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Maps, plates, charts, etc., may be filmed at different reduction ratios. Those too large to be entirely included in one exposure are filmed beginning in the upper left hand corner, left to right and top to bottom, as many frames as required. The following diagrams illustrate the method: Les cartes, planches, tableaux, etc., peuvent dtre filmds d des taux de reduction diffdrents. Lorsque le document est trop grand pour dtre reproduit en un seul clichd, il est filmd d partir de Tangle supdrieur gauche, de gauche d droite, et de haut en bas, en prenant le nombre d'images ndcessaire. Les diagrammes suivants illustrent la mdthode. I 1 2 3 1 2 3 4 5 6 i ^sa^M:fstvmt)mBmmj>'asai^!issi!^T--^^-sT,-r — ~ Brain Lesions and Functional Results. Bt DANIEL CLARK, M.D., Tohonto. [Head liclVuc llif C'liiiiiila iMtMliciil Assciciatioii, at Ottawa, September Ist, 1880. | There is great clanger in mccliciil research to accept as theories preconceived notions based on a few isolated cases, and then to fortify these dubious interpretations of physical 01' mental jihenoniena liy dragging in, neck and heels, every iota which seems to corrobo- rate our views. On the other hand, the ardent but discreet investigator will adopt no great general principles until he has at his command suHicient data upon which to base them, beyond the bare presumption of vague probabilities. Richet, in his " Histology and Fliysiology of the Cerebral Convolutions," says in the pre- face: "There is nothing more baneful than to treat hypotheses as certainties. On the con- trary, when serious criticism has revealed the defects and feebleness of an experiment, a real service has been rendered, for it may incite to new exj)eriments and unequivocal conclusions. Inductions from probabilities or ill-demonstrated experiments are unreliable, and intelligent scej)ticism is more valuable to the advance of science than unbridled enthu- siasm." Tliis honest expression of such an investiga- tor shoidd lead us to pau.se before drawing conclusions and establishing theories with in- suliicient proofs. It will be seen in the cases adduced of lesion of the brain, that this organ can stand more rough treatment in many of its parts than almost any other organ ot the body. In fact, such laceration of its delicate structures can take place without any serious mental or physical disturbance, that we almost unconsciously take for granted that many parts of it must be of secondary importance in the animal economy. It is true that a large majority of those injured in the brain are afterwards afflicted with such disea.ses as epilepsy, paralysis, head distress, loss of memory, and the like ; yet it is remarkable how many examples of the most extensive .esions of .le Inain can be found with no such results. In a monogra])h pul>lished by me a short time ago, I endiuivoured to show that localization of functional power resided only in the basal ganglia, and that the masses of cerebral substance above them were only depositories of nervous energy. If this opinion be based on a physiological fact, it would help to solve this enigma. It is well known by all medical readers that a sharp controversy has been carried on, and antagonistic opinions have been uttered by the leaders of thought in our profession, on the functions of the convolutions of the brain. They have been mapped out with the accuracy of the streets of a city, and each district has been allotted its own work to do. Although no dividing line exists in the substance of the brain, yet the comparatively slender divisions of many of the sulci are made to be boun-* daries of functional energy, in which great differences of operation exist. It is not the province of this paper to take up this subject in detail, but rather to show by the record of cases how foreign bodies and diseases can virtually destroy many of these so-called BRAIN LESIONS AND FUNCTIONAL RESULTS. centres without any commensurate functional disturbance such as might be expected if these j.arts were distinct organs ; also to show that mentality is not interfei-ed with in these cases to the extent which at one time we were led to believe. The psychical results would be a good nut for the bumjjologist to crack in these days of infidelity in the doctrines of Gall and Spurzheim. All anatomists know that although the ^ fissures of the brain in man maintain a certain degree of uniformity in direction and outline, yet the diflerences in detail are considerable. It will also be observed that these fissures do not make distinct divisions of the surface. The even continuity of the surface ot every convolution, by means of an isthmus (so to speak) at the extremities and sides of each, indicates no striking dividing line between each of them. The dijjs in the grey matter, lying underneath these fissures and in proximity to the white substance, show that a certain degree of uniformity in quantity of grey matter is present throughout the periphei-y of the brain. It is true that diflPerences in cell formation are seen in the various layers of the cortical sub- stance, but tliese cellular distinctions are found only in each layer. There is no physiological distinction found in the various convolutions distinct fi-om one another, to account for the varied functions in these so-called motor centres, as claimed by the Ferrier school. The uniformity of cell structure in the separate layers of the cortical substance is continuous, ' and nowhere bounded by the surface fissures and convolutions. In other words, all the convolutions are similar in structure, and were sections of each cut out from without inwards, and submitted to the closest analysis, no microscopist could tell where to locate each part. All are as uniform as would be sections of the cortical substance of the liver or kidney. If we compare the convolutional structures of -the cerebrum with that of the cerebellum, it will be seen that they are constructed on the same plan (llichet). In the region where the distinctive giant cells exist {i.e., in the fine layer type of the ascending frontal and pari- etal convolutions), all the cortical regions of grey matter have no distinctive anatomical characteristics except the presence of giant cells. Charcot suggests that all the difl'orent sized cells may be of the same kind in different degrees of development. In this way he thinks it possible that oven motor centres may change their centres. This is a convenient theory to account for the fact that such an attack as aj)lmsia often passes away, although its so-called motor centre I'emains impairtd. This want of dividing lines on the external surface of the brain is, on physiological grounds, a momentous objection to distinct centres in the cortical substance. Let us now consider this subject from another i)oint of view. Fritsch, Hitzig, and other ex})erimenters, agree that in no appreciable degree do mechanical or chemical agents excite motion in the cerebral substance. Excitation by galvanism is said to be very feeble and very limited in either the cerebrum or cerebellum, and this want of response is seen throughont. It is evident that in this way — i)owerful as the agent is — no functional centre could be found on the surface, llcrrman shows that even after the grey matter is destroyed by chemical cauteries, a very feeble current of galvanism applied