F- CLINICAL ASPECTS OF SPINAL CORD INJURIES
317
when the patient was awake and there was incontinence during sleep. Olivecrona (1935)
described bladder dysfunctions in patients with parasagittal and frontal tumours.
Foerster (1936) described a case of metastatic hypernephroma of the gyrus fornicatus of
the left side reaching into the lobulus paracentralis who suffered for 8 years from focal
epileptic fits, which started as a rule in the right big toe but repeatedly also with sudden
involuntary micturition. On the other hand, a unilateral meningioma of the lobulus para
centralis, causing focal epileptic fits starting in the contralateral big toe and foot, may not
necessarily elicit vesical dysfunction, as described in another of Foerster's patients. Dur
ing my visiting professorship at Duke University, Durham, U.S.A., in 1969,1 saw several
patients from the Vietnam War with parasagittal injuries of the cortex who were suffering
from disturbances of micturition (frequency, urgency and incontinence). Some of them
had initially urine retention for varying periods.
Subcortical influences
In recent years the work of Tang & Ruch (1955, 1956, 1967) has revealed more details of
the subcortical control of the brain which has amplified and clarified the findings of
previous workers in this field (Barrington, 1921, 1925; Rabat
et
a/., 1936; Langworthy
et al. 3
1940). Following transhypothalamic, intercollicular, supra- and infracollicular
decerebration in the normal cat, they found a number of descending pathways exerting
both facilitatory and inhibitory influences on the micturition reflex. From their studies
they concluded: (a) Oblongata and posterior pons have no micturition centres but are
merely 'way stations' of descending inhibitory and facilitatory pathways ofhigher cerebral
centres. This is contrary to Kuru & Koyama's (1961) views, who considered oblongata
and posterior pons as seats of actual micturition centres, (b) However, the anterior pons
has a strong facilitatory influence on the spinal segmental micturition reflex, (c) This
pontine centre is in turn restrained by cerebral areas above the intercollicular level. In
transection of the mid-brain (intercollicular decerebration) the pontine centre is released
from central inhibitory influences, resulting in lowering of the threshold of the micturition
reflex. Ruch & Tang found the volume of fluid necessary to elicit the micturition reflex
to be as low as 4 and 8 ccs as compared with the normal threshold for micturition of
40/80 ccs in correlation with the size of the cat. Transection below the pontine centre
results in complete loss of micturition reflex.
Descending and ascending pathways within the spinal cord
There is still discrepancy of opinion with regard to the localization of the descending
cerebral pathways within the spinal cord (Budge, 1864; Foerster & Gagel, 1932; Hun-
sicker & Spiegel, 1933; Wrack, 1943). According to Rothfeld & Rabiner (1954), cortical
impulses to the sacral spinal micturition centre are mediated through fibres arising from
the cerebral cortex and they transverse the cortico-spinal tracts. From my own experience
on antero-lateral cordotomies in man and that of other workers in this field (Foerster,
1936; Kahn & Rand, 1952), it can be concluded that bilateral cordotomy of the spino-
