Reprinted frcm the Colorado Medical Journal, January, 1897. 
RESPIRATORY PARALYSIS FROM HEMORRHAGE AROUND 
THE MEDULLA. 
By S. 0. HOPKINS. M. D , 
Denver, Colo. 
Ledtirer and Clinical Lecturer on Nervous and Menial Diseases, Medical 
Department University of Denver. 
Through the kindness of my friend, Dr. J. N. Hall, I am able to 
report this most interesting case, and have added other cases of the 
same character, but brought about by different causes. 
Mrs. X., aged 27, well developed and rather fat, was pregnant, 
and exactly ten calendar months after her last menstruation and five 
months and twelve days after feeling motion, began to be in labor. 
At the end of twenty four hours, moderate dilatation of the os had oc- 
curred. Position of head, O. D. P. After repeated 15-grain doses of 
chloral were administered, the last dose accompanied with one-eighth 
grain of morphine sulphate, dilatation of the os to the extent of three 
inches occurred. This amount of dilatation was reached after the pa- 
tient had been in labor for thirty-two hours. At this time, in consult- 
ation with Dr. T. E. Taylor, it was determined by measurement that 
the pelvis was of natural size and, under chloroform, forceps were ap- 
plied (high operation) and extraction made. Child, female, about 
seven and one-half pounds in weight, and well developed. Heart beat 
vigorously, but there was no sign of a respiratory movement. All ar- 
tificial mea.s known to stimulate respiratory action were employed 
without success; nevertheless the heart continued to beat for fifty min- 
utes, when we made traction on the tongue, and the child breathed for 
twenty minutes, after which this method lost its effect and the mouth 2 
to mouth method was used, but the heart gradually failed, and the 
child died two and a half hours after birth. 
An autopsy was held twenty-four hours after death. The exter- 
nal surface was normal, excepting a few bruises upon the head, super- 
ficial, and caused by the forceps. Examination of the brain showed 
that a hsemorrhage had occurred around the medulla, due to rupture 
of the anterior spinal artery, a branch of the vertebral. Nothing ab- 
normal could be found in any other portion of the brain. 
Dr. J. T. Eskridge1 reports a case of tumor and large cyst of the 
cerebellum, with symptoms extending over several years. 
The patient was eleven years old, and suffered from spastic seiz- 
ures, with all the classical symptoms of tumor of the brain. The day 
that she died the patient developed Cheyne Stokes respiration, and at 
two p. m. respiratory action ceased, but the heart continued for sev- 
eral minutes while artificial respiration was employed. 
Hughlings Jackson2 reports a case of cyst of the cerebellum; weak- 
ness of spinal muscles; death from failure of respiration. The patient 
was a male, thirty years old, who suffered from symptoms of an intra- 
cranial lesion, from 1889 to February 13, 1890. The day previous to 
his death he suffered from a severe headache, with occasional vomit- 
ing, and at six p. m. he suddenly became unconscious and his breath- 
ing ceased, though his pulse continued fairly good. Artificial respira- 
tion was commenced at once and continued until 2:30 next morning, 
when the heart stopped beating. During the eight hours and a half 
that artificial respiration was continued, there was no sign of natural 
breathing. 
J. F. Atkins3 reports the following interesting case of tumor of the 
cerebellum: "J. B., aged 42. One evening I was callled to see him 
in the ward, and found him in a state of coma. A few minutes later 
he stopped breathing, but his heart was still beating (140 per minute). 
Artificial respiration was at once commenced and continued for three 
hours and a quarter. At the expiration of this time he commenced 
breathing naturally, and it was no longer necessary to perform artifi- 
cial respiration. A few days later he was as well as before the onset 
of the coma, and was able to walk with assistance. He died eight 
weeks afterward f:om asthenia, and the cerebellar tumor was verified 
at the post mortem. 
