of twelve months he was a
second time seized, and, since that period, he has had two distinct attacks
every year ; for the last two or three years he has been nearly in the same
condition as at present.
" State of the cheelts and mouth. — When he is made to laugh, the right
cheek rises in the same degree with the lefl ; when he blows (lie always
I
Ixxiv PARALYTIC AFFECTION
bursts into a laugh when asked to whistle), the buccinator of the right
cheek is in as much action as on the other side. When his nose is irritated
by snuffing ammonia, the actions of the muscles, preparatory to sneezing,
are equal on both sides of the face. The right cheek, and the right side
of the mouth, fall lower than the left. When a piece of bread was put
between the teeth and right cheek, the patient could not push it from its
place, but was obliged to pick it out with his tongue. The saliva constantly
flows from the right side of his mouth, and when drinking, part of the
fluid escapes from the same side. The loss of the sensibility of the orbi-
cularis oris was farther shown by the inabihty to hold a pencil, or a
tobacco-pipe, in the right side of his mouth.
" The comparative degree of sensibility in the two cheeks was next
examined ; when he was pricked on the right cheek with a needle he
seemed perfectly insensible, even though I drew blood ; but on giving
the least prick to the left side, he immediately started; the same difference
in the degree of sensibility was observable in pulhng a hair from each
whisker. The sensibility of the right and left limb corresponded with that
of the cheeks.
" On putting hartshorn to the right nostril he inhaled it as well as with
the left, and immediately all the symptoms observable in a person about to
sneeze were presented*. As the nose was turned up, and the alae nasi of
both sides were equally in action, this was a sufficient proof of the state of
the paralysed side being here very different from the condition described
in the foregoing cases. The power of the fifth over the nose was tried:
by tickling the inside of the right nostril no effect was produced; but on
tickling the left nostril the symptoms of sneezing were again evident.
** The motion of the eye was perfect.
" He could close the eye-lid of the paralysed side as well as the other ;
and when his nose was irritated by the hartshorn, or when he laughed, the
orbicularis oculi and corrugator supercilii were in complete action, so that
there was not here that heaviness in the expression of the upper part of
the face, which is so remarkable in paralytic persons. Here, then, was
* The apparent sensibility of the nostril over which the fifth had lost its influence may be
explained, by supposing that the fumes of the ammonia passed by the posterior nares to tlie
other nostril, and thus caused sneezing.
OF THE FACE. Ixxv
proof that those actions of the eye-brows which we find to be deficient,
when the portio dura is affected, are, in a case of common palsy, left
entire ; indeed, we may have daily opportunities, while walking in the
streets, of observing that patients with palsy of one side of the body, have
no difficulty in closing the eye-lids."
In the next case, both systems of nerves seem to have been affected.
No. XXXVI.
** Phipps, a bricklayer, on the 1st of September, 1821, fell from a scaffold
thirty feet high. His right clavicle was broken, his right loin and hip were
much bruised, and he received a severe contusion on the head, the marks
of which were particularly observable in a puffiness behind the right ear,
and in bleeding from the same ear and from the nose.
" He was in a state of stupor when brought into the hospital, but from
this he recovered in the course of the day. For the two or three first days
he appeared to suffer only from the effects of concussmi, never having any
of those symptoms which are generally attributed to compression. On the
fourth day it was observed, that the angle of the mouth was drawn rather
to one side, and there was also a degree of inequality in the contraction of
the pupils.
" On the sixth day it was remarked, that while he was asleep, the right
eye was more than half open, while the left was closed.
" The notes of the case are very full up to the 24th of September, and
show that the patient had, during the interval, gone through the common
series of symptoms which accompany that sligiit inflammation of the brain
which is often tlie consequence of concussion.
*' On the 1st of October, he was made an out-patient, his face being, at
this time, very much distorted. Tiie general appearance of his face was
that of a man who has suffered paralysis from apoplexy; but it was further
remarkable, that when he spoke or laughed, the distortion was much in-
creased, the mouth being pulled more to the left side than I ever saw in
any other patient.
/2
Ixxvi
PARALYTIC AFFECTION
" The following notes were taken at this time. There appears to
be total paralysis of the muscles of the right side of the face. When
he smiles or laughs they are passive, while those of the left are regu-
larly in action. If he attempt to whistle, he cannot close his lips suf-
ficiently; when he blows, the right cheek is dilated, but passive like a
distended bladder ; he can smoke, by putting the pipe into the left side of
his mouth ; he throws the smoke out of the right side, but in doing this,
the action is evidently confined to the muscles of the left cheek.
" The cheek and mouth hang down, as in the common case of hemi-
plegia— he cannot by a voluntary act move his cheeks ; when a piece of
bread is put between the cheek and teeth of the right side, he cannot push
it out with the buccinator, but picks it out with his tongue. He cannot
hold his pipe or a pencil with the right side of his lips. These may be
considered as sufficient proofs of the total paralysis of the muscles of the
face.
" The difference of the sensibility in the two cheeks was very distinct.
When a hair of the right whisker was pulled, he was not conscious of pain ;
but he started immediately on pulling one from the left. When his cheeks
were pricked with a needle, his expression was — ' I feel you push against
the right side, but in the left you prick me.' When he brought his jaws
forcibly together, he said he was not conscious of striking his teeth on the
right side, although he felt them most distinctly on the left. On examining
the state of the nose, we found that it was impossible to excite the muscles
of the right nostril to any action.
•' Both the orbicularis oculi and corrugator supercilii were so com-
pletely paralytic, that he could neither close his eye, nor knit his brow on
the right side.
" On examining how far the branch of the fifth, which passes to the eye
and eye-lids, was affected, we found that the symptoms did not exactly
correspond with those observed in the parts regulated by the other divi-
sions of the fifth pair, for when a hair was pulled from each temple, or from
the eye-brows, the pain felt in the two sides was nearly the same. Neither
the temporalis, nor masseter muscles of this side were paralysed. The
motions of the eye-ball were so far perfect, that he could follow an object
carried before him, but he could not direct both eyes truly, he saw double.
OF THE FACE. Ixxvii
The contraction and dilatation of the pupil of the right eye were much the
same as in the other eye.
" He can put out the tongue and move it in every direction with the
greatest ease: the motions are all apparently correct and natural; he can
throw a morsel from one side of the mouth to the other, and towards the
throat, and he can pick it out from between his cheek and teeth.
" These observations led us to conclude, that not only the motor lingu£e,
or ninth nerve, but also the glosso pharyngaeal were perfect."
This case differs from the common examples of partial paralysis of the
face, not only in there being evident marks of paralysis while the muscles
of the face are at rest, but in the sensibility of the skin of the same side
being in a great measure destroyed. It differs also from the case of hemi-
plegia.
The first difference which we observe in it, from the case of common
hemiplegia, is, that the paralysis is confined to the face. Secondly, that
the paralysis is on the same side with that on which the head is injured.
Thirdly, that the palsy is more evident, when the patient is made to
sneeze or laugh. From these circumstances, we may conclude that there
was here an injury of the skull affecting both the fifth and the seventh nerve.
No. XXXVII.
James Gulland, aetat. 26. — Was admitted into the Middlesex Hospital,
April 1.5, 1823. His mouth and left cheek are twisted towards the right
side : the whole surface of the left side of his face is insensible : he has lost
the power of moving the eye of that side, and it has lately become inflamed ;
he complains of a deep pain in the temple of the same side.
His trade has been so profitable as to enable him to live in a most
dissipated manner during the last five years. He has frequently strolled
about the streets at night in a state of drunkenness, and has for three weeks
never thrown off his clothes, and has been seldom in bed. He has been
twice affected with syphilis ; he was confined by his first attack for eighteen
months, during which time he was under the influence of mercury. After
regaining his health, he frequently experienced a pricking pain in his left
Ixxviii PARALYTIC AFFECTION
eye and temple, so severe as to prevent his reading, especially by candle-
light. About twelve months ago he was knocked down : he fell on the
back of his head, and wounded the occipital artery ; he thinks that he has
never been quite well since that time. On the 13th of October, last year,
one of his comrades noticed to him that his mouth was drawn to one side ;
this induced him for the first time to observe in a looking glass the con-
dition of his face. He tried to spit, and observed that his saliva, instead
of passing through the centre, was squirted out of the right corner of his
mouth, which was contracted. His lips were in other respects perfectly
natural, being possessed of sensibility and the power of motion. He could
then likewise close the eye-lids of the left eye, but to do this he required
to shut the other eye also.
On the following morning he was conscious of a peculiar numbness
above the left eye. This numbness gradually spread over the left cheek,
and at the same time affected the external and internal surfaces of almost
all that side of his head. He lost the sense of taste on the left side of his
tongue, and in little more than a fortnight he became deaf in the left ear.
Now he complains principally of the inflamed condition of the left eye
(which commenced about ten days ago), and of the pain in his left temple.
The above circumstances he himself could relate distinctly. The
following is an account of his present condition, April 20.
The left side of his face is drawn towards the right, and is slightly
oedematous. The left nostril is collapsed, and does not expand during
breathing. The mouth is distorted towards the right side. When he
speaks, the two sides of his face are distinctly marked by a line of division;
the action of the muscles of the mouth and nostrils, on the right side, being
quite distinct, while those on the left are motionless. He has lost all power
over the left eye-lids ; until lately, he could elevate his upper eye-lid,
although, since the time of his first attack, he has always experienced a
certain difficulty in closing it. At present the eye-lid hangs down flaccid
and shut ; he is unable to press the eye-lids together.
The sensibility to touch is gone on the greater part of the left side of
his head and face, and this insensibility extends to the vertex of the head.
OF THE FACE. Ixxix
The surfaces of the conjunctiva and eye-Hds are also completely insensible;
the eye is inflamed and ulcerated ; the left side of the nose, the cheek, the
upper and lower lips, are all equally insensible ; but he is sensible when
touched upon the left side, below the under jaw, and even over the lower
jaw itself, as high as the inferior part of the lower lip. The external ear,
and likewise the back part of his head, nearly as high up as the vertex,
retain their natural sensibility.
The internal surfaces of the left nostril, and of the mouth and gums
on the same side, are insensible to touch ; and he has neither the sense of
taste nor common feeling in this side of the tongue. In consequence of this,
portions of food have sometimes lodged within the left side of his mouth,
without his being aware of their presence, until they became actually
putrid.
The power of moving his tongue is quite perfect : if at rest, it lies in
its natural position within the mouth ; nor is it dragged towards either
side when he is told to move it. Being tickled with a probe on the left
side of the root of his tongue, the sensation of nausea and the effort of
retching are produced as on the opposite side. He can open and close his
jaws ; yet it can be observed, when he is made to clench his teeth, or to
bite forcibly, that the masseter and temporal muscles of the right side are
hard, rigid, and strongly in action, while the same muscles belonging to
the opposite side are totally different in that respect, for they feel soft and
flaccid.
With regard to his left eye, it has been ah'eady noted, that it is de-
prived of common sensibility, and that he has no power of shutting or
raising his eye-lid. Besides these, he possesses no command over the
eye-ball : his eye remains fixed and motionless, and directed straight for-
wards. No motion exists in the pupil when a light is presented to the
eye. He has the power of vision, although he sees dimly; this is, pro-
bably, on account of the eye being inflamed, and the cornea ulcerated
and opaque. When both his eyes are closed, he is sensible of a red light
in the left eye, while nothing is visible in the right one *.
* See remark on this, in the first paper on the motions of the eye.
Ixxx PARALYTIC AFFECTION
He was questioned as to the period when he observed that he had lost
the power of directing the left eye to objects, but he was unable to inform
us, because he had always imagined that the one eye was as much in motion
as the other.
August, 1824. — Several of the symptoms of paralysis, both of the
portio dura and of the fifth, are become more indistinct ; he has re-
gained a little power over the motions of the eye-lids, and of some of the
muscles of the face, and the surfaces are endowed with a slight degree of
sensibility.
In this case we may observe, that the symptoms show the affection to
be limited to the seventh and fifth nerves of the left side, and they best
correspond with the supposition, that a disease of the bone, or membranes,
has affected these nerves in their course, and is gradually extending forward
to the nerves of the orbit.
No. XXXVIII.
Affection of the Nerves of the Face.
A gentleman, of 25 years of age, consulted me on the recommendation
of Dr. Cheyne, of Dublin. He begins the history of his complaint so far
back as 1825, when he had pains in his head, which came on for two or three
hours in the day, and which he attributed to bathing in the river. These
pains affected the left temple and side of the nose. They increased in-
sensibly, but were not constant ; on the contrary, during his travels they
changed so as to make him attribute the variations to the effect of some
peculiarity in his place of residence. Thus he left Paris on the 1st of
October of that year, and, " strange to say, the pain which afflicted me
so severely and constantly, both night and day, suddenly left me before I
was twelve miles from Paris, and did not return during that month whilst
I remained in London." But when he went home to Ireland, his old pain
attacked him with greater violence than before. There were some further
irregularities in these attacks of pain. Thus, on one occasion, on taking
OF THE FACE. Jxxxi
wine, the pain suddenly left him : on another, while sitting at dinner, the
pain became suddenly so severe, as to require persons to hold him in the
agony of his sufferings.
In the summer of the second year, having gone to the coast for sea-
bathing, the pains increased with a new train of symptoms j his sight
frequently became dim for a short time, and things appeared to turn
topsy-turvy. Now for the first time he took medical advice : and his
surgeon, after acting upon the belief that this was nothing more than the
effect of disordered bowels, advised him to go to Dublin, for his jaws
became affected. He found, one morning, that they were locked, and says
he was obliged to open his mouth with his hands. This spasm gradually
went off in the course of the day, and the pain subsided. Next morning
he found a great stiffness about his mouth, and felt as if his lips were
swoln. " But," he adds, " this was but the commencement of that stiffness
which has been my complaint ever since."
In Dublin he had leeches applied, his head was shaved and blistered
with tartar-emetic ointment ; blisters were applied behind the ears, and
he took strong doses of calomel. The medical gentlemen there made him
walk, to observe if the motion of his limbs was perfect. At this time he
thinks his memory must have been impaired, for although he fell and hurt
his arm, yet he so far forgot the circumstance, that his mother had oc-
casion to remind him of it.
He never had any sore throat, nor suppuration in the ear, and never
felt any paralytic weakness of the side.
His present condition is this. The expression is almost entirely in
the right side of his face. The eye-brow on the left side cannot be knit.
The forehead on that side is smooth. The eye-lids do not perfectly close
in winking. He can draw up the side of his mouth with the zygomaticus,
yet it is with an effort, and less perfectly than on the opposite side. He is
not altogether without feeling in this left side of his face ; but there is very
considerable numbness, and he experiences a scalding sensation in the edge
of the tongue, all along to the tip, on the left side. He has perfect motion
in the tongue. Its surface is deeply coated. There are no swellings about
the ear or jaws.
m
Ixxxii PARALYTIC AFFECTION
This gentleman was ordered small doses of salts with sarsaparilla,
an application of steam to his ear and side of his neck, and a seton under
the occiput. The opinion being, that although suspicion might attach to
the state of the bowels, yet an inflammatory attack had certainly injured
the roots both of the fifth and seventh nerves. A very careful and re-
gulated diet was enjoined, and hopes were held out, that with these
precautions an amelioration would take place in the expression of the
countenance.
I shall give here the outline of one or two cases from foreia:n authors.
No. XXXIX.
*' A phthisical patient * had a suppurating tumour on the parotid
gland, which exposed the mastoid portion of the digastric muscle. Para-
lysis of the face came on gradually, and at length the following symptoms
presented.
*' The eye-ball was perfectly under the control of its muscles. The
upper eye-lid could be moved. The lower eye-lid was relaxed and everted.
The eye was constantly weeping.
" The nose was dragged to the left side; the nostril of this side
remained narrow, while that of the other was dilated by the action of its
muscles. The mouth was dragged to the left side. The tongue was
perfectly free in its movements.
" When she laughed or spoke, the expression was most strange. On
the right side, her face was as that of a dead person, while the left was
Jiighly excited. In speaking, we could see the buccinator puffed out and
relaxed alternately, like the leather of a pair of bellows.
*' Whilst sleeping, the upper eye-lid covered the pupil, while the
lower eye-lid was depressed and everted. Some hairs on her upper lip
were pulled, which awoke her, and made her complain of being teased.
* See Descot sur les Affections Locales des Nerfs, p, 318. 1825. — M. Descot published
before the translation of these papers into French by M. Genest.
OF THE FACE. Ixxxiii
" At her death, respiration was convulsive. The eye-balls rolled in
their sockets : the muscles of the left side of her face contracted with
force, while those of the right side remained still ; and the mouth and
nostrils being convulsively pulled towards the left side, a frightful ex-
pression of countenance was produced."
There is a minute account of the dissection given ; but it is sufficient
to say, that a portion of the seventh nerve, corresponding with the breadth
of the ulcer, was destroyed; the two ends of the nerve which were thus
separated appeared as if teased out.
M. Descot, perfectly candid as to the source from which he takes
these views, leaves me under obligation to him.
He remarks, that it is inexplicable how she continued to possess the
motion of the upper eye-lid. I would offer this observation. M. Descot
having seen two extremities of the divided nerve, it must have been a
branch or portion only which was here destroyed. For if the nerve had
been destroyed as it makes its exit from the stylo-mastoid foramen, its
course before it splits being very short, he might have seen one extremity
coming out from the bone : he could not have seen the corresponding
end of the nerve, but must have detected many branches. No doubt,
therefore, the superior division of the pes anser'mus had escaped the effect
of the inflammation and ulceration. The branches of the portio dura which
go along the temple to the upper eye-lid had remained entire : hence the
action of the upper eye-lid was perfect, whilst the lower eye-lid, and all the
rest of the face, were paralysed. I have stated, that, from an abscess before
the ear, I have seen the eye-brow fixed, while all the rest of the face con-
tinued in possession of its natural motions : no doubt, because the superior
branches only of the diverging nerve were engaged in the disease.
In the same author there is an instance given of destruction of the
portio dura, by suppuration in the temporal bone, which was attended with
paralysis of the face, and difficulty of swallowing. The latter symptom
took place in the case referred to at p. vi. under Dr. Gregory's care. See
the System of Anatomy, p. 508, vol. ii.
m 2
xi\r PARALYTIC AFFECTION
No. XL.
1 select the following quotation from Beclard's notes upon the partial
Paralysis of the Face. In these he makes reference to my discoveries, as
explained by Mr. Shaw in his paper in the Med. Chir. Trans. 1822. " II
y a quelque mois qu'en enlevant une tumeur carcinomateuse de la region
parotidienne droite d'une femme, le tronc du nerf facial fut excis6. Le
cote droit de la face est reste paralyse ; mais la paralysie ne devint appa-
rente que dans les mouvemens de la respiration et de la parole : dans tout
autre cas elle est a peine apercevable." Descot sur les Affections Locales
des Nerfs, p. 313. I would just observe upon this, that many years ago
I saw my brother perform this operation with similar effects. At my
entreaty, during the operation, instead of cutting out the root of the dis-
eased parotid gland, which would have been attended with a division of
the carotid artery, he was induced to apply a ligature around the root of
the tumour, which of course included the portio dura. If the branches of
the fifth pair were repeatedly cut for the tic douloureux, and the portio
dura cut across or encircled with a ligature, without a conception arising
in the operator's mind of the functions of these nerves, it brings us forcibly
to the conclusion, that it is through the knowledge of the anatomy, and
not by what is termed experience, that we are to obtain correct notions of
the functions of parts, and more especially of the nerves.
The singularity of the following case is, that without any affection
attributable to the condition of the brain, and without loss of sensibility to
the face, or loss of motion in the tongue, the functions of the portio dura
of the seventh nerve were temporarily interrupted. But the condition of
this girl was attended with this remarkable consequence, that she retained
her good humour, and sometimes laughed heartily, as it is happily ex-
pressed by the narrator, as if behind a mask, — her face being quite im-
moveable and grave, whilst the emotion and sound of laughter prevailed.
OF THE FACE. Ixxxv
No. XLI.
Syphilis. Paralysie du Nerf facial. — Traitement specifique. SHon;
Vesicatoires. — Guerison.
Salle Saint-Jean, No. 12. Une jeune fille, ag^e de 16 ans, grande,
bien developp^e, r^glee depuis plus de dixhuit mois, d'une bonne sante
habituelle, contracta une blennorrhagie vaginale et ur^trale au commence-
ment de Novembre, 18*28. Elle ne fit aucun traitement et vint a Paris
six semaines apres, c'est-a-dire vers le 20 Decembre. Elle portait k cette
6poque une tumeur peu volumineuse sur la region frontale gauche. Le
surlendemain de son arriv^e, pendant la nuit, sans douleur prealable, sans
cause accidentelle, elle ^prouva un engourdissement dans la joue gauche,
toute la face de ce cote ^tait raide et insensible, et le matin elle s'aper9ut
que la bouche ^tait tres-fortement d6vi6e k droite. La langue 6tait un
peu raide et la parole embarrass^e. II n'y avait du reste aucun autre
symptome.
Un m^decin appele de suite prescrit une saign^e de bras, on en
pratique une seconde le soir du meme jour; des sangsues sont appliquees
a I'anus le lendemain, et le tout sans succes. Deux jours apres la malade
est conduite a I'Hotel-Dieu.
L'ecoulement blennorhagique et I'exostose de la bosse frontale gauche
sont constates, la malade n'eprouve du reste aucun symptome c^r^bral ou
gastrique. La langue est mobile, sans deviation, et Ton voit que la difRculte
de parler r^sulte de I'immobilit^ de la joue et des levres. Deux jours de
suite on administre I'^m^tique en lavage, le troisitme jour on fait une
saign^e de bras, il n'en r^sulte aucun changement. On commence alors
le traitement anti-syphilitique de M. Dupuytren, qui consiste en pilules
composees d'un huiti^me de grain de deuto-chlorure de mercure, d'un
demi-grain d'opium et de deux grains d'extrait de gayac. On donne trois
de ces pilules par jour; la malade boit un ou deux pots de decoction de
salsepareille avec addition de 4 a 6 onces de sirop sudorifique.
Huit jours apres I'apparition de la paralysie a gauche, le m6me symp-
t6me se manifesta subitement a droite, et la malade en se r^veillant n'offrait
Ixxxvi
PARALYTIC AFFECTION
plus de deviation de la face, mais bien un relachement complet, une im-
mobilit6 absolue de tous les traits du visage. Les paupieres ne se fermaient
qu'a moiti6, et les larmes coulaient sur les joues j les l^vres restaient
b^antes, agit6es comme deux drapeux par I'air expire. La langue n'^tait
pas afFect^e. Cette paralysie de la face n'avait lieu que pour le mouve-
ment, car la peau et les muqueuses n'avaient rien perdu de leur sensibilite.
