The tonic treatment of epilepsy and kindred nervous affections

Front matter

The Library of the Wellcome Institute for the History of Medicine

MEDICAL SOCIETY OF LONDON DEPOSIT

Accession Number

Contents

Chapter I. . . . . p. i to p. 36.

Epilepsy, Difficulties of Diagnosis— Auraa in— CunviUsive— Non-Convulsive — Asthma and — Connection Between — Seat of Origin of — Condition of Brain and Higher Centres in — Structural Changes of Brain in Old-Standing — Power of Control.

Causation of Epilepsy — Hereditary Predisposition, Ages of First Commencement of Epilepsy — Statistics— Slate of Constitution in Epilepsy —Influence of Puberty — Hysteria — Induced.

Chapter I

There is probably no disease which offers greater or more serious obstacles to the formation of a correct diagnosis than Epilepsy : its seat of origin and its causation are equally obscure ; purely paroxysmal in its nature, the intervals of attack are often periods during which the patient enjoys his usual health marked by no signs of disorder or derangement ; and after death the pathologist often looks in vain for any positive structural changes in the brain or spinal cord which would account for seizures so terrible in their nature. It has been said, indeed, that Epilepsy is a disease which has no morbid anatomy ; and this is probably true, so far at least as the earlier stages of the disease are concerned ; for in all likelihood the immediate cause of the epileptic seizure lies not in any structural change in any part of the nervous system, but in some statical alteration, possibly some change in the

B electrical condition of the ganglionic cells, which form, as it were, the seat of government of the cerebral control. Any traces of alteration or destruction of tissue found after death, such as those discovered by Professor Van der Kolk to exist in the medullae oblongatse of old-standing epileptics are, I believe, results of long-continued and frequentlyrepeated paroxysms, not causes of them ; though it is highly probable that these lesions, when once established, do to some considerable extent lessen the power of resistance to the on-coming of the attack, and, indeed, so far act as irritants as to keep up the habit of Epilepsy. Science, then, in its present state of advancement, being able to tell us nothing positive concerning the conditions which give rise to so grave a malady — the physiologist and the pathologist being equally at fault, and able to do little more than propound vague theories — it remains for those who are brought much into contact with this class of disease, and who have large opportunities for clinical observation, not only during the actual period of attack, but also in the intervals, when to an ordinary observer no ailment whatever might be supposed to exist, it remains for these to endeavour to determine whether any, and if any, what conditions are present in such persons which may account for the occurrence of the disease. Under these circumstances it is well to start any investigation from a position or point the truth of which is clearly

OF EPILEPSY.

ascertained and beyond question. Now, it is clear that the actual epileptic seizure is due to the sudden discharge or escape of an accumulation of nerve force from some point situate within the cranial cavity, though the exact spot from which it takes its departure, and the precise method of its liberation are still moot points. This abnormal escape, or explosion, as it may be termed, of nerve force takes place with more or less suddenness, and when the action is delayed, the more severe symptoms are usually heralded by nervous sensations of various kinds and of different degrees of intensity. These warnings, or aurae, as they are termed, may be either motor, or sensory, or a combination of both, or psychical ; but more often they are motor only. They vary much in their strength and direction, and are frequently incomplete, that is to say, they pass off without the occurrence of the graver phenomena of an actual attack. It has been said that these motor aurse commence invariably in the smaller muscles, such as are engaged in the performance of more special actions, and gradually spread to those larger muscles which fulfil general actions : thus these premonitory spasms often commence in the fingers or toes, and gradually travel upwards and invade the larger, and more important muscles. The reverse of this is observable with regard to the sensory aura, as these originate in the general, and travel from thence to the special ; thus, the first symptom of a visual aura may be the perception of sparks of fire, or sudden darkness, or of a general red light pervading everything ; this will be followed by a distinct illusion or hallucination. Thus, a patient of mine saw first a general red glare over every object in the room ; this was followed, after a short interval, by the vision of a dog surrounded by rays of white light ; after this the actual epileptic seizure occurred immediately. In other cases the aura may consist of some derangement of one or other of the nerves of special sense, in the form, for instance, of an unpleasant smell in the nose ; in some cases this may precede the actual attack by as much as twenty-four hours. Gustatory aurae are much more rare. What may be termed visceral aurae, that is sensations proceeding from the pit of the stomach, are extremely common and are often accompanied by a sensation of sinking or faintness, and at times even of sickness. In some cases of Epilepsy these sensations would appear to be almost constantly present, and would certainly appear to be connected with the solar plexus. The frequency with which irritations of the stomach and intestines give rise to sudden epileptic or epileptiform seizures, points very clearly to the powerful influence which the s)'mpathetic nervous system exercises on the convulsive centres.