to this surface ja-oduced a slight movement, and significantly adds that in cutting away slices from the brain, the effect was more decided in proportion as the central regions were ap- proached (llichel). In other word.s, the focus of nerve energy seemed to be in the ganglia at the base of the brain, and that the destruc- tion of the cerebral substance did not produce that disturbance of the system commensurate with the loss of substance once supposed to be .so necessary to the continuance of physical life and mental action. Richet says, in speaking of the localization theory as projjounded by Ferrier and his ardent followers, that " Absolute inflexible localization of the motor zones is impossible. There are zones which encroach upon each other, but none of these zones have limits of determined, vigorous constancy. The best proof of this is the difference existing among authors." If this mean anything, it is that although paralysis and abnormal functions of the brain in many instances follow the destruc- tion of certain cortical parts, or are the results Sit36&&SffliS»aSu«tte L'« of giant lie different in different is Wfty he centres may convenient at such an y, iiltlioiigh nipaiied. he external cul f,'round8, centres in )w consider of view, nters, agree echanical or he cerebral )i is said to either the IS want of is evident agent is — imd on the n after the il cauteries, 1 applied to i^enient, and away slices decided in s were up- s, the focus the ganglia he destnic- lot produce niuensurate posed to be diysical life localization r and his 5 inflexible impossible, upon each "6 limits of The best ing among it is that unctions of the destruc- the results BRAfN LKHIONS AND FUNCTIONAL RESULTS. of disease, and althougli a certain degree of uniforuiity in physical re.-sults follows, yet it is equally true that these same areas may be destroyed without any such nuinifeslations following Their own experiments are *.aken as proofs of this fnct. These circumscribed areas cannot, therefore, by any show of reasoning, be the organs which are the centres of difitinct functional activity. The.so local chang(!S may affect the co-ordinating and mental powers, but the centres of these acti- vities must be sought for elsewhere. To reconcile these undoubted variations in results, and i)o.ssibly arrive at the truth, let it be assumed that the basal ganglia are the centres of these functions. Let it also be assumed tliat the cerebrum and cerebellum are not directors of motion, but only conneroalors of nerve energy, both receptive and functional. Let us say that the.se ganglia are focal centres to all the nerve ti'acts of the system. What- ever nerve injury may do in other parts of the nerve mass within the skull without dangerous results, it is evident by ex])eriments and the havoc of di'«oase, that no serious impairment can take place in all or any part of these ganglia without disaster; hence their supreme importance : in fact, this focus of influence might be called the metropolis of life. Mauds- ley, in "The Pathology of Insanity," says: " The disturbance of the cortical cells is in reality secondary ; it is a retlex functional result of the primary morbid action that is going on in the neighbourhood." And again : " Portions of the hemis\)heres may l)e cut away without the patient feeling it, though he is fully conscious." Ferrier locates the motor centre of the o))posite up[)er limbs in the upper part of the ascendin(j frontal convolution : in i\\?> first frontal convolution, the movements of the head ; in the second or centre convolution, the motive power of the facial movements; and in the third convolution, the centre of the movements of the tongue and lips in monkeys, and the centre of the faculty of articulate speech in man. This is often called Broca's convolution In the superior parietal lobe is located the centre for the movements of the lower limbs. The gyrus anguiaris is said to possess some influence over sight. Dr. Laffont, in a paper read before the Paris Anatomical Society of last year, states that " the centre which con- trols the circulation of the abdominal viscera is in the floor of the fourth ventricle, because local irritation of this part produces unusual activity in the blood movement of the liver and intra abdouiinal organs." Other investi- I gators equally credible say that the grey sub- stance of the fourth ventricle is the motor centre of respiration ; the occipital lobes, the centres of vision. Aj)ha3ia, or the loss of ideo-motor coordina- tion, is circumscribed by some to disease or injury of the posterior part of the third left frontal convolution. In passing, it may be said that Ferrier still farther divides his functional foci, and puts " subjective auditive sensation " in the first temporal convolution, and "subjective olfactory sens ition " in the cornua ammouis. In short, it may be said that, in cerebral localization, the encephalon docs not represent a homogeneous organ, an unit, but rather an association or a confedera- tion composed of a certain number of diverse organs. To each of these organs belong dis- tinct i)hysical properties, functions, and facul- ties (Charcot), it is well to keep these views in mind and see if they are corroborated by facts. It is to be remembered that there is no direct nervous communication with the body from the cerebrum and cerebellum except through the basal ganglia, notwithstanding statements to the contrary. Whatever injury disease or traumatic lesion may inflict on these upper nerve masses with comparative impunity, analogous injury from the' same causes cannot be inflicttjd on the central or base organs with- out dangerous results. In other words, these are, in my opinion, the true motor and sensory centres of the system, and there is no necessity of going beyond them to prove a localization theory. The distinction between these by well-defined boundaries and the want of uniformity in structure point strongly to distinct functions. The outshoot of the spinal cord, and the numerous nerve ramifications, ^. only to th% organs of special sense, but i UiJO to the locomoti\'e and organic systems. fiRAliy LESIONS AND FUNCTIONAL IIKSUI/FS. ■«!' f point oiit tliese diHtricts as being the poculiar focal centres of functional and psychical life. If this theory ho correct, it can explain all the phenomena manifested by experiments made, and I itliologiciil conditions found, on the cor- tical sulwtiaice, without resorting to the chart made out by such shifting, incomplete, and chingealile boundaries as the sulci of the con- volutions afford. The " bumpologist " con- veniently locates all mental centres in the cortical substance nearest to his manipulations, j and ignores all the similar surfaces at the base ,' and between the hemispheres, because this , terra mcoynita is not convenient to ina[» out. He cannot reach these parts; therefore they must be useless a}>pendages. He forgets nature has no lumber room. In somewhat the same way the Ferrier school of investigators find certain functional disturbances following the abrasion, excision, or galvanism of definite cortical parts, with a considerable degree of iinifcjrniity. leased on these manifestations, already, with considerable confidence, it is said nearly all the functions of the body are located on the exterior part of the nerve mass, which is within reach of experiment, and somewhat