The Localization of Lesions in the 
Pons and Preoblongata. 
CLINICAL LECTURE DELIVERED AT THE PHILADELPHIA HOSPITAL. 
CHARLES K. MILLS, M.D., 
Professor of Mental Diseases and of Medical Jurisprudence in the University of 
Pennsylvania ; Neurologist to the Philadelphia Hospital, etc. 
[Reprinted from International Clinics, Vol. 111., Fifth Series.] The Localization of Lesions in the 
Pons and Preoblongata. 
CLINICAL LECTURE DELIVERED AT THE PHILADELPHIA HOSPITAL. 
CHARLES K. MILLS, M.D., 
Professor of Mental Diseases and of Medical Jurisprudence in the University of 
Pennsylvania ; Neurologist to the Philadelphia Hospital, etc. 
[Reprinted from International Clinics, Vol. 111., Fifth Series.] THE LOCALIZATION OF LESIONS IN THE PONS 
AND PREOBLONGATA. 
CLINICAL LECTURE DELIVERED AT THE PHILADELPHIA HOSPITAL. 
Professor of Mental Diseases and of Medical Jurisprudence in the University of 
CHARLES K. MILLS, M.D., 
Pennsylvania; Neurologist to the Philadelphia Hospital, etc. 
Gentlemen,—During this and the last lecture term I have shown 
you a number of cases of disease of the cranial nerves and of the pons 
and oblongatas. Several of these cases have died, and you have seen 
how closely the focal diagnosis of a small gross lesion in a restricted 
and structurally complicated region can be diagnosticated. The gross 
specimens, microscopical sections, and drawings from one of these cases 
were exhibited during the last term, and to-day I show you also the 
Pig. 1. 
specimens, with photographs and 
drawings, of another case. Both 
of these cases are illustrations of 
localized pontile softening, such as 
would be expected from destruc- 
tive lesions. Both involved im- 
portant longitudinal and transverse 
tracts and the root-fibres of certain 
cranial nerves. The lesions were 
small but deeply situated. 
With Wilder, I prefer to re- 
strict the term pons to the some- 
what cylindrical body occupying a 
ventral or inferior position in the 
cerebro-spinal axis between the 
Diagram showing the relations of the 
pons, preoblongata, and postobiongata to the 
fourth ventricle, iter, gemina, and cerebellum; 
Q, quadrigeminal body; V, fourth ventricle. 
crura and the postobiongata,—usually termed the medulla oblongata, 
—applying the term preoblongata to the important strip of nerve- 
substance between the pons proper and the fourth ventricle, its dorsal 
.surface being the floor of the ventricle. The nuclei of the cranial LOCALIZATION OF LESIONS IN PONS AND PREOBLONGATA. 
151 
nerves, from the fourth to the twelfth, are situated in the oblongatas. 
The pons proper is largely made up of fibre tracts, but it contains also 
a few special nuclei. In Fig. 1 are shown the relations of the oblon- 
gatas to each other, to the pons, and to the fourth ventricle. 
For the purposes both of focal diagnosis and description it is well 
to have some readily applied topographical scheme. The common 
method of dividing parts into thirds is convenient and useful. The 
llolandic or motor region of the cortex, for instance, is frequently 
referred to with relation to the upper, middle, or lower thirds of the 
Fig. 2. 
Fig. 3. 
Subdivision of the ventral aspect of the 
pons into thirds, showing the relations of im- 
portant structures to each subdivision. 
Subdivisions of the lateral aspect of the 
pons and preoblongata. The nerves are in- 
dicated by the Roman numerals. 
central fissure, and convolutions and lobes are often divided into thirds 
in describing the positions and extensions of lesions. By dividing the 
combined pons and preoblongata into thirds in two directions, we are 
able to focus our attention upon any one of nine segments. The diag- 
nostician must know the gross anatomy of this region, and to some 
extent he should be familiar with its nuclei and fibre systems, as shown 
in microscopical sections. 