La malade ne soufFrait pas, et sa physionomie habituellement tres ex-
pressive, conservait alors un caract^re s^rieux qui contrastait singuliere-
ment avec sa disposition d'esprit. On I'entendait rire aux Eclats, mais elle
riait comme derriere un masque. Get ^tat lui causait beaucoup de chagrin.
Le traitement fut continu6 avec la plus grande r^gularit^. En m^me
temps on appliqua un vesicatoire sur la joue gauche, tres-pr^s de I'oreille,
on en mit successivement plusieurs autres sur la meme region du cote
oppos6, puis derriere les oreilles ; enfin on placa un large s^ton a la nuque.
II causa beaucoup de douleurs, et ce ne fut qu'au bout d'un mois que la
suppuration fut bien ^tablie, que Ton put s'apercevoir de ses bons effets.
Au bout de deux mois de traitement, la mobilite des joues reparut peu-
a-peu, la malade cessa de dormir la bouche ouverte, les paupieres se rap-,
proch^rent de plus en plus et le larmoiement diminua. II est a remarquer
que les sens n'ont jamais 6t6 affectes ; I'odorat, le gout ont conserve leur
finesse. La sensibilit6 de la peau n'a ^prouve aucun changement.
La sant^ de cette jeune fille n'a ofFert aucune alteration, son app^tit
etait excellent, cependant elle craignait de manger dans les commencemens
de sa maladie parce que les joues immobiles laissaient les alimens s'amasser
entre les arcades dentaires et leur face interne, la bouche s'emplissait, sans
pouvoir se vider, par la formation et la deglutition du bol alimentaire.
Plus tard elle s'habitua a cet ^tat, sa langue, ses doigts et divers instrumens
servaient a supplier Paction des muscles buccinateurs et labiaux.
Ainsi que nous I'avons dit, I'am^lioration a et6 lente, et ce n'est que
peu-i\-peu que les muscles de la face ont recup6"e la faculty de concourir
aux ph^nomenes de la respiration, et de peindre les Amotions int^ieures.
Nous avons vu la malade ^ternuer sans presenter cette expression de la
face, si remarquable dans cette circonstance ; elle baillait en abaissant la
machoire, mais les levres et tout le visage, n'indiquaient en aucune maniere
la sensation qui accompagne I'accomplissement de cet acte. Nul doute
OF THE FACE. Ixxxvii
que si une circonstance quelconque eut occasionn^ de la dyspn^e, les
ailes du nez ne fussent restees immobiles au lieu de se relever et de
concourir a cette expression d'angoisse qu'on observe si souvent chez les
asthmatiques.
Apr^s quatre mois de s^jour k I'Hotel-Dieu, cette jeune fille est sortie
dans I'etat suivant. L'exostose de la bosse frontale gauche a disparu, la
blennorrhagie est gu^'ie, et la sant6 gen^rale est excellente. La figure
ronde et fraiche exprime avec vivacit6 toutes les sensations physiques
et morales 5 le rire seul est un peu froid, c'est-a-dire que le mouvement
des levres ne semble pas correspondre a la rapidit^ et k I'^tendue des
mouvemens du diaphragme et des cotes. La mastication est facile et les
alimens sont bien reunis en bol. Les paupiferes se rapprochent compl^te-
ment, mais il faut un l^ger effort, et souvent les larmes coulent sur la joue.
Le seton est maintenu en place, et tout porte a croire que dans quelques
mois il ne restera plus a la malade que le souvenir de cette affection
singulih'e.
Si les belles experiences de Charles Bell sur les usages des nerfs
enc(!'phaliques avaient besoin d'etre confirm6es par des faits cliniques, cette
observation serait plus propre qu'aucune autre a d^montrer la justesse de
son opinion sur les fonctions du nerf facial. On a vu survenir dans cette
maladie tons les accidens qui resultent, chez les animaux, de la section de
ce nerf a sa sortie du trou stiloidien. II est probable que chez elle une
exostose l^g^re a comprim6 les nerfs a leur sortie du crane. L'efficacit6
du traitement anti-syphilitique n'est pas contestable dans ce cas. Les
topiques irritans et r^vulsifs ont achev6 la cure ; ils etaient indispensables,
car souvent apres la destruction de la cause qui occasionne une paralysie,
ce symptome a encore besoin d'etre combattu par des stimulans locaux.
P. M. d..m. P.
No. XLIL
Consequences of cutting' the Portio Dura in operation.
" Dear Sir, — The case to which I alluded in my lecture this mornings
as illustrative of your views, was that of a young lady from Scotland, who
Ixxxviii PARALYTIC AFFECTION OF THE FACE.
had a tumour deep seated behind the angle of the jaw. It was partially,
and but partially removed by an eminent surgeon in this town. In per-
forming the operation, the respiratory nerve of the face appears to have
been divided, the mouth being drawn to the opposite side to a much greater
extent than is common in hemiplegia connected with apoplexy j the ala of
the nostril and the whole side of the face participating in the paralytic
affection. But the most distressing part of the evil consists in the loss of
power over the eye-lids, in consequence of which they cannot be brought
together, so that the eye is never properly covered. The tears escape
upon the cheek, and there are frequently slight attacks of ophthalmia ; or
perhaps it would be more correct to say, that some degree of inflammation
is always present. The circumstance occurred several years ago, and no
improvement whatever has taken place.
" Respectfully and very truly yours,
** R. Macleod.
" January 17th."
No. XLIII.
Case of Paralysis of the Face.
In M. le Professeur Roux, of Paris ; communicated by himself to M. Descot.
" I have for many years been subject to rheumatism, which has most
commonly been seated in the loins. In the month of October, 1821, I
was attacked with paralysis of the right side of my face. I am not aware
of having been exposed to any influence which was likely to excite rheu-
matic disposition in the muscles or nerves of the face ; but it appears from
the circumstance of the muscles being paralysed that some irritation has
existed, probably a rheumatic irritation of the facial nerve. When the
paralysis was complete, I began to feel pain in the temple, and there was
oedematous swelling in the part. During the course of this complaint I
have experienced two circumstances which may lead to the detection of
the facial nerve becoming affected. 1. The membrane of the tympanum
was painfully sensible even to slight noises. 2. The sense of taste was
affected in the right side of the tongue, so that every thing tasted metallic.
TRISMUS AND PARALYSIS. Ixxxix;
This last symptom has even been a precursor of the complaint, beings
observ^ed twenty-four hours before the occurrence of paralysis. In other
respects, little pain was experienced, even in the trunk or the branches of
the facial nerve. There has been no diminution of the sensibility in the
skin of the face. The paralysis of the occipito frontalis muscle, of the
orbicularis palpebrarum, and of all the muscles of the lips, on the right
side, was complete. I have been like a patient who has hemiplegia, pro-
nouncing words imperfectly, unable to blow with my mouth, laughing only
on one side, feeling an inconvenience in eating, from want of action in the
buccinator, deprived of the power to close my eye-lids," &c. >
This complaint ceased gradually as it began, yet rather more slowly.
This is the sort of case which is apt to throw the pathologist into dif-
ficulty, and therefore we shall give it some consideration.
The sensibility evinced in the ear indicates an inflammation in the
course of the portio dura, or at least an affection commencing there, and
by influencing the trunk of the nerve, producing the paralysis of the face,
I have stated why the respiratory nerve of the face, and the sensitive nerve,
take diflferent routes to their destination ; but it is not to be supposed that
the sensibilities and motions of the face are in any degree more independent
of each other than those of the arm, or any other part of the body. Ac-
cordingly, irritation and pain produce in the face what irritation and pain
may do in any other part of the body. I would only suggest to the ob-
server, that he should distinguish those motions which are expressive of
pain from those which are spasmodic and incontrollable *. This will be
especially necessary in studying the disease called tic douloureux.
No. XLIV.
Case of Trismus, conjoined with Paralysis of the Face.
Thomas Jones, aet. 29, a groom, was admitted into the Middlesex
hospital under Mr. Bell's care, October 10th: he complained of a painful
* We find trismus and tic as a title j diseases quite distinct classed together.
n
xc
TRISMUS AND PARALYSIS.
stiffness in his jaws, and the muscles of one side of his face were paralysed.
He stated that, on the last day of September, while dressing his horse, it
struck him with the fore-foot upon the right side of his head, and knocked
him down. He remained insensible for some time. When he returned to
consciousness he felt weak, and a little sick. There was a wound, as if
made by the heel of the shoe, just ov^er the external angular process of the
frontal bone. Nothing however was done for him, and he lived as usual.
It was mentioned by his master that he was much given to drinking, and
that at one time his head and hand trembled from its effect like an old person's.
On the fourth day after the accident he first perceived that his face was
twisted to one side ; he then had also some difficulty in speaking and
swallowing. It was not till the 6th October that he consulted a medical
man, who recommended him to come to the hospital.
The face is twisted to the left side, as in the cases of partial paralysis
from injury to the portio dura of the seventh pair of nerves ; and this dis-
tortion of the face is most observable when he speaks. Upon being asked
to close his eyes, the left is shut, but the eye-lids of the right side are very
imperfectly closed, and in the attempt the cornea is turned up. The
feeling on the right side of the face is as perfect as on the left. It cannot
be perceived how far the motion of the tongue is impeded, as he cannot
open his mouth freely: he is apt to bite both his tongue and cheek while
eating. The wound on the side of the orbit resembles a mere scratch,
nearly healed. There was no bleeding from the ear after the accident,
and he hears perfectly with both ears. There is a fulness and rigidity
about the masseter muscle on the right side, and Mr. Bell thought there
was a preternatural swelling before the right ear.
Hirudines, xii. ante aurem.
Pil. Colocynth. cum Calomel, gr. x. statim, et mane haustus purgans. Lotio Plumbi
Acet. cum Opio ad partem dolentem.
11th Oct. — The house surgeon w^as called in the morning to this
patient, as it was reported he was seized with a fit. He found him strug-
gling like one who is suffocated. He seemed to labour from a difl^iculty
of expectoration ; his jaws were firmly clenched ; his face was livid; the
muscles on the right side were relaxed and drawn to the left side ; those
TRISMUS AND PARALYSIS. xci
of the neck were rigid, and in strong action. It required the power of two
men to restrain him in bed. Two drachms of the tincture of opium were
administered in small quantities between his teeth, after whicli the fit left
him. He was quite sensible during it, and called it an attack of the
cramp. To-day his jaws are more firmly closed. He complains of a pain
at the back of his neck, as if something were dragging or pinching him
there. His bowels have been opened. Pulse 110, and firm.
Cucurb. cruent. occipiti.
Hydrarg. Submur. gr. x.
Tinctura Opii^ 5ss- 3tiis horis.
12th Oct. — The patient to-day was visited by Drs. Latham, Watson,
and Hawkins. The teeth are more closed. The attempt to swallow brings
on violent convulsions in his throat and chest ; he refuses to take any
drink, and he has not taken his medicines, from the fear of bringing on
these attacks. The suffering of which he complains most is from the
phlegm in his throat, which makes him cough, and he throws out his saliva
as in hydrophobia. During the paroxysms he starts up in bed ; and we
find him now sitting on the side of it, unwilling to lie down, as he is afraid
of a recurrence of the fits.
Capiat Hydrarg. Submur. gr. x.
Enema Opii.
Cucurb. cruent, nuchae ad Jx.
Descendat in bain, calid.
Cataplasma cum Lotione Plumb. Acet. cum Opio ad vulnus.
gi Extract. Tabaci. Unguent. Hydrarg. part, aequal. fiat Unguentum. This ointment
to be rubbed upon the neck and jaws.
13th. — Yesterday he was put into the warm-bath, which was followed
by a copious perspiration, and he expressed himself relieved by it. The
fits attacked him four or five times during the day, and they continued
about five minutes each time. He was unable to speak during them. His
head was thrown back and his chin was tilted up, but not so much as to
be called opisthotonos. He has never complained of spasms in his epi-
gastrium. He possessed a perfect command over his arms, legs, and head;
but he had convulsive twitchings as he lay in bed. About seven in the
n 2
XCli TRISMUS AND PARALYSIS.
evening his jaw began to be relaxed, but this was accompanied with
evident symptoms of approaching dissolution. He sunk gradually, after
having had severe fits, and died this morning at ten o'clock.
V Examination, 24 hours after death. — The features were distorted, as
during life. The right eye was wide open, while the left was shut. The
cicatrix on the side of the head was examined, but nothing appeared to in-
dicate any morbid condition of the parts in its neighbourhood ; the skin
only seemed to have been divided. The fibres of the orbicularis palpebra-
rum, which were under the cicatrix, seemed natural, and the bone was
not injured. The parotid gland was in a healthy condition. When the
branches of the supra orbital nerve and those of the portio dura were mi-
nutely traced towards the wound, nothing remarkable could be observed in
them. There was a small gland, not bigger than a field bean, imbedded in
the substance of the parotid gland, and lying in contact with the portio dura.
When this was cut into, it was found to contain a little purulent matter,
but the nerve was not adherent to it, and did not seem altered in its struc-
ture. When the brain was examined, the tunica arachnoidea was found
slightly opaque, and the veins were more turgid with blood than natural.
There was also some serum in the ventricles, but in other respects, on a
close examination of this organ, and of the nerves coming from it, the ap-
pearances were perfectly healthy. The roots of the fifth pair of nerves,
and the course of the portio dura through the temporal bone, on the right
side, were carefully examined, without detecting any alteration from their
natural structure. The spinal marrow seemed healthy. The nerves of
the sympathetic system (in the abdomen and the chest) were examined,
without discovering any thing preternatural. The viscera, both of the
thorax and abdomen, were in a healthy state, and the lungs were not more
gorged with blood than is common. The glandulse truncatas at the root of
the tongue were enlarged, but there was no redness marking inflammation
either in the fauces, larynx, or oesophagus.
Mr. Bell, in his observations on this case, first remarked its resem-
blance to some cases of partial paralysis of the face, in which he had been
consulted during the present season. He admitted that the incapacity of
closing the eye, and the total loss of motion of the lips and cheek on one
side, deceived him when he first saw this patient in the waiting-room.
DISEASES OF THE FIFTH. xciii
The anomaly of the case was, that on the side where the hurt had been
received, the exterior muscles of the face, all those influenced by the portio
dura were in a state of paralysis ; whilst the muscles of the jaws, supplied
by the fifth pair, were in a state of tetanic spasm. He related a case
of paralysis of the muscles of the face on one side, produced by a blow
upon the head ; but he added, that, in the present case, on looking retro-
spectively, there was no reason to suppose the symptoms referrible to an
injury of the brain, much less to an injury of the nerve passing through the
bone; it was, he conceived, a case of trismus, arising from the slight bruise
of the integuments of the temple operating upon a constitution morbidly
predisposed. The only peculiarity was the partial paralysis : he could not
charge his memory, at that time, with another case where this symptom
was combined with trismus. A. S. •
No. XLV.
Disease of the Portio Dura extending to the Fifth.
" Stephen's Green, May 7, 1827.
" My Dear Sir, — It is high time for me to thank you for your kind-
ness in sending me your last publication on the Nerves, which clearly
illustrates your notions of the functions of the various parts of this system,
and which must directly lead to a new and useful line of treating some of
the diseases of that system.
" Permit me to trouble you with the outlines of a case at present
under my care, which present a combination of symptoms not often met
with.
" Mr. S , about eighteen months ago, suffered severely from pain
in the occiput and back of the neck. This suddenly and unaccountably
left him, and again returned in August last. About the middle of October,
he was affected with paralysis of the left side of the face, attended with a
slight dilatation of the pupil of the left eye, an inability to close the eye-
lids, and, agreeably to your account of such cases, with the turning up of
the eye-ball when he attempts to close th^ lids. On the attack of paralysis.
xciv DISEASES OF THE FIFTH.
the pain of the occiput and neck ceased, but returned again with great
severity, and without any assignable cause, early in January. By the ex-
hibition of calomel, to the extent of nine grains a day, the pain was re-
moved, and, with it, giddiness, great weakness of the limbs, nausea, and loss
of appetite ; which symptoms had attended the recurrence of the pain.
This attack, however, left after it a new and distressing symptom.
" Mr. S. now complained of great coldness in the affected side of the
face, of a total want of feeling in this part, of want of taste in the left side
of the tongue, and of such imperfection in chewing, that he repeatedly
pinched his cheek between the molares teeth when' he attempted to chew
at this side.
" Mr. S., about four weeks ago, had another attack, equally severe
with either of the former, and attended with extreme weakness of the limbs,
with more of giddiness, of vomiting, and more complete loss of appetite.
In this attack he lost flesh most rapidly. Again the use of calomel, with
a small caustic issue to the occiput, has restored him to tolerably good
health ; the insensibility of the face and tongue remaining as it had been
after the second attack of pain. It may not be amiss to add, that Mr. S.
had been repeatedly subject to a purulent discharge from the left ear.
Should any remarkable change take place in this case, I shall be happy to
communicate it to you, if you think it worthy of your attention.
" Believe me, dear Sir,
" Yours very sincerely,
"A. COLLES."
No. XLVI.
Dissection which shows the Portio Dura compressed hij a Diseased Gland.
" Few opportunities nave as yet occurred of ascertaining the condition
of the nerve in those interesting cases of local paralysis which have been
so beautifully illustrated by Mr. Charles Bell and his lamented friend the
late Mr. Shaw. It is probable that there is either an inflammatory action
in the nerve itself or its coverings ; or that tlie nerve is affected by disease
of some of the parts through which it passes. The only case in wliich I
DISEASES OF THE FIFTH. XCV
have had an opportunity of examining the parts, since I was acquainted
with the discoveries of Mr. Bell, was lately, in a woman about forty years
of age, who died of organic disease of the stomach. About a fortnight
before her death, she was seized with twisting of the mouth and paralysis
of the orbicularis of the left eye. She had afterwards considerable in-
distinctness of speech, and before her death there was inflammation of the
left eye, with an evident tendency to sloughing of the cornea. A small
hard tumour was felt under the ear, deeply seated betwixt the angle of the
jaw and the mastoid process. On dissection, no disease could be discovered
in the brain. The tumour under the ear was found to be of the size of a
small bean, very firm, of an ash colour, and when cut across, it discharged
thin puriform sanious fluid from minute cells in its substance. It lay
directly above the facial branch of the portio dura, and there was con-
siderable appearance of inflammation in the cellular membrane surrounding
the nerve ; but I could not discover any deviation from the healthy struc-
ture in the nerve itself. I thought it was diminished in size at the place
where the tumour lay over it ; but in this I might be mistaken." — Pa-
tJiological and Practical Researches on the Diseases of the Prain and Spinal
Cord, by Dr. Abercrombie, p. 415.
No. XLVII.
" Stamford, 10th July, 1829.
" Sir, — Mr. , who will deliver this to you, became a month
since affected with paralysis of the muscles of the left side of the face.
This affection had been preceded by pain near the foramen stylo-mastoi-
deum and parotid gland, but not so severe as to excite much attention
from the patient, till questioned on the subject. That the mischief waS in
the course of the nerve, and not at its origin, was indicated by the absence
of all symptoms that might be referred to the brain, and by the portio
mollis not being affected. The treatment, therefore, was directed by the
principles laid down by Mr. Shaw, founded on your discovery respecting
the use of the nerves, and the truth of which these cases so strikingly
xcvi PARALYSIS OF THE FACE.
illustrate. The muscles have lost their power, but retain the sense of
feeling, because that is transmitted by another nerve.
" I have applied blisters and leeches behind the ear, and over the
parotid gland, attention being paid to the state of the prim« vise : the
parts affected have been well rubbed with a stimulating embrocation. I
was about to apply the cupping glasses behind the ear, and to have re-
course again to the leeches and blisters, in concurrence with the opinion
of Mr. Cooper, of this place. The patient being called to town, I am
desirous that he should avail himself of the opportunity of obtaining your
opinion, and which he is anxious to do.
" I am, Sir,
" Your obedient servant,
" Edw. Hatfield.
" To Charles Bell, Esq."
No. XLVIII.
" Soho Square, 14th July.
" Dear Sir, — I have made an accurate examination of your patient's
symptoms, and I think your diagnosis correct. The face is twisted to the
left side. The right nostril does not move in respiration. The eye-lids
of the left side are not closed when he winks, although, when he attempts
it, the eye-ball is turned up, the cheek is relaxed, and the forehead on
the left side unruffled. These are all symptoms of compression on the
portio dura. I find no discharge from the ear. There is no reason to
apprehend affection of the brain ; and, lastly, just between the mastoid
process and the upright portion of the lower jaw, I find an enlarged gland,
which is tender on pressure. I hope, therefore, sir, you will proceed to
fulfil your intentions :
" 1st, By the application of leeches behind the ear.
*' 2d, By steaming the side of the head and of the neck with vinegar
and water.
" 3d, By the use of a stimulating embrocation or liniment.
PARALYSIS OF THE FACE. xcvii
" I would commence with a smart dose of calomel and scammony,
and continue to give an alterative dose of the blue pill at night, with a
cupful of decoction of sarsaparilla and lime water, in equal parts, twice
a day.
" I am of opinion that your patient will get quite well, and I shall
have pleasure in hearing from you.
" I am, dear Sir,
" Your very obedient servant,
" Charles Bell."
By a letter of the ISth August, Mr. Hatfield gives an account of his
patient's gradual amendment.
No. XLIX.
The symptoms of the following case, in which I was consulted, are
by no means uncommon. A gentleman returning from hunting was
thrown ; he lacerated his scalp, and suffered concussion. He lost a great
quantity of blood, was reduced very low, and remained subject to an
aftection of his head, which after years has returned at intervals. It will
come on in consequence of the conversation, heat, and light of a dinner
party, even although he does not exceed ; and on other occasions any
direct disturbance of the stomach will produce it. He has headache and
pain along the course of the nerves on one side of the head, a tenderness
and indescribable sensation on the scalp, a puffing of all that side of the
face, and swelling of the eye-lids of the same side. This after a day or
two, by rest and evacuations, subsides. Still he becomes liable to it on
any excitement of the mind, or derangement of the digestive organs.
Such attacks, as I have said, are not unfrequent ; and it is only when
the puffiness and sensibility affect the seventh nerve that the paralytic
affection comes on. Morbid sensibility and tumefaction result from the
affection of the fifth, and form the primary class of symptoms. The
seventh nerve partaking of the influence, palsy of the corresponding
muscles is thus in a secondary way produced ; while, by an indiscriminating
0
XCVlll DIVISION OF THE FIFTH NERVE.
observer, the pain and the paralysis are attributed to the affection of the
same nerve.
No. L.
Many years ago, I was sent for early in the morning to Lord ,
who had suffered all the tortures of the tic douloureux, and had submitted
to have the nerve of the cheek (the suborbital bjanch of the fifth) divided
by Mr. Pearson. He had been brought suddenly, from the severity of
pain, and the recommendation of his medical advisers, to the resolution of
submitting to the division of the frontal branch of the fifth nerve.