hasty conclusions are drawn from the results. All the rest of the brain mass, which has a substance exactly similar in structure to the external grey mattei-, is jiractically ignored, in spite of its paramount importance, which is evident from the complexity of the structure, and from the fatal results which flow from injury to these central parts. It seems to be overlooked that any injury to the cortical substance must necessarily affect the lower ganglia, to which it lies in juxtaposition, and to which it stands so nearly related. The periphery of the bi-ain doubtless has much to do in stimulating to action these centres. In the latter are found the distinctive seats of functional activity, and in the superimposed mass the residuary power to impel, but not to direct — to give additional vitality, but not to indicate the mode and direction this force is to take. This discriminative power is left to be jjerformed by these central glands, which are safely situated in the centre of these sympa- thetic and active auxiliaries. "Not only is this true in respect to function, but it is equally true as respects sensation. Sensation and function have a community of interests, and are focalized together. Dr. Symonds, in tho Gulstonian lectures, says : " Pain does not seem to be in the nervous matter, whether vesicular or tubular, of the cerebral heini- s|)heres, or of the cerebpllum. No evidence of feeling has been obtained by vivisectors till they approached tho sensoiy ganglia — the thalami o/jtici and corpora quadrlgeviina. But these are the centres of sensation to all parts of the body as well as to the head." It is satisfactory to see that recent investi- gators are paying more attention to the central organs. Their researches go to show that very important functions are likely to be found having their excito-motor centres in the internal parts of the brain. These ex- periments, as far as they go, point to tho probabilities of my theory of localization. Richot, in speaking of cerebral excitation hy means of electricity, is forced to say in exjila- nation of certain phenomena, " Known facts demonstrate that excitation of the convo- lutions which surround the sigmoid gyrus act with extreme energy upon the ganglionic centres of the brain (opto-striated bodies). It is possible that such excitation culnnnatod in the cerebral centres, and that these centres thus surcharged discharge to the muscles." Charcot says, iu speaking of the lenticular nucleus of the corpus striatum: "These grey nuclei are possibly so many centres endowed with distinct properties and functions." This is a germ idea of the theory which I propounded several years ago in the following words : " Large portions of the cerebrum and cerebellum may be taken away from the living body without immediate danger of death ; but the organs in the base of the brain, from which spring the numerous nerves so essential to life, cannot be touched in vivisection or by disease with im])unity. From this central region nerve influence radi- ates to every part of the body, making its con- nections with the depositories of nerve power in the spinal cord and with the ganglia of the sympathetic system." — (Vide "An Ani- mated Molecule," p. 38.) If Charcot had added to his hypothesis the probability chat the base and central ganglia were the true and nnA/iX fj'jsroiYs and functional lu-jsn/rs. nation and i'voH'.H, and uIh, in the (locH not r, wliother l)nil liemi- evidence viviHtctors inj^lia — the lina. But o all jmi'ts nt invcsti- tiio central show tliut coly to be centres in Tlie.se ex- int to the realization, citation liy y in exjihi- lown facts le convo- loid gyrus ganglionic odies). It nnnatod in entres tluis ." Charcot nucleus of nuclei are ith distinct germ idea veral years je j)ortiou8 Y be taken immediate ;he base of numerous touched in impunity, lence ladi- ng its con- irve power ganglia of 'An Ani- arcot had ty chat the true and only motor cenfcrcH, a Holntion of the ditllcul- ties which surround the Kcrricr systf^n could be arrived at without ignoring the doctrines of localiz,ha8ia. It lias l)een found in nunihors of uxaniploH that aphtiHia is found with this convolution intact. Not only this, hut it is known that H|tf!<'ch, in its different forms of language, Huch as writing, reading, singing, drawing, and imitation — in faet, aphasia in all its forms — follows lesion in the Island of Reil. {London, Lancet, Amcr. Ed., July 1880, p. 34.) A[)hasia is known to exist as the result of disease in the right hemisj)here, and that not in the corresponding third frontal of that hemisphere. It cannot be 8upj)OHod this reputed motive brain tissue which excites tiie functions of speech may bo destroyed, and yet the pecu- liar energy which animates it can remain un- abated after its obliteration has taken place, unless it is claimed that the corresponding convolution on the right, in a vicarious way, j does the work of its fellow. If such were the case, then the third left frontal convolu- tion could claim no pre-eminence as the sole seat of the faculty ot articulate language. To get over this difficulty, this school of thinkers introduces what is called the theory of supple- mentation. They say some other part of the cortical substance comes to the rescue when any centre of function is destroyed. This neighbourly assumption of peculiar and distinct labour is not found in any other part of the system, however willing the organs may be to give a helping hand to one another. We are told it may be the corresponding i)art of some other cortical area. This is virtually a giving up of the doctrine of these so-called " true motor centres." Here let me say, in passing, that a fallacy in vivisection often arises in forgetting that experiments on the brains of inferior beings by the destruction of parts do not always produce analogous effects on man when cor- responding parts are injured. We may re- move the whole of a cerebral hemisphere of a pigeon or rabbit with the only functional result of a slight impairment in flying or jump- ing. No hemiplegia will follow, such as is the case with like injury to the dog or monkey. Man is much more sensitive to such lesions, only in certain parts. In fact, tlie whole brain may bo removed in many creatures without affecting tht'ir locomotion. We know that in man discaHCiHUch as sclerosis, and softening, may cut off the spinal cord from cerebral inlluenne, yet functional activity goes on with unabated vigour. In the same way, we find that if tho base and central organs remain unim[)aire(l, no markt^d symptoms arise, except by sympa- thetic connections with adjacent parts. Tliis shows the fallacy of reasoning by apology be- tween man and animals baHeli/ of blood is nseded, there js fonnd the greatest functional activity. We are all well acquainted with the wonderful distri- bution and anastomoses of the blood in the base of the brain, both in the circle of Willis and in the cerebral arteries springing from this polygon of vessels. Wo are also aware of the fact that two sets of branches shoot from these main trunks in almost parallel lines. The one class g^eg into the medullary and cortical sub- stance in an outward direction from those cen- tral reservoirs, btit does not reach the surfaoe. Another class runs to the jjoriphery and forms the pia mater, from which branch inwarus numerous arterioles to supply the cortical