With regard to the frequency with which aurae precede the epileptic attack, Dr. Gowers states that

OF EPILEPSY.

in 1000 cases in which its presence or absence was noted, 505 felt these premonitory symptoms, which in 495 were unnoticed. If these statistics were sufficiently large to enable us to form a reliable opinion, it would appear that, in about one half of the cases, consciousness was retained sufficiently long to enable the patient to perceive the on-coming of the attack. In the other half, the paroxysm would occur instantaneously, the patient losing consciousness in a moment without the slightest warning. Although it is in many cases difficult, as I shall presently show, to distinguish simple Epilepsy from other kindred disorders — hysteria more especially— yet I think it may be taken as a rule that every case of pure Epilepsy is attended by complete unconsciousness. No doubt certain cases do at times come under notice, in which even this symptom may be simulated ; but they are, I think, not difficult to detect.

In describing Epilepsy I prefer to adopt the usual method of classification, and describe the disease under its two forms — convulsive and non-convulsive — {le hatU mal and le petit inal). Convulsive Epilepsy may be complete or partial, that is to say, that the nerve force, when liberated from the discharging centres may find its way down all the motor tracts, thus producing a general convulsion, or, it may pass down one single efferent nerve, or a single group of nerves, and so produce a local or partial convulsion. This will depend on the amount of resistance offered by the neighbouring centres, and perhaps also partially on the force of the discharging lesions. In the commencement of a convulsive seizure, it is usually seen that one side of the body is affected sooner than the other ; very commonly the head is twisted over to one side. This circumstance may arise from several distindl causes ; it may be due to the first throes of the convulsion, before the discharge has become bilateral ; or it may be determined by the more powerful muscular state of the side principally affe(5led. The phenomena which attend the commencement of an epileptic seizure succeed each other with perplexing rapidity ; there is commonly a sudden pallor, succeeded by a flush ; in many cases a cry, sometimes shrill, sometimes more like a deep bellow, caused by the sudden expulsion of air, from the violently contracted chest, through the spasmodically narrowed aperture of the glottis. This cry sometimes occurs so early in the series of symptoms that the patient is, in some cases, able, after the subsidence of the attack, to recall the memory of the sound which ushered it in.

The first changes of colour, which I have described, are, so soon as the tonic convulsion has become thoroughly established, changed to a deep congested flush, caused by the engorgement of the veins of the head and neck from obstruction of the venous circulation by muscular pressure. The heart's action is now found to become very irregular and tumultuous ; the pulse at the wrist is in consequence similarly affected ; the eyeballs are protruded and their action is distorted, being usually turned in the same direction as the head and neck ; the tongue is in many cases pushed forward between the teeth by the spasm of the hypoglossal muscle, and torn and lacerated by the convulsive grinding of the jaws. The difficulty of respiration, in consequence of the spasmodic contraction of the chest walls, is often considerable. After a time the supply of nerve force, which has to pass off, becomes gradually exhausted, and the tonicity of the muscular spasm ceases ; the patient gives a few sobbing respirations, and the congestion of the head and face begins to diminish ; irregular clonic spasms, however, continue to recur at intervals.

It is observable that this relaxation of the muscles sets in first in those which are most closely connected with the convulsive centres, these being naturally the first to become impUcated in the discharge, are also, of course, the soonest exhausted and have earliest expended their quantum of nerve force. The attack over, the patient usually sinks into a deep stertorous sleep, from which he awakes with aching limbs and head, and a feeling of intense nervous prostration.