I have here ventral, lateral, and dorsal views of the gross appear- 
ances presented by the pons and preoblongata (Figs. 2, 3, and 4), repre- 
sented as divided into thirds by horizontal dotted lines. The lines 152 
INTERNATIONAL CLINICS. 
shown on the different surfaces correspond as determined by sections of 
actual specimens, the planes of the sections being at right angles with 
the cerebro-spinal axis. 
The cephalic and middle thirds of the ventral portion of the pons 
(Fig. 2) contain chiefly transverse and longitudinal fibre tracts ; what 
these are will presently be learned. The third nerves are seen 
emerging between the cephalic third and the crus, and at the junction 
of the pons and the postoblongata are the abducens, and more laterally 
the facial and auditory nerves. On the lateral aspect of the cephalic 
Fig. 4. 
Fig. 5. 
Subdivisions of the dorsal aspect of the pons- 
preoblongata. 
Position of the nerve-nuclei, root-fibres of the 
fifth, and medullary or acoustic striae. 
third, near the crus, the trunk of the fourth nerve appears, and the 
fifth nerve in the middle third, while the seventh and eighth nerves 
are seen in the lower third of the lateral as well as of the ventral third. 
In the cephalic division (J.) of the dorsal aspect is seen the postgeminum 
or posterior tubercles of the quadrigeminal body, and also the fourth or 
pathetic nerve at its origin and in part of its course. The middle third 
[B) includes the prepeduucle, or superior cerebellar peduncle, and a por- 
tion of the floor of the fourth ventricle. Both the middle and caudal 
thirds are partly traversed by the medipeduncle, and the caudal third 
((7) by the acoustic or medullary strife. 
In order to progress with our diagnostic work, it is now necessary LOCALIZATION OP LESIONS IN PONS AND PKEOBLONGATA. 
153 
to pass with our mental vision beneath the surfaces of the bodies we 
are considering. Let us first glance into or just beneath the floor 
of the fourth ventricle. With the aid of Fig. 5, which is largely 
diagrammatic,—the relations of the parts being, however, as in actual 
specimens,—the positions of the nuclei of the third, fifth, sixth, seventh, 
and eighth nerves are made evident. The nuclei of the third nerve are 
situated in the gray matter along the course of the Sylvian aqueduct, 
cephalad of subdivision A, and the nucleus of the fourth nerve adjoins 
the nuclei of the third in the upper portion of this cephalic segment, 
lying chiefly beneath the postgeminum. Both the sensory and motor 
nuclei of the fifth nerve are in the middle 
third, while the nuclei of the sixth and 
seventh and a large part of the eighth 
are in the caudal or lower third. Hence, 
when nuclear symptoms referable to any 
one or more of these nerves are present, 
the topography of the lesions causing them 
can be understood and readily stated with 
reference to these subdivisions. 
Fig. 6. 
The root-fibres of the nerves which 
spring from these nuclei have, it must be 
remembered, within the substance of the 
preoblongata and pons, courses of consid- 
erable extent and complexity before they 
appear on the ventral and lateral aspect 
of the pons. In Fig. 6 a general idea is 
given of the dorso-ventral routes pursued 
by the root-fibres of the third, fourth, 
fifth, sixth, seventh, and eighth nerves. 
In this illustration new lines are shown, 
drawn longitudinally and at right angles 
to 'those already used in making the sub- 
divisions A, B, and C; thus giving in 
lateral view nine segments, the thirds A, 
B, and C each being subdivided into 
thirds,—three ventral, three dorsal, and 
A lateral diagrammatic view of 
the course of the root-fibres of the 
cranial nerves from the third to the 
eighth. The diagram is shown sub- 
divided into thirds longitudinally 
(D, E, and F) as well as horizontally 
(A, B, and C). 
three intermediate (that is, intermediate between the dorsal and the 
ventral segments). 