and medullary parts not reached by the vessel? springing from the centre. These two sources of supply are not only distinct as between each of their own vessels, but also unconnected to a great extent with one another. The anasto- moses between these two sets of vessels is very slight indeed. The streamlet in each can be dried up or seriously interrupted in many ways without disturbing the nei;;hbouring vessels to any appreciable degree. This accounts for so many circumscribed lesions in these parts, and for the little effect they produce on the adjacent tissues and circulation. I am inclined to think, that on account of this localization of circula- tion, and consequently a tendency to restricted HRAIN LESJUNl^ AND FUNCTIONAL RESULTS. vliolo bruin [>H without ow that in -«ning, may 1 inlluenne, h unabated tlmt if the iiiiinpaired, by synipa- artH. Tiiis ir»logy be- (cperinientfl. great differ- fow words >ocl in the itifully the blood than ebruin and I that when ed, there u ij. We are erful distri- ood in the hi of Willis ig from tluH waro of the from these I. The one iortical sub- » those cen- tbo siirfaoe. y aiid forms 3h inwariis cortical and the vessel? two sources etween each nnected to a The anasto- jsels is very each can be many ways g vessols to oiints for so e parts, and the adjacent ed to think, n of circula- te restricted areas of disoaBo, a good many fallacioB of reasoning have obtained currency in respect to centres of function. H«'ubn<'r cites pathologi- cal cases wliicb indicate that obliteration of one ot the large vessels of the coitical system, or any of its branches, has during life given no pronounced symptom. (Charcot.) Lot us now turn to the arterial circulation in the yrei/ centnil (janglia. This section in- cludes the thulami optici, the corpora atiiata and their appendages. It needs only a mo- ment's reflection of our anatomy to realize that the central ganglia are la"gely supplied from the Sylvian artery, as well as from the nutrient vessels, which spring in large num- bers from all the cerebral arteries and from the basilar at its bifurcation. The sum total of all these shows a much gi-eater capacity for blood sujjpiy per square inch than in any other part of the brain. Such being the case, we know this augmented normal supply means proportionally increased activity. Hence it follows as a matter of fact that any abnormal increase or decrease of blood means a greater or less jihysical or mental perturbation. Conges- tion, as well as anuimia, is followed by the same results — that is, more or less suspended sensibility and veta»-Jed voluntary action. Where the blood supply is found to be naturally the most copious, there is greater susceptibility of this kind, and as a corollary it may be added, there is functional activity in proportion to the normal blood sujjply. The difference in this respect between the cortical substance and the central parts is most nurked. This points to the former as being only subsi- diary to the latter, taking the circulation as a physiological basis to judge from in this respect. Although the central and base ganglia are much less in bulk than is the corti- cal substance, yet, about one-half of the blood which enters the encephalon is distributed to the former. It would be interesting to know if this unequal supply has anything to do with the pathological fact that in hemiplegia from cortical disease we find it " limited, transient, and variable" (Charcot), but in paralysis of the body from central disease it is permanent, general and uniform. It is a pathological fact that paralysis, general or partial, can be pro- duced by any jHirt of the brain being affected with intlamnuition, embolus, or tumour ; show- ing that loss of function is not consetpient on degeneration or destruction of some localized spot. That part of the brain which demands the greatest amount of blootl in the performance of its work must necessarily liave the greatest activity. Let me then repeat in another form that a very superficial knowledge of the brain circula- tion indicates how direct and ample is the blood supply to the base and central ganglia in ' comparison with the cortical supply. This is especially true of the arteries which'run to the corpus striatum and tfuilamua opticus. The cortical substance is nourished in a roundabout way through the pia mater, but the central sys- tem is reached directly through the large central vessels springing from the circle of Willis, which furnish a perfect fountain of blood supply near at hand. So distinct and important is the circulation in this grand centre, that when obliteration of the Sylvian artery takes place, all the ganglionic centres are afiected, and cerebral hemiplegia accompanied by hemiantes- thesia is the result. This physiological fact alone shows the greater importance these ganglia hold — it seems to me — as functional centres in comparison to the cortex or even the entire hemispliores. Since writing the above, I find that Prof. M. SchifF, of Florence, has caught the same idea, when he says, in his monograph on " motor centres," that " human and comparative pathology have stated with certainty that the motor centres do not extend above the base of the brain." Unless my at- tempt to be brief has led to ambiguity, it will be seen that among the probabilties of this obscure subject, the explanations I have given in defence of the theory enunciated are based on — I. The radical difference found in the circu- lation of the blood, both as to mode of distribu- tion and quantity, leading to the reasonable inference of greater functional activity existing in the centre than in the circumference of the brain. The more life-action in any part, the more is blood supply needed. II. The want of uniformity in functional results, when definite and alike portions of the a'^' ///.'J /A l.h'SKtNS AND FUNVTIiiNM HEHUI.TH, cortical Hulmtttnco are Htiiiniliitod, inipiiirod or doHtroyed ; hcuoo, tliiH cannot l)o tlio Hciit ol" Ho-called truo motor ccntroH. III. It would be conHOiumt with imtliologi- cal and cx|»<'iinioi>tiil IketH to locate tliOKO motor und jdiyHioal ceiitniH in tlio ImHO and contro ganj^lia ; yet in Hympatlietic ndtitionH, l)eiiig influenced, l)Ut not a'i«ohit('ly controlled, by the cortical subHtunce. IV. The want of distinctive jjliyHiologicul features in the different convoluticvns. I will now give a few exaniplts of brain injury, illustrative of these views. Tiie first are culled from the surgical records of the war of the late American rebellion : Private Ilnglies was wounded at the battle of Antietam. The hospital reports say that the injury was a perforation of tlie ^kull by a single conoidal musket bail entering near the inner posterior angle of the right ))arietal, and emerging at a higher point of the left parietal, making, after traversing a portion of the brain, a large exit wound. At the time of this ex- tensive injury he dragged himself from the field, but he did not lose his consciouimeas. Eight days after the injury, it is reported the general condition of the patient was good ; aup[iuration had commenced, no fi'brile action existed, the pulse was regular ; sleep not ma- terially disturbed, mind clear, and manifested no signs of compression of the brain, or inflam- mation of its riembranes. When the swelling of the scalp subsided, a prominence of brain substance was found — one