A Third Contribution 
TO THE STUDY OF 
Localized Cerebral Lesions. 
BV- 
E. C. SEGUIN, M.D., 
Clinical Professor of Diseases of the Mind and Nervous System in College of 
Physicians and Surgeons, New York; Corresponding Member of 
the Societe de Biologic of Paris, and of the Verein 
fur Innere Medicin of Berlin, etc. 
[Reprinted from the Journal of Nervous and Mental Disease, Vol. 
XIV., June, 1887.] 
NEWYORK: 
J. H. VAIL & CO., 21 ASTOR PLACE 
1887. A Third Contribution 
TO THE STUDY OF 
Localized Cerebral Lesions. 
BY 
E. C. SEGUIN, M.D., 
Clinical Professor of Diseases of the Mind and Nervous System in College of 
Physicians and Surgeons, New York ; Corresponding Member of 
the Socidtd de Biologic of Paris, and of the Verein 
frir Innere Medicin of Berlin, etc. 
[Reprinted from the Journal of Nervous and Mental Disease, Vol. 
XIV., June, 1887.] 
NEWYORK: 
J. H. VAIL & CO., 21 ASTOR PLACE 
1887. A THIRD CONTRIBUTION TO THE STUDY 
OF LOCALIZED CEREBRAL LESIONS.1 
I OFFER the two subjoiiTed cases as additional evi- 
dence of a localization of motor functions in limited 
areas, cortical and subcortical, of the cerebrum. The 
first case more especially demonstrates the results of a 
superficial irritating lesion of the cortex. 
While separately considered, these cases may not be of 
very great value, yet, taken together with the evidence 
already accumulated, they seem worthy of record. 
Case I.—Relating to the face-centre. In collaboration with Dr. 
J. L. Hicks. 
Summary : Right hemiparesis, most marked in the right cheek; 
clonic convulsions in right cheek ; slight fever ; no aphasia or 
choked disk. Recovery after prolonged use of iodide of potas- 
sium. Sixteen months later, death after symptoms of acute men- 
ingitis. Autopsy shows a patch of simple adhesive meningitis 
over a part of left motor area, and recent acute tubercular men- 
ingitis. 
A boy aged 7 years, named Harold, very intelligent and healthy, 
seen at Flushing in consultation with Dr. J. L. Hicks, Jan. 13th, 
1885. 
For about two weeks before this date, it was noticed that the 
child was not as well as usual—even before Christmas his right 
hand felt numb at times, and an examination of his copy-books 
revealed a change in his handwriting ; less steady writing, an ine- 
quality between different words, in contrast to previous remarka- 
ble uniformity of the script. An attack of measles appeared Dec. 
23d (1884), and ran a very mild course. During this week of ill- 
ness, the patient several times complained of his right hand “ going 
asleep,” and feeling “queer.” 
1 Read at the second annual meeting of the Association of American Physi- 
cians, June 3d, 1887. For first and second contributions, vide Seguin, “ Opera 
Minora,” p. 202 and p. 495, New York, 1884. 4 
E. C SEQUIN. 
On Jan. 2d, after slight fever on the preceding day, it was ob- 
served that he spoke thickly, that saliva dribbled from the right 
buccal angle, and that the right cheek and arm were decidedly 
paretic ; the leg slightly so ( ?). There was neither headache nor 
aphasia; the mouth temperature ranged from 98.5° to ioo°. After 
cutting the gums over some molar teeth, improvement appeared. 
On Jan. 9th, one hour after a very mild faradic application to 
the weak muscles on the right side, there occurred clonic convul- 
sive movements in the right cheek, with suspension of speech and 
turning of eyeballs to the right. No spasm in other parts; patient 
fully conscious. This facial monospasm lasted for more than two 
hours. No return of convulsive movements since ; the tempera- 
ture has ranged from 98.5° to 99.5° (in mouth) ; the right face 
(upper lip near median line especially) and the right hand have 
occasionally felt numb and “ queer.” Speech has been thick .at 
times, and a few times he has used the wrong word. No gastric 
disturbance, but constipation has been present. 