I performed the operation, marking the notch in the frontal bone,
and drawing my scalpel along the inside of the orbitary ridge. What
I remarked, with some misgiving of my own precision, was that no
effect was produced on the motions of the forehead and eye-brow, which
made me a second and third time draw my knife across the course of the
nerve, &c. down to the bone ; but no paralysis of the muscles took place.
Neither had paralysis of the muscles of the cheek followed the former
operation on the second division of the fifth nerve. I treasured these cir-
cumstances long in my mind before they led to any formal conclusion.
No. LI.
" Chatham Barracts, Sept. 13th, 1828.
" Dear Sir, — The following case, which came under my own obser-
vation at the time of its occurrence, struck me as being illustrative of
your theory of the nervous system ; and as I have watched the progress
of your discoveries in that branch of physiology, while a pupil in Wind-
mill-street, with much interest, I feel that I am but performing a duty in
transmitting it to you.
" While the British troops were quartered in Portugal last March,
Lieut. fell with considerable force from the top to the bottom of
a fliglit of stairs, having missed his step in the dark, wiien the left side of
his face struck with violence against a flag. On seeing him some hours
DIVISION OF THE FIFTH NERVE. xcix
after the accident, I found that all that side of his head and face was much
swollen and bruised ; he complained of headache and a numbness of the
face. I bled him at the time, and ordered aperients and fomentations to
the part injured. When the symptoms of injury of the head had disap-
peared, and the swelling had abated, he continued to complain of numb-
ness of the left side of the face, extending from just below the orbit, along
the ala nasi to the tip of the nose, and to the upper lip, exactly as far as
the centre of its depression, corresponding precisely with the distribution
of the facial division of the second branch of the fifth pair of nerves.
*' On searching for the cause, I readily found that the margin of the
infra-orbitary foramen, formed by the superior maxillary bone, was broken
off, causing a sharp spicula which presses on the nerve, or has divided it
at the very point of its exit upon the face.
*' It is now six months since the accident, and the side of his face is still
quite insensible to the touch, or even when gently pricked with a sharp
point ; the razor skims over the left side of his upper lip unfelt, and when
he applies a vessel to his mouth, a sensation is imparted as if its edge were
broken off at the part which touches the affected lip.
" The expression of his countenance is not at all affected, for when he
speaks, laughs, or sneezes, the muscles of both sides act in perfect unison.
" I am, dear Sir, yours very truly and respectfully,
■^ " John J. Russell.
Memb. Col. Surg, and
Assist. Surg. 63d Regt.
" Chas. Bell, Esq. London"
I have noticed, in the text, the effect of injury of the third division of
the fifth or mandibulo-labralis to be the insensibility of the corresponding
portion of the lip, which, with these two last cases, complete the proofs
drawn from experience in the human body, that the sensibility of the face
results from the three facial branches of the fifth pair.
o2
c DISEASE OF THE FIFTH NERVE.
No. LIL
Affection qfthejifth Pair of Nerves.
« 21st October, 1822.
" L. A., a healthy girl about twenty, received seven years ago a blow
from a stick on the right eye. The blow mustrhave been severe, as her
eye was blood-shot, and could not be opened for several days. From this
time she thought the sight never was so good as in the other eye. About
four years since the dimness increased, but she could still distinguish small
objects, till June last, when she was affected with a pain in the right ear,
deafness, and a discharge. About the same time she suffered from severe
headaches, affecting only the right side, and, soon after, she lost the sight
of the eye altogether. The motion of the iris remained perfect, but she
felt a dull pain at the internal canthus, which seldom abated, and at times
there was a copious flowing of tears. Things continued in this state for
about two months, when the pain and discharge from the ear ceased, and
in a few days more the surface of the eye became perfectly insensible to
the touch. This loss of feeling extended to the lining of the eye-lids, to
the skin covering them, and to the skin on the cheek and forehead for
about an inch surrounding the eye ; it did not go beyond the middle line
of the face. When she told me that her eye was dead, as she expressed it,
to be certain, I drew my finger over its surface, and so far was this from
giving her pain, that she assured me, she could not feel that I was touching
it at all. The eye-lids made no effort to close while I was doing this, but
the conjunctiva appeared sensible to the stimulus, as a number of vessels
on the surface of the eye became immediately injected with blood. At this
time a perpetual blister was applied behind the ear, and 2 grs. of calomel
given night and morning, with a view of affecting her mouth. After a
few days, however, the pain in the ear came on, with increased deafness,
but scarcely any discharge ; and at the same time the sensibility of the
eye and surrounding skin returned, and has continued ever since. The
sight is totally gone, but she suffers no other inconvenience, excepting the
partial headaches, and at times the pain at the inner corner of the eye.
DISEASE OF THE FIFTH NERVE. Cl
She has had throughout a perfect command over the muscles of the eye
and eye-lids, and can shut the latter completely. There has been no
affection whatever of the muscles of the face.
" November 21st, 1822.
" On the 25th October late at night, she was found lying on the stairs
in a fit. She recovered after some time, but the fit, with violent convul-
sions, returned at intervals through the night. From the description
given, the fits were not epileptic, but well-marked hysteria attended with
the globus, flow of urine, and peculiar affection of mind, I saw her early
on the 26th. She had insisted on being dressed, and declared she was
quite well. She acknowledged, however, that the headache (hitherto
confined to the right side) was now general. Her answers were tolerably
coherent, but given in a childish petulant manner. The state of the eye
was unchanged. Her pulse was 80, full and strong. She had men-
struated a fortnight before, and had always been regular in that respect.
I bled her very largely, had her hair removed, and a cold embrocation
constantly applied to the vertex ; she was also well purged with salts and
senna, her feet bathed, and she was confined to bed in a dark room.
" 27th. — She appeared more collected in her mind, but had still the
diffused headache. Pulse reduced in strength. She got the senna mixture
again, and a large blister was applied to the nape of the neck.
" 28th. — Her head much better. Her mind quite tranquil. Pers*. in
usu embrocationis, nccnon Mist. Cath®. et pediluvii.
*' 29th. — Headache quite gone ; apparently free from complaint."
" Notwithstanding these favourable appearances, I still apprehended
that an organic disease might be extending itself in the head, and as the
hysteria, from her very full habit, was evidently connected with plethora,
I continued the purgatives daily, kept her confined to bed, and on the
very lowest regimen."
" November 2d. — She told me that she had felt all night as if there was
sand in the blind eye, and sometimes sparks of fire seemed to pass through
it. There was no change in the appearance of the eye. On the 3d, when
Cll DISEASE OF THE FIFTH NERVE.
she awoke, these sensations were gone, but she was agreeably surprised to
find that her sight was restored. When the left eye was closed, she could
see large objects very distinctly with the right, but could not read or
discern any thing very small.
" On the 4th, she could read small print, and since that time has
continued perfectly well. The sight, she thinks, is not quite so good as
in the left eye, but pretty much as it has been since she received the hurt.
" Whatever was the nature of this injury) it appears to have only
given the predisposition to disease. The gradual manner in which the
sight was lost, and its sudden recovery when her system was reduced by
severe evacuation, point out the connexion of her complaint with the in-
creasing fullness of her habit. Notwithstanding the coincidence of pain
and discharge from her ear, her case is evidently different from those
described by Mr. Bell. The only nerves affected appear to have been the
optic, and, at one time, the first branch of the fifth pair ; and there was no
muscular affection whatever. Her ear had been quite well for some time
before this last illness.
" Nov. 16th, 1822."
No. LIII.
Short Abstract of a Case of Disease of the Fifth Nerve.
(From Dcscot, p. 316.)
It appears that MM. Serres, Majendie, Lisfranc, and Georget were
present at the dissection of this case, and that the following circumstances
were stated previous to the operation. The patient had been epileptic;
for six months there had been inflammation of the eye, coarctation of the
pupil, and opacity of the cornea; the conjunctiva was insensible to a
feather; the nostril of the same side was insensible; sulphat of quinine
was not tasted on the side of the tongue ; the gums were spongy, dark-
coloured, and detached from the bone ; the hearing was very dull on the
right side ; the patient could chew perfectly well.
On dissection the fifth nerve of the side affected was remarkably
altered. At its origin it was found soft, yellowish, and reduced almost to
DISEASE OF THE FIFTH NERVE. cm
a jelly; and this derangement could be traced two lines into the tuber
annulare. The nerve, traced forwards, exhibited the same soft, yellowish
appearance, excepting the muscular portion, which was natural. The
diseased nerve was a line and a half less in diameter than that of tlie
sound side.
I must remind the reader, that, at the time of this dissection, M.
Majendie had proclaimed a discovery, than which nothing could be less
founded in reason. I had proved that the sensibility of the head and face
resulted from the fifth pair; but he asserted that vision, smelling, and
hearing, were bestowed through the operation of the fifth pair; and the
above dissection was declared to confirm the truth of his discovery *.
Had this assertion been correct, it would have been a severe blow to
the students of anatomy. They trace the optic nerve into the eye, the
olfactory nerve to the membrane of the nose, and the auditory nerve to
the cavities of the ear. But what availed all this, if the French physiolo-
gist had proved, instead of the first, second, and seventh nerves, that the
fifth was the nerve of smelling, seeing, and hearing?
But, as I have explained in the text, the fifth nerve bestowing sen-
sibility, and that sensibility being the safe-guard upon the organs, we
cannot be surprised that those organs should, in the absence of their
natural guardian, be irritated and inflamed, and consequently deranged by
the disease of the fifth nerve.
This is especially true of the eye. I have taken great pains to
explain the apparatus by which it is protected, and the sensibility which
excites that apparatus into operation; but when the sensibility is with-
drawn, the apparatus is useless, and the eye becomes inflamed by irritation.
I have noticed in the text the difference between the sensibility of
the interior membranes of the nose and the power of smelling; the one
depending upon the fifth, and the other upon the first nerve. I have also
shown that the common sensibility of the nostril was that which excited
to sneezing and blowing the nose, and that these actions were to the
*"Cette coincidence d'une lesion du nerf trijumeau, avec I'alt^ration de I'oeil et des
gencives, la perte de Taction des sens, est d'autant plus curieux qu'elle confirme les rc^sultats
ol)tenus par M. IMajendie par la section des ncrfs de la cinquierae paire."
CIV AFFECTION OF MUSCLES OF THE FACE.
nostrils what winking is to the eye, the means of removing whatever is
irritating or offensive.
But I need make no further observations upon this case; it will be
understood, in all its bearings, upon perusal of the preceding papers.
No. LIV.
Affection of the Muscles of the Jaw.
I have, in my first, fourth, and fifth papers delivered to the Royal
Society, noticed, that the muscles of the jaw are supplied by the fifth
pair, a cerebral and voluntary nerve, whilst the muscles of the face, pro-
perly, are moved by the portio dura, a respiratory nerve. The affections
of the latter are very common, of the former more rare, unless in disease
of the brain, or in the instance of tetanus.
A gentleman brought his daughter to me: the account he gave
would have induced me to believe the case an aneurism rather than an
affection of the nerve, there was so much talk of swelling and pulsation.
I gave the following opinion: — There are, in this lady's case, two distinct
subjects of consideration. The swellings to which the side of the head is
subject arise from occasional violent spasmodic states of the muscles of
the jaw on the left side; the masseter is, from time to time, brought
powerfully into action, so as to present to the touch a round hard ball.
The temporal muscle, which lies on the side of the head, is subject to
alternate actions and relaxations which resemble pulsations.
The second point must be separated. The upper and lower jaws on
the left side are deficient in growth. The cause of this defect of growth
is very obscure, and the influence, of whatever nature, must have struck
and had its effect nine years ago, in childhood. It is beyond control.
The first object will be to remove the local mischief in the sensibility
of the gums; and the second indication is to remove, if possible, any
source of irritation that may be in the uterine or digestive organs.
This lady returned, about two years and a half after this report, with
her mother, who had a nervous affection of the eye : she had not met with
any relief in all that time, and despaired of being cured. Its long con-
tinuance, however, did not bear me out in my first opinion, that it
DISEASE OF NERVES IN THE ORBIT. cv
depended on the state of the gums, but rather on some more permanent
disorder of function.
No. LV.
Case of Disease of the Nerves within the Orbit.
Martha Symmonds, get. 41, Northumberland ward. This woman
was admitted into the hospital for a disease apparently seated in the left
orbit. Nine months ago she had a paralytic stroke, attended with the loss
of power in her right arm, and she lost the sensation of the arm, neck, and
face, on the same side. She lost, also, her power of speech, excepting
only to " babble," as she says. She recovered from this attack, and went
into service. About eight or ten weeks ago she was alarmed by a com-
mencing dimness in both her eyes, and she was obliged to leave her place
on account of this dimness of her sight. Both her eyes were equally
affected, and there was no redness or opacity perceptible in either of them.
She placed herself under a medical gentleman because she dreaded a return
of the palsy. About six weeks ago the upper eye-lid of the left eye fell,
and she could not raise it. At that time she suffered great pain above
the left eye, and the pain extended upon the left side of her forehead.
She at the same time lost the vision of this eye, although she could distin-
guish by it the light of day from darkness. She could direct the motions
of this eye-ball as well as of the other at that time, and the appearance of
the eye was natural.
Five days before she was admitted into the hospital, she experienced
a violent deep throbbing pain in her left eye, and from that time the eye-
ball, as she says, became enlarged, until it projected considerably beyond
the orbit. Two days before her admittance she was totally blind in that
eye, and was deprived of sensation on the surface of the whole eye, eye-
lids, the internal corner of the nose, and upon the left side of her forehead.
At present her left eye is covered with its upper eye-lid, and projects
greatly from its natural situation. The lower eye-lid is everted, as a con-
sequence of the projection of the ball of the eye, and the conjunctiva is
P
cvi DISEASE OF NERVES IN THE ORBIT.
tumid and projecting. She cannot raise the upper eye-lid, although, when
it is raised with her finger, she can squeeze it down again, and winks with
a motion which corresponds naturally with that of the other eye. It may
be a question, whether the globe of the eye is enlarged or only protruded.
The pupil is unnaturally large, and the iris is without motion. She cannot
move the eye-ball in any direction. The vyhole eye is insensible : she has
just had her lower eye-lid scarified, and she was not sensible of pain. She
allows us also to press with our finger on the surface of the eye without
complaining of any pain, or winking ; although, as we said above, she
can still wink, and does wink with tliis eye-lid when the other eye is
threatened.
Oct. 6. — To-day some further examination was made of this w^oman's
face and head in order to ascertain the extent of insensibility. It was
stated in our last report that she has lost sensation in the surface of the
left eye and eye-lids, in the corner of her nose, and upon the forehead. In
these parts, she says that now the loss of sensation is less complete, because,
when she had her eye-lid scarified the other day, she felt pain, which she
did not when it was scarified before. The eye also seems diminished in
size.
Besides those parts which we have already described as being affected,
she has, in a partial degree, lost sensibility to touch in that part of her
cheek which is just under the orbit, and downwards upon the side of her
nose, and upon the left side of her upper lip, and also within the cavity of
the nose on the left side. However, when the point of the pin was brought
near to the ear, or upon the skin which is over the lower jaw, she then was
sensible of pain. A piece of linen was twisted so that it might be intro-
duced into the left nostril : she allowed us to push it upwards as far as we
could, and during this operation she only observed, that she was sensible
of its presence. Turning it about within her nostril did not make her
sneeze. When we tried the same experiment on the other nostril, she was
unable to bear the tickling produced by the loose threads of the cloth, be-
fore it was introduced into the nostril. Now she informed us that she is
in the habit of taking snuff; and she is not only insensible to its usual
agreeable effects, but unconscious of its presence in the left side of the
nose. We next made her close her right nostril, and inhale strong spirit
DISEASE OF NERVES IN THE ORBIT. cvii
of ammonia ; and then repeated the same experiment on the other nostril.
There was a very obvious difference in the effects produced by the am-
monia on the two sides of her nose. She told us she could smell the
ammonia on both sides ; but still she could not bear to hold the bottle
containing the ammonia so long at the right nostril as we observed that
she could at her left. When the bottle was placed under the right nostril,
its pungency affected her almost immediately, so much that she could not
bear it ; on the other hand, she allowed it to remain for a considerable
time under the left nostril, and even snuffed it up strongly before she was
inclined to remove it. During these experiments we observed that the
right eye became suffused with tears ; the left eye, on the contrary,
appeared to be dry in its surface.
In order to ascertain further to what degree her sense of smelling was
affected, we tried the effect of some substances which possess odour with-
out pungency. On applying oil of anise-seed to her left nostril, while the
right one was shut, she inhaled it powerfully, but was sensible of no smell.
Then a piece of asafcetida was tried, but still she had no kind of sensation,
either pleasant or the reverse. She was sensible to these odours on her
right nostril.
The state of her mouth was examined; with the point of a pencil we
pressed against the upper gums, on the left side of her mouth, and the
inside of her cheek, where it is reflected off the gums, and she appeared to
have either very slight or no sensation at all. She volunteered to put a
spoonful of mustard between her gums and her cheek ; and she seemed
very little incommoded by such an experiment. The sensibility of the
other parts of her mouth was natural.
The circumstances of this case make it difficult to determine exactly,
where the disease is seated, which thus produces the destruction of the
optic nerve, the third and fourth nerve, the first and second divisions of
the fifth nerve, and the sixth nerve. Among these nerves we might add
the olfactory nerve ; but it may be made a question whether the function
of that nerve is directly or indirectly affected : the issue of the case will
probably determine this matter. However, from the condition of the parts
without the orbit, we observe, that the power of closing the eye-lid, and
CVlll DISEASE OF NERVES IN THE ORBIT.
>
of winking, is retained, when the power of raising the eye-lid is gone, and
the sensibility of the eye-lids, and of the eye itself, is completely lost. It
is the portio dura which is distributed to the orbicular muscle of the eye-
lid, and bestows the power of winking. We see, likewise, that she can in-
hale powerfully, and can perfectly mpve the muscles belonging to the
nostril and upper lip of the left side, when at the same time the skin which
covers these parts is insensible. Still that power belongs to the portio
dura. This nerve, passing to the face by a circuitous way, and being
therefore uninjured by pressure within the orbit, permits her to move the
left nostril and the side of her mouth in a natural correspondence with the
other side of her face, although both the first and second divisions of the
fifth nerve are included in the disease, and are destroyed along with the
first, second, third, fourth, and sixth nerves.
May 20th, 1829. — Since she left the hospital she has been a constant
sufferer. The pain in her head has never left her; it is principally seated
over both her eyes, and over the left in particular. For three years she
has observed that this pain is aggravated for a fortnight before her monthly
periodical return ; she says she does not know what to do, her suffering is
so great. The pain varies in a remarkable manner with the changes of
the weather ; she knows wiien rain is approaching by the increase of the
pain, and immediately after it is over, the pain is relieved. She has not
had a return of the loss of speech, or of the paralysis of her arm, since she
left the hospital, but she has had fits, and she has suffered from cramps
in the back of her neck and right breast. The arm which was formerly
paralytic, becomes about once a month numbed in such a manner that she
cannot use her fingers, and this is accompanied with great pain; these
il| attacks do not last for more than five minutes. She walks quite well.
The loss of sensation is principally in the forehead: when pricked
with a sharp point in any part as high up as the crown of the head, she
had no feeling ; but in the temples and below the orbits, and on the nose,
she retains sensation. The left eye is blind; the pupil large and im-
moveable; the motions of it are gone; the surface is insensible; it is clear,
and it remains fixed in the centre of the orbit.
DISEASE OF THE FIFTH NERVE. cix
No. LVI.
Of painful Affections of the Face from Disease of the Fifth Nerve.
The sympathetic pains, produced by internal irritation, are continually
calling for the attention of the physician, and some of the most distressing
cases we witness belong to this class of disorders. I shall not dwell on
the instances of external pain regularly produced ; such as those of the
mammse in women, of the arms, shoulder, or back, of the hips and hams, in
disorders of the head, &c., lungs and stomach, or of the colon, kidneys,
uterus, &c. These affections are of every day's occurrence, and well deserve
attention, but we must circumscribe ourselves here to the disorders
illustrative of the true anatomy of the nervous system, and which are
explained by the study of that system.
I am of opinion that the disease called tic douloureux has its source
in visceral irritation, communicated through the sympathetic nerve. That
nerve, we have seen, is universally connected with the nerves of the arms
and lower extremities, as well as with those of the head. The disease
takes place in the extremities as well as in the head; I have seen its
effects in the toe and in the finger.
In the painful affection of the face there is often a symptom which I
may say I recognize as proceeding from intestinal irritation, I mean the
sensation of scalding. This sensation of scalding is very common in the
lower extremities. A purgative in its progress through the canal will
sometimes be attended with this sensation, but often will happily remove
it. I have a patient who, on any accumulation of irritating matter col-
lected in the intestines, will have a severe scalding sensation from the
hip to the heel. This affection is attended with tenderness on pressure,
and if permitted to continue will assume the character of sciatica. The
degree of severity to which this painful affection of the limb will extend
is very surprising; I attended a lady who described to me her sufferings
in very animated language: — a scalding and burning pain extending down
the back part of the thigh ; she could not rest in bed, but remained on
her knees by the side of the bed; she took five hundred drops of laudanum
ex DISEASE OF THE FIFTH NERVE.
in the night, another indication of the severity of her suffering. In this
condition she had been for several years. After visiting her two or three
times, I prevailed upon her to let me see the part affected, for I had
imagined she had some severe cancerous ulceration, but on the hip and
thigh, and leg, the seat as I supposed* of this cutaneous ulceration, there
was not the slightest discoloration, there was, in short, no disease there;
nor was there any defect at all, for although she had been for years con-
fined to her bed, on some alarm of fire from the smell of smoke in the
night, she was the first of the family on the stairs ! But my purpose is
not to fill my pages with these cases, but to restrict myself to the fifth
pair.
The painful affection of the face called tic douloureux is seated in
the fifth pair, and for the most part in the second division of this
trigeminus nerve; and so convinced am I that it is the more direct
connexion established betwixt the sympathetic nerve and the fifth that
produces this pain, that I could wish to divide the sympathetic in the
neck, if I thought I could do it with safety.
The pain of this disease is inexpressibly severe. In the note of the
case from which I now quote, the paroxysm begins with much sneezing,
and itching of the side of the forehead: the pain begins at six o'clock, and
continues for twelve hours, when it is at its height; then she cannot
speak, owing to the severity of pain; she lies on her right side, and keeps
the fingers pressing the temple. As to the kind of pain, I got nothing
but this expression: — "It is an overbearing pain." It does not throb;
there is no burning sensation, but a shooting and darting; it goes off at
once; her head begins to itch, and as soon as the pain is gone she is
quite well again.