inch in height, and three inches in length — in which the pulsation of the arteries could be distinctly observed. Spiculae of bone came away from time to time, and the tumour subsided within the cranium. On December 20th, 1870, or over eight years after the injury, he was examined by two medi- cal men. Previous to tiiis time he liad worked in an iron foundry. His memory remained (piite good. He had no paralysis, and it is reported by Drs. Keen and Thomson that it is remark- able to observe the almost entire restoration of his mental faculties,* especially in view of the probable deep lesion of the brain, both by the primary injury and the subsequent fungus cerebri. It will be seen that in this case there was no functional disorder, excrjit that, for a sliort time at first, " the bruin functions Hcemwl clouded." This might bo expected for a time. Private* Sheridan was shot through the loft tcnipoial region. The missile hxlgcd in tlm brain and was never extracted. At the close of the war he was discharged — recovered, und received no pension. No functional disturb- ance. ('orporal I'arnum, wounded by a round Imll entinintr the cranium and brain matter, llu recovenid, and was put on the Veteran Reserve Corps. He was not pensioned. Ho was none the worse for the wound. ^ Private Dillo'i was wounded by a bullet which entered the cranium very near tlie superior angle of the occipital bone, and Imd passed anteriorly into the sul)stance of the brain. He lay on the field of battle two days without any attention. After being a year in- valided h(f returned to active service, perfectly well phy.sically, but with the intellect slightly impaired. Afterwards ho was mustered out of the service perfectly well, and was not pensioned. The ball was not extracted. After the first shock there was no functional disturbance. I'rivate Bemis, woundtd by a ball en- tering a little outside the left frontal pro- tuberance, and passing backwards and out- wards. It removed a piece of tlie squamous portion of the temporal bone, with brain substance and membranes. When the jjatient entered the hospital, brain matter was oozing from the wound. At first, respiration was slow ; pulse 40 ; th" right side was paralyzed, and there was total iiisen.sibility. Three days after the injury the bullet was extiacted from the substance of the left hemisi)here. It was a conoidal ball and badly shattered. He then rapidly recovered, and the report says that in four months and a half afterwards " the men- tal and the sensory faculties were unimpaired." On October SOth, 1870, he wrote : " I am still in the land of the living. My health is good, con- sidering what I passed through. My head aches some of the time. I am married and have one child. My memory is aflected, and I cannot hear as well as I could before I was wounded." These were the only results of this BliWill /////1/A^ fJ'.'SlONS AND FllNi'TloSM UllHln/rs. IT I'or 11 Kliort oiis Ht'cniwl ■<;t(Hl for a ii,i,'li tli(. |,,ft iIK'<1 ill the t tl'H clone ovcied, und ual (liHturl)- I round hall iiiittf'i". lie VM\ HcHerve <' wiiH iiono ly a bullet near the :n', and Imd ance of the ,lo two days ig a yoiir in- C(3, J)Cl'f»!CtIy lect slightly itered out of t iHjnsioned. !;(;r the first irbanco. u ball en- f ion till pro- du und out- e squamous with brain the patient was oozing iration was ) i)aralyzed, 'J'hiee days s exti acted Lsphere. It tered. He rt says that 3 " tilt! meu- nimpaired." I am still in is good, con- My head larried and ected, and I (fore I was suits of this eitensive laoeratioM of brain matter. The Hiight functional -UHturbanco did not cor- rospond with the doctrine of cortical functional centres. Sergeant llotherhain, wounded ut Gettys- hurg by ti niusket Ijall, which penetrated the Hkull near the right frontal eminence, paHsed directly inwards and lodged somewhere on the iiienibranos or in the brain substance. The opening through the bono was similar to that made by a trephine, and the track of the l>all could bo followed on the dura mater with a probe for a considerable distance!, as that mem- brane was detached from its natural connec- tion with the skull. The ball wus not ex- tracted. There was lio perceptil)le loss of power, motion, or sensation on either side of tiie body. Tluirc was no arterial excitenunit His recovery was ri pid, and five weeks after the injury lie was liuloughed for fifteen days, at the expiration of which time he returned to duty, having suderod no inconvenience from the injury. After this several bones exfoliated, but his mind was not impaired to any percepti- ble degree. For some time after the wound was received, he was assigned light duty in the Veteran Reserve Corps Hospital. Lieut. Brown, at the battle of Wilson Creek, received a penetrating gunshot wound of the cranium and brain. The ball was not removed for seven years after the injury, but in a few days after being wounded he was fit for duty. In January, 1871, this ofHcer was on duty as captain in the l;Jth Infantry. Private Stallman, wounded at Winchester by a musket ball, which entered at the right \ temple and emerged at the opposite side of the head. In spite of this serious lesion of brain, in a few months he was put on light duty. He had no strabismus, and we are told that, although his mental faculties were slow and uncertain and his memory impaired, he had no hallucina- tions nor mental aberrations. The year follow- ing the injury he was pensioned. No functional impairment except the above mentioned. Private Haggart was wounded by a conoidal musket ball, which struck the left side of the head, and passing through carried away a large ^part of the left half of the occipital bone. At first he became insensible and lost more than 2 an onnce of cerebrum, leaving bare the nionin- geal artery. Seven monlliH afterwards he waH discharged fr -in the hospital. At that time both eyes were dila'ed, causing dimness of vision, but his intellect was good, and he could vead very coaise print. lie? dietl four years afterwards, but it is not recorded what was tho cause of death. This extensive lesion only produced these slight results. Seigenut Woodman was woiuided by a gun- shot missile, which entered above tho left frontal eminence and (merged at a point one, inch behind tho upper margin of the right ear. He was unconscious for several hours. At the wound of exit eight small boms afterwards dis- charged, lie was aliv>! three years afterwards, and it was reported that the organs of special sense and the intellect wore unimpaired. Private Plunily was wounded by a conoidal musket ball, which entered at the inner angle of the left eye, and after passing through the brain substance! itemeiged l)eliin(l the left ear. On March 7th, 1867, nearly three years after tho wound was inflicted, he was in good health, and a pensioner. The only physical results were obscuration of the vision of the left eye for a short timo, the dischaige of pus from the orifice of entrance of the bi'I and through the right nostril and upper part of the posterior nasal cavity into the mouth. Private Sechler was wounded by a conoidal ball, which struck the os fronds over the right eye and pafc^sed into the brain. He not only lived, but returned to duty six months after wards, and was at the close of the war mus- tered out so well that he did not even receive a pension. The ball was not extracted. No functional results. Private Samuel D. Solomon was wounded at Bull Run, Aug. 27th, 1862, by a carbine ball, which struiik at a point two inches behind the tip of the left ear. The missile entered the brain to the extent of two inches and was not extracted. When struck he fell to the ground, but retained his consciousness. Healthy sup- puration followed, and a fragment of Vjone was discharged from the vvound. He suffered from headache, and also from acute darting pains across the base of the brain, from the right tei 'e to tJie scar of the wound. No paralysis I 10 BMAIN LKHIONS AND FUNCTIONAL RESULTS. Mr i ■{. '1 I existed, and the functions of the body were generally well performed. He afterwards served in a Washington Hosj)ital in tlu! capa- city of nurse, and was discharjaed the service in the suVjsequent year, with no record of mental unsoundness or functional disability. Corporal Wood, wounded at the battle of Winchester by a conoidal ball, which fractured the occipital bone and entered the brain. This was Sept. 19th, 1864. He whs e.xaniined by a Confederate Board, on March 24th, 18G5, whose members reconnnended that he might be employed at .some post where the duties were not laborious, showing his mental faculties ponld not have 'been impaired to an ap[)reciable degree. No functional results were seen. Private Sheridan was wounded at the siege of Vicksburg by a canister shot. The missile entered the left parietal bone, immediately posterior to the coronal and three inches from the sagittal suture, passed horizontally inward, a distance of two and a-hnlf inches and lodged. The ball could not bo extracted. He suffered but little inconvenience. The wound sup- purated freely, sometimes bled, and small frag- ments of bone escaped. Six months after, he was placed to work on the levee, and experi- -cnced no trouble, except on approach of a storm, when he had a dull pain and sensation of weight. In eight months after the wound was received he returned to duty. Lieut. Lilycrantz, wounded at Fort Pulaski. The ball perforated the os frontis, over the right superciliary ridge. When first seen after the injury he was vomiting freely, and about a fluid ounce of brain matter had ex- uded from the wound. A probe, five inches long, glided easily, by its own weight, its full length directly backwards through the wound without coming in contact with the ball. For ten days the patient showed a tendency to sleep, but was easily aroused and would con- verse freely, constantly wandering, however, from the topic of conversation. He could, at this time, neither taste nor smell, and his hearing and sight were much impaired. He recovered his mental faculties to such an extent as to be employed in Government service at Washington, and died five years afterwards. During this time he articulated distinctly ; had no paralysis, but had occasion- ally slight attacks of ejule »sy, but they were becoming slighter as time wore o" J. have culled these cases out of 5.59 persons who received penetrating or perforating frac- tures of the skull. These 559 were selected out of 4,350 cases of gunshot wounds of the cranium and its contents. Of that large number many were alHicted with functional and mental disturbance, but in no two cases of similarly injured were there like residts. Dr. Van Peynia gives a record of a singular case in the Buffalo Medical and Simjical Jour)ial, December, 1873 : — A man, aged 50, was found comatose and brought to the Buffalo General Hospital. He 8ubse([uently was sufficiently roused to give his name and age. He died .six days after admission. On post mortem examination, the meninges on the light side were found con- siderably congested. On removing the brain a collection of pus was found at its base, extending from the medulla oblongata forwards. The lateral ventricles were also found filled with a purulent collection. At this moment, as the incisions were being extended, some- thing was heard to fall on the tray on which the brain was lying. To our utter amazement this was found to be a bullet. The ball, which was of small size and considerably flattened, had been liberated by the knife. The con- viction was forced upon us (says the surgeon) that the external opening, through which the ball had passed, had been overlooked during the lite of the patient, and that this was the real cause of death ; but our astonishment was increased when, after a careful examina- tion of the surface, no opening could be found, As a last resort, th"* cranium was examined from the interior ; and on the anterior surface, above and a little to the right of the left orbit, was found a fracture of tlie fi'ontal bone, the internal table of which was extensively fissured. With this as a guide, we again made search for the external aperture, and again failed in finding an opening, but finding a discolouration of the skin over the seat of the fracture, of a lead colour, circular in shape, and the size of a ball. There was not the least sign of a wound or the slightest scar. The BRAIN LESIONS AND FUNCTIONAL li/'JSlILTS. 11 had occiision- it they were 559 persons orating frac- vevG Hclccted )undH of the tlmt large 1 functional 10 two cases e results, of a singular nd Siiryical omatose and ospital. He ised to give : days after nination, the 3 found con- ]g the brain at its base, ata forwards. found filled his moment, 3nded, some- I'ay on which r amazement e ball, which >ly flattened, ). The con- the surgeon) ^h which the oked during this was the istonishment hil examina- ild be found, as examined )rior surface, of the left frontal bone, extensively >, we again )erture, and aut finding a 3 seat of the ir in shape, not the least scar. The wound, which must hnve existed, had healed perfectly, and left nothing but tbiw leaden dis- colouration to show its foi'iner presence. Tlie course of the ball llnough the brain could still be traced by a probe to the placfs where it had lodged, n(?ar the anterior surface of the me- dulla. The opening in the bone was filled in with a gelatinous material through which tenaculum passed readily. There was no previous history of the case, but it was evident that the wound had been inflicted a considerable time before death ; and seeing the patient had not found refuge in a poor- house, hospital, or asylum, the inference is fair that the intellect had not been much ini[)aired, if any, up to the fatal attack. 1 am the more ready to think so, from the immunity enjoyed by i)atients similarly alHicted. There could not have been serious functional results as he liad been able to look after himself. A somewhat analagous case is recorded by Dr. Prewitt, of the City Hospital, St. Louis (St. Louis Medical and Surgicnl Journat) : — A man, aged 32, shot himself with a pistol. The ball entered the forehead about an inch and a half above the supra-orbital ridgo. He recovered in a little over a month, and without marked impairment of intellect. He died eleven months afterwards from erysipelas. No functional impairuient is mentioned. Asst.-Surgeun P. F. Harvey, U.S.A., reports the following case {vide American Journal of the Medical Sciences, July, 1879) : It is that of an Lidian Agency ])hy8ician who received a Winchester riHe-ball three inches and a quarter above and one inch behind the right external auditory meatus. The missile took a transverse direction across both hemispheres toward the left supra -orbital convolution. A grooved director was easily passed in this track, a distance of five inches, without, how- ever, reaching the Ijall. The patient did not lose consciousness on leing wounded, and complained only of "seeing stirs" and of some confusion of ideas. He recovered so rapidly that, after five days of jonvalescence, he took a journey of 90 miles, in December, in an open buggy, alighting several times to make liis way on foot through dee]) snow- drifts. At the end of this exertion, however, two convulsions occurred, and the wound in the head re-opened. I n a short time complete eonvalcKoence ensued. Six months after the n'OTinding the jiatient travelled across the plains to bis iiomo in Indianapolis, and on his arrival reported himself in excellent condition. Dr. Hopwood, of Ashton-under-Lyne District Infirmary, iOngland, gives, in the Loudon Lancet, an account of a case under his care last summer. A male patient, aged 28, was engaged in removing the centre support ot" the arch of a brick-kiln, and l)efore he could' get out of th(i way the arch fell, burying him and several others in the ruins. All the bones of the fact! were crushed in ; and among other injuries the coronoid process of the lower jaw was broken oil', and there was a depressed fracture of the temporal lione jufct above the zygoma, from which the brain protruded to about the size of a strawberry. The coronoid process of llie lower jaw and the zygoma were removed, the juolrudiug brain matter was sliaved off and the temporal bone devated. Temperature at this time was 99° Fah., pulse G2. Tiie patient was perfectly sensible when Itrought to the Intirmary, and thought he was only slightly hurt. There was no shock, nor had there been any. The pupils were perfectl^y'^^ regular, .and there was no paralysis. There was no menial disturbance at any time, and ten days after the injury he said "he felt as well as ever he did in his life." The injury was inflicted on 30ih July, 1879, and on Oct. 14th following, he was (piite well and working regularly. John MacEvoy, of I'aterson, N.Y., a lad of 15 years of age, was gathering sawdust in a sawmill list December. He had crawled under a circular saw going at a speed of 2,500 rov(dutions a minute. The saw was twelve inches in diameter, and nine inches of this was under the table. Becoming startled by a noise, the boy suddenly raised his head, bringing it in contact with the saw. The saw had made a clean S'.vrej) fn in the upper part of the frontal bone to the right side of the nose. The right ujjper eyelid was c mipletely severed, but the eyeball was untouched. The cut was three-sixt( enths of an inch wide, and the edges of the wound were smooth. The boy was able I 'i 12 BRAIN LESIONS AND FUNCTIONAL RESULTS. 4 iih afterwards to walk, and told how the accident had Imiiponed. Ho appealed to tlio jdiyHician to Have his life, saying that ho did not want to die. During the dressing of the wound the boy straightened up several times, and the physicians were obliged to tell him repeatedly to lie still. He obeyed as readily as a well [)er8on would and under.stood what was re- quired of him. lie took in his hand a glass of whiskey which was given him, wliich he drank without assistance. The accident haj)j)ened on Monday ; and during the week his intellect remained unimpaired until Saturday, when convulsions set in and he died. No post mortem was allowed by the parents, so the exact extent of the injury could not be ascei'- tained. Taking the extent of the surface wound as a basis of conjecture, or, speaking mathematically, as the segment of a circle, the deepest serrated rim of the saw must have entered at least two inches into the skull and brain t -gether. The cut was as clean as if done with a sabre, and was no doubt done almost as rapidly. Towards the end, paralysis set in ; but, strange to say, the medical men differed as to which side or limbs were par- alyzed. No functional impairment was seen lifttil the boy was dying. Dr. Quin, the Chief Surgeon of the hospital where the boy lay, gives another case which came under his notice years before. There was a boy named Murphy who fell out of a window of considerable height upon the curb- stone in the street. He struck it with his forehead. When he was jjicked uji, more than a teaspoonful of brain matter oozed out of his head. He got well, physically and mentally, and lived to be 22 years old, although he was only 5 years old at the time of the ac- cident. Of another case the doctor says : " There is Joe Murphy. You may see him almost any day walking round the streets here. He is lame and drags one foot a little. One day, in 1864, I was going along the street, when some peojile came running after me. I went into a basement and found Joo Murphy had been shov 'n the right eye two minutes before with a bullet 38-900 calibre. I probed the wound and found the bullet flattened against the back of his skull. It is there yet ; but Joe got well, and his mental faculties are unimpaired. I've been intending to make a post mortem examination of his head, but 1 begin to think the old man will outlive me." In the Canada Lancet of April, 1872, Dr. T. 11. Dupuis, of Kingston, Ont,, states the case of a boy who had been injured by a fall from a horse while going at a rapid rate. The lesion was a compound fracture at the middle of the superior portion of the left parietal bone, with considerable laceration of the bi-ain. The broken piece of bone was nearly an inch and three-quarters long, three quarters of an inch broad at one end, and thi-ee-eighths of an inch at the other. One edge of this i)ieoe was driven down into the brain in such a manner that its surfaces occu- pied a position perpendicular to their original situation, while the other edge remained in situ, being still attached to the solid bone by the dura mater, which formed a sort of hinge upon which the fragment turned. The history of the case states that the injury had been inflicted by the sharp edge of a stone.. After exploring the wound with the points of the fingers — which passed in readily to the depth of half an inch or more — the fragments were extracted by means of forceps. Nearly a tablespoonful of brain substance was lost. At first, the patient was comatose. This state continued for two days. At the end of the second day he had lucid intervals. On the third day consciousness began to return, and with it voluntary motion. At this time the wound was discharging disin- tegrated brain matter, mixed with grumous blood and pus. Thirteen days after the acci- dent the delirium was gone, but the mind was fickle and temper irritable and capricious. Without entering into the whole history of the case as given, it may be said, the doctor adds, that a month after this lesion had taken place all effects of this severe injury had passed away, except a slight puffy appearance about the face, a little clumsiness in his movements, and some irritability of temper. Since that time, he became as healthy and strong as ever he was. The patient was closely watched during the course of his illness, but the doctor BRAIN LESIONS AND FUNCTIONAL RESULTS. 