The root-fibres as well as the nuclei of the third nerve chiefly lie 
cephalad of all the above subdivisions. In the cephalo-dorsal third it 
will be seen that the root-fibres of the fourth nerve and that branch of 154 
INTERNATIONAL CLINICS. 
the fifth formerly called descending, but now known as the ascending 
branch, pursue their way. In the dorsal and intermediate segments of 
the middle third {B) both descending and ascending roots of the fifth 
nerve are seen, as are also a few of the curving fibres of the curiously 
twisting roots of the seventh nerve; while in the dorsal and inter- 
mediate segments of the caudal subdivision (C) are crowded the root- 
fibres systems of the sixth, seventh, and eighth nerves. 
Making now dorso-ventral sections through the middle of each of 
the subdivisions A, B, and C, the appearances of such trausections, as 
seen under low powers of the microscope, would be much as shown on 
each half of Figs. 7, 8, and 9. Fig. 7 shows the appearance of a sec- 
tion through the middle of the subdivision A, Fig. 8 of one through 
the middle of the subdivision B, and Fig. 9 of one through the middle 
of the subdivision Cl In these figures are brought into view not only 
the appearances in section of the root-fibres and nuclei of the nerves, but 
also of various important longitudinal and transverse tracts,—the super- 
ficial and deep transverse fibres of the pons, the pyramidal tract, the 
fillet, the peduncles, some of the most important of the cranial nuclei 
and root-fibres, and certain special nuclei and tracts, as the superior 
olive, the lateral nucleus, the dorsal longitudinal bundle, and the central 
tegmental tract. 
The merest glance will show that in all positions the most important 
parts involved in lesions of the ventral and of the intermediate seg- 
ments will be the superficial and deep transverse fibres and the pyramids. 
The fillet lies about the junction of the intermediate and dorsal seg- 
ments, varying in its median and lateral positions in different cephalo- 
caudal sections. Nuclei and root-fibres are most prominent in dorsal 
segments. 
The pyramidal tract dominates the symptomatology of ventrally 
situated pontile lesions, its destructive lesions, no matter where situated, 
giving certain uniform symptoms, and others which will vary somewhat 
according as the lesion is more cephalic than caudal, or the reverse. It 
is the great tract from the motor region of the cerebral cortex. In the 
O 
mid-brain it gives off fibres which cross to the nuclei of the third and 
fourth nerves of the opposite side. In its course through the pons it 
sends fibres to the cell-nests of the motor fifth and of the abducens and 
facial nerves ; but throughout its entire course, until the spinal cervical 
cord is reached, it contains the fasciculi for the arm and leg of the op- 
posite side. Hence destructive lesions of this tract will always give 
paresis or paralysis of the opposite extremities. When the lesion is in 
the cephalic portion of the pons, before the decussation of the pyrami- LOCALIZATION OF LESIONS IN PONS AND PEEOBLONGATA. 
155 
dal fibres for the trigeminal, abducens, and facial nerves, some ocular 
and especially some facial paresis may be present. This loss of power 
in the face must be distin- 
guished from that caused by- 
lesion of the facial root-fibres 
or nuclei. The paralysis of the 
face is central, and has features 
similar to that shown in the 
arm and leg. It is usually in- 
complete, although it may be 
more marked than when caused 
by a lesion situated higher in 
the pyramidal tract or in the 
cortex. It does not give the 
electrical reactions of peripheral 
facial paralysis. 
Fig. 7. 
Fig. 8. 
Irritative lesions of the 
pyramidal tract in the pons 
and elsewhere may give rise to 
monospasm, or even to unilat- 
eral convulsions, chiefly affect- 
ing the limbs and face of the 
opposite side. 
Often, in lesions of the ven- 
tral portion of the pons, the 
cranial nerves at, just before, 
or just after their superficial 
origins will be involved, giving 
various forms of so-called alter- 
nate hemiplegia. In lesion of 
the lower ventral third, or 
conjointly of the ventral and 
Fig 9. 
