189, 302 Hæmorrhoids, forcible dilatation of anus in treatment..

THE CANADA LANCET,

A MONTHLY JOURNAL OF

MEDICAL AND SURGICAL SCIENCE.

VOL. XII. TORONTO, SEPT. IST, 1879.

Original Communications.

OF THE SYMPTOMATOLOGY OF CORTI
CAL LESIONS OF THE BRAIN.

BY C. W. COVERNTON, M.D., ETC., TORONTO. (Translation from "Le Progrès Medical).

eralized, but their fundamental character is not to be general at the first onset, but to appear first in the face or in an extremity or in a limited segment of an extremity, according to the seat of the lesion provoking it. Often they are not accompanied by any loss of consciousness, and in cases where loss of consciousness occurs it takes place some time No. 1. after the onset of the convulsions, instead of being initial, as in cases of true epilepsy. Partial epilepsy has a great diagnostic value; it indicates an irritative lesion of the motor zone, that is to say, a lesion which does not destroy abruptly the office of the cortical structure. Palsies of a cortical origin are associated, or not, with partial convulsions, sufficiently frequently they are accompanied by a primitive contraction. Most frequently they commence under the form of a monoplegia, and may remain limited to parts primarily attacked or extend M. le Dr. Dario Maragliano, physician of the progressively to the entire half of the body, accordAsylum for Insane at Reggio Emilia, has recently ing as the cortical lesion remains stationary or published an interesting work on the symptoma-extends successively to all the cortical motor centology and diagnosis of cortical lesions of the tres of one hemisphere. In other cases palsy folmotor zone of the brain. This attempt at didactic | lows an inverse march; it assumes at the beginning systematization of symptoms by which the lesions the hemiplegic form, then it diminishes little by of the cortical structure may be comprehended, little in certain parts and fixes itself on others in a merits careful attention. It shows the important condition of incurable monoplegia, for once they hold on the foreign mind the doctrine of motor are definitely established, cortical palsies are accomlocalization has taken, and proves that this doc-panied like those which result from central lesions, trine, notwithstanding the opposition it encounters, with secondary contraction and descending degenpenetrates every day more deeply into the clinical eration of the medulla spinalis. In short, vasodomain under the patronage of accomplished phy-motor palsy is in general less marked following sicians equally apt in the examination of patients and in the practice of autopsies. The paper of M. Maragliano is in effect essentially clinical; the author has understood the truth developed under various circumstances by M. Charcot, namely, that the study of cerebral localizations in man should only be undertaken with the assistance of notes taken at the bedside and confirmed by autopsies, accompanying vaso-motor trouble, such are in the and that if experimental physiology seeks to throw opinion of M. Maragliano the principal charactera light on clinical study, it can in no case subject istics of palsy of a cortical origin. The other it, or speak magisterially in a domain which is not symptoms of lesions of the motor zone have less its own. The two principal symptoms of cortical importance than the preceding; they may neverlesions of the motor zone are convulsions and pal-theless be useful aids to diagnosis, and merit theresies. The convulsions of cortical origin have been fore a notice. Lesions which are limited exactly carefully studied in recent times; they are often to the motor zone never give rise to anesthesia. designated under the name of partial epilepsy or Calender, in St. Bartholomew's Hospital Reports Epilepsy of Jackson. They are generally unilat- for 1869, attributes a great diagnostic value to the eral, often even confined to one extremity or to an existence of intense cephalalgia occupying a fixed isolated muscular group. They may become gen-locality, persistent, obtuse and heavy. Some ob

cortical lesions, than as a consequence of central lesions, or to speak more exactly, is dissipated quicker and more completely in the first case than in the second. To recapitulate, the dissociation, the progressive establishment or the gradual disappearance, the variability, the frequent conjunction of primitive contraction, the relative lightness of

servations seem to show the exactitude of this circumscribed palsies or hemiplegia, the gradual view, and to point out that if even cephalalgia is apposition of which may be considered as the not observed in all cases, it corresponds often when reunion of several monoplegias; if this palsy is it does exist with the seat of the lesion. When accompanied with precocious contraction or with there is no spontaneous pain, it is possible some aphasia: if there is in the palsied limbs only a times to reveal, by percussion of the head, a pain slight and transitory elevation of temperature; if, limited more or less intensely. Percussion ought finally, we discover an obtuse pain spontaneous or to be practised directly with the finger (middle by provoked by percussion, occupying a circumscribed preference), by striking light and rapid taps over part of the head, the diagnosis of a cortical lesion different points of the cranium. When a localized nature of certain lesions, or of certain concomitant lesion exists at the surface of the brain, this meth. functional troubles. Aphasia, for example, coinodical exploration provokes frequently an intense cides much more often with cortical lesions than pain at a limited point, which corresponds with the with central lesions: its existence alone presupseat of the cortical lesion. Dr. Robertson, in the poses a cortical lesion. Softening concerns more Journal of Mental Science, July, 1878, p. 274, often the cortical than the central portions, if for reports some cases in which this method had been reasons not necessary to enumerate here, there is to him of great assistance in establishing diagnosis, reason to think that the patient under observation Cranial thermometry may also in certain cases is affected with softening, the conclusion would be render real service. Studied in recent times by probability of cortical lesion. In utilizing all these Broca, E. Maragliano, Gray (Journal of Nervous elements, we may often arrive at determining in a and Mental Diseases, July, 1878), and still more precise and certain manner a diagnosis of cortical recently by Paul Bert (Biological Society Meeting lesion. Unfortunately it is not always thus, and of 18th January, 1879), it has already given some in a good number of cases diagnosis is uncertain precise results from which the clinical observer may derive profit. In order that thermal variations may have value, it is necessary that there should be between two symmetrical points of the cranium a very notable difference (one degree! centigrade at least) for differences of some tenth of a degree only may be observed in physiological conditions. The diseased side will, besides, be sometimes colder, sometimes hotter, than the healthy side, according to the nature of the lesions of which it is the seat. It will be colder, for example, if we have to do with arterial obliteration, and hotter when an inflammatory lesion is con

cerned.

Such are the principal signs of cortical lesions of the motor zone. It is necessary to add that, besides these direct signs, the physician may often utilize in a diagnostic point of view, considerations drawn from the march of the disease, from the summing up, which we think it right to translate textually. If there exists, he says, convulsions, limited or making an appearance at first before becoming general, in a group of isolated muscles,

not accompanied or accompanied only tardily with

a loss of consciousness; if consecutive to these convulsions or alternating with them, there are

The

and even impossible. M. Maragliano indicates
the principal clinical eventualities in the following
cannot be in doubt. A reunion of all these symp-
toms is not even necessary to assure the diagnosis.
The simultaneous existence of partial convulsions
and of a palsy in the form of monoplegia or hemi-
plegia, permits the diagnosing with a sufficient
certainty a cortical lesion of the motor zone.
aspect of things differs when convulsive phenomena
are absent, even when all other symptoms are ex-
isting. Diagnosis loses all character of certainty
in this case; it becomes simply probable. It is
impossible also to diagnose a cortical lesion in
cases where lesion of that structure is so extended
of the motor zone, as that happens as a following
as to destroy from the commencement the whole

to the obliterations of the cortical branches of the

fissure of Sylvius. Hemiplegia, then, differs in no particular from the ordinary variety of central origin. Finally, diagnosis will be impossible when we find ourselves in the presence of a total hemiplegia, on the mode of evolution of which no particulars can be gathered. We add no commentary to these conclusions, which appear to us to be the actual statement of our knowledge, the most probable expression of the truth.