The seat of the pain is in the right temple and the side of the right
eye; sometimes it begins in the right side, and then shifts to the left side,
quite as painfully. In the case from which I take this note, the patient
says the attack is preceded by a weakness in the stomach, "as if something
were alive," and it goes off with the same sensation.
In another case the pain came more suddenly, and struck with more
violence in frequent shocks, like those of electricity, and in this patient,
too, there was an attempt to stop the suffering by pressure on the nerve.
DISEASE OF THE FIFTH NERVE. cxi
By his experience he had discovered the anatomy of the fifth pair of
nerves. Since, on the sudden recurrence of the pain, I have seen him
apply his hands to his face, and press a finger firmly on all the points
where the branches of this nerve make their exit from the bones of the
face; pressing one finger on the infra-orbitary hole, another upon the
inner canthus of the eye, a third upon the frontal nerve, and a fourth
before the ear; and he would stand so, fixed in posture and trembling
with exertion.
I have instances before me of the lingual division of the fifth being
similarly affected. " In this lady the pain in the tongue is sometimes in
the papillae, near the root, sometimes in the tip, but always in the same
side of the tongue. There is no difficulty of speaking, unless from the
pain, and yet it is not a soreness, but a burning and smarting — sometimes
the whole mouth is affected, even down to the throat, burning like fire."
There is a division of this class of diseases which must be dis-
tinguished— painful affections of the face, which do not come from
irritation through the sympathetic system of nerves, but from direct
injury to some branches of the fifth pair itself; but where the pain is
referred to a different portion of the nerve, and generally to the cutaneous
or more superficial branch. We iiave an instance of this in the severe
pains which attend the shooting up of the dens sapientiae in a narrow jaw;
in the distress which attends disease of the antrum and caries of the bones
of the face, through which the branches of the fifth pass to the face.
Note. — Mrs. S. For fourteen years she has experienced pain in the
eminentice frontales (she places the points of her fingers there) ; of late
the pain has been more in the root of her nose; when seized with a
paroxysm, the tears flow from her right eye in a stream ; when she touches
the right nostril a pain strikes to her forehead; sneezing, and still more
coughing, gives her great pain; laughing and crying have the same effect;
bringing the teeth together brings on the pain ; washing the right cheek
with a soft sponge brings on the pain ; any change in the temperature of
the atmosphere affects her; when she goes into the open air, or when, after
having been out a little, she comes into the house, a sharp pain darts up to
the forehead. On examining this patient's mouth, the teeth were observed
to be black, and the gums unhealthy and ulcerated: on removing two of
CXll DISEASE OF THE FIFTH NERVE.
the anterior molares of the upper jaw, matter flowed from the antrum.
On her next visit, I still found the fangs of another tooth remaining buried
in the gums, and the adjoining teeth black and the gums spongy. These
I ordered to be removed also. After this she could press the side of the
face without exciting pain, or bringing on the paroxysm, as heretofore.
On her next visit, the gums appeared healthy, the pains were much re-
lieved, but still periodical: the solution of cerussa acetata and opium con-
tinued to give her immediate relief.
Such are not the symptoms of the true tic douloureux, but of that case
where the internal branches of the fifth pair, being irritated by disease,
produce pain in their external branches.
We have another set of symptoms in the following note, which I take
also from my private case book.
Mrs. F. — The burning sensation commenced on the left side of her
tongue, and has gradually increased for twelve months, until it now
extends over half the tongue, and mouth, and face, and head. It is a
sensation as if her mouth M'ere burnt ; she has lost the sense of taste in
the affected side of the tongue; she is not aware when a portion of meat
is lodged betwixt her tongue and cheek. There is a numbness of the
corresponding side of the face, which she says is like the pricking of a
thousand needles, as when the hand or foot goes to sleep by pressure on
the nerves. The end of a feather passed three inches into her left nostril
gives her no sensation, and does not produce sneezing ; yet she has the
smell of both nostrils. On making her describe the extent of" deadness"
with her finger, she runs it round the left side of the chin, and on the
side and ridge of the nose. She imagines that there is a dryness of one
side of her mouth, but it is not really so; there is no difference in the
sides of her mouth to appearance. The pain is aggravated by speaking
or by eating; and still more by coughing or sneezing. When she moves and
twists her flice, she says there is much stiffness to her feeling; but the
action to all appearance is quite entire. She says that " the side of her
face is, in a manner, dead ; and yet it cannot be dead from the constant
pricking pain in it."
The affected side of her face is subject to become swollen, red, and
DISEASE OF THE FIFTH PAIR. cxiii
livid, and extremely hot ; so that to allow her to sleep, she must then keep
the lotion applied. She says she thinks she must die but for this lotion
(solution of opium and cerussa acetata). It is remarked, that to relieve
a painful itching at the back part of her ear and on the temple, she
pinches the skin, but does not scratch it, for then great suffering is the
consequence, and the pain extends all over the side of the face.
Such symptoms I conceive to come from direct disease of the fifth
nerve, or from inflammation involving it.
Continuation of the preceding Case hy Dr. Whiting.
" Mrs. r. called on me August 2d, 1827, foi' advice for a disease of
which she gave the following history: —
" Twelve months previously she first felt an unusual sensation on the
left side of the tip of her tongue as if it were burnt ; this feeling soon
extended over the left half of the organ, and afterwards over the left side
of the palate, gums, and face ; it was accompanied by an almost total loss
of the sense of touch in the parts affected. The uneasiness had been
constant from its commencement, increased however by the motions of
the face, and by the contact of the hand or any solid body.
" At the period when I first saw her, the boundaries of the disease
were, the ridge of the nose, the raphe of the upper and lower lip, the
lines which mark the division of the right and left sides of the palate and
tongue, the margin of the left lower eye-lid, the anterior edge of the
meatus auditorius externus, and the horizontal ramus of the lower jaw.
In none of the other parts of the face was there any evidence of disease.
The morbid condition of the parts affected were, as has been described ; both
taste and feeling were lost from the left side of the tongue, so that she
was obliged to chew on the right side only, and if the food lodged at any
time between the teeth and cheek in the left side of the mouth, she was
obliged to remove it with the finger. The motions however of every
part of the face were properly performed, the features not at all distorted,
the tongue protruded in a straight line, the temporal and masseter
muscles appeared to act powerfully on both sides; she had no difficulty
in utterance, except occasionally, when much excited; her general health
CXIV DISEASE OF THE FIFTH PAIR.
seemed good, her appetite was strong, her bowels were confined, and
her tongue rather white. Since the age of twenty-one a violent headache
had frequently distressed her, which she described as going off by the
face; it was accompanied with sickness and vomiting of bile: this head-
ache had continued to return at intervals since the commencement of her
present ailment.
" On October 8th, 1827, I find I reported that the symptoms had
gradually increased in severity, and the disease extended somewhat be-
yond its former boundaries.
" September, 1828. — From the last date to this she had been nearly
lost sight of by me; she had been for some time under the care of Mr.
Charles Bell. On visiting her at this time, I found that she still had a
distressing sensation on the left side of her face, &c., although altered in
its character; her speech had become indistinct, her face was drawn to
the right side, the masseter and temporal muscles of the left side had
ceased to act, the tongue was protruded towards the left side, the hearing
of the left ear had ceased; she could raise the left upper eye-lid by
voluntary power, but could not keep it elevated; the effort to raise the
globe of the eye was attended with headache and giddiness ; there was
considerable secretion of tears; she was emaciated and bed-ridden, and
complained of great and constant pain at the back part of her head.
" About a month before her death her intellects became confused,
her breathing difficult, her speech quite indistinct, and her deglutition
impeded; she occasionally ground her teeth with violence, and her jaws
were often firmly clenched, apparently by tlie contraction of the muscles
of the right side: she seemed to die at length (in February, 1829) from
difficult respiration, and want of the power of swallowing.
" Post mortem appearances. — The frontal bone was more than one
third of an inch thick, and studded with numerous granulous eminences,
causing corresponding indentations on the surface of the brain; the
vascularity of the dura mater was increased, but not more adherent than
usual to the bone; the substance of the cerebrum and cerebellum had
more blood than it is generally found to contain after death, but was
otherwise of a liealtliy aj)pearance; about one ounce and a Iialf or two
ounces of serous fluid was found in the ventricles; a tumor containing
DISEASE OF THE FIFTH PAIR. cxv
fluid of the colour of urine (considerably darker than that taken from the
ventricles), about the size, and not unlike the form, of a pigeon's egg
was discovered on dividing the tentorium on the left side, bounded by
the petrous portion of the temporal bone, the pons verolii, and the left
lobe of the cerebellum ; the part next to the pons had contracted a slight
adhesion to it, and had by its pressure produced considerable indentation
on the left side of it; the tumor seemed on minute examination to be a
growth from the inferior surface of the crus cerebelli,just behind the junction
of the pons verolii ; this morbid growtli consisted of a bag partly mem-
branous, and partly medullary, the interior of which was cellular, and
contained a fluid which has already been described, in a manner not very
unlike the vitreous humour of the eye, excepting the colour of the fluid.
The first and second pair of nerves on the left side were as usual; the third
was slightly displaced by the tumor; the fourth undisturbed; the fifth
appeared to come from the fundus of the tumor, passed under the dura
mater at its usual place; it was flattened and thin as if from pressure,
and could be traced along the coat of the tumor no further than within
about half an inch of its origin. The sixth pair was healthy; but the
seventh, both portia dura and mollis, was completely involved and lost in
the tumor from a quarter of an inch from its origin to the meatus
intern us ; and into this foramen no nervous structure could be seen to
enter, but a substance resembling the membranous portion of the tumor
and apparently a process of it ; both portions of this nerve however were
distinct from each other at their origin, and of their usual appearance.
*• John Whiting, M.D.
" 250, High Street, Southwark.
" March, 1829."
From whatever cause it may proceed, whether from the more exquisite
sensibility of the fifth nerve, or its more remarkable connexions, certainly
all nervous affections are peculiarly apt to fall with a concentrated force
upon it. Thus, in injuries of other nerves, the first symptom, before
the affection spreads to the other voluntary muscles, is stiffness of the jaws.
In several instances of injury of the nerve in amputation, also when the
q 2
cxvi AFFECTIONS OF THE TONGUE.
nerves have become entangled in the cicatrix of the stump, the pain
has struck into the face and jaws, producing a tic.
The following cases are in illustration of the paper where it is shown
that the nerves of the trunk, neck, and throat are divisible into two
distinct systems : the one the symmetrical system of nerves common to
all creatures, for bestowing the offices of sensation and voluntary motion,
whose centre, therefore, is in the sensorium; the other a class of super-
added nerves, called the respiratory system. These last are nerves which
can perform their principal functions independent of the brain, and con-
sequently of volition ; for although they be dependent for some of their
functions on the efforts of the will, their principal actions may proceed
during sleep, or when, from any other cause, there is an entire loss of
sense and voluntary motion.
The nerves of this last class are more easily excited in dying animals :
they, in fact, retain life the longest, since they continue to influence the
actions of respiration when sensation and volition have ceased. Thus
forming a class of themselves, they are excited by sympathies which do
not reach to the other nerves, and are sometimes left entire in their
functions, when the other class of nerves is peculiarly the seat of dis-
turbance. The following cases will exhibit them very subject to derange-
ment; and will, at the same time, show the necessity of disentangling
them anatomically, in order to distinguish the symptoms of disease which
belong to them.
The two classes of nerves of the body are similar to the two classes
of the face; but the intricacy of the former will make it long before I
have such an accumulation of evidence as I have thrown together in
illustration of the nerves of the face. When practitioners shall have a
distinct notion of the anatomy of these respiratory nerves, cases will
accumulate.
AFFECTIONS OF THE TONGUE. cxvii
No. LVII.
Affections of the Tongue.
" July 21, 1825.
" Sir, — I shall feel obliged by your answering this letter at your
earliest convenience ; *****
********
********
" In consequence of your important discoveries relative to the nerves,
I am particularly desirous to have your opinion on the following case.
The invalid is an unmarried lady, nearly seventy years of age, who has
enjoyed uninterrupted good health up to the present illness. She has had
occasional short attacks of gouty inflammation in both feet, and also in the
knees, of very short duration. From the first of her complaining to the
present moment, she has been free from headache and from pain, numb-
ness, or debility of the limbs. The vision and hearing are natural ; the
appetite good; the bowels regular, and the sleep natural. In short, there
is not the slightest deviation from sound health, except in the particulars
I shall relate.
" Some few months ago she had some difficulty in using the tongue,
and in expressing particular words. This difficulty has gradually increased,
and now she cannot protrude the tongue, or even move it. She has lost
her speech altogether. The tongue itself is soft and pulpy; but it retains
its sense of taste and of feeling. The deglutition is impaired, and
occasionally she is distressed with a sense of suffocation, in attempting to
swallow food, which she is now obliged to do with great care. She cannot
hack up any thing from the throat, nor draw any thing from the posterior
nares by a back draught. The features of the face are quite natural,
and the skin retains its feeling. The saliva occasionally flows from the
mouth, &c.
" R. W. Robinson, M, D.
" Preston."
In the body of the work, the offices of the three nerves of the tongue
are slightly sketched out. This case is descriptive of a paralytic affection
CXVill LOSS OF SPEECH.
of the ninth nerve, a cerebral and motor nerve; and therefore I gave it as
my opinion that the symptoms were more alarming, as proceeding from
the brain, and threatening apoplexy.
When I have cut the ninth nerve in a dog, the motion of the tongue
was lost, the power of feeding himself was lost, and it was necessary to
destroy him. The power of deglutition however was entire, when the
morsel was put within the touch of the back part of the tongue, and
the grasp of the fauces. The motion of the tongue to turn the morsel in
the mouth was lost, and there was inabihty to place it in the fauces, but
no other defect resulted. This seems to be exactly the condition of this
lady. That she can swallow, is evident from her surviving the attack,
which circumstance declares the glosso-pharyngeal nerve in activity; and
we are told, that she had the taste and the natural feeling of the tongue,
that is, the function of the fifth nerve was entire.
I recommended in this case nauseating medicines, leeches under the
mastoid processes, and a seton across the neck near the occiput, and any
local appearance or gout to be encouraged.
I attended at the same time a young lady who could not swallow, and
a boy who entirely lost his speech: 1 had the latter under my control, and
can vouch for the accuracy of the detail. Suspicions often arise, that a
trick is played off when these curious nervous attacks are witnessed. The
anatomy of the nerves, and the study of their functions, should enable the
physician to examine symptoms with accuracy, to distinguish the natural
train of connexions which cannot be imitated, and thus to banish suspicion.
No. LVIII.
Case of Frederick Hill^ cet. 10. Loss of Speech.
" Jliddlesex Hospital.
" This boy cannot speak, and therefore is accompanied by his mother.
She says that from childhood he has been subject to a pain in his ear.
About twelve months ago, he was seized with an obstinate pain in his left
ear, which gave him no rest, night or day. The pain extended to his head
and face, and appeared sometimes to be in the bones of the forehead, and
the sockets of his eyes. It then affected his teeth, and he had toothache
LOSS OF SPEECH. CXix
in every tooth in his upper jaw. After this his left eye became much
affected, and he lost his sight.
" From this attack he recovered, as she describes, by large bleedings,
and injections into his ear, leeches behind the ear, shaving the head, and the
application of blisters. Twice he heard something crack within his head,
and these sensations have been followed by the discharge of matter from
the ear, with relief. The discharge does not seem to have been trifling,
for she says it was at one time constant for some hours, and the fever and
pain were so great, that he became delirious, and he was restrained with
great difficulty by means of a strait jacket.
" It should have been noticed, that, when at the worst, he was so
irritable, that the slightest unexpected noise, even the striking of a clock,
would bring on one of his fits. About five weeks ago, he began again to
complain of pains in his ear, which increasing, brought on delirium before
night. He was now unable to eat or move his jaws, or even to speak, such
motions producing a crackling pain in his ear. The day after this he was
seized with a fit, in which it required two men to hold him for about
half an hour, during which time he was insensible; and when it left him,
and his senses returned, he was speechless.
" On the 7th October he was admitted into the hospital. He had
then a discharge from his ear, accompanied with pain in the temple, and
was relieved by leeches and fomentations. About a week after his ad-
mission, he threw himself down in a violent fit of passion, as it would
appear, and from this moment he was entirely deaf.
'* Another striking circumstance has arisen since that time. His left
arm has become useless : it hangs by his side, and he cannot raise it. He
can move his fingers, but not his arm; and from the middle of the arm to
a little below the elbow, it is acutely painful when touched.
" He is now brought under Mr. Bell's care, who has made a par-
ticular examination of his condition. The actions of respiration are
perfect. When he smiles, there is no inequality in the action of the
muscles of the face. He is reported to make noise enough in laughing.
When cupped, he hollowed out, and they thought every moment he
would speak, yet there was no articulate sound. The boy is acute, and
understands every thing communicated to him by writing. When by
this means he is asked to speak, and when the throat is grasped during
cxx LOSS OF SPEECH.
the effort, there is not the slightest motion perceptible in the muscles of
the tongue. Yet he can masticate and swallow with ease; he can nearly
touch the point of his nose with his tongue; he can turn it down to the
chin and sideways. When his surgeon's name is written, and he is asked
to pronounce it, he remains fixed with his mouth open. When by signs
he is told to close his lips in the manner necessary to pronounce the
letters h and jo, and when he is then asked to pronounce these letters,
there seems an utter inability. The consent of action between the chest,
larynx, and mouth, seems to be lost.
" This patient was repeatedly purged with calomel and jalap. He
had leeches applied behind the ear, fomentations to the side of the head
by means of steam, and blisters.
" Nov. 22. — This boy's condition is considerably improved. He
tosses the arm which was affected over his head, smiling obviously in
exultation. It is reported that he is now able to whistle; and as this is
an action in which the muscles of the chest and lips are associated, it
appears to be a contradiction to a former statement; but on witnessing
this attempt, we find that he makes a faint noise by drawing in his breath,
and that, in fact, he cannot whistle. He is asked if he can hear himself
whistle, and he says no. Being urged to say how he knows when he is
whistling, he takes the slate very readily to write, but finds a difficulty in
expressing himself.
" Nov. 24. — A slight spasm observed on the lower lip.
" January 7. — About a fortnight ago, this boy, being distressed with
the confinement of the hospital, made entreaties to be dismissed. He
came to-day, with his mother, among the out-patients. She says he
thinks it hard to be tormented when there is nothing the matter. He
would do any thing to avoid blistering, and being promised that nothing
should be done to him if he will make a noise and try to speak, his
mother telling him to call the cat, he attempts it very readily. His
efforts confirm the former statement, that he is incapable of putting the
tongue and larynx into co-operation in speech. The mouth is shut, the
tongue and larynx perfectly still, and he makes a noise by impelling the
air against the posterior nares. It is still necessary to communicate with
him by writing.
" Soho-squarc, July 5. — The mother brought her boy to me this
LOSS OF SPEECH. cxxi
morning, and gave me the following account. The terror of the boy, and
his extreme violence, prevented her from following up my advice, but three
mornings ago he recovered his hearing and his power of speech at the
same time. She had just been observing that he could not be very ill,
since he was tumbling about, and throwing his heels over his head in bed.
Soon after his sister came running down stairs, saying that her brother
could speak, and a quantity of matter had come from his head into his
mouth. From that moment he could hear, and with a painful degree of
acuteness, the boy saying that the air rushed through his head. She
describes his voice, too, as at first unnatural, and as if he spoke with
difficulty ; a circumstance which cannot surprise us, when we recollect
that it is nine months since he could speak a word. He has at present an
extreme tenderness in the upper part of his head, and cannot bear to be
touched there. His mother says the matter which came into his mouth
was very offensive. A little matter comes from his ear. There is cotton
in his ears, but it is for the purpose of dulling the sensation."
This case of Hill's is not demonstrative, for happily there was no
dissection to ascertain the precise nature of the injury to the nerves ; but
it is illustrative. There appears to have been an abscess, originally pro-
duced by disease of the temporal bone, and affecting the nerves of the
base of the brain, first affecting the fifth nerve, and then spreading its
influence to the seventh and ninth. If the disease had produced its
influence mechanically and by pressure, there would have been no ob-
scurity, and one side only would have been affected j but I imagine that the
inflammation had disturbed the operations of the nerves, without altogether
destroying their influence, deranging, for instance, the fine associations
necessary to speech, without arresting the action of the muscles of the
tongue*. It is remarkable, that the bursting out of matter, probably
from the Eustachian tube, had such an instantaneous and simultaneous
effect in restoring both hearing and speech.
The want of the power of swallowing, and the want of power of
* See Dr. Abercrombie's cases in the Edinburgh Medical and Surgical Journal, July, 1818.
r
cxxii LOSS OF SPEECH.
speaking, when occasioned by remote irritation, are not more extraordinary
than the sounds which are produced from the same cause.
I have been consulted by a young lady of 15 years of age, wlio had
a convulsive barking noise like a cough, excepting that the larynx was
alone affected, and there was no conforming action in the pharynx, velum,
and lips. She would sometimes cough naturally in the intervals of this
noise, but this natural coughing did not interrupt the return of the
unpleasant hard bark at the rate often times in a minute ; it ceased when
she was asleep, but the moment she was awake the family heard the noise,
intolerable from repetition. It continued a month, and returned three
successive winters.
I have seen an instance in a young woman, where the same cause
produced a more permanent and alarming effect, a spasm in the glottis,
so continued and so severe, that the attendants called upon me to perform
laryngotomy.
All the subjects of these odd cases, which we do not understand, get
well. This is consolatory to a patient, certainly, but not very satisfactory
to ourselves. Ought it not to be a question, what nervous affections are
consequent on trivial irritation? Without entering on the question,
whether disordered health be followed by the imperfect and deranged
action of tlie uterine system, or whether the latter be the primary
disorder — the ovaria are the source of irritation ; and the consequences
are exhibited through the most susceptible system of nerves, the respira-
tory system. Hence the disorder of the stomach, the spasms, globus, the
difficulty of deglutition, the aphonia: hence the affection of the counte-
nance, the tears, the sobbing, and spasms of the eyes and face, and throat,
and chest, and stomach.
Within the space of one month the three following instances of fracture
of the vertebra? of the neck have occurred in my practice. In one instance,
the bones were broken at the lower part of the neck, and the patient
lived some days. In the second instance, the vertebra? of the neck were
fractured in the middle of the neck, and the man lived half an hour. In
the last instance, the uppermost vertebra was fractured, and the death was
immediate.
FRACTURE OF THE SPINE. cxxiii
No. LIX.
Cases of Fracture of the Spine.
Case I. — Percy Jf^arcl, 29th May. — Cliarles Osborne, aetat. 26. — On
Saturday evening this man was putting pulleys into a window sash when
the small steps on which he stood slipped from under him, and he was
precipitated through the window into the area, a height of thirteen feet.