J 1 i• i i 
lateral thirds, the alternate 
hemiplegia will be of the arm 
r° # # 
and leg of the opposite side, 
i u j? .1 n 
and may be of the face on the 
same side ; or facial, abducens, 
, -j., . . 
and audltoi y net ve pai aIySIS 
of the same side may ‘coexist 
Transections of the pons and preoblongata 
about the middle of each of the thirds A, B, and C, 
represented in the previous diagrams The thirds 
D, E, and F correspond to the similarly designated 
thirds in Fig. 6. These figures show the relations 
and position of the most important structures; 0.5., 
supJior olive. at> central tegmental tract. x.c. 
and c., locus ceruleus; D.1.f., dorsal longitudinal 
fasciculus; L.f., lateral fillet; L. n., lateral nucleus; 
the numerals refer to nerve nuclei and roots. 
with the paralysis of the extremities. In the middle ventral third, 
especially if the lesion extends laterally, paralysis of the leg and face INTERNATIONAL CLINICS. 
of the opposite side may be associated with both motor and sensory 
paralysis in the distribution of the fifth nerve. In the cephalo-ventral 
segment the lesion may extend so as to implicate the third nerve, giving 
the oculo-motor type of alternate hemiplegia, or some paralysis of the 
third and fourth nerves may show on the same side. 
The superficial transverse fibres of the pons which lie ventrally to 
the pyramids contain chiefly cerebellar fasciculi. In the middle third 
of the pons they run nearly horizontally, having a more oblique course 
in the lower and upper thirds. They connect special portions of oppo- 
site halves of the cerebellum, and also portions of the lateral lobes of 
the cerebellum with the opposite cerebral hemispheres. The symptoms 
given by lesions of special bundles of these superficial transverse fibres 
are not yet thoroughly known. I have reported a case in which, ap- 
parently as the result of a small hemorrhage involving these fibres, as 
well as some of the deeper parts of the pons, the patient had atrophy 
of one lateral lobe of the cerebellum and of the opposite hemicerebrura. 
Passing to the intermediate segments, as seen in the transections 
Figs. 7, 8, 9, it will be seen that the pyramidal tract occupies part of 
this region, which also contains the deep transverse fibres and, near the 
junction of the intermediate and dorsal thirds, the fillet. A lesion 
centrally situated in the substance of the pons will, therefore, give 
symptoms the result of the destruction of these deep transverse fibres, 
and, if the lesion extends ventrally and dorsally, of both the pyramidal 
tract and the fillet. The deep transverse fibres constitute largely the 
structure known as the trapezium or trapezoid body, whose size and 
position show its physiological importance and the necessity of giving it 
a place in clinical diagnosis. Flechsig, Bechterew, Hans Held, Bruce, 
and others have shown that in it is the path of the cochlear nerve, 
which branch of the eighth pair is the true nerve of hearing. Fibres 
of the trapezoid body pass to the various auditory nuclei, and also to 
the roof nucleus of the cerebellum, and connect with the superior olives 
both of the same and of the opposite side. According to some author- 
ities, the trapezoid fibres unite with the fillet, and according to others, 
they intersect it. While the lower or caudal border of the trapezium 
corresponds nearly to the same border of the pons, cephalad it only 
reaches as high as the place of emergence of the sensory root of the 
fifth nerve, and, therefore, it would be chiefly involved in lesions of the 
two lower thirds of the pons, as given in the diagrams. 
The superior olive, which extends the whole length of the pons, is 
closely approximated to the dorsal surface of the trapezium, and is 
located, therefore, near the junction of the dorsal and intermediate LOCALIZATION OF LESIONS IN PONS AND PBEOBLONGATA. 
157 
segments. Bechterew believed that the superior olive acted as a reflex 
centre for correlating the movements of the head and eyes with auditory 
impressions, and its lesions might therefore be expected to interfere 
with such correlations, causing a lack of response by the head and eyes 
to sounds coming from various directions. The connections of the 
superior olive which have been traced are with both accessory nuclei of 
the auditory nerve, with one or possibly both cerebellar roof nuclei, 
with the nucleus of the sixth nerve on the same side, with the dorsal 
longitudinal fasciculus of the opposite side, with the lateral columns of 
the cord, and with the postgeminnm. 
As the fillet, or at least its most mesal portion, is a part of the 
great sensory tract, its lesions cause disorders of sensation. Numerous 
oases have been reported in which deeply situated pontile lesions have 
given rise to anaesthesias, and especially to impairment or loss of the 
senses of pain and temperature ; and numerous studies of degeneration 
following focal lesions have also shown the part played by the lem- 
niscus as a sensory tract. The acoustic tract runs in the lower lateral 
division of the fillet to the postgeminnm, so that lesions of the lateral 
fillet, like those of the trapezoid body, should give affections of hearing. 
In the dorsal or preoblongatal portion of the region we are con- 
sidering the structures are complicated. Here in various positions are 
the nuclei and root-fibres of the fourth, fifth, sixth, seventh, and eighth 
nerves; and, in addition, certain special fasciculi, as the dorso-longi- 
tudinal bundle and the central tegmental tract. Dorsal lesions in 
different fore-and-aft segments will, therefore, give varying forms of 
paralysis of the face ; of trigeminal paralysis, motor and sensory ; and 
of single or associated ocular palsies. As the third, fourth, and sixth 
are all nerves to the ocular muscles, and as in various movements of 
the eye these muscles act to a greater or less extent together, both on 
the same side and across the median line, the nuclei of these nerves 
must be anatomically connected, and lesions of their associating and 
correlating fibres will give special disorders of ocular movements. 
Some of the connections, it is believed, are by the dorsal longitudinal 
bundle. 
Many of the curving strands in the pons and oblongatas run from 
the nuclei of the motor cranial nerves, partly to the opposite dorsal 
longitudinal bundle and partly to this fasciculus on the same side. 
Bechterew, Edinger, and others have demonstrated a central teg- 
mental tract, beginning near the dorsal accessory nucleus and passing 
cephalad in the mid-tegmentum. In one of my cases of thalamic dis- 
ease with involvement of the superior limb of the internal capsule, 158 
INTERNATIONAL CLINICS. 
this tract with both inferior olives was found to be markedly degener- 
ated, showing that it probably reaches to and even beyond the inter- 
brain. According to Bechterew, it terminates in the leuticula. The 
position of this tract, according to Edinger, is shown in Fig, 9 {C. t.). 
This tract may serve to correlate the cell-nests of the sensory cranial 
nerves, as the dorsal longitudinal fasciculus does those of the motor. 
Let me now enforce some of the points which I have endeavored 
to make with reference to segmental localization in the pons, by refer- 
ence to recent and past clinical experiences in this hospital and else- 
where. Here are the photographs of Case 1., one of the patients re- 
ferred to at the beginning of the lecture (Figs. 10 and 11). He died 
a few weeks since. When he was brought before you the diagnosis 
was made of a lesion involving the abducens root-fibres and pyrami- 
dal tract in the pons. 
This man had a history of syphilis. Eight or nine months before 
his death his left eye showed a tendency to turn inward, and for a time 
he saw double, and occasionally he had spells of vertigo. His left 
extremities were weaker than the right. He was extremely emo- 
tional, and often laughed or cried without motive or incitement. (See 
Fig. 11.) No anaesthesia was ever determined, but both legs seemed 
to be rather hyperaesthetic. Knee-jerks were exaggerated, especially 
on the left; muscle-jerks were also increased, and ankle clonus was 
present on both sides. The plantar reflexes were marked. 
His vision was reduced to about one-half in the right eye and one- 
third in the left, but his fields could not be determined. The'retinal 
arteries were small. Accommodation was good. The right external 
rectus muscle was paretic, the left was paralyzed, and ocular movements 
were restricted in accordance with these conditions. 