13 yet; but ^(Utes are o 111 like a u], lillt 1 ve me." 1H72, Dr. }tiit(!8 the i-ed hy a ivjiid rate, re at the the left eration of jone was 'ng, three end, and ler. One I into the aces occu- r original lained iii olid bone a sort of led. The le injury dge of a with the in readily nore — the f forceps, substance comatose. At the intervals, began to tion. At ng disin- grumous the acci- mind was apricious. istory of 16 doctor lad taken id passed ice about •vements, nee that I as ever watched le doctor 1 failed to detect any morbid mental manifesta- tions that seemed to indicate injury to any distinct phrenological development. It will be seen that no disturbance of functions took place commensurate with the injury, nor were they such as would be ex- pected by the school of surface localizers. In the Montreal Hospital Reports for 1879, we have two cases recorded. The first is a case of a wound inflicted by a swiftly-revolving circular wood-saw. It produced serious lesion in the centi'al part of the first and second frontal convolutions on the left side. The skull wound extended in an oblique direction from above the outer angle of the left orbit across the frontal, through the anterior superior angle of the right parietal and terminated about the centre of this bone. It had pene- trated through the membranes, and at the central part the brain substance was lacerated and exposed and could be seen pulsating. The post mortem revealed a large rent extending from the longitudinal sinus downwai-d and outward to a point a little anterior to the beginning of the fissure of Silvius. The central portions of the first and second left frontal convolutions were completely destroyed. The patient was unconscious for about ten minutes after the accident, but when taken to the hospital became quite conscious and at that time had no paralysis ; nor are we told that either one or the other supervened before death, which took place two days after the accident. In the same Hospital Reports, the history of a second case is given : A joung man, aged 22, was accidentally shot by the discharge of a pistol. The bullet entered the skull above and a little in front of the right ear. From the first he was perfectly conscious, not par- alyzed, and gave a rational account of how it happened. A probe was inserted into the wound, and it passed freely into the frontal lobe in the course of the bullet. Pulse 60; no elevation of temperature. The accident happened March 8th, and he died of consump- tion, Aug. 1 2th following ; but between these two periods there was no unusual mental disturbance. Without giving the details of the autopsy, suffice it to say, that the bullet entered the brain substance in the right in- ferior frontal convolution, just in front of the { ascending branch of the Sylvian fissure. From this point the course of the bullet was upwards and forwards, passing out at the inner surface ; of the frontal lobe and lodging between the brain substance and the falx, where it lay surrounded by a firm membrane. A firm membranous canal marked the course of the bullet, and the brain substance about this was somewhat softened. This extensive destruction- of brain tissue did not turb the mind. M. Flourens, of Paris, some years ago, exper- imented on animals, not only to show the i curability of brain substance, but also to de- j monstrate how much brain tissue can be injured I without the untoward physical and mental i results formerly apprehended and dreaded He I trepanned the skulls of dogs and rabbits, made a small opening through the dura mater into the substance of the brain, and then put bullets into the wound. These bullets gradually penetrated through the cerebral ! matter by their own weight. When the ball j was small, he found that the whole thickness j of the lobe of the brain, or of the cerebellum, i might be traversed by it without occasioning i any symptom or disturbance of function. Th^ ' fissure made by the passage of the ball remains I for some time as a canal ; it then closes up and cicatrizes. (L'i nion Med., 1863.) Dr. Thomas Smith, Surgeon to St. Barthol- omew's Hospital, London, gives, in the London Lancet of January last, an interesting case in. which the patient made a good recovery with- out loss of mental or physical power. A man, 35 years of age, shot himself with a revolver through the head. The bullet passed in at one temple and out at the other. Half an hour after the accident the pupils were found to be natural, pulse feeble, and respiration na- tui-al. The patient was quite corrscious, and answered questions correctly concerning his name, age, and address, and of his own accord. He was an educated man and spoke in German, but when addressed in either French or Englisli he would reply in the corresponding language. He showed no signs of mental incapacity, nor was there any loss of motor power. He vomited a good deal at first, and at that time 14 BRAIN LL'SWNS AND FUNCTIONAL RESULTS. •>i. blood and cerebral substance were forced from the wound in tlie right toniplf. For Hevcral days he boeaiii" quite initulilo anres8ion, I his special senses were unimpaired ; his loco- BRAJN LESIONS AND FUNCTIONAL RESULTS. 16 was fliitnaged j'Tf.L above the ctional centre 1 ) of its being rital lobes were imraediate re- i inflictedl la ) to fill up tlian •8? I had the [■ret tilled with ;tional centres !i up by this '. was called to d been kicked nil was crushed e median line, ivl and paiietal tctured and bone had been I brain, over an m. The meni- ich and brain of an ounce in ) wound much ig down upon it saw him he ho bones, cut nembranes and Consciousness miperature re- let rise at any lose a night's vening of the lis intervened, •version of any There was no •ge cavity re- o school to the c informed me :ain irritability ch he did not ligent as ever, dth the usual noticeable in He was under ears after the ised from his n compression, ired ; his loco- motion and grasping power normal ; and his bodily health good in every particular. These examples might be indefinitely ex- tended. Medical literature is full of evidences of destruction to the brain matter of the Were wo even to consider the brain a dual organ the dilliculty would remain, where cor- responding sides are simultaneously injiired. In all the dual organs of the body we find sudden injury to one is always followed by \ |i| i cerebrum and cerebellum without any serious iin[)erfe(t work in its fellow until time is given impairment of mental power or physical tunc- to allow provision to be made for the extra tions. Let a brain be taken, and wires passed laliour imposed. When we find no impair- through it to indicate the course of the missiles ment in function consequent on destruction of in these cases I have mentioned, and it will be \ one so called motor centre, we are led by Been that brain substance has been injured in uniform analogy to doubt a doctrine so anonial- almost every conceivable direction, yet with ous and contradictory. At least, it is better no results at all commensurate with the lesions to receive with caution a theory which is being inflicted. If these parts are motor centres, accepted, based upon exceptional examples, then have we the miraculous phenomena of which do not account for the physical results, organic operations without an organ ; of varied except in isolated cases. The mental effects seen, and disti'ict functions without a motive power ; as consecpient upon brain injury, would prove of uniform results without an efficient cause. . too prolific a theme for present investigation. I 1 Printed at the Guardian Offlce, 80 King Street East and 4 Court Street, Toronto. tfiM1i,fi«'j