We not only find these phenomena present in the above class of 
cases, but they are observed in shock, this fact having been pointed 
out by J. F. Kramer4. He says that death due to syncope is produced 
i. Medical News, August it, i&)5- 
2. British Med J ournal, F . , 1894.. 
3. British Med. Journal, Mar. 31, 1894. 
4. Boston Med. and Surg. Journal, Dec. 3,189b. 3 
by paralysis of the respiratory centers, the cardiac centers remaining 
intact. 
This strange condition can be explained by a study of the anat- 
omy and physiology of the nervous mechanism of respiration, and of 
the cardiac action. In the first place, we know that the respiratory 
centers are situated in the floor of the fourth ventricle, at the upper 
and back part of the medulla. As to the cardio-inhibitory centers, we 
do not know the exact position of them, but they are in close proxim- 
ity to the former. The pneutnogastric nuclei are situated in the me- 
dulla, and from them fibres run to the respiratory and cardio-inhibitory 
centers; therefore the function of the vagi is two-fold; first, to regu- 
late the respiratory action, and, secondly, to inhibit the heart's action. 
Experimental physiology has proven this fact, that if we make a sec- 
tion of the pneumogastric nerves, we will not have complete failure of 
respiration, but it produces a marked change in respiratory movement, 
in that each breath becomes deeper and more prolonged than normal, 
while the rate of respiration is reduced about one-half. This can be 
explained by the fact that the respiratory centers are both reflex and 
automatic. 
The pneumogastric nerves form a large portion of the supply of 
nerves to the heart and, as stated, the function is to regulate the 
heart's action by communicating with the cardio-inhibitory center in 
the medulla. The heart not only receives its nerve supply from the 
pneumogastric nerve, for it has been proven by the experiments of 
Gaskill5 and others, that the fifth, the sixth, the seventh and the 
eighth cervical, and the first, but principally the second, dorsal nerves 
pass to the cervical sympathetic ganglia, and hence, by the cardiac 
splanchnic, to the heart. When these nerves are affected by inflam- 
mation, as they are in some cases of ascending neuritis, we will have 
sudden death due to failure of the heart's action. On the other hand, 
if we stimulate the pneumogastric nerves with an electrical current we 
at once cause a stoppage of the heart's action for a short time, whereas, 
if we make complete section of these nerves it will cause an increase in 
the rapidity of the heart's action. The most interesting physiolog- 
ical experiment known of in this connection is the following: 6If we 
injure or destroy the medulla, we cause instant death; but if the 
portion of the medulla between the calamus scriptorius and the vaso- 
motor center be destroyed, respiration ceases, although the heart's ac- 
tion is undisturbed. We cannot positively prove why this takes place, 
but we surmise that in this space the fibres which run from the pneu- 
mogastric nuclei to the respiratory center have their course. 
In studying these cases it is a difficult task to come to a definite 
j. Medical News, Jan. 6, i8qb, page i. 
b. Foster's Physiology, page 230. 4 
conclusion as to the exact causes and structures involved, producing 
this strange condition. I am of the opinion that, in the first case, the 
disturbance of respiration was caused by direct pressure upon the re- 
spiratory center, over the portion of the medulla between the calamus 
scriptorius and the vaso motor centers, for if the pneumogastric nuclei 
were infringed upon we would have the cardiac action involved, in con- 
junction with respiration. This naturally leads up to another ques- 
tion: Why is it that respiration is affected and the hearts action un- 
impaired when the centers are situated so close together? 
In the first place, the fibres which run to the respiratory center 
occupy this space, and, secondly, the cardio inhibitory centers must 
be much more resistant than the former. This view would not only 
hold good in the case of haemorrhage, but also in tumors of the cere- 
bellum, where they produce pressure on the medulla. 
Buzzard has suggested that in tumors of the cerebellum which 
have caused failure of respiration, where the heart continued to beat, 
that it is due to the fact that the same changes take place in the re- . 
spiratory centers that are found in the optic nerves in this class of 
cases. But if this be true we would have respiration gradually fail- 
ing, and not suddenly, as in the above cases. The only explanation 
one can give for these phenomena occurring in shock is that the re- 
spiratory apparatus is less resistant than other portions of the nervous 
system, especially the cardio-inhibitory apparatus.