I omit many details in this case unnecessary for our present purpose. 
The man, before death, developed gradually increasing mental and 
paralytic symptoms. 
On autopsy, the lesion which chiefly concerns us in the present 
connection was found in the pons. A transection through the pons 
within the' limits of subdivision B of our diagrams revealed a ventral 
lesion near the median line in the right half, which appeared to be 
limited, as shown in the drawing, Fig. 12. Subsequently, micro- 
scopical sections were cut and mounted by Hr. A. O. J. Kelly, from 
which drawings, shown in Figs. 13 and 14, were made by Dr. J. C. 
McConnell. These show that the area of softening and surrounding 
degeneration extended much farther than appeared in the fresh speci- 
men. It reached to a considerable distance on both sides of the Case of pontile lesion (Case II.): Fig. 10 shows paralysis of the external rectus and expression of the face at rest; Fig. 11 shows the 
patient’s expression at the time of uncontrollable emotional disturbance. 
Fig. 10 
Fig. 11. LOCALIZATION OF LESIONS IN PONS AND PIIEOB LONG AT A. 
159 
median line, as shown in both drawings by the lighter areas. The 
destruction and degeneration involved both pyramidal tracts, the deep 
transverse fibres, and to a less extent the superficial transverse fibres. 
The root-fibres of the right abducens, and to 
a large degree those of the left, were also 
probably implicated. The destruction was 
much greater on the right than on the left 
side, causing a large shrinkage in general 
bulk on the right. The paralysis and paresis 
of the extremities were due to the involve- 
ment of the pyramidal tracts. Implication 
of the abducens root-fibres caused the ocular 
paralysis of one side and the paresis of the 
other. 
Fig. 12. 
Case ll.—Last year a case of pontile 
lesion was shown to the class, and re- 
ported at the meeting of the American Neu- 
rological Association by Dr. John Zimmer 
and myself. The day before admission to 
the hospital the patient was attacked with 
vertigo, double vision, and paresis of the 
right arm and leg. She had imperfect ar- 
ticulation ; at rest the right eye turned 
Drawing showing the posi- 
tion apparent size of the 
pontile lesion in the fresh speci- 
men fr°m Case r- in the text- 
and illustrated in Figs. 10 and 11. 
strongly to the right, while the left was not deviated; both eyes could 
not be turned together to the left; the lateral movement of the left 
Fig. 14. 
In Figs. 13 and 14 are shown the microscopical appearances of the lesion in Fig. 12. The degen 
eration is seen to extend across the median line and over a large area. 
eye to the right was also impaired, and slight nystagmus of both 
eyes was present. The lids of the left eye could not be fully brought 
together. Right facial paresis was present. Tendon and muscle phe- 160 
INTERNATIONAL CLINICS. 
nomena were much exaggerated in the paretic limbs. No anaesthesia 
was discovered As determined at the autopsy, the pontile lesion 
was a circumscribed softening with hemorrhagic infiltration, reaching 
at its cephalic extremity nearly to the ventral surface of the pons, 
more caudally extending towards the raphe, and about the middle 
of the pons slightly crossing the mesial line. The area of softening 
Pig. 15. 
Pig. 18. 
Pig. 16. 
Fig. 17. 
Diagram showing the antero-posterior dimen- 
sions of the pontile lesion in Case 11. 
became smaller and more deeply 
situated as it approached the post- 
oblongata, which it almost, but 
not quite, reached. Drawings 
were made by Dr. Zimmer of the 
appearances presented at the time 
of the autopsy, and Figs. 15, 16, 
and 17 give a good idea of the 
Figs. 15, 16, and 17 show the position of 
the pontile lesion in Case 11., described in the 
text, the sections being through A, B, and Cof 
Fig. 18. 
position and apparent extent of the lesion as then noted. Fig. 18 
shows that the longitudinal extent of the lesion was such as to involve, 
on the left side of the pons, all three of our subdivisions A, B, and C. 