In many cases small ecchymoses are found on the head and neck, from the rupture of capillary vessels during the attack. Such is the description of an ordinary paroxysm of convulsive epilepsy. The milder form of the disease {le petit mal) consists of a temporary loss of consciousness only, of longer or shorter duration ; it may be so momentary as to be almost overlooked by the patient; in childhood especially it is liable to be passed over as a matter of little or no consequence. In a case formerly under my care, and which afterwards developed into severely convulsive Epilepsy, the patient perfectly remembered suffering from these slight attacks as a child, though at the time little attention was paid to them, either by himself or others. He was then in the habit of terming them " seeming hours." These seizures were probably similar in their charadler to those which Dr. Hughlings Jackson has described under the name of " dreamy states." Patients affli(5ted with this minor form of Epilepsy may be attacked at any time ; but I have, I think, noticed that they are more liable to be seized with the fit of unconsciousness while taking food ; at any rate, the seizure very often does occur at meal times. The patient rarely falls, but may, if standing, stagger ; if walking, stumble ; but in several cases, which have come under my notice, the power of walking has remained perfedt during the whole period of unconsciousness. If occupied at the time of seizure, they are apt to drop or throw down anything they

OF EPILEPSY.

may have in their hand. A child, now under my care, commonly loses consciousness while drinking, or swallowing food ; so that it is necessary that her cup should always be held, otherwise she would drop it. Patients constantly invent terms of their own to describe their seizures : thus, I have heard them called " waves," " turns," "feelings," "sensations." They are apt to vary greatly in intensity, and may range from simple transient moments of forgetfulness, or confusion, to complete and prolonged loss of consciousness. But although these former fits of confusion constantly occur in alternation with the more severe attacks, in which consciousness is totally extinguished, yet it is only the latter which can be strictly classed under the head of Epilepsy. Indeed, most epileptics are liable to suffer more or less from temporary giddiness and confusion of thought, more especially when exposed to sudden excitement, or alarm, or when walking in crowded streets. These slighter paroxysms vary very much in the outward manifestations by which they are accompanied. They may or may not be attended by slight twitchings of the facial muscles ; there may or may not be change of colour, though in many cases there is a sudden very transient pallor, at times succeeded by a flush on returning consciousness. In others the fit is announced by a groan, or sigh, or by a sudden exclamation often expressive of discomfort, or by indistinct and unintelligible mouthing; in others there is a curious munching or chewing movement of the jaws ; in some no sound is uttered. In most cases the eyeball is fixed, and a vacant expression occupies the countenance. A variation of this form of disorder has been described, by Dr. Hughlings Jackson, under the name of " dreamy states." The patient would appear to be scarcely unconscious, but usually imagines himself to be transported to some distant locality, or to be engaged in conversation with persons whose identity he is afterwards unable to recognise. These attacks often commence with, or are preceded by, sensations of faintness, or sinking, which arise apparently in the solar plexus. The strange feeling permeates the whole body, and leaves behind a sense of prostration and considerable temporary loss of memory. A patient of mine, who suffers from the seizures, and in whom I have frequently witnessed their occurrence, has often endeavoured to describe the nature of the sensations she experiences. She says, " I have been away," " I have been talking to people I don't know," " I don't know where I have been." In this case, although a change of colour takes place, not amounting to pallor, yet the pulse is unaltered, nor does the temperature fall. The attacks sometimes last as long as an hour, and usually occur in groups of from four to eight in two or three days, after which there will be a period of complete immunity for about a month. They also frequently come on during the night.

OF EPILEPSY.

1%

In some cases this slight Epilepsy would appear nothing more than a prolonged hesitation while in the middle of a sentence, or an apparent inability to express what the patient wished to say. During this period, however, it will be found that there is unconsciousness. In some rare cases of this form of the disease, the length of time over which the loss of consciousness extends is considerable. A child, now under my care, in whom the attacks only come on during the night, suffers from these protradled syncopes, which last in some cases over half an hour. They are only to be detected by the extreme coldness of the limbs ; the feebleness of circulation is great, the child being to all appearance dead. For reasons hereafter to be explained, these minor attacks, though far less terrible in their outward phenomena, produce a far greater amount of mental prostration than those which are convulsive. Indeed, the state of mind following such seizures is often most perplexing, as patients will frequently perform extraordinary actions while thus distraught, and are usually very obstinate and difficult to manage.

