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brain said to be devoted to speech, movement of the tongue and lips, smell and taste, and yet the patient had exhibited no symptoms. In explanation it must be remembered that irritation of the center, for the lips or tongue, or the portion presiding over taste or smell, gives rise to movements on one hand or sensations on the other. A sudden and violent destruction may or may not cause the loss of the function, provided that corresponding parts on both sides of the brain are not destroyed, as has been primarily noted.
It is probable that in the case under discussion the inflammation was owing to the second debauch, and on account of the rapidity of the destructive changes and early comatose condition, the results of the preliminary stage of excitation were not noticed.
In conclusion, it would seem that the subject of cortical localization is pretty well established, and a careful attention to the results of experiments and cases that confirm, and a like careful examination of cases appearing to controvert the theory, will only end in strengthening our faith.
Daniel N., aged 52 years, carpenter by trade. Twenty-five years before last sickness was suddenly attacked with convulsions. There were no premonitory symptoms, except that for a little time before he was noticed stammering occasionally in attempting to talk. He had about twenty convulsions in all. They were severe paroxysms. He had sometimes one or two a day; then a day or two interim before returning. They thus continued until ceasing entirely in a short space of time, there being no tendency to a return of the convulsions until his last sickness. There was no paralysis excepting cephasia, for a short time.
He was an invalid, however, for about one year, when he was sufficiently restored to resume his trade, which he continued for all the years intervening until last sickness, seeming not any different from his former self excepting a loss of memory, frequently forgetting where he had put anything that he had been using. His wife thinks that his memory was more defective in every way than before the attack.
There was a small tumor on the back of his head, which gradually grew during these years to be a tumor of three inches in diamHe occasionally complained of severe pain in it. It was there long before the above mentioned attack. In April, 1885, the tumor was removed by the knife. After the operation he continued at work most of the time until October, when he was compelled to give up. His wife thinks, however, that he was never well after the operation. He was peevish, fault-finding and very irritable, becoming quite angry at little things.
He now frequently complained of headache, which increased daily. He would sometimes say that the old pain was there in the back of his head, and think that the tumor was returning. For a month or more, before he took his bed, he was not well; he acted strangely; slept badly; was feverish at night; complained of numbness of limbs; was costive, although his appetite was good, and he was never sick at the stomach. He persisted in being at work up to October, 1885, when he had to give up and take his bed. He occasionally had light convulsions during October, November and December. Sometimes during the entire summer he would forget words, but this was now much more marked. Most of the time during his sickness he could see only one half an object. A few times he saw two objects. He spoke of this trouble only two or three times, while the hemiopia was rather persistent. There was a gradual failure of both mental and physical forces, until finally he took no interest in anything-in a word, was demented.
partial paralysis There was also
During the latter part of his sickness he had of right side, more marked in leg than in arm. paralysis of the tongue and muscles of the pharynx. This was very distressing during the last two months of sickness. He could scarcely speak or swallow. He became very much emaciated and died in April, 1886, about one year after the removal of the tumor.
Dr. Bunton and I made an autopsy in the presence of Drs. Moore and H. C. Boyd. On removing the calvarium the brain appeared a little flattened, the cortical vessels were enlarged, giving the surface a pinkish color. Having loosened the brain and lifted it from its bed, on inspection there did not seem to be extensive lesions. The cortical portion of the posterior lobe seemed thinner and much paler than that of the other lobes. On separating the hemispheres we found the entire covering a thin shell not more than one quarter of an inch in thickness. The brain tissue of each hemisphere was softened to almost the consistency of custard and of a grayish white appearance. There was not any healthy brain tissue in either of the hemispheres, but the entire cerebral substance was softened and broken down. The cerebellum was healthy, excepting a few points seemed to be softening.
Edes, in Pepper's Practice, says that a general softening of the
whole brain does not and can not occur, since a vascular lesion sufficient to cause anæmic necrosis of the whole brain must cause death before softening would have time to take place. Here was a case that the blood supply was cut off from both cerebral hemispheres, and softening did take place throughout the entire cerebral portion of the brain, and the man lived seven or eight months, or perhaps twenty-six years, while this process was going on. We did not in this investigation examine the vessels as we should have done, but we know that they were completely plugged up, for there was not a remnant of a blood vessel in all this soft mass of matter. If Edes included in his statement the cerebellum, of course he must be correct; but if he means the cerebrum alone he is mistaken, as demonstrated by the case herein recited. The left side is the one usually softened, because the vessels of the left side are more readily entered by an embolus, the left carotid being more direct in its course, or at least its mouth being more readily entered by a foreign body with the blood current. The middle and anterior cerebral vessels are branches of the internal carotid, the posterior cerebral are from the vertebral. They are united by communicating vessels at the base of the brain, forming the circle of Willis, making such perfect anastamosis that if either trunk was obstructed by an embolus, thrombus, or any other cause before the communicating branch was given off, the brain would still be nourished by means of this very wise anatomical arrangement. If, however, the obstruction should occur beyond the communicating branches, into either vessel, that part of the brain receiving its nourishment from it must become anæmic and die, because those vessels do not anastimose as other vessels, and hence a collateral circulation can not be established to supply the portion of brain thus deprived.
If paralysis exists it is usually the right side, the left brain being the one usually softened. The topography of the brain, from the study of a large number of cases, being so well understood, the expert can nearly always locate the part of the brain deprived of its blood supply, but he can not so readily differentiate the particular form of trouble or character of the lesion producing the symptoms in a given case. My opinion in such cases is not worth much, for my observation has been limited. I saw the case reported in this paper about three months before death. Having the history
given as above detailed, I was inclined to believe that there was a cerebral tumor that had existed for a long time, and that it had produced the former symptoms, and that from some cause it had not been growing until the removal of the external tumor, when it took on new life and produced all the symptoms before us. If there was not a tumor I believed that he had softening, which was found to be the true condition. Da Costa says, "that there are no pathognomonic symptoms, the presence of which would enable us to declare without hesitation that we are dealing with softening of the brain, or the absence of which would justify us in concluding that it does not exist."
Nothnagel says, "that the diagnosis of hemorrhage, or of embolism, or thrombosis, can not in any case be unreservedly made.” There are two kinds of softening, the red and the white. The red is the result of inflammation and runs an acute course. The white is either caused by a thrombus formed in situ from disease of the vessel or from an embolus carried in the blood current, plugging the artery, preventing the circulation in the part. We may have local softening from the pressure of clots, tumors, or depression of the skull.
The more common cause is, however, from emboli. Thrombosis is peculiar to the aged. Embolism may occur at any age, but more frequently from the ages of twenty to sixty. We thus have data by which we may differentiate with some degree of certainty as to the above lesions. Other pathological conditions however are much more difficult to the general practitioner. Even the most expert diagnosticians are very reserved in giving a positive opinion.