He thinks he fell upon his back ; but he is uncertain, as he lay for some
time senseless. He lies now in bed, supine and powerless, but describes
the part injured to be the spine between the scapulae. As we desire to men-
tion only the essential features of this case, it is better to say at once, that
this was a deception, that he felt the pain of the injury at a point con-
siderably lower than the fracture, and that on his death it was discovered
that the arches and bodies of the sixth and seventh cervical vertebra? were
broken.
The lower extremities are motionless and insensible. He can raise
his shoulders and bend his arm, but over the motion of the hands he has
no power.
Another report adds — his expression is singular; he says he can
move his arm by the strength of his shoulders, which is exactly true, for
by moving the shoulder he can give a certain rotary motion to the
humerus, and, consequently, move the fore-arms when they are bent at
the elbow. The skin of the arms, however, retains its sensibility to the
point of a pin. The abdominal muscles are relaxed, and the viscera feel
flaccid. He can make no effort to expel the urine; his urine is drawn
off by the catheter, and his faeces pass involuntarily: there is priapism.
When I induce him to attempt an effort and to strain, no change on the
abdominal muscles can be felt; there is no firmness or rigidity in them.
The integuments of the abdomen and of the chest, as high as the nipples,
are insensible.
His breathing is frequent, and at each inspiration the chest is heaved
with a short and quick movement: at each expiration the abdomen is
protruded with a sudden shock and undulation. The belly, during this
r 2
CXXlV FRACTURE OF THE SPINE.
effort of breathing, is uniformly soft and full ; when drawn in, it is by the
elevation of the ribs, and when the chest falls, it is protruded.
He has been observed to yawn naturally. Query. Can he cough?
An examination has been made to-day to answer this query. When
he is asked to cough, he pulls up the ribs and extends the chest, and lets
them fall: he coughs, but not strongly: it is obviously by his power of
raising the chest and giving elasticity to the ribs, and by the weight of the
parts falling, that he is enabled to expel the breath. He cannot divide
the expiration into two coughs, nor give two impulses to the air; but
each time he coughs the elevation of the chest must precede it.
On spreading the hands and fingers on the side of his chest the action
of the serratus muscle could be felt, and also the lower margin of the
trapezius muscle was felt to becom.e firm during the act of inspiration, as
when he prepared to speak.
Being asked if he had sneezed by any chance, his answer was — " No,
sir; I cannot blow my nose." This was not that he could not raise his
hand to his head: he was conscious of wanting the power of forcibly
expelling the air. Mr. B., taking a handkerchief from a nurse, and
holding the patient's nose as a woman does a child's, the patient could
not blow the nose; he could not give that sudden impulse of expiration
which is necessary.
In one of the reports of this case it was stated that the patient was
disturbed by horrible dreams. This is very likely, from the respiration
being in part obstructed; but it was omitted to verify that observation
during the patient's life.
It is remarkable in this case, that on feeling his stomach, he of his own
accord, marks the difference of sensibility, internal and external. He says
he feels internally, but he does not feel on his skin. He feels me when I
press the stomach, and has complained of the griping from his medicines.
This man died in the night of the seventh day from the accident.
The night nurse gave no particular description of the manner of his deatli,
further than that he seemed desirous to speak and could not : he made
attempts to articulate, but was unable.
FRACTURE OF THE SPINE. cxxv
No. LX.
Case II. — James Saunders, aetat. 45, June 30. — This man fell only
four feet, but he fell backwards, and struck his neck against an iron
railing. The transverse processes of his fifth and sixth cervical vertebrae
were found to be fractured; and there was diastasis of the articulations
between these vertebras. The body of the sixth vertebra was fractured.
The spinous processes, also, of the fourth and fifth vertebrae were found
fractured at their bases.
The house surgeon reports of this man, that when he was brought
into the hospital he was perfectly sensible; that his face indicated great
alarm and anxiety. Every time he drew his breath it was attended with
an effort to raise the shoulders, and a contraction of the muscles of the
throat: every time he breathed, his head appeared to sink beneath his
shoulders. On putting his hand on the pit of his stomach no motion of
the viscera of the abdomen could be perceived. He had no feeling even
in the upper part of his chest: he had feeling on his face and neck, and
indistinctly near the collar bone. He had a motion of his hands, a sort
of rolling motion, which may have proceeded from the shoulders. When
he spoke it was in a tremulous voice, like a man frightened : his voice
was weak, but he did not speak in a whisper: the sound of his voice was
more like sighing than common breathing. The pulse was felt at his
wrist. In ten minutes after he was brought in, half an hour from the
time of the accident, he died.
No. LXI.
Case III. — On the following day a man was brought into the hospital
dead. He had fallen fifty feet, and had lighted on the ground upon both
his shoulders. By the accounts of the men who carried him to the
hospital, he appears to have been instantaneously killed. The dissection
sufficiently proved that he was killed suddenly. For besides extensive
fracture and injury to the lower part of the spine, the atlas and dentata
were found fractured. The tooth-like process of the vertebra dentata was
broken through just at its base. It was separated completely, and was
cxxvi FRACTURE OF THE SPINE.
found embraced by the transverse ligament in its natural situation upon
the atlas. The arch of the atlas was partially fractured on each side, and
a portion of its body, where the process of the dentata rolls upon it, was
also fractured and detached.
By this fracture the medulla oblongata was injured, and the breathing
instantly interrupted.
No. LXII.
A young man was brought into the Middlesex Hospital, who had
fallen upon his head. He soon recovered, and lay for some time in the
hospital without exhibiting a symptom to raise alarm. He had given
thanks to the assembled governors of the hospital, and had returned into
the ward for his bundle, when, on turning round to bid adieu to the other
patients, he fell, and in an instant expired. Upon examining his head, it
was found that the margins of the occipital hole had been broken: no
doubt it had happened that, in turning his head, the pieces were displaced,
and had closed and crushed the medulla oblongata, as it passes from
the skull.
No. LXIII.
A man was trundling a wheelbarrow in Goodge Street, which is
immediately adjoining the Middlesex Hospital: in going from the
carriage-way to the flag-stones he met the impediment of the curb-stone.
He made several efforts to overcome it, and at length drawing back the
wheelbarrow he made a push, and succeeded; but the wheel running
forward, he fell, and remained motionless. He was taken into the
hospital, but he was found to be quite dead. The tooth-like process
of the second vertebra of the neck had burst from the transverse ligament
of the first. The impulse given to the head had done this violence, and
had at the same time carried forward the spinal marrow against the
process, and on which it was crushed.
These two last cases occurred before my time, but I have had two
instances of sudden death from dislocation of the atlas from the second
vertebra of tlic neck. In short, the fact is perfectly well ascertained.
FRACTURE OF THE SPINE. cxxvii
No. LXIV.
A patient, who had a deep ulcer in the back part of the throat, was
seized with symptoms hke those of apoplexy. These symptoms con-
tinued for two hours. At this time the patient's head fell suddenly
forward, and he instantly expired. On dissection, it was found that the
ulcer had destroyed the transverse ligament, which holds the process of
the dentata in its place. In consequence of the failure of this support,
the process was thrown back, so as to compress the spinal marrow. The
parts are preserved in my collection.
We have here another proof that when the medulla oblongata is
crushed, the death is instantaneous; and that the respiratory nerves,
being those of expression, no contortion or mark of agony accompanies
this sudden death. But there is another important feature here: the
apoplectic symptoms preceded the crushing of the spinal marrow. If this
disease had occurred lower in the spine, it would not have been different
from the common case of paralysis of the lower extremities from disease
of the vertebrae, where the communication of inflammation to the spinal
marrow or its theca, and not the mechanical pressure of the bones,
occasions the defect of sensibility and motion.
No. LXV.
A man was brought into the hospital, having had a severe injury
of the head. Two attendants were doing their duty to him ; one was
letting blood in the arm, whilst the other was shaving his head: the blood
suddenly stopped, and the operator looking up, saw that the patient had
ceased to breathe, and was without motion or expression of any kind.
On dissection, it was found that the fracture had gone through the
foramen magnum of the occipital bone, leaving a loose portion. By
merely turning the head in shaving, the loose portion of the bone had
been turned upon the spinal marrow, and crushed it.
I have seen various examples of fractured spine, but none better calcu-
lated to illustrate the function of the nerves of respiration than those described
above. But the following case of diseased vertebrae is very instructive.
cxxviu DISEASE OF THE SPINE.
No. LXVI.
Case of Palmer. — Effects of Disease of the Spine.
" October 4, 1825. — James Palmer, jet. 16., was admitted into the
hospital, under the notion that he was suffering from a blow upon the head.
But, on inquiry, it is found that he received no violent injury, and that
a man in good humour had struck him with his open hand on the top of
the head. It is not possible that this could have hurt him, unless the
disease we are presently to describe had made some progress.
" The surgeon, on examining this patient and hearing his story,
directed his attention to the spine, and on feeling the nape of his neck,
he desired that a minute account of his history should be made out.
" The patient states, that about three months ago he caught a violent
cold, attended with sore throat, and stiffness and swelling round the neck.
When the general swelling subsided, there came on a swelling at the back
of his neck, which continued to increase until he felt a numbness in parts
of his arm and fingers, and likewise in the leg. He at length lost the
use of the right arm and leg, and was brought here in the condition
to be described.
" There is a swelling round the spine on the back of the neck. It is
a thickening of the ligaments and cellular membrane around the bones ;
the tumefaction is greatest on the right side of the neck. He complains
of no pain, and to a certain degree he can bend his neck. He requires
assistance to move either the arm or leg of the right side. The left side
is less affected. On the 8th of October an issue was made on each side
of the cervical spines. They were made with a cut of the scalpel, and
bled freely. Next visit he was sensibly better ; he could move his arm
and leg. But on the following visit he was in the same state as when
admitted. . •
*' It being supposed that so immediate and so short aji influence could
only be attributed to the loss of blood, eight leeches were applied round
the issues, and ordered to be repeated.
" 14th. Within the last few days he is worse. He complains of more
DISEASE OF THE SPINE. cxxix
numbness, and can neither move leg nor arm. He has pain down the
right side of his neck. When he attempts to move the head, he has
great pain, and the pain is increased when the head is permitted to fall
forwards. A stuffed collar is ordered to be applied so as to support the
head in every position of the body, and to give rest to the inflamed
vertebra. The issues to be frequently touched, and kept active, and
leeches to be applied round the issues. His bowels are attended to.
" 18th. — This boy breathes better, feels better, and turns his left
hand more freely: and, as the pulse admits of it, the leeches are to be
continued.
" 19th. — To-day he is certainly not better. He lies a little twisted;
his breathing is more laborious. He complains of the difficulty of
breathing, and being asked to say in what respect, he says it requires
more effort in speaking, and he cannot continue it without increasing-
difficulty.
" 20th. — He is worse to-day. Upon being asked for his hand, which
he supposed was lying across his breast, he was much surprised to find it
lay by his side.
«' 2,5th. — His breathing is difficult; he complains of a sense of weight
upon his chest; his voice is much more feeble. He cannot call out; and
when he endeavours to do so, it is very feebly; and he says it appears as
though his voice came from his neck. On examining the muscles by which
he breathes, we readily discover the sterno-cleido mastoideus in strong
action. The abdominal muscles are totally inactive and loose.
" 7th January. — From the wasting of the abdominal muscles the motion
of the intestines can be seen through them, and from their state of
relaxation the hand can be pressed very deep under the scrobiculus cordis;
in doing which he is sensible of pressure against the stomach, although
insensible on the integuments of the belly. When he attempts to cough,
he raises his chest, but can give no impulse in discharging the air; he
expires by the falling of the chest merely.
*' Among other circumstances it deserves notice, that, when asleep,
his thighs are involuntarily drawn up ; and of late his limbs are thus con-
tinually drawn up, and he has no power of pushing them down. About
s
CXXX DISEASE OF THE SPINE.
a week ago he was attacked with pain in his head, and had the sensation
of water trickUng down into his ears; since which he has been deaf.
" Sept. 1. — It is now some months since any note has been taken of
this case, and the improvement is remarkable. The motion of the right arm
first returned, and then of the left. He afterwards began to move his right
leg, and then the left. At last he managed to get out of bed, and crawl
about the ward: he is now, with the aid of crutches, able to walk to the
water-closet. He complains of pain in his jaw on the left side.
" In all this time, the treatment has consisted of attending to his
torpid bowels, that no distressing accumulation might take place; and
care has been taken to keep the issues in his neck active, and to preserve
the vertebrse from being moved.
" Mr. Bell, who is curious to observe the effect on his voice, makes
him call the nurse, which he does now of himself whenever he sees his
surgeon approaching on the visit. This is to show how much he improves.
When this experiment was first made, he raised his sternum by evident
exertion, and let it suddenly go down in pronouncing the word, nurse.
Of late the power of enforcing the voice by the action of the muscles of
expiration has been resumed.
" 28th. — He now walks about the ward, and has the use of both legs
and arms; but the right arm is the weakest.
" He knows when the fingers of the right hand are touched; but if
you close them while his head is turned away, he is not aware of their
position, unless the points of the fingers touch the palm; so that if you
extend the fingers, he says they are bent. His speech is much improved,
and all the functions of the body restored." — "Was made an out-patient."
This case of Palmer is very interesting, and abundantly confirms the
result of the cases of fracture of the spine. By the progress of inflamma-
tion beginning in the vertebras, and propagated to the spinal marrow, we
see the function of the spinal marrow slowly debilitated, and at length the
symptoms coming to resemble those produced by the crushing of the
spinal marrow by the broken vertebrae. But here we can observe the
gradual failure of strength, and the consequence of inactivity, in the
DISEASE OF THE SPINE. cxxxi
wasting of the muscles. The most remarkable effect of this was the
possibility of seeing the intestines moving, and the relaxed abdominal
muscles partially rising and falling according to the distention and con-
traction of the intestinal canal. This state of the abdomen permitted us
to examine the stomach, and to ascertain that its sensibility was entire;
and it is fair to conclude, that this was through the influence of the par
vagum. TJie branches of this nerve to the stomach, like its sub-divisions to
the larynx and pharynx, are in possession of two functions; the peculiar
sensibility of the part is bestowed, and the arrangement of the muscles is
formed, through its influence. It must be remembered, however, that this
double office proceeds in all probability from its receiving additional branches
from the spinal nerves just as it is emerging from the base of the skull.
As the symmetrical system of nerves to the trunk became impaired,
the muscles supplied with the accessory respiratory nerves became more
excited, and rose higher into action. At the same time, the voice became
feeble. This is easily understood, for the strength of the voice results
from the impetus with which the breath is expelled. In this case, the
active muscular power of expelling the breath was lost, with the other
voluntary powers of the trunk and extremities; and by this we see the
importance to life of these accessory nerves of respiration, for continuing
to possess power over the diaphragm, serratus magnus anticus,trapezius, and
sterno-cleido mastoideus, they supplied a force of inspiration sufficient to
preserve life, until amendment took place in the spinal marrow, and com-
mon spinal nerves. No one, I apprehend, will be bold enough to affirm,
that if the muscles of the neck and trunk had been as entirely deprived of
action as the abdominal muscles were in this case, the patient could have
survived by the mere action of the diaphragm.
If the diaphragm were to act alone, it would pull down the margins
of the chest; and in as far as the diaphragm tended, by its action and by
its descent, to produce a vacuum, the ribs, by their yielding to the action
of the diaphragm, and their descent, would render the muscular effort
nugatory; for inasmuch as the cavities of the thorax would be enlarged in
their long diameter by the descent of the diaphragm, so much would they
be diminished transversely by the descent of the ribs and sternum. But
when tlie serratus and mastoideus raise the thorax at the same moment
*2
cxxxu DISEASE OF THE SPINE.
with the contraction of the diaphragm, circumstances are materially altered.
The ribs and sternum are raised against their elasticity, and consequently
opposed to that state to which they would recoil even in death. The
expansion of the margin of the chest increases the effect of the muscular
effort of the diaphragm, the arch of that septum is contracted and bears
down, and the abdominal viscera are lifted up, which, on the cessation of
effort, recoil by gravitation into their position; and thus the elasticity of
the ribs, and the weight of the parts opposing the muscles of inspiration,
preserve the life when the muscular power of expulsion is gone. There
would in like manner be a defect in expiration; for if the diaphragm acted
alone, the margins of the ribs would be drawn down, and when it relaxed,
they would fly up by their elasticity and expand the chest: thus inter-
fering with expiration.
That accomplished physician. Dr. Cooke, conversant as he is with all
authorities, touches on that of Boerhaave. " Boerhaave notices the fact,
(of the organs of respiration and the action of the heart being entire in
jjaraplegia,) and observes, in explanation of it, that the moving powers of
the viscera can scarcely be said to arise from the nerves of the spinal
marrow, but from the fifth, sixth, and eighth pair, and the recurrent
nerves of Galen." 1 hope it is not necessary to prove that these nerves
are altogether insufficient for the purpose. This admission of the opinion
of Boerhaave by an author whose work immediately preceded the pub-
lication of my papers, and by one so fully informed by study and ex-
perience, shows how long this department of our science has been
stationary.
No. LXVII.
The case of Mrs. G. has recurred to me. That lady's condition
was very interesting, and might have been used as illustrative of my
views of the nerves.
She was quite helpless, sat in a reclining posture, supported with
pillows, and surrounded by officious relations and maids, for she had
her eyes and her senses. She had totally lost the use of all the voluntary
muscles ; her legs and arms lay motionless ; her tongue refused utterance ;
DISEASE OF THE SPINE. cxxxiii
she attempted to speak with her mouth open, and, in a manner, from her
breast; her eyes moved, and were expressive; her face had expression,
she smiled pleasantly, and could frown.
Her great suffering was an indefinable uneasiness and consequent
fretfulness, which occasioned the attendants ffreat trouble in liftino- her
and turning her continually. That she could swallow, her long suflTering
sufficiently proved. She breathed easily.
The remarkable circumstance here, was the total want of all motion of
the bodily frame, unless in the actions of respiration, which were perfectly
free.
In the former edition I mentioned this case ; but the above note,
which is somewhat more particular, I have since found among my papers.
No. LXVIIL
Lynn, March 6th, 1829.
"Dear Sir, — The case to which you allude I recollect transcribing
partially from my notes, and forwarding to you, in April 1827, as
follows: — ' The power of moving the limbs entirely lost; can utter only
indistinct guttural noises ; senses of sight, smell, taste, hearing, and feeling,
perfect ; breathing regular and easy ; eyes bright ; countenance natural in
expression ; deglutition defective ; the effort often exciting distressing
paroxysms of cough and choking ; contents of bladder and rectum regularly
evacuated ; though latterly, at times, with some difficulty.'
" I was called in at an advanced period of the disease, and could not gain
a very clear account of the previous progress ; but, I have much pleasure
in extracting from my note-book all the particulars I could collect.
" Two years preceding the above report, the lady, upwards of fifty years
of age, of a delicate, nervous temperament, whose health previously had
been tolerably steady, sustained a severe fall, striking sharply the lower
part of the spine, and back of the head and neck ; the immediate symptoms
produced were, slight stunning ; nausea and faintness, which soon
passed off. Some little time after this accident, she complained oc-
casionally, of headache and dizziness ; and in the course of a few weeks it
was observed, that she walked hesitatingly, dragging slightly the left leg,
cxxxiv DISEASE OF THE SPINAL MARROW.
which she noticed as feeling weak ; to these symptoms succeeded after
awhile, hesitation of speech, and an unusual thick guttural pronunciation,
and a consciousness of some difficulty of moving the tongue whilst eating
or speaking. The left arm now became weakened. In this state she
continued for a time, when after a second fall, by which the back of the
head was forcibly struck against the edge of an open door, the weakness
of the left side rapidly assumed a more decided paralytic character, and
appropriate treatment was instituted, but with little effect ; as the right
leg began to feel uneasy, from twitching of the muscles, and the hand of
that side became weak, and affected with numbness, alternating with
pricking and tingling in the fingers ; and ere long the state of this arm be-
came similar in all respects to the left : the speech became more and more
indistinct ; and the difficulty of swallowing gradually increased. Con-
trivances to enable her to communicate with her attendants were now
resorted to ; and as long as she was able to direct a small stick to
letters printed on pasteboard, she could make those around sensible of
her wants and wishes : but for some weeks before her death, she lost all
power of moving the hands and arms. My report to you conveys the
state in which she continued to the last ; excepting that the muscles of the
neck lost their power, and the saliva could not be retained in the mouth.
It appeared also, from the flaccid state of the abdominal muscles, that the
expulsion of the faeces and urine was latterly chiefly effected by the action
of the diaphragm.
" At no time, during my attendance, was there any particular
acceleration of pulse, or other indication of fever; and never the slightest
wandering, or loss of memory. The paralytic symptoms marched on un-
impeded by any treatment.
" I could never discover any loss of sensibility ; it was natural in degree,
and uniform over the whole surface of the body : the slightest pressure of
the legs, toes, fingers, or arms, was immediately perceived. During the
act of yawning, or sneezing, no motion of the arms was observed. Tlie
muscles of the neck and trunk were the last to give way ; she could nod,
slightly turn the head, and bring the trunk forward, to within a few weeks
of her death, after all power in the extremities had ceased. She frequently
coughed, and occasionally sneezed ; and had the power almost to the last,
MOTION LOST, SENSATION REMAINING. cxxxv
of producing sounds by expelling the air rapidly from the lungs : but it
could not be called distinct shouting.
" I subjoin the dissection of this case, which took place 36 hours after
death.
" The skullcap being removed, the dura mater appeared of an un-
usually dull blueish cast ; and cutting through it, a quantity of limpid
serum, to the extent of six ounces, escaped. The pia mater was of a
slight milky colour, and many patches of gelatinous matter were effused
between it and the arachnoid. I considered the membranes generally as
thickened, but the vascularity not unnatural. The substance of the brain
might be said to be somewhat softer than usual, but the season was ex-
cessively hot, which may account for it. Throughout the mass, nothing-
was observed that could be construed into alteration of structure. In the
ventricles, rather more fluid than common was found : the nerves at the
base, and the medulla oblongata, were carefully examined, and appeared
free from disease ; but the membranes towards the foramen magnum,
and the sheath of the cord, as far down as the sixth cervival vertebra, were
thickened, and highly vascular ; and this was particularly remarkable at
the anterior part of the sheath of the spinal canal. I removed the fourth,
fifth, and sixth arches, of the vertebrae of the neck, in consequence of their
spines projecting, and found the anterior half of the cord, in this space, in
a semifluid state, approaching nearly to the consistence of cream, whilst
the posterior portion possessed its usual firmness.
" I liave been led into this lengthy detail, in consequence of your
requesting a minute description of the case ; and should any part of it
appear obscure, I am ready to answer such questions as you may deem
necessary to put to me.
" The fall appeared to bring on low inflammation ; effusion was the
consequence, and the paralysis, the effect of the pressure from the fluid.
" I am, dear Sir,
" With the greatest respect,
" Very much your obedient Servant,
" Thomas Ingle."
I give the following instance to show how independent the act of
breathing is of the state of the brain. It is written by an old pupil, on
CXXXVl RESPIRATION INDEPENDENT OF THE BRAIN.
whose accuracy I have a perfect reUance, and whom I expect to see one
day in the first rank of his profession.
No. LXIX.
A Child breathes after the Brain has been destroyed.
" After the membranes liad given way, and the Hquor amnii had
escaped, the midwife on examining found another membranous bag pre-
senting, which she naturally supposed belonged to a second child, and
therefore did not interfere. During the passage of this bag under the
os-pubis it suddenly burst, and the whole of the brain escaped from the
opening very much smashed, and hanging together only by its membranes.
The child breathed with perfect freedom and cried strongly, rolling its
eyes about in a wild, staring manner. It moved its lower extremities
freely, and that not from spasm, but obviously in obedience to external
impressions. There was no motion whatever of the upper extremities.
" In this state it remained for about three hours, when all motion in
the extremities ceased; the eyes became fixed, and the breathing gradually
slower till it ceased altogether, just seven hours after the birth of the
child. During this time neither urine nor meconium passed, nor liad
there been any haemorrhage from the vessels of the brain.
" On examination, the occipital bone and the posterior part of several
of the cervical vertebrae were found wanting, and their place had been
occupied by fluid, surrounded by a membranous bag; an instance of spina
bifida of the neck. The spin&l marrow was perfect.
" A somewhat similar case occurred to me about three years ago, when
I had occasion from peculiar circumstances to remove the brain of a child
through the anterior fontanelle. In that instance, about ten minutes
elapsed before its birth, yet it drew a deep inspiration, and would have
cried had it not been prevented ; and the motions of the lower extremities
continued about half an hour, although the whole of the brain liad been
removed, and a blunt instrument repeatedly thrust down the foramen
magnum.
" I am, dear Sir, yours very truly,
" Berners Street." '* J- SwEATMAN.
SPASMODIC AFFECTION, &c. cxxxvil
Even the more common case of hemiplegia, or the defect of motion
in one half of the body longitudinally, affords us the opportunity of di-
stinguishing the act of respiration from voluntary action. For although
the patient cannot, by a direct effort of the will, move the muscles of the
side of the neck, or of the shoulder, yet when he draws breath, coughs,
sneezes, or yawns, these muscles are put in action *.
I have observed, that when the spinal marrow is cut through by a
fracture of the spine, and the accessory nerves of respiration alone remain
to animate the chest, the patient can yawn, but he cannot cough.
Yawning is an act of the respiratory system, in which the muscles of
inspiration are slowly brought into action.
The following communication from Dr. Abercrombie will throw
additional light on this subject; and the intelligent reader need not be
informed, how successfully this gentlemen has cultivated the pathology of
the brain.
The note was addressed to the late Mr. Shaw.
No. LXX.
" I think the following case will be interesting to you and Mr. Bell.
I had some time ago under my care, a man affected with hemiplegia of
the left side; the palsy complete, without the least attempt at motion,
except under the following circumstances: he was very much affected
with yawning, and every time he yawned the paralytic arm was raised up,
with a firm steady motion, until it was at right angles with his body, (as
he lay in bed on his back,) the forearm a little bent inwards, so that his
hand was above his forehead at its greatest elevation. The arm was
raised steadily during the inspiration, and when the expiration began,
seemed to drop down by its own weight with considerable force. He
* The most ingenious men, as Boerhaave and Van Swieten, will, with all their knowledge
and erudition, be defective in their account of such cases, from attending to the muscles without
considering the sources of the muscular power. See the valuable works of Dr. Cooke, in the
part Palsy, p. 36.
t
cxxxviii SPASMODIC AFFECTION OF THE
continued liable to the affection for a considerable time, and it ceased
gradually as he began to recover the natural motion of the limb.
" Very sincerely yours,
" John Abercrombie.
" Edinburgh, 26th jMarch."
No. LXXI.
Spasmodic Twitching of the Hespiratory Muscles of one Side.
The unpleasant spasmodic actions of the muscles of the face, noticed
in the text, are very common. This, in the slighter degree, is continued,
in some instances, upon the side of the neck and chest, through the in-
fluence of the same class of nerves. The following is an excerpt from a
communication on this head.
" At every interval of three minutes or thereabout, there is a sniffing
and twitching of the nostril of one side, the eyelids of the same side are
at that moment spasmodically closed, and the angle of the mouth forcibly
drawn towards the angle of the jaw; the chin is tilted upwards and side-
ways, and there is a wriggle and retraction of the shoulder. While there
is this audible sniffing and contraction of the face and shoulder, there
appears to be a motion of the diaphragm, and of the muscles of the side
of the chest; and this I judge of in part from the motion produced, but
principally from the drawing of the breath, which causes a sound at the
moment that the spasm of the face takes place."
This is the description of a very frequent disorder. It interferes
with no necessary action of the parts, for it ceases while the patient is
actively engaged, as if the voluntary effort could stop the tendency to
spasm in tlie respiratory system; it is, however, increased by agitation
and speaking.
These motions are sometimes very ludicrous. In conversing with a
MUSCLES OF RESPIRATION. cxxxix
patient with nervous affection I could hav^e believed him a cobbler; his
forearm being half bent, and his hand closed with the thumb projecting:
whenever he became animated in discourse he gave a jerk across his
stomach, which I cannot describe more shortly than by saying it was like
that of driving an awl through a piece of leather. It was obviously con-
nected with his speech, and I must therefore imagine was an affection of
the serratus anticus magnus.
No. LXXII.
Note. — The gentleman who came in to me this morning, has the
slighter degree of spasmodic affection of the face. There is a tremulous
motion of the eyelids of one side, which is sometimes accompanied with
a drawing of the corner of the mouth. It begins with a twinkling of the
fibres of the orbicularis muscle, and is followed with a sardonic grin, owing
to a slight contraction of the muscles inserted into the angle of the mouth;
with an agitation of the cheek like the effect of emotion, as if he were
about to cry. It comes on when he is anxious, or when people look
steadily at him. This nervous affection seems to have been produced by
great depletion ; it occurred about seven years ago, after an inflammation
of the chest, for which he was bled on five successive days. I must
recollect, however, that he is subject to spasmodic asthma, for which he
says it is necessary to undergo bleeding and blistering. He comes to me
in the expectation that I sliould do some operation on his face to stop
this motion. This I could do effectually, but I have explained to him
that a worse effect would result in the loss of power over the eye-lid.
No. LXXIII.
A Spasmodic Affection of the Respiratory Nerves and Muscles.
" Anne Roper, in June, 1825, was admitted into the physicians'
ward, having a spasmodic affection of the muscles of the face, neck, and
t2
Cxl SPASMODIC AFFECTION OF THE
chest, which has no perfect intermission. She ascribes her present con-
dition to having had dysentery, followed by prolapsus ani, a short time
ago, which occasioned great distress. She says she has never been well
since. Her bowels, at present, are out of order, and the catamenia are
irregular.
" The condition of this woman is very peculiar: in her common
breathing inspiration is performed with a sudden spasmodic action: but
she is also affected at intervals with more violent spasms, and her respira-
tion is then hurried and distressing. On the commencement of a paroxysm,
she bends her body slightly forwards, and thus prepares herself as it were
for the attack : her nostrils are dilated widely, the angles of her mouth are
dragged forcibly downwards, there is a constriction of the throat, and the
shoulders and chest rise convulsively, as when a person has cold water
poured upon the head; the inspirations are deep and violent, and are
attended with a sniffing of the nostrils, the air being inhaled through them
only, and not through the mouth. The fibres of the platysma myoides
start into view, and there is a quick rising and falling of the pomum
Adami; the sterno-cleido mastoideus and trapezius on both sides, act
powerfully, fixing the head and elevating the shoulders.
" The spasmodic action of these muscles exists to a considerable
degree constantly, yet it increases in paroxysms which last so severely
for a few minutes that she is deprived of the power of speech, and seems
to be almost suffocated. These paroxysms recur at irregular intervals.
It was observed by the attendants, that when she was excited by walking
about the ward or by replying to our questions, they returned more fre-
quently.
" She could move her head with perfect freedom when we requested
her, but still the spasmodic action continued. She also raised either
shoulder, or twisted her face to one side, when she was desired. This
woman continued under the care of the physician for about a month, and
was discharged cured."
The case was successfully treated by Dr. Southey.
MUSCLES OF RESPIRATION. cxli
No. LXXIV.
Case of disordered Action of the Muscles of the NecJe.
November 18, 1826.
A gentleman came this morning to consult me on account of a
painful and spasmodic condition of the muscles of the side of his neck.
About twelve months ago his mind was exceedingly harassed, and to
this he attributes his present symptoms. His countenance betrays want
of general health, his stomach and bowels have required attention. He
has been consulting the usual fashionable round of medical gentlemen.
He has taken five grains of the blue pill at night for some time. His
complaint is a wry neck. The position of his head is not constantly awry.
He can turn it in all directions, but at times (and I think while conversing
with me) his head is gradually and by little and little turned round, until
his right ear comes near to the sternum, and the chin is pitched upwards,
and to the left side. The sterno-mastoideus is of Herculean strength,
and when you grasp it in its state of action, it is as large as the biceps of
a powerful man.
The contractions extend to the muscles of the neck and shoulder,
corresponding with the distribution of the nervus accessorius, or superior
respiratory. I made him strip, but could not observe that the serratus
magnus was at all affected*.
In this case we have an affection of a respiratory nerve, distinct from
the common voluntary nerve, and bearing an analogy with the more
common instances, because more observable ones, of the affection of the
portio dura in the face.
* His pain was in the mastoid process behind the ear. But this was an indirect effect of
the complaint, and proceeded from the violent action of the muscle.
cxlii SPASMODIC AFFECTION OF THE
No. LXXV.
Spasmodic Action of the Sterno-cleido Mastoideus, 2)roduci?ig a continued
^lotion of the Head.
Anne Turrell, aged 19. Northumberland ward. — This young woman
received an injury of the chest. The blow was so severe as to break the
bone of her stays, and was followed by spitting of blood. The treatment
necessary for this complaint brought her very low. She describes herself
at this time as oppressed with a heaviness and numbness of one side of
her head and flice, and having the sensation of cold water poured down
her neck. This continued until the commencement of this singular
motion of the head, whicli is the most remarkable symptom in her com-
plaint. Conceiving this condition to be an effect of weakness, she left
the hospital into which she was first received. From that time, however,
until she came into the Middlesex Hospital, the motion of the head has
continued.
" There is a perpetual rolling of her head night and day. It was first
noticed whilst she was in bed, by a patient who lay near her. The head
turns twenty-two times in the minute. The action producing this rolling
motion is in the sterno-cleido mastoideus, trapezius, and splenius muscles,
first of the one side and then of the other, so as to move the head on the
tooth of the dentata as regularly as if it were swung round by a pendulum;
and this continues night and day. Her breathing appears to be perfectly
easy; there is deafness in the right ear, and a degree of lassitude in the
right side."
This young woman continued an object of interest for some months,
her complaint being principally referred to her stomach. She was at
length seized with an attack of h.-cniorrhage from the lungs. She was
repeatedly bled, and consequently reduced low, and became hysterical.
But what was remarkable, was the amendment of this motion in the
head under the general dcbihty. 'ilie motions became quicker, and the
MUSCLES OF RESPIRATION. cxliii
rotation to a less extent, like the diminished oscillation of the pendulum,
from being shortened; and when in bed asleep, the motion ceased.
Another attack of haemoptysis succeeded; but, notwithstanding, the
affection of the muscles of her neck diminished. She was made an out-
patient; and in a few days after I saw her visiting her old friends in the
hospital, entirely free of the unnatural motion of the head which had so
long distressed her, and in high spirits.
It has been observed, that in this case the spasmodic motion reached
the muscles on the side of her neck, and that there was a weakness of one
side. I am not, therefore, authorized to affirm, that the complaint was
seated in the accessory nerve ; nevertheless, it is my belief that it was so,
and that it is the susceptibility of this nerve which makes the sterno-cleido
mastoideus muscle so frequently the seat of those deranged actions.
No. LXXVI.
Spasmodic Contortion of the Head and Neck.
Mary Preston, aged 19. — This young woman was brought from the
physicians' ward into mine, that I might have more frequent oppor-
tunities of studying her case.
" The sterno-cleido mastoideus, and the trapezius of the left side, are
subject to almost continual actions, which twist her down to that side;
the ear is brought near to the shoulder, the head turned round, and the
chin pitched up, whilst the shoulder is elevated, and the body bent.
These violent actions arc attended with considerable pain.
" The actions of the muscles are not constant nor regular. The
violent contractions come at intervals. The sterno-cleido mastoideus first
comes into action, drawing the head forwards and downwards ; then comes
the trapezius, twisting the upper part of the trunk, and carrying the
shoulder to the ear.
" This has continued with longer or shorter intervals, about eighteen
cxliv SPASMODIC AFFECTION OF THE
months. It began by slight degrees. She first perceived that she had a
drawing of the head towards the shoulder, with little pain, and slight in-
convenience. Previous to this attack she had been delivered, after a
severe and protracted labour. She is now obliged to support her head
with her hands, otherwise it is drawn completely down to the shoulder.
She complains of pain in the head, which is attributed to the continual
action of the two muscles."
I am often obliged to cease conversing with her, and to draw off the
pupils from the ward, seeing that her anxiety increases the violence of the
spasm. I ordered to this patient a soft-stuffed collar, to be put round the
neck, on which I hoped the head might rest, and save her from the ne-
cessity of carrying her head, as it were, continually in her hands, which
was a thing painful to witness. But no support or control by bandage
could be borne.
When first brought into the surgeons' ward, she was found to have
scarlatina ; after this I thought I had got some indication, in her vomiting
three lumhric'i. After a course of worm medicine, she had an attack of
continued fever ; and it was necessary, in her debilitated state of
health, to send her out of the hospital*.
* Ohstlpitas lateralis. Musculi sterno-mastoidei dextri strictura^ Boerhaave^ Consult page
220. Tulpii. lib. 4. cap. 57- Boneti. IMercur. Compil. page 130.
" Syndicus Genevensis sexagenarius^, vir rebus publicis diu intentus incidit in obstipitatem
lateralem : caput ipsi^ vellet noUet, dextrorsum vertebatur, sine inclinatione, adeoque ab oppositi
lateris sterno-mastoideo musculo trahebatur fortius et ab antagonista debilius : in utro horum
foret vitium roboris aucti vel imminuti, vix cognosci poterat, nee tensio alterutrius musculi id
satis indicabat. Praescripta incassum multa remedia ut apud nos aquarum thermalium affusio,
suaserat Boerhaave sequentia, 1°. de lapsum aquae calidas in nudum caput mane et vespere ad
septera minutorum spatium quotidie per sex septimas cum frictionibus moderatis : post has em-
brochas: 2\ locum dextri musculi sterno-mastoidei mane et vespere inungcndum diu unquento
althacEc composito : .3". totam plagam sinistri sen antagonista; eodem tempore fortiter confrican-
dum pannis siccis, succini accenso fumi penetratis, ut ejus robur invalescens parum faceret equi-
librio cum antagonista obtinendo.
" Ohslipitas spasmodka. Boneti. Lorry de Melanch. p. 115. [Lscsionis artificialis sani-
tatis exeraplum ad producendam integritatcm cjusdem est in descissione artificiali musculi sani ut
par sit laeso, et contractio cesset. Quod o chirurgis et suadetur et fit.]
" Parochus quinquaginarius, ab studio acriori, incidit in motus spasmodicos alternos et
laterales capitis, quos reprimere vel suspendcre vix poterat interdiu, caput in latus inclinatum
MUSCLES OF RESPIRATION. cxlv
Is it too much to ascribe the affection of these muscles to their strain
in the act of cleHvery ? Nerves are over-exerted by violent actions, as
much as muscles are over-strained. I have known the shoulder of a little
girl fall quite down, in a temporary palsy of the muscles which support it;
and in that case it was presumed to be owing to an over-strain. We are
quite in the dark as to the particular nature of the disturbance in the
nerve. Apparently from the same cause we see a class of muscles become
suddenly paralytic, or subject to occasional twitchings, or to violent and
continual actions, by which they are inordinately increased in strength.
I think the reason of the obscurity in these cases will be apparent to
the reader. It is not the muscle properly which is diseased, but the nerves :
and it is not all the nerves of the muscle, but only one class, which is the
reason why tiie muscle is so strangely and spasmodically contracted, whilst
it is still under the influence of the symmetrical voluntary nerves. The
muscle being an engine moved by two distinct powers, and one of these
only being deranged, is the reason of the difficulty in comprehending
the case.
The practice advised in the foot note at the bottom of p. cxliv. is
not to be thought of. The intelligent reader will perceive the difference
between this affection of the accessory nerve and the disease of the sterno-
cleido-mastoideus, for which an operation is advised by modern surgeons,
and that without these studies the diagnosis will be difficult.
No. LXXVII.
Case of Affection of the Respiratory Nerves on the Side of the Chest.
Physicians' Ward, March, 1824.
aet. 50. — We have not met with a more distinct case of affection
of the respiratory nerves of the side, than is now presented to us in
this patient. The following is a description of his condition :
manu sustinendo, sed noctu somno urgente compescebantur. Morbus per plures menses per-
severabat cum prsescripserim fomenta emollientia, occipiti applicanda, nam convellebantur
musculi, qui a parte colli postica ad caput tendunt : praescripsi etiam narcotica, juscula pulli,
dein lac asininum, balnea domestica, cet. a quibus melius habuit." — Sauvages.
U
cxlvi SPASMODIC AFFECTION OF THE
" If he attempt to lie upon his left side in bed, his head is lifted from
the pillow by a rapid succession of contractions of the muscles upon the
right side of his neck and right side of his thorax ; so that, instead of
lying at rest, his head and shoulders are raised from the pillow, and the
upper part of his body forms a curve. These contractions are attended
with pain, and this pain he cannot otherwise describe than by saying it is
like a cramp. When he lies upon his right side he is more at rest, the
weight of his head and shoulders counteracting the contraction of the
muscles, and keeping him in some degree steady. On being asked
whether these contractions disturb him during his sleep, he says he is
sensible of their diminution as he is dropping asleep. When he sits up,
the head is gradually drawn to the right side, and there is an obvious
contraction of the right side of his neck. The sterno-cleido-mastoideus
swells, and the trapezius is very distinctly in action ; so that the ear is drawn
to the shoulder, and the whole body becomes bent, and the head approaches
to the side. In this state the pain he suffers is seated behind the mastoid
process and at the acromion scapulae, that is, at the origin and insertion of
the sterno-cleido-mastoideus muscle and the insertion of the trapezius.
He complains also of the pain and spasm striking from his back to the
scrobiculus cordis, as if the diaphragm were affected. He also complains
of a pain which is seated in what he calls his ' swallow ;' that is, a
spasmodic affection of the throat accompanies the affection of the external
muscles, but he has no impediment in swallowing.
" When we say to him, ' What, sir, cannot you hold up your head at
all?' he makes an exertion and sits upright, suppressing his breath. But
when he speaks, his head begins to descend towards the riglit side by
a succession of little movements, until he is quite bent down as before
described. When we attempt to hold his head towards the left side, we
see the sterno-cleido-mastoideus in violent action on the right side, and
the muscles of that side are powerful so as to overcome us. When we
hold the head down to the right side, he can pull against us with the
muscles of the left side : he has the voluntary power of these entire, but
they are not so strong as the muscles of the right side ; it appears that by
use the muscles of the right side have acquired great volume and strength.
At first one might imagine that there was paralysis of the muscles on the
MUSCLES OF RESPIRATION. cxlvii
left side. But we find that it is not the ordinary contraction of the
muscles of the right side of which he complains, but of a violent spasmodic
and painful action. That there is no paralysis is obvious from this, that
he can move his head to either side, twist round his mouth either towards
his left or his right ear, turn his head in any way you choose, and raise
his right or his left arm equally, throwing them over his head : all these
motions he can perform when the spasm is not upon him. When it does
come on, then the muscles of the right side only are affected with con-
tractions, and those of the left side are perfectly relaxed.
" Twenty months ago, he says, he was raising a crow-bar, and he felt
something snap at the upper and back part of his neck (and he puts his
finger to the posterior insertion of the sterno-cleido-mastoid muscle). He
does not say, however, that he felt pain at that time. A month after this
he began to have pain, and still he points to the same place, the back part
of the mastoid process. The pain has gradually increased with the
violence of the contractions ; and, as we before said, the pain is like that
of a cramp, and there is no pain in the intervals of spasmodic action."
Although the source of this complaint be obscure, yet it is a stage
in the inquiry to ascertain that the spasmodic contractions are confined
to the influence of the respiratory nerves of the trunk of one side. And
indeed without the preceding account of the nervous system, the contrac-
tions here contemplated must have remained among the very great variety
of nervous symptoms, which, owing to our indolence, are yet presented
to us as mere accidents of nature which it is not expected we should in-
vestigate. It would appear that this man's condition has been produced by
the violence, of exertion. We have learned that in violent efforts to lift
weights, the muscles of inspiration are brought into aid of the merely
voluntary act ; and I have many cases to show that violent exertion
or long excitement of nerves, and continued exertion of particular classes
of muscles, are followed sometimes with paralysis, and sometimes with
irregular minute spasmodic contractions, which are very distressing.
u 'Z
cxlviii SPASMODIC AFFECTION OF THE
No. LXXVIII.
The following case will illustrate the distinction between the respira-
tory and voluntary nerves.
Mr. , surgeon, and a West-Indian, called upon me to hold some
conversation on his own case. He attributed his unhappy condition to a
malignant fever, with erysipelas, during which there had been exhibited a
great deal of calomel, as much as thirty grains at one dose, which cured
him ; but he thought it left him subject to a gastric affection, with chronic
inflammation.
However that may be, this is his present condition. On falling asleep,
just at the moment when volition and sensibility cease, tJie involuntary
motions also stop, with a sensation of death, under which he awakes
generally convulsed.
His medical friends have sat by him and watched him, and they have
found that when sleep is overpowering him, the breathing becomes slower
and weaker, the heart and pulse also fall low, and cease to beat as
sleep comes on, and after a short time he awakes in tremor.
This gentleman is very naturally in much apprehension that some of
these attacks may terminate existence. But he is young, and I think the
attack is essentially different from the case of angina pectoris. The case
presents to us a lively idea of what would result, were the involuntary
nerves subjected to the same law with the nerves of sense and volition,
for then sleep, by overpowering both, would be death !
No. LXXIX.
Sjja.wiodic Action in the Sterno-cleido-mastoideus and Trapezius Muscles.
Mr. D. a farmer, 58 years of age. — The first appearance of this 1
patient was characteristic. He walked past me to the further corner of
MUSCLES OF RESPIRATION. cxlix
the room, and standing there upright, and with his head as it were forced
into the corner, he began to speak to me. He said his complaint commenced
with a lowness of spirits, accompanied with a pain and weight at the back
of the head, and down the shoulders; and this he particularly felt when
riding on horseback. At this early stage his head was not pulled down,
although his friends observed that it was a little awry. This was four
years ago; it is about a year since he began to feel the pulling upon his
head. He feels now as if a weight pulled it down ; and to keep himself
tolerably easy he must hold his head with both his hands. When he sits
upon a chair he throws his head over the back of it, in such a manner as
to make the weight of it counteract the pulling on the muscles of the
neck. When he stands up and allows the muscles to have their influence,
the occiput is turned to the right shoulder, and drawn down to it; and of
course if you are standing before him, you see his profile with the chin to
the left shoulder and pitched up. He has pain, especially in walking,
across the ribs on the right side, and this is attended with a catching and
shortness of breath; and he describes it by saying, it is hard work
walking; and he draws his fingers along the attachments of the serratus
magnus to the ribs.
If you put your hand broad upon the side of the neck whilst the head
is pulled down, you feel a powerful action in the trapezius muscle. The
sterno-cleido-mastoideus is also in powerful action, that is to say, the
sternal portion of it; and a strong cord of the trapezius, and of this
anterior portion of the mastoideus, may be felt as they act in rapid suc-
cession, rolling the head in a singular manner, at the same time that it is
pulled down. He complains of a pain just under the tubercle of the
occiput, and on the ligamentum nucha?. He describes a sensation of
catching on the left side of his face.
When he coughs, there is neither increase nor diminution of the
spasms. Being asked as to this point, he observes, however, that on the
moment of swallowing a morsel, the pulling of the neck is brought on.
When fatigued, he rises and stands in his present position, with his head
and left shoulder resting against the wall, his feet at some distance from
the wall, and his heels off the ground; and thus his body forms an arch
cl SPASMODIC AFFECTION OF THE
from the feet to the shoulder. This patient was attended by Mr. HeeUs
of Limehouse.
No. LXXX.
Spasmodic Action in the Sterno-cleido-mastoideus and Trapezius Muscles.
This gentleman is distressed with a spasmodic affection of the side
of the neck. By the death of a relation he was involved in harassing family
disputes, under which he is sensible his mind has suffered. Although
enjoying good health, he has been subject to bilious attacks, and has had a
discharge from his left ear.
When coming into the room he presents exactly the same appearance
as the farmer who lately left me. He supports his head with his hand, and
seeks relief as soon as possible by propping his head against the wall, or
by letting it fall over the back of the chair, supporting the occiput with the
hand. He complains that his face is forcibly drawn round to his shoulder.
His sterno-cleido-mastoideus muscle, during this state of constraint, is as
hard as aboard; but when the paroxysm is at the worst, and when the
mastoid process is drawn towards the sternum, he can by volition, and
in a temporary manner, relax the muscle and poise the head equally;
but this is for a short time only; the incontrollable action of the muscle
returns and drags down the head, twisting the face to the left side, and
pitching up the chin. A rigidity of the right side of the neck, attributable
to the lateral portion of the trapezius, shows that that muscle partakes of
the spasmodic action. There is no complaint of the side of the chest nor
difficulty of breathing. The agitation of riding over the stones makes him
.worse. When he is lying down, and when his head is propped with
pillows, it remains almost quite still. The pain in the back of the neck
appears to be rather the effect of continued exertion than of any thing
inflammatory. When the paroxysm is severe, the convulsion extends to
the muscles of the larynx, and he makes attempts as if it were to get rid
of something which was producing a huskiness in his voice. When he
MUSCLES OF RESPIRATION. cli
supports his head and is at rest, the act of drinking brings on the
paroxysm.
He is at perfect rest only when he is asleep.
No. LXXXI.
Case communicated by 3Ir. Alexander Shaw.
" Thomas Brown, jet. 58, a shoemaker in Ayr, has suffered for
nearly three years from a spasmodic affection of the muscles of the neck
and shoulder. A year or more previous to his being attacked with this
complaint, his health became broken, which he says was owing to his
being addicted to drinking, and reduced to a state of great poverty. He
first perceived a stiffness in one side of his neck; he had also a weakness
in the left half of his body, but he did not lose the command over the
parts thus affected. The spasms in the neck came on suddenly, and they
were at the beginning very nearly of the same kind as they are now.
" During each of these spasms his head is drawn down gradually, and
by successive actions, so that the left, side of his face comes almost in
contact with his shoulder ; but there is, in addition, a rotatory motion of
the head, by which the chin is turned round and tilted obliquely upwards,
towards the opposite side. His head is thrown back on the nape of his
neck, his mouth is drawn open, and the whole of the left side of his face
is twitched with a succession of frequent convulsions; the shoulder on
the same side is elevated, and the arm is thrown forwards across the
body when the head is thus drawn down. These spasms are repeated ten
or fifteen times in the course of a minute. At intervals during the day the
same paroxysms come on with increased severity. Then the convulsions
of the face and neck are of the most violent kind: his arm and shoulder are
shaken backwards and forwards with a kind of shrugging motion, and with
amazing rapidity, so that the whole body partakes of the tremor. While
these very severe fits last, which is for about a minute each time, his
breathing is performed with difficulty, and he gasps as if he were suf-
focating; altogether he exhibits the appearance as if he were submitting
clii SPASMODIC AFFECTION, &c.
to the most extreme suffering. During the course of the day he is attacked
frequently M'ith these violent paroxysms, but he cannot assign any reason
for their being brought on at one time more than another.
" On examining him when the usual spasms were taking place, the
left sterno-cleido-mastoid muscle was distinctly larger and more prominent
than the other; and it became hard and round when the spasms occurred.
It appeared that the anterior fibres of the trapezius were likewise firmly
contracted when the spasms took place, but the condition of this muscle
was not so easily ascertained as that of the other.
" He has a constant pain in the left side of his neck, principally
seated at the mastoid process of the temporal bone, but extending also
along the course of the clavicle. He said it was long before he fell asleep
at night, owing to his head shaking against the pillow. When asleep, his
friends have told him, that his head lies perfectly still ; and in speaking of
this, he expresses the regret which he feels each morning when he avvakes,
being conscious that his sufferings were immediately about to begin again.
He is able to walk about the town. Various remedies have at different
times been tried, but without producing any perceptible benefit."
No. Lxxxn.
A Case of Spasmodic Affection of the NecJc.
" Francis Barney, a healthy man 27 years of age, by trade a blacksmith,
was in February last seized, without a previous illness, with a spasmodic
contraction of the muscles of the neck. The spasms were slight for a few
weeks, but they have since been severe and frequent, though not per-
manent. During the contraction, the face is forcibly drawn to the left
side; and it would seem, " that the clavicular portion of the sterno-cleido-
mastoideus is alone affected, or at least more especially. To give some
idea of the violence of the spasms I only need say, that all the power a
strong man can exert is insufficient to counteract them. Although this
spasmodic affection has now continued for nine months without any
CASE OF WRY NECK. cliii
material alteration, the patient's general health does not appear to have
suffered. He was not under my care until July, but from the gentlemen
who attended him I am informed, that the treatment in the first instance
consisted of general and local bleeding, free purgation, afterwards
mercury, followed by antispasmodic stimulants of turpentine, &c. ;
irritating applications had also been applied to the antagonist muscle,
with the hope of exciting a stronger action, and counteracting the spasm of
its opponent. I have never thought this spasm owing to a want of power
in the antagonist muscle, but have rather apprehended that it depended
upon an affection of the accessory nerve, and had consequently no great
expectation from medical treatment ; but having witnessed decidedly
good effects from strychnine in partial paralysis, I thought it deserved a
trial in this intractable case; it was therefore prescribed; at the same time
a large seton was inserted in the neck. The strychnine was continued
for a month in full doses, producing its usual effect, but no real benefit.
He afterwards became a patient in an infirmary, where he derived no
advantage whatever. Some attempt has since been made to keep the
head steady by mechanical means."
No. Lxxxni.
Case of Wry Neck.
" Sheffield, June 27, 1829.
" Sir, — About December, 1827, Master was seized during the
night with a stiff neck; it excited little attention; he played with his
schoolfellows as usual, some of whom playfully, but rather rudely, twisted
his head in a contrary direction. When he returned home at the
Christmas holidays, I was requested to see him. I found his general
health very much deranged, and his sterno-cleido-mastoideus muscle on
the right side rigidly contracted. Leeches and fomentations were
applied to the mastoid extremity of the muscle; alterative medicines
were prescribed ; strict attention was paid to the bowels ; and after some
weeks his general health very much improved: still the muscle remained
as rigid as ever. During the summer, his father took him to London, and
a:
cliv CASE OF WRY NECK.
you were consulted. I believe he was advised to go to the sea, and a
steel apparatus was recommended. The sea, I understood, was of service
to him; but as the apparatus did not improve his neck, and injured his
back, it was, after some weeks' trial, laid aside. A vigorous system of
shampooing was then adopted, together with very active exercises. His
health improved; he grew taller, and stouter; and by a great effort he
could stand straight: but the moment he relaxed his efforts, his chin
turned towards his shoulder, his spine became curved, and he relieved
himself by resting on one leg.
" All remedial measures were at length abandoned, and this last half
year he was sent to school. His general health has continued good, but
his sterno-cleido-mastoideus is just as it was.
" Mr. has requested me to correspond with you respecting his
son. I presume, to learn whether, from my description, and your notes
or recollection, you have any further plan to propose. Whether you
would recommend any division of the muscle, or whether, before giving
any further opinion respecting him, you would wish to see him. In the
latter case, I believe his father would immediately take him to London.
" I am. Sir,
" Respectfully yours,
" Arnold Knight, M.D."
This young gentleman is gradually improving by shampooing and
proper exercises, which put the muscle on the stretch.
No. LXXXIV.
The wry neck is a different complaint from these spasmodic affections
of the mastoid muscle.
Note. — Sir has been brought to me under the idea that he
had disease of the spine, but from his appearance in coming into the room,
I saw that the character of the distortion was entirely different from that
produced by disease or weakness of the spine. I soon discovered that
ON THE NERVOUS CIRCLE. civ
his manner of holding his head was not a habit, as the family supposed,
but an inevitable consequence of the state of the sternal portion of the
mastoid muscle. The head is not inclined to the left shoulder as if it were
equally drawn, or had fallen, from the paralysis of the muscles of the opposite
side; the ear is twisted to the shoulder, the chin pitched up, and the
shoulder of the affected side is higher than the other. This appearance
immediately drew my attention to the sterno-cleido-mastoideus muscle,
when I found that the portion of it which runs from the sternum to the
mastoid process was as firm and unyielding as a cord, and checked the
movements of the head.
The distortion of the neck and shoulder arose from the accommodation
of the vertebrae to the state of the mastoid muscle ; and from the same cause
arose the inequality of the shoulders, since the rigidity and shortness of
the sternal portion of the muscle was in part relieved by the elevated
position of the clavicle, just as by the depression of the mastoid process.
This disease is a degeneration of the fibres of the muscle into a ten-
dinous texture. It is relieved, however, by proper exercises and the
shampooing of the muscle.
On the Nervous Circle.
QAn extract taken from the Author's Lectures delivered to the College of Surgeons.]
In reviewing these facts regarding the nerves of the face and head,
a question of much interest arises; for, since we have found that there
are nerves provided to carry the influence of the will to the muscular
system, and that there are other nerves, distinct in their nature, whose
office it is to give sensation, it may be very naturally asked, can that
property or influence, which is conveyed by a nerve, go backwards and
forwards along the same filament, or through the same tube ? or, on the
other hand, does the nervous fluid (to use the hypothetical term) pass
ever in the same direction, outwards from the brain in one nerve, and
towards it by another? You know what has been imagined about the
function of a nerve : some have conceived that it is a vibration along a
x9,
clvi ON THE NERVOUS CIRCLE.
minute cord; others that the nerves are fine tubes, having an aethereal
fluid passing through them; or again, that there is a galvanic fluid
attached to the filaments, explaining the functions of the nerves on the
analogy of electricity or galvanism extending along wires.
Now I say, that whatever hypothesis you choose to adopt, the question
may very naturally be agitated, can that influence, conveyed through a
nerve — ^be it a vibration, or a fluid, or some galvanic influence — can it, I
say, be propagated by the same tube or fibre backwards and forwards, in
two opposite directions, at the same instant of time? I appreliend that it
cannot.
When this difficulty is stated, and is fairly before us, we look to those
experiments, which prove that nerves are of a different nature, with in-
creasing interest. Thus we have seen two nerves going to the same
muscle, divided; and when we touched one of these nerves at its ex-
tremity connected with the muscle, the muscle was excited; but when we
touched the extremity connected with the brain, it was attended with no
result. On the other hand, taking the other nerve also connected with
the muscle, (the branches of which can be seen dispersing themselves to
its minute fibres) and irritating it as we did the former, the muscle was
quiescent — no power was propagated in that direction; but taking the
other extremity of this divided nerve (that connected with the brain), and
pinching it, there was pain. What, then, is the difference of these two
nerves? Is it in the direction in which they convey their impression,
since it is proved that they are both connected with the sensorium, and
both connected with the muscles ? I am inclined to say that it is so ;
that the distinction of their functions depends on the course of the fluid
through them, or the direction by which the impression is propagated. It
may then be the same sort of influence which is excited, and the difference
may only be in the direction in which that influence is propagated; for,
otherwise, I am quite at a loss to explain how it shall happen, that here
are two nerves going into the body of a muscle, of equal size, similar in
appearance, distributed in equal branches, both sinking into intimate con-
nexion with the muscular fibre: and if you injure the one, there is not the
slightest motion in the fibre of the muscle; if you injure the other, the f
whole muscle is convulsed. It is from this process of reasoning, and by
CASE OF PARALYTIC AFFECTION. clvii
considering these facts, that I am incHned to say there is a circle in the
nervous system ; that one nerve conveys its influence towards the muscle,
and the other gives the knowledge of the condition of the muscle by the
influence propagated from the muscle towards the sensorium. At all
events, you observe that a mistake has hitherto universally prevailed in
supposing that one nei've could perform two functions of opposite
tendencies.
I need not carry you back to the proofs which we had in the eye,
that one nerve, be it either a nerve of sense or a nerve of motion, was in-
sufficient for the protection of that organ ; but let us consider the influence
of the nerves of sensation and motion in the body, and the necessity for
their co-operation. I shall illustrate this subject by a case, which you will
know how to appreciate, when I tell you that it is from one of the most
acute and intelligent men of our profession (Dr. Ley).
No. LXXXV.
Case of Paralytic Affection, in which sensation was diminished on one
side and the power of motion on the other.
" My Dear Sir, — The case about which you have more than once
expressed an interest was this :
" Mrs. W. was delivered by a midwife at Kilburn. Her labour was
easy, but followed by profuse hsemorrhage upon the separation of the
placenta, and after its exclusion from the uterus.
*' She revived from the state of exhaustion immediately consequent
upon the loss of blood, but at the end of about three or four days became
feverish, and complained of severe headache : for a week, however, she
had no other assistance than that of the midwife.
*' At the end of this time (about ten days after her delivery), the
headache continuing, and being now accompanied with some degree of
' numbness on one side,' I was requested to see her.
clviii CASE OF PARALYTIC AFFECTION.
" I found her labouring under severe headache, not confined to, but
infinitely more violent upon one side than the other, and occupying the
region of the temporal and occipital bones above the mastoid process, and
attended with considerable pulsation.
" Upon one side of the body there was such defective sensibility, with-
out, however, corresponding diminution of power in the muscles of
volition, that she could hold her child in the arm of that side so long as
her attention was directed to it ; but if surrounding objects withdrew her
from the notice of the state of her arm, the flexors gradually relaxed, and
the child was in hazard of falling. The breast, too, upon that side, par-
took of the insensibility, although the secretion of milk was as copious as
in the other. She could see the child sucking and swallowing, but she
had no consciousness, from feeling, that the child was so occupied : turge-
scence of that breast produced no suffering, and she was unconscious of
what is termed the draught on this side, although that sensation was
strongly marked in the other breast.
" Upon the opposite side of the body there was defective power of
motion, without, however, any diminution of sensibility. The arm was
incapable of supporting the child ; the hand was powerless in its gripe ;
and the leg was moved with difficulty, and with the ordinary rotatory move-
ment of a paralytic patient ; but the power of sensation was so far from
being impaired, that she constantly complained of an uncomfortable sense
of heat, a painful tingling, and more than the usual degree of uneasiness
from pressure, or other modes of slight mechanical violence.
" Medicinal agents, including blood-letting, general and local ;
blisters ; purgatives, &c. directed, first by myself, afterwards by Dr. P. M.
Latham, to whose care I directed her in the Middlesex hospital, were of
little avail, and she at length left the hospital, scarcely, if at all, benefited.
*' At the end of a few months she again proved pregnant. Her de-
livery, at the full time, was easy and unaccompanied with haemorrliage, or
other formidable occurrence, but at the expiration of about ten days she
complained of numbness on both sides. Her articulation was indistinct:
she became more and more insensible, and sunk completely comatose.
" Upon examination of the body no positive disorganization of brain
could be detected. The ventricles, however, contained more than usual
CASE OF PARALYTIC AFFECTION. clix
serum ; and there were found, more especially opposite to the original
seat of pain, thickening, and increased vascularity of the membranes, with
moderately firm adhesion in some parts ; in others, an apparently gela-
tinous, transparent, and colourless deposit interposed between them.
" Such is the outline of a case which I have been in the habit of
quoting in my lectures, as an illustration of one of the pathological con-
ditions which I have repeatedly observed as a consequence of great and
sudden loss of blood ; and as a proof that it is a state of local congestion
allied, if not amounting to, actual inflammation. It, however, obviously
involves many other interesting points connected with those intricate
subjects which you have so successfully unravelled.
" I am, dear Sir,
" Yours, very truly,
" H. Ley."
This illustrates the fact that the motion of the muscles is governed
through a consciousness or perception of that motion. Indeed it can
only be from a sense of the condition of the muscles of the hand and arm,
for example, that you know the position they are in when there is no
contact, and, therefore, no exercise of the sense of touch. The man
whose arm has been amputated, has not merely the perception of pain
being seated in that arm, but he has likewise a sense of its position.
I have seen a young gentleman, whose limb I amputated, making the
motion of his hands to catch the leg and place it over the knee, after the
limb was removed, and the stump was for some time healed ; so a man,
who has lost his arm close to the armpit, has a perception of that arm
changing its position. It is by this sense of the condition of muscular
action that we are enabled to regulate the whole muscular system, and
balance the body.
No. LXXXVI.
In the following excerpt from a letter of consultation, Mr. Bailey of
Thetford describes an affection of the nerves of sensation as opposed to
those of motion.
clx CASE OF PARALYTIC AFFECTION.
" Mrs. , aged 66 years, a lady of high respectabihty, consulted me
in October last, in consequence of experiencing a numbness in the hands
and fingers, which to her sensation felt as if some sand were interposed
between them and the object touched. There was no want of power in
the muscles, excepting a slight stiffness, as any substance could be firmly
grasped. So impaired is the sense of touch, that it is with difficulty she
can distinguish the object wanted: this is particularly the case when
feeling in the pocket. With the exception of these sensations, her general
health did not appear to have suffered. There is no pain complained of;
the appetite natural; the digestive powers strong, and the alvine secretions
perfectly correct; the pulse was regular as to strength and number of
pulsations.
" In April last, I am sorry to say, the symptoms increased, and
became extremely distressing; the fingers seemed more loaded than ever,
and the difficulty to take from her pocket what might be wanted (from
want of accurate touch,) was more evident; with this a considerable
tightness about the abdomen, extending round the back and up the
shoulders and chest, was experienced, as if she were corded in different
parts, rendering it difficult to turn in bed or rise; these same sensations
affect the thighs and legs, which appear not to belong to her. With all
these symptoms no pain is complained of."
Partial Paralysis of the JSluscles qftJw Extremities.
This is an obscure subject, but there is a circumstance which has
occurred so often in examining patients thus afflicted that I must note it
down. The paralysis does not extend to a part of the arm or leg, nor is
it a defect, reaching so far up the limb or so far down the limb, but it
is an affection of the muscles which are naturally combined in action ;
although these muscles lie in different parts of the extremity, and are
supplied by different nerves, as they are by different arteries. For ex-
ample, the muscles of the thumb may be affected, but then the wasting
will not be confined to the short muscles of the ball of the thumb, but will
extend to those muscles of the thumb which lie upon the fore arm, and
these wasted muscles are lying in contact with others which are plump and
WASTING OF MUSCLES OF THE THUMB. clxi
powerful. Or sometimes all the extensor muscles will lose their power,
while their opponents preserve it, producing a characteristic position of
the limb. It will sometimes happen that one class of muscles having
suffered, another class will come into play, and be developed by unusual
exercise. 1 have found the action necessary for writing gone, or the motions
so irregular as to make the letters be written zigzag, whilst the power
of strongly moving the arm, or fencing, remained.
No. LXXXVIL
Wasting of the Muscles of the Thumb.
Smith, aet. 22, an ironmonger. — A year and a half ago he was sud-
denly deprived of the use of his right thumb. The right arm, and indeed
the muscles of the whole body, retahi their power; even the adductor
muscle of the thumb has its proper action : but the abductor, flexor brevis,
opponens, that is, the muscles which form the ball of the thumb, are wasted;
so that you feel the bones and the strings of tendons over them. When
a comparison is made between the long extensors of the thumb on both
the arms, those of the right appear to be considerably wasted, and they
want the rigidity which belongs to those of the left arm ; yet the tendons
start out when he brings these muscles into action. He has been employed
in serving out the goods in an ironmonger's shop, and has never had any
thing to do with the severe work of manufacturing: he has not at any
time worked much with lead, or with any paints: he has had no affection
of the bowels that he can recollect: he has never had any complaint to
denote an affection of the brain, nor any pain in the course of the nerves.
No. LXXXVIII.
I was consulted during the last year by the parents of a young
gentleman, 15 years of age, in whom this paralysis of particular muscles,
and consequent wasting of them, was very distinct. In my note of the
case it is stated, that two years before visiting me, he had scarlet fever,
y
clxii WASTING OF MUSCLES OF THE THUMB.
attended with sore throat and deUrium, for eight or ten days. It was
after this fever that his right arm was first perceived to be weak. Sub-
sequently the left arm became weak, and this muscular debility increased
without any pain or apparent disturbance of his general health.
The muscles of the thumb are not wasted, and the flexor muscles
of the wrist and fingers are powerful ; he can grasp his father's hand
so as to make him cry out. Yet the extensors of the wrists and of the
fingers are weak, so that the hand remains generally bent, and at an
angle with the arm. Whilst the forearm is firm to the feeling as you
grasp it, the muscles of the arm are wasted and loose, so that you can feel
all the processes of the humerus, from its upper to its lower end : the
deltoid muscle is also quite gone. The rotation and motion of the arm
are very curiously performed by the muscles inserted into the scapula,
which are firm and strong, so that the arm is thrown about by the rotation
of the scapula upon the chest. The muscles which come down from the
neck to the shoulder are particularly strong, and it is by them that the
scapula is heaved up and a secondary kind of motion given to the arm.
All the muscles which are for bracing down the scapulae to the chest, and
drawing them backwards, are wasted, and the inferior angles of both the
scapulae start out three inches from the ribs. It is astonishing with what
energy he can fling his arms about, by those muscles alone which come
from tlie neck to the shoulder : for example, he jerks on his coat, and
draws it upon his back, solely by the action of the muscles of the neck ;
when undressed, he can swing his arms round and round ; but it is by
adjusting the action of raising the scapulae with the gravitation of the
upper extremity that he contrives to do this, and seems to possess a more
extensive influence on the muscles of the arm than he actually does. He
is tall, and is still growing fast.
On the 17th September, I was again visited by his mother, when
she reported that his muscular strength had declined, particularly in the
right leg, and that it required two men to place him on the seat of the
carriage. His spirits are excellent ; his remarks shrewd ; and his education
is proceeding : he has grown considerably.
These affections of particular muscles, or classes of muscles, imply a very
partial disorder of the nerves. A disease of the brain, or a disease in the
PARTIAL PARALYSIS OF LOWER EXTREMITIES. clxiii
course of the nerve, must influence the whole limb, or that portion of it
to which the nerve or nerves are distributed. But in these cases, par-
ticular subdivisions of the nerves, included in the same sheaths, or run-
ning the same course, are affected. I am inclined to attribute such partial
defects to the influence of visceral irritation. In that case, it must still
be the influence of the sympathetic nerve which produces it ; and yet,
on the other hand, it seems impossible to account for such entire loss of
motion without the intermediate influence of the brain.
No. LXXXIX.
Case of partial Paralysis of the Lower Extremities.
July 23d. — The consultation this morning is connected with this
subject. The patient is a young gentleman about eighteen. All the
muscles of the lower extremities, the hips, and the abdomen, are debilitated
and wasted. The extensor quadriceps femoris of both limbs is wasted, and
yet the vasti externi have not suffered in an equal degree. A firm ball,
remarkably prominent just above the knee joint, marks the place of the
vastus externus, while the rectus is quite wasted and gone. He has no
defect of sensibility in the lower extremities. The upper part of the body,
the shoulders, and arms, are strong. There is no defect perceptible in the
evacuation of the bladder or of the bowels. There is a slight curvature or
projection of the lumbar part of the spine. He is weak, and subject to
palpitations on going up stairs ; his tongue is coated. Altogether, his
state of health is very irregular. On some days his spirits are good, on
others he is depressed and unable to move. Much of this, he says, de-
pends upon excitement or amusement, and very much on the state of his
digestion.
This paralytic debility of the muscles came on gradually: he was first
sensible of it at a public school, about eight years ago. It began with a
weakness in the thighs, which disabled him from rising ; and it is now
curious to observe how he will twist and jerk his body to throw himself
upright from his seat. I use this expression, for it is a very different motion
from that of rising from the chair.
y2
clxir AFFECTION OF THE
Affection of the Voluntary Nerves.
I could give cases of various affections of the voluntary nerves, but
the patients might be made uncomfortable by a report of their condition.
The most common instance is an impediment in speech, when the consent
of the muscles is imperfect; but this sometimes extends to all the voluntary
muscles of the body. I find that some are capable of lifting a heavy weight,
or walking fifteen or twenty miles, and yet they have not the proper com-
mand of their limbs: there is an insecurity and want of confidence in the
motions of the body, which overtakes them upon any excitement; a paralysis
of the knees which prevents the individual from putting one leg before
the other, and which endangers his falling. Thus a gentleman, capable of
great bodily exertion, on going to hand a lady to the dining-room, will
stagger like a drunken man ; and in the streets any sudden noise, or
occasion of getting quickly out of the way, will cause him to fall down,
and in this manner a want of confidence produces a nervous excite-
ment which increases the evil. With confidence, the power of volition
acts sufficiently; there is neither defect of speech nor irresolution in the
motion of the limbs when the person is at ease, or under a flow of spirits.
Such cases are very curious in their details, as exhibiting an extra-
ordinary degree of incapacity for the affairs of life, proceeding from slight
defects. There is neither disease of mind nor of bodily organs; the cor-
poreal frame is perfect; the nerves and muscles are capable of their func-
tions and proper adjustments; the defect is in the imperfect exercise of
the will, or in that secondary influence which the brain has over the re-
lations established in the body.
Note. — To the last hour of these papers lying beside me, I believe
that I could add new circumstances in proof of tlie accuracy of the general
doctrines.
Dec. 'IC), , an elderly maiden lady, consulted me on account of a
cancer in the breast ; but of all her more formidable symptoms, none gave
lier so much anxiety as an insensibility of the lower lip : her attention was
called to this hy feeling only one half' of the cup in drinking. On touch-
VOLUNTARY NERVES. clxv
ing the left side of the nether hp, I found that she had no sensation in all
that part supplied by the mandihulo lahralis nerve. The motions of her
lips were perfect.
Upon feeling deep under the angle of the jaw, I discovered a hard
glandular tumour, which was attached to the upright portion of the jaw, and
no doubt pressed on that branch of the fifth nerve which enters the in-
ternal foramen of the lower jaw.
Mr. Drew, of Gower-street, saw the patient with me this morning,
and observed the circumstances.
In the course of the same forenoon I had the advantage of meeting
Dr. Holland, to consult on the following case : —
A lady, in travelling up from the west of England, was exposed to
cold. The left side of her face is swoln and very painful, attended with
a ringing in the ear of the same side. She is unable to shut the left eye-
lids ; she cannot frown on that side ; the cheek and mouth on the same
side are without expression of any kind. She has a difficulty of speaking,
and when she smiles the face is drawn frightfully to the right side. Fluid
falls from the left side of her mouth.
On putting the point of the finger behind the angle of the jaw on the
left side, the part is very tender, and a swelled gland can be distinctly felt,
which no doubt presses upon, or involves, the portio dura.
The contrast of these two cases, occurring within twenty-four hours
of each other, is very striking, and some years ago would have been in-
v^aluablc to me. AVhilst in attendance upon these cases, Mr. Summers, of
Euston-square, brought a patient to consult me in apparently similar cir-
cumstances with the last; that is to say, paralytic on one side of his face,
with an inability to close the eye-lids of that side. I observed that this
gentleman, in detailing the circumstances, pressed his left cheek against
the bone with the point of his finger. This was to draw tight the left angle
of the lips, which gave him the power of speaking more distinctly, by the
motion of the right side of his mouth. This case was distinguished from
the others by there being no external tumour, and it was important to
notice, that he had some time ago a general weakness of the muscles of the
same side of the body, from which he had recovered; that his father had
clxvi
AFFECTION OF THE VOLUNTARY NERVES.
had a paralytic seizure, leaving weakness on one side, and that his sister,
twelve years before, had been affected in a manner similar to his own pre-
sent condition ; and moreover, it was observable that he had pain in the
occiput, just behind the ear. These latter circumstances gave a character
of more importance to this case than to the preceding, where the cause was
external.
I may just add, that a patient has been sent to the hospital, who ex-
hibits a most remarkable instance of twitching of the face, from an affection
of the portio dura. The patient is made aware of the commencement of
the attack by a motion behind his ear, and in fact a remarkable agitation
of the occipito-frontalis muscle accompanies the twitching of the face.
PI, ATE
>z^ia/u«iiC. in^ ^jf/:uuiuU
'LATIB 11.
-^-^ " iiii ^^^
V/
6^^//. cy
//•
V'//y//////
/v/rj.
'fAayi^iy^y'^ {^;//
' Ut t^ i-y sf.^Ttxa^ i/^
EXPLANATION OF THE PLATES.
PLATE I.
A A B B C C Spinal marrow.
1 1 Branches of the fifth pair, or Trigeminus, which arise from the
union of the crura cerebri and crura cerebelli in two distinct roots, on the
posterior of which a ganglion is seen, like the ganglion of the spinal nerves.
The branches of the fifth nerve are universally distributed to the head and
face; but the anterior root goes only to the third division.
2 2 Branches of the Suboccipital Nerves, which have double origins
and ganglions on the posterior roots.
3 3 The branches of the four inferior Cervical Nerves and of the first
Dorsal, forming the Axillary Plexus : the origins of these nerves are similar
to those of the fifth and the Suboccipital.
4 4 4 4< Branches of the dorsal nerves, which also arise in the same
manner.
5 5 The lumbar nerves.
6 6 Tlie sacral nerves.
PLATE II.
A Cavity of the skull.
B Medulla oblongata.
C C Spinal marrow.
D Tongue.
E Larynx.
clxvill EXPLANATION OF THE PLATES.
F Bronchia.
H Stomach.
1 Diaphragm.
The third, sixth, and ninth nerves are not lettered, but only the fol-
lowing respiratory nerves.
Ill Par vagum, arising by a single set of roots, and passing to the
larynx, the lungs, heart, and stomach.
2 2 Superior laryngeal branch of the par vagum.
3 Recurrent or inferior laryngeal branch of the par vagum.
4 Pulmonic plexus of the par vagum.
5 Cardiac plexus of the par vagum.
6 Gastric plexus or corda ventriculi of the par vagum.
7 Fourth nerve, a nerve of this system to the eye.
8 Respiratory nerve or portio dura to the muscles of the face,
arising by a single root.
9 Branches of the glosso-pharyngeal.
10 Origins of the superior external respiratory or spinal accessory
nerve.
11 Branches of the last nerve to the muscles of the shoulder.
12 12 12 Internal respiratory, or the phrenic nerve to the diaphragm.
13 Inferior external respiratory to the serratus magnus.
PLATE III.
This plate represents that portion of the spinal marrow from which
the nerves of the axillary plexus go off.
A A The medulla spinalis.
B B B B The sheath or theca of the spinal marrow.
C C C C C C The anterior roots of the spinal nerves, coming down
from the anterior or motor column of the spinal marrow, before they join
the posterior roots, and before they pass out of the slieath.
D D D D D The posterior roots of tlie spinal nerves. Between these
distinct roots the ligamentum denticulatum intervenes. This is trans-
parent, being a process of the tunica arachnoidea.
,
Mile ICIc
Drawn Ay /'/if//.
Puiluhed
A
J'
•i»
Enipwed In .IBtwue.
■■nan kC Fei']83o-
PJLJiJTE IV .
-}u
/.^■•nJljiL^iittsk^ hv Zona-nii! n
EXPLANATION OF THE PLATES. clxix
E E E E The ganglions formed upon the posterior roots of the
spinal nerves. It is seen in this plate that after the ganglion is formed
on the posterior root, the two roots coalesce and intermingle to form the
nerves.
F F F F F F The axillary plexus formed by the interchange of
branches.
G G The lower cervical ganglion of the sympathetic nerve.
H H H H The sympathetic nerve forming its connexion with each
of the spinal nerves.
Whilst we perceive that the sympathetic system is essentially distinct
in character from the other nerves, the fact is here demonstrated that its
connexions are universal; we see that each twig may be considered as the
root or origin of the nerve, with as much propriety as some authors describe
the fifth or sixth as giving origin to the sympathetic system of nerves*.
PLATE IV.
This plate represents the medullary portions which we trace from the
base of the brain: — the crura cerebri, the pons varolii, the medulla oblon-
gata, and nerves arising from them.
He who makes himself master of this plate can have no difficulty in
comprehending the whole nervoiis system ; — he holds the key to it in his
hand.
A A The CRURA cerebri.
B The PONS VAROLII.
C C The corpora pyramidalia; parts of the medulla oblongata.
D D The CORPORA olivaria; lateral eminences of the medulla ob-
longata.
E The sheath left on part of the medulla spinalis.
II. The SECOND pair of nerves at their union.
III. The THIRD pair of nerves, arising from the crura cerebri.
IV. The FOURTH pair of nerves, arising round the crura cerebri.
* These connexions of the sympathetic with the spinal nerves are formed where the two
roots have coaksced, and the fibrils can no longer be distinguished from one another — See Scarpa.
clxx EXPLANATION OF THE PLATES.
V. The FIFTH PAIR of nerves, arising in two distinct portions from
the side of the pons varolii. On the right side (the left of the plate), the
posterior and larger root, the sensitive nerve of the head, is seen to arise
distinct; the anterior and lesser root, the motor nerve, arises separately.
On the left side (the right of the plate), the muscular root of the nerve
is seen to twist round the sensitive portion and join the third division.
a The muscular portion.
h The Gasserian ganglion, formed on the sensitive portion.
c The ophthalmic and superior maxillary nerves, derived from the
sensitive portion of the fifth.
d The inferior maxillary nerve, in which are combined the anterior
and posterior portions of the nerve.
VI. The SIXTH NERVE, the abducens.
VII. VII. The poRTio DURA of the seventh nerve, the respiratory
nerve of the face.
e e The portio mollis, or acoustic nerve.
VIII. VIII. The EIGHTH PAIR of iicrvcs, consisting of the three re-
spiratory nerves, viz: —
f f The glosso-pharyngeal nerve.
g g The par vagum.
h h The spinal accessory nerve, or superior respiratory nerve.
IX. IX. The NINTH NERVE, being the lingual nerve.
X. The TENTH NERVE of the head, according to the system of Willis ;
properly the first of the spinal nerves, having, like these, two roots, one
anterior for motion, and another posterior for sensibility.
I i The ganglions on the sensitive roots of the nerves.
k A twig of communication between the posterior roots of the two
superior spinal nerves.
XI. A spinal nerve, strictly resembling the fifth nerve in its double
roots, and its ganglion on the sensitive root.
If we bcghi our review of this plate by tracing up the columns of the
spinal marrow, and observing the origins of the nerves in a regular series,
we shall have a distinct conception of the system.
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EXPLANATION OF THE PLATES. clxxi
PLATE V.
This figure represents a portion of the base of the brain of Mrs. F.,
wliose case is related at page cxii.
A The left hemisphere of the cerebellum.
B The pons varolii.
C The medulla oblongata.
D A morbid sac, which pressed upon and destroyed the fifth nerve
of the left side.
E The fifth nerve, wasted and almost reduced to cellular texture.
PLATE VL
A VIEW OF THE NERVES OF THE FACE.
In this plate the two distinct classes of nerves which go to the face
are represented ; the one to bestow sensibility, and the other motion, that
is, the motions connected with the respiratory organs.
The nerves on the side of the neck are also represented. These I
have discovered to be double nerves, performing two functions ; they
control the muscular frame, and bestow sensibility on the skin. Besides
these regular spinal nerves, w^hich are for the common endowments, the
nerves of the throat are represented. These latter nerves are the chords
of sympathy which connect the motions of the neck and throat with the
motions of the nostrils and lips ; not merely in swallowing and during
excited respiration, but in the expression of passion, &c.
A The respiratory nerve of the face, or, according to authors, the
portio dura of the seventh nerve.
a Branches ascending to the temple and side of the head.
h Branches which supply the eye-lids.
c Branches going to the muscles which move the nostrils.
d Branches going down upon the side of the neck and throat.
e Superficial cervical plexus.
ff Connexions formed with the cervical nerves.
g A nerve to the muscles on the back of the ear.
s 2
clxxii EXPLANATION OF THE PLATES.
B The eighth nerve, par vagum, or grand respiratory nerve.
C The superior respiratory nerve, or spinal accessory nerve.
D Ninth nerve, or lingualis.
E Diaphragmatic or phrenic nerve.
F Sympathetic nerve.
G Laryngeal nerve.
H Recurrent laryngeal nerve.
i Glosso-pharyngeal nerve.
I. Frontal nerve: a branch of the ophthalmic division of the fifth.
II. Superior maxillary nerve : a branch of the second division of the fifth.
III. Mandibulo-labralis : a branch of the third division of the fifth.
IV. Temporal branches of the third division of the fifth.
V. Ramus buccinalis-labialis : a branch of the third division of the
fifth, prolonged from the motor root.
VI. VII. VIII. IX. Spinal nerves.
PLATE VII.
In this figure the superficial nerves of the face are turned oflT, and the
distribution of the third division of the fifth to the muscles of the jaws and
cheek exposed.
A The portio dura of the seventh or respiratory nerve of the face,
coming out from the stylomastoid foramen; the principal branches are cut
and folded forwards.
B The trunk of the portio dura of the seventh, dissected off the face
and pinned out, while it is left at its connexions with the branches of the
fifth on the cheek and lips.
C The branch of the third division of the fifth nerve, which joins the
plexus of the portio dura before the ear. Some experimenters, ignorant
of this junction of a sensitive nerve with tlie muscular nerve, have oc-
cupied themselves with experiments to ascertain the degree of sensibility of
the portio dura.
1) III tiiis figure tlie massctcr muscle is dissected from the jaw-bone
Flaie
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EXPLANATION OF THE PLATES. clxxiii
and lifted up to show D, the branch of the fifth pair of nerves going into
the muscle.
E The ramus buccinalis-labialis, that branch of the fifth nerve which
goes to thebuccinator, triangularis, levator labiorum, and orbicularis muscles.
F That branch of the fifth nerve which separating from the mandi-
bulo-labralis goes to the muscles which depress the lower jaw.
G The suborbitary nerve, a branch of the fifth nerve.
H The mandibulo-labralis, a branch of the fifth nerve coming out
from the bone to the muscles and integuments of the lip and chin.
I A branch of the fifth nerve descending from the orbit.
D E F are muscular branches of the fifth nerve, and are motor nerves.
C G H I are sensitive branches cf the same nerve which join the branches
of the portia dura in its universal distribution; and although these branches
of the fifth enter the muscles, they possess no power over their motions.
B is the portio dura, which, though taking the same course with the last,
is for a different purpose; while it is a motor nerve it is enabled, by its
association with the respiratory nerves, to excite those actions of tlie face
and lips which are necessarily connected witli the act of breathing.
PLATE VIII.
Fig. 1. Represents the fifth nerve dissected out and seen on its lower
surface.
A The posterior or sensitive root before it forms tlie ganglion.
B The Gasserian ganglion.
C The anterior or motor root of the nerve passing the ganglion.
D The third or lower maxillary division of the fifth nerve.
E The motor portion joining the lower maxillary nerve and forming
a plexus with it. From this plexus go off the muscular nerves to the
muscles of the jaw, viz: —
1. Temporalis.
2. Massetericus.
3. Buccinalis-labialis.
4. Pterygoideus.
.5. Mylo-hyoideus.
clxxiv EXPLANATION OF THE PLATES.
F Division which joins the portio dura.
G Mandibulo-labrahs.
H Gustatory nerve.
I The chorda tympani.
Fig. 2. This figure represents the gangUon on one of the spinal
nerves, to show its resemblance to the ganglion of the fifth nerve in every
particular.
A The posterior or sensitive root of the nerve.
B The ganglion formed upon the posterior root.
C The anterior or motor root of the nerve; this arises in minute
branches which join to form the larger subdivisions, whilst the posterior
root is composed of simple and abrupt portions. This division joins the
sensitive division beyond the ganglion exactly in the same manner that
the motor portion of the fifth joins the lower maxillary nerve.
Fig. 3. Represents one of the ganglions of the sympathetic nerve to
show how different it is from those on the symmetrical system of nerves.
In fig. 1 and 2 the nerve, on entering the ganglion and escaping from it, is
separated into branches in a manner very different from the mode in which
the sympathetic nerve joins or forms its ganglions*.
PLATE IX.
Fig. 1. Represents the medulla spinalis.
A The pons varolii.
B B The anterior medullary columns of the spinal marrow, con-
tinued from the corpora pyramidalia.
C Corpus olivare.
D Corpus restiforme.
1. The origin of the respiratory nerve of the face.
2. Origin of the glosso-pharyngeal nerve.
* Authors who have treated of the anatomy of the ganglions have not distinguished between
the two classes of ganglions as belonging to the sensitive and sympathetic systems of nerves.
Plate E..
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EXPLANATION OF THE PLATES. clxxv
3. Origin of the par vagum.
4. Origin of the spinal accessory nerve, or superior respiratory
nerve of the trunk.
Fig. 2. Plan of the respiratory nerves in their course through the
body.
A The sterno-cleido mastoideus muscle.
B B The trapezius muscle. It is seen to arise from the back of the
head, and from the spine; it is inserted into
C The scapula, and
D The clavicle.
E E The serratus magnus anticus. It is left at its attachment to the
ribs, but cut off from its insertion into the scapula, so as to expose the
trapezius and the spinal accessory nerve.
F The lower surface of the diaphragm.
G The upper surface of the diaphragm.
H The larynx.
The four great muscles (A B B E E F G) are powerful muscles of
inspiration.
To simplify this view, the regular or symmetrical system of nerves
is not presented in this drawing, but only the respiratory nerves. It is
the entwining of nerves of distinct systems which produces the apparent
intricacy. If the spinal nerves were represented crossing these, and the
network of the sympathetic superadded to them, we should have all the
seeming confusion of the dissected body.
1. Respiratory nerve of the face, or portio dura of authors.
2. The glosso-pharyngeal nerve.
3. The superior respiratory nerve. It is seen to pass through the
sterno-cleido mastoideus muscle, and to supply it with branches; then to
take a course down the side of the neck, branching exclusively to the tra-
pezius muscle.
4. The phrenic or diaphragmatic nerve. It is seen coming out from
the spine, and running a direct course to the diaphragm.
5. The external respiratory nerve of the chest. It is like the last
nerve in its origin, but it deviates in its course, passes on the outside of
clxxvi EXPLANATION OF THE PLATES.
the chest to supply the powerful respiratory muscle, the serratus mag-
nus E E.
These three nerves with the par vagum combine the sterno-cleido
mastoideus, the trapezius, the serratus magnus, and the diaphragm, with
the lungs, the larynx, the tongue, and nostrils.
6, 7' The nerve of the par vagum. Coming from the same origin
with the other respiratory nerves, it passes down to the internal organs;
but in its passage gives off these : —
8. The superior laryngeal nerve, a branch of the last nerve.
9. The recurrent nerve ; a branch also of the par vagum. Where the
par vagum is in the thorax (7) at the same time that it sends off the re-
current (9), it sends off many small nerves to the heart and the lungs, and
then descends in a plexus on the oesophagus, to the stomach.
THE END.
LONDON :
PUlNTiiD HY THOMAS DAVISON, W UlTEF R J A IIS.
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