The three transections from which the other figures are drawn would 
have fallen respectively within our subdivisions A, B, and C, but not 
exactly in the planes represented by the transections of normal struc- 
tures (Figs. 7, 8, and 9). It was found on microscopical investiga- 
tion that the area of destruction and degeneration extended for a 
considerable distance beyond the lesion as it appeared in the fresh 
state, reaching both across the median line and in other directions, as 
shown in a drawing by Dr. J. C. McConnell (Fig. 19). At one LOCALIZATION OF LESIONS IN PONS AND PREOBLONG AT A. 
161 
position close to the median line it reached almost to the floor of the 
ventricle. 
Fig. 19. 
Microscopical appearance of a transection through the lesion in Case II.; the 
section was made through the middle third of the lesion in about the position 
shown in Fig. 16. 
Years ago I published the account of a case of tumor of the pons, 
in which the chief symptoms of focal lesion were hemiparesis, partial 
right ptosis, diminished sensation on the left side of the face and right 
limbs, conjugate deviation of the eyes and rotation of the head to the 
right, persistent epistaxis, and a tendency to hemorrhage from the mu- 
cous membranes. The autopsy revealed a gumma about half an inch 
in diameter, distinctly limited to the left cephalic quarter of the pons. 
Another case of central softening of the pons has also been reported 
by me. None of the cranial nerves were superficially involved, although 
the lesion was unusually large. The clinical history showed headache, 
a vertiginous seizure followed by partial right hemiplegia, left con- 
vergent strabismus, defective articulation, and paralysis of the left arm 
three weeks after the attack ; another seizure, accompanied by great 
emotionality, profuse perspiration, difficulty in breathing and swallow- 
ing, inability to speak and to thrust out the tongue or open the mouth 
wide, and paralysis of both arms and legs; and at the last conjugate 
deviation to the right. 
Conjugate deviation of the eyes and head is a not infrequent accom- 
paniment of lesions, and especially of tumors towards the cephalic 
extremity of the pons, Vaso-motor phenomena, such as pallors, flush- 
ings, and the epistaxis and mucous hemorrhages referred to above, may 
be present in pontile lesions, as may also special temperature changes. 
These are probably due to implication of vaso-motor and heat centres ; 
but time will not permit the discussion of the entire subject of pontile 
lesions in this lecture. 162 
INTERNATIONAL CLINICS. 
Thus far in the cases to which I have called your attention the 
diagnoses have been confirmed by autopsies. Recently a patient of 
peculiar interest in connection with my lecture was admitted to the 
men’s nervous wards,—an excellent example of conjoint trigeminal and 
facial paralysis, with some impairment of hearing. He is a young man 
of about twenty-six years of age, with a history of syphilis. About 
two weeks before admission he observed that the right side of his face 
was paralyzed and insensitive. When admitted, examination showed 
complete paralysis of the right facial or seventh nerve, also of the 
muscles supplied by the motor division of the fifth nerve. The patient 
was also anaesthetic on the right side of the face, including the conjunc- 
tiva and cornea. The hearing, as determined by the watch, was good 
on the left side, but on the right it was necessary to bring the watch 
close against the ear before its tick could be heard. He had, however, 
no tinnitus. Taste was lost on the right side both on the anterior 
and posterior portions of the tongue. He had neither paralysis nor 
anaesthesia of any part of the body below the neck. The symptoms 
in this case are probably due to a lesion of the lateral aspect of the 
pons, although they might be explained by a lesion within the sub- 
stance of the pons and preoblongata, so situated as to injure or destroy 
the sensory and motor root-fibres of the fifth, the facial and glosso- 
pharyngeal root-fibres, and some of the acoustic root-fibres, or per- 
haps fibres of the auditory tract in the trapezoid body or lateral 
fillet. The electrical reactions in the muscles of the face were those of 
peripheral paralysis.