In those cases, then, in which such after effefts are known to occur, it is highly important that they should be in the hands of a careful and watchful attendant, otherwise distressing results are likely to occur. Dr. Gowers looks upon these sequelae of attack as hysteroid in their nature. I have already alluded to some rare forms of convulsive Epilepsy, in which the attacks are confined to one nerve, or one group of nerves. This is undoubtedly the history of many cases which are usually looked upon as and termed asthmatic ; indeed as I shall endeavour presently to show, there is a close connection between Asthma and Epilepsy. Two cases, which illustrate this, have occurred in my practice : one quite recently, the other some years since. In the first, a boy of fifteen, who had been subject for some years to very acute attacks of asthma, was seized suddenly with convulsive Epilepsy, during the existence of which the asthma completely left him, but returned on the disappearance of the epileptic seizures. In the second case, which gives a still better example of the localised form of the disorder, a boy of sixteen, who had a strong inherited tendency to nervous disease, was liable to be attacked, especially after any unusual exertion, over-fatigue, or over-excitement, with parox3^sms which were clearly due to a discharge of nerve force, down the track of the pneumogastric, as all the resulting symptoms occurred in organs which derived their nerve supply from that source ; and in these the greatest irritation was manifested. The best proof of the nature of the attacks was afforded by the boy becoming, after a time, the subjeft of generally convulsive Epilepsy of a severe type, from which, however, he ultimately completely recovered. In these partial cases the real origin of the disorder is apt to be overlooked, or

OF EPILEPSY.

its cause sought for in some other direcftion than the right, so that the neurosis may lose its partial character and become general, no remedial steps being taken. Such cases, of purely local disturbance, are not difficult to account for on physiological grounds. It is clear that the instability, and h}-persesthesia, is limited to one nerve centre only, and that the neighbouring centres are possessed of sufficient stability to prevent their joining in the discharge.

It is impossible, in the present state of our knov/ledge, to define with any certainty the exadl spot in the nervous system from which the Epileptic seizure takes its departure. Dr. Hughlings Jackson is of opinion that the discharge originates in the ganglionic cells of the grey matter of the cortex cerebri ; and this opinion is to a great extent borne out by the experiments of Dr. Ferrier, who found that convulsive seizures, identical with those of Epilepsy, could be produced by passing a Faradic current through certain regions of the grey matter of the cortex. But it would be best to give Dr. Hughlings Jackson's theory in his own words : " Scientifically," he says, " I should consider Epilepsies on the hypothesis, that the paroxysm of each is dependent on a sudden temporary excessive discharge of some highly unstable region of the cerebral cortex. There is, in other words, in each Epilepsy, a discharging lesion of some region of the cortex cerebri. The discharging lesion is nothing more than a group of cells whose instability is raised above normal. The discharge of the highly unstable cells constituting it (the primary discharge) leads to secondary discharge of healthy cells in other centres (collateral or lower) with which there is an anatomical connection by fibres, the degree and width of the secondary discharge varying according both as the force of the current, developed by the primary discharge, and the resistance opposed by fibres, and by cells of the healthy centres." Dr. Gowers accepting, as everyone must, the discharging lesion theory of the disease, thus argues the question as to the seat of the primary discharge : " What grey matter is it," he asks, "which thus suddenly stimulates the nerve fibres and the muscles ? It is hardly necessary to remark that the spinal cord acts only as a conductor, and that the over-acting grey matter is to be sought for above it, within the cranium. Regarding the encephalic masses, we have two classes of facts ; first, there exists in the medulla oblongata, adjacent to the centres which regulate the respiratory movements and the state of the vessels, structures capable of giving rise by their adlion to general convulsions, the convulsive centre of Nothnagel. On the other hand, of all regional lesions of the brain, lesions of the convolutions stand incomparably first as causes of convulsions;

OF EPILEPSY.

and experiment also demonstrates that irritation of the cortex in the motor region has the same effect. The tendency of experience then is, that both the cortex and the medulla may originate con\'ulsions. The teaching of pathology is, as Dr. Wilks long ago insisted, that epileptiform convulsions have in most cases their origin at the surface of the brain. It may be doubted, however, whether the pathological facts alone, or in conjunction with experiments, quite warrant the conclusion that Epilepsy is a disease of the convolutions." Dr. Burdon Saunderson is of opinion that convulsive Epilepsy is most probably caused by the irritation being conveyed from the cortical centres to those more deeply seated, and in which the convulsive action is really organised ; and this view is confirmed by the fa(5t that motor adtion only becomes bilateral through the medulla oblongata. It would seem probable that the difference between the two forms of Epilepsy is determined by the direction of the discharge ; the convulsive form taking its departure from the convulsive centres of the medulla, and passing unresisted throughout the body, the lesser form being a discharge from an unstable group of cells in the cortex cerebri, which, passing downwards, finds the medulla (the convulsive centres) stable and unprepared to join in the discharge, which is thus arrested. Or, it is possible that the vasomotor centre only participates in the unhealthy action, so i6 that a contraftion of the capillary system of the brain produces a sudden and temporary loss of consciousness.

If, however, we consider what slight causes suffice to produce disturbance of the mental processes, it seems hardly necessary that the solution of the difficulty should be sought in the latter possibility. Whether, then, the discharge originates in, and is confined to, the higher centres of the cerebral cortex ; or whether, as seems possible, it is referred from those centres to the medulla oblongata, from whence it takes its departure upwards through the cerebrum proper, in the form of a spasmodic capillary contraction, causing unconsciousness, must remain at present doubtful. Indeed, the weight of evidence, respecfting convulsive forms of the disease, would seem to favour the belief of Nothnagel, who gives it as his opinion, " That the primary seat of the discharge, the seat of the disease, is the convulsive centre of the medulla oblongata." This central spot of the nervous system, " nodus vitae," as it has been termed, is the seat in which motor power becomes bilateral. In the spinal cord below, divided as it is into two lateral portions, between which there is no decussation of the motor nerves, and in the cerebrum above, in which most functions would appear to be unilateral, an injury of one side produces a merely unilateral effeft ; and it is only through the medium of the medulla oblongata that a bilateral contrac5tion

OF EPILEPSY.

can be produced. This is well illustrated by an experiment of Dr. Brown Sequard's. That observer divided one half of the spinal cord in dogs, opposite to the lower dorsal vertebrae ; this produced, after a period of three weeks, convulsions which affefted both sides of the body, which convulsions could be at any time brought on, by irritating the nervus trigeminus of the side on which the injury had been inflicted. Thus if the cord was divided on the left, irritation of the left cheek produced the attacks ; if both sides of the cord were divided, irritation of either cheek would produce them. We must infer from this, that the sense of irritation travelled slowly up the cord, to the medulla oblongata. Indeed, the convulsion could only be induced by irritation of a nerve springing direftly from that spot.

I have long observed that epileptic patients usually exhibit extreme sensibility of the upper part of the spine, especially if pressure be made on the space between the occiput and upper cervical vertebra. The sensations, which such pressure gives rise to, are often intense, and are frequently referred to the stomach, as a sickly sinking sensation ; to the throat, as a choking feeling ; or to the face, as a sudden sensation of flushing, — indeed, a change of colour may actually occur. These facts point, no doubt, to an exalted sensibility of the whole of the upper part of the spine. In several instances I have succeeded in giving rise to the premonitory symptoms

c i8 which usually preceded an attack, by exercising this pressure. Again, fafts connecfted with the occurrence of epileptic seizures, which have their origin in irritations transmitted by the sympathetic nerve, all bear evidence to the important part borne by the convulsive centres at the base of the brain. Dr. E. Long Fox, in treating of the influence of the sympathetic nerve in the production of Epilepsy, says, "The numerous instances of true Epilepsy, caused by reflex irritations from distant organs, travelling upwards by way of the sympathetic, are not wholly explicable by the theory of the instability of cells [by which he means no doubt the cells of the cortex] . The epileptic condition consequent on irritation of the uterus and its appendages, the gastric Epilepsy in men, which Pommay speaks of as answering to uterine Epilepsy in women, are only some of the examples of this reflex condition." The faft is that these irritations, and numbers of others similar to them, are neither more nor less than exciting causes of the epileptic seizure, and probably in this respe(5t correspond in value to the instability of the ganglionic cells of the grey matter of the cortex cerebri ; and that neither would of itself be sufficiently powerful to force on general convulsions, were the ruling centres of the medulla oblongata sufficiently stable to resist the sense of irritation conveyed to them. It is indeed evident that deficient stability of the convulsive centres, in and about the

OF EPILEPSY.

medulla oblongata, is the principle cause of Epilepsy, and that other centres, both in the brain and spinal cord, may be liable, by their deficient stability, to discharge themselves in the dire6lion of the medulla ; yet so long as these chief controlling points maintain their control and power of resistance, they prevent the slight partial discharge from passing beyond this point and becoming general. The only exception, I believe, to this rule, is to be found in that class of cases in which the initiating cause is so intense as to overpower the strongest and most stable nervous control ; examples of which are to be found in those cases in which exostoses and other growths from the inner table of the skull, syphilitic or other clots and tumours in the substance of the brain itself. Rapid loss of blood, as in post partum haemorrhage, must also be classed in this category.

It has always seemed to me possible that the normal balance of pressure of circulation is one element of stabihty in the cerebral centres, and that when this is suddenly disturbed, as it would be by sudden extreme haemorrhage, that the rapid loss of support causes the cells to discharge themselves. I may here remark that the views I have just expressed are not altogether inconsistent with the theory of Epilepsy propounded by Dr. Hughlings Jackson, except that he would appear to attach less importance to the controlling power of the convulsive centres of the medulla oblongata. In almost all respects he coincides with the views of Dr. Burdon Sanderson. Further evidence as to the real seat of Epilepsy is furnished if we watch carefully the initial symptoms of an epileptic seizure : we find that the phenomena, which attend the earlier stages of attack, are all of them such as would arise from the irritation of nerves which either take their origin from, or are in intimate relation with, the medulla oblongata. Thus, the prehminary pallor is traceable to the spasmodic action of the vasomotor centre ; the peculiar cry is due to sudden contraction of the rima glottidis and the contraction of the chest, which forces the air through the narrowed opening. Or, as Van der Kolk has pointed out, the first disordered action may manifest itself in difficulty of respiration. In my own experience, it has frequently happened that attacks have commenced by choking whilst in the act of swallowing — a fact which has been noticed by other observers also. Joseph Franck states that, in seven out of twenty-six patients treated at Wilna, vomiting was the first observable symptom. Now, in all these cases, which are examples of the most common forms of commencement of the epileptic seizure, the parts implicated in the production of the phenomena derive their nerve supply directly from the centres of the medulla oblongata. Other minor facts point also in the same direction. In many cases of Epilepsy, especially in children, but also frequently in old standing epileptics, there is a

OF EPILEPSY.

remarkably free flow of saliva, often of an especially glutinous character, a fact which points clearly to an increased excitability of the centre for control of the secretion of saliva, which is situated in the same important centre. The protrusion of the tongue, again, though it is not, as a rule, one of the earher phenomena of the attack, is an action so closely connected with, and so significant of, an irritated condition of the same spot, that it cannot be passed by without remark. It was indeed from this observation of changes, which had occurred in the capillary vessels in the track of the hypo-glossal nerve, that Van der Kolk deduced his strongest reasons for indicating these centres of the medulla oblongata as the point of departure of the epileptic convulsion. Returning to the consideration of the bearing of symptoms upon the seat of the disease, it is to be observed that in all those cases in which the source of irritation, or the exciting cause, is situated at a distance from these nervous centres, the convulsions do not become general, nor does any loss of consciousness occur until the irritation has reached these important centres. Thus, when the patient is able to describe the nervous sensations which precede the actual attack, unconsciousness always supervenes so soon as the wave of nervous irritation reaches the head ; the same occurs with sensory aurae. The experiments of Drs. Kussmaul and Tenner, though they clearly misled those observers into forming an incorrect theory as to the immediate cause of convulsions, yet afford strong proof that the medulla oblongata is the seat from which the epileptic seizure takes its departure. They first excited convulsions in rabbits, by cutting off the supply of arterial blood to the brain and medulla oblongata; they then removed the cerebrum, even as far as the crura ; and in one or more instances the cerebellum itself vvas sliced off ; yet, notwithstanding this mutilation, the convulsions still continued. These very crucial experiments would certainly seem to place the seat of convulsion below the cerebrum proper. Again, if the supply of blood to the spinal cord was cut off by applying a ligature to the arch of the aorta, no convulsions but paralysis ensued ; but when the aorta was tied, and compression of the vessels of the neck also made, thus cutting off the supply of arterial blood to the medulla oblongata, convulsions came on immediately. We must, consequently, infer that the seat of general convulsion must necessarily be situated within the cranium. Yet the fact, that convulsions continued after the cerebrum and cerebellum had been removed, would clearly limit the seat of origin to the sensitive parts lying at the base of the brain, those excitable regions indeed which Marshall Hall grouped together under the name of medulla oblongata. If we now proceed to compare the facts just detailed with others which are to be gathered from the results of post-mortem examinations of