Inquiry into possible causes reveals no serious injury to the 
head, although a “slight” (?) fall on knees, arm, and forehead 
from a velocipede occurred about three months ago. No pul- 
monary, renal, or aural disease. 
Examination.—Mind clear, speech normal (it was thick a little 
while ago) ; no headache or cranial tenderness to percussion. 
Only lesion in eyes is great myopia, with posterior staphyloma and 
large veins. Right cheek is paretic, the tongue deviates to the 
right ; the right hand is weak, and in walking there is a slight 
drooping of body to right. The knee-jerk is low on both sides, 
but more marked on the right. No anesthesia. Heart normal. 
Mouth temperature ioo° ; pulse 90, regular. 
The diagnosis was uncertain as between a tumor in the left pre- 
central gyrus (its lower third and adjacent part of second frontal 
gyrus) or a localized meningitis over the same part. The idea that 
such very localized (“Jacksonian ”) symptoms could be reflex from 
irritation about the gums I could not entertain. 
Treatment.—Fluid extract of ergot in doses of 5 drops, and 
saturated solution of iodide of potassium, 10 drops every three 
hours. Absolute rest and plenty of liquid food. The iodide to 
be rapidly increased. 
Jan. 27th. The iodide has been given in doses of 75 drops 
(about 5 grams) three times a day. Great improvement has oc- 
curred; occasional numbness of right cheek and hand. lodide o 
be reduced. 
Feb. 16th. Paresis of right cheek is constant, though the arm 
is stronger and well used, and no spasm has occurred. No dis- 
turbance from the iodide, now used in doses of 30 drops ter die. 
April 29th. Except paresis of right cheek, has been remarkably 
well until yesterday, when the following occurred ; a numbness 
began in right forefinger, extended into the arm, to the right side 
of face, right half of tongue, and right heel (not toes!). There STUDY OF LOCALIZED CEREBRAL LESIONS. 
5 
was no spasm. The right upper lip was decidedly swollen, and 
there was drewling from right corner of mouth. No aphasia, 
headache, or fever. To-day, the cheek is paretic, but not more 
than before the attack, and there is still some prickling in the right 
hand. Otherwise well; advise rapid increase of iodide to 45 drops 
ter die. 
May 28th. Except right facial paresis, has been well until 
18th inst., when an attack, like the one above described, occurred 
(similar except that there was no numbness in the leg). There 
was another attack on the 19th. Excitable. On 22b, had attack 
of severe transverse frontal headache of short duration. Is taking 
65 drops of iodide ter die j and this was subsequently increased to 
100 drops ter die (about 20 grams per day) without unpleasant 
effects. 
Examined again June 13th. Distinct right hemiparesis, most 
Fig, i.—Patch of localized adhesive meningitis over the second frontal and precentral 
gyri of the left hemisphere in case i. 
marked in the face; no anaesthesia; speech and optic nerves nor- 
mal. General condition good, except pallor. Advised stop medi- 
cine; patient to be gradually allowed more liberty and watched 
carefully. 
Oct. 3d. Has been very well. On June 17th, a slight attack of 
numbness occurred. The paresis has passed away, except that, 
when tired, the right cheek droops somewhat. It is to be observed 
that, although numbness appeared first in the hand in some of 
the attacks, the cheek was the seat of the greatest and most per- 
sistent paresis, and that the clonic convulsions occurred only in 
the facial muscles (the lower set); so that it might reasonably be 
concluded that the lesion of the left hemisphere was chiefly in or 
upon the cortical face-centre. 
The next year early in April, 1886, the lad developed unmis- 6 
E. C. SEGUIN'. 
takable symptoms of acute general meningitis : headache, photo- 
phobia, vomiting, slow and irregular pulse, temperature of ioi° 
and io2°. May ist, delirium set in with higher temperature, and 
death occurred the next day. In this attack, there were no con- 
vulsive or paralytic phenomena. The ophthalmoscope was not 
used. 
The autopsy, on May 4th, revealed the ordinary recent lesions 
of tubercular meningitis. This was intense over the pre-pontic 
base of the brain, over the apices of the temporal lobes, and well 
up into both fissures of Sylvius. There was much gelatinous effu- 
sion about the chiasm. The rest of the brain showed no evident 
meningitis. The ventricles were largely dilated and filled- with 
clear fluid. The cerebral substance, especially its cortex, was pale. 
Microscopic examination showed abundant cellular infiltration of 
the pia, and many globular and muff-like tubercular masses along 
the blood-vessels. 
The most interesting result of the autopsy was finding the 
lesion which had caused the symptoms of the previous illness. 
This was a patch of intimate adhesion, without evident exudation, 
between the dura and the pia (or its arachnoid layer), situated 
over the ventral part of the left precentral gyrus and the adjacent 
(caudal) end of the second frontal gyrus, over a space one inch 
(25 mm.) in diameter. Although quite firm, the adhesion gave 
way to traction without decortication. It was a localized adhesive 
meningitis situated over the face-centre, and impinging upon the 
arm- or hand-centre. It was wholly dorsad of the speech-centre, 
and decidedly ventrad of that part of the precentral gyrus in which 
lesions cause primary and predominant symptoms in the fingers 
and hand.1 
While the face-centre was the seat (in the first illness) of 
the chief irritation and greatest malnutrition (anaemia), it is 
evident from the symptoms that there was more or less 
extension of irritation (very much as in electrical experi- 
ments in animals) to the rest of the motor area of the same 
side. 
It seems to me that, taken together with other recorded 
cases, this case goes to support the view that in the human 
brain the cortical centre for the face is in the caudal end of 
the second frontal gyrus, where it is continuous with the 
precentral gyrus. 
1 Compare Case IV. of first contribution for intermittent aphasia caused by 
localized meningitis over Broca’s speech-centre ; and Case I. of second contri- 
bution for brachial monospasm and monoplegia caused by a tumor in the middle 
part (vertically) of the precentral gyrus. “ Opera Minora,” p. 211 and p. 495. STUD V OF LOCALIZED CEREBRAL LESIONS. 
7 
Case II.3—Bearing on the question of the location of the leg- 
centre. 
Summary : Paresis of right leg ; clonic spasm in right abdo- 
minal muscles ; right hemi-epileptic attacks with first spasm in ab- 
dominal muscles ; then in the leg, last in the arm (none in face). 
Repeated similar attacks without loss of consciousness ; paralysis 
of the right leg, paresis of right arm ; no aphasia or choked disk. 
Death ; sarcomatous tumor in white substance of left hemisphere, 
subcortical, situated dorso-laterad of the paracentral lobule. 
Mr. F. W., aged 49 years ; seen Nov. 22d, 1881. Has enjoyed 
good health, with exception of occasional headaches, which have 
been less troublesome in the last few years. Denies syphilis and 
injury to head. 
About a year ago had severe left occipital neuralgia ; the region 
midway between morbid process and median line being hyperses- 
thetic. Pain distinctly worse at night. This lasted one month and 
has not recurred. Was generally weak and in poor health during 
the past summer ; legs felt heavy, and feet were “ sensitive ” in the 
morning. The right foot was weaker and oedematous ; there was 
no numbness ; and he was able to keep at work during the 
autumn. 
Some four or five weeks ago, there was marked increase in the 
difficulty in walking. The right foot was dragged rather stiffly 
with the heel raised. Was unsteady. About Nov. xst, after applica- 
tion of an electrical current, he had a first attack of spasm limited 
to the right abdominal muscles. A day or two later, there was a 
more severe seizure, spasm beginning in the right abdominal 
muscles, extending to the leg, and lastly to the arm of same side. 
No spasm in face, and no loss of consciousness. The right arm 
and leg were weak for half an hour after attack. Since, he has 
had numerous similar attacks, always on the right side, and with- 
out loss of consciousness ; from six to eight seizures a day. 
Marked paresis of the right limbs. No aphasia, headache, vomit- 
ing, or mental disturbance. 
Yesterday (Nov. 21st), in an attack, spasm extended to the right 
face and the left limbs; he lost consciousness (attack witnessed 
by Dr. Bruce, a relative). 
Examination.—Pallor ; heart and pulse normal; no aphasia. 
The right pupil is a little wider than left, both active ; optic nerves 
normal.2 There is no facial or lingual deviation, but the right arm 
and leg are very paretic. In the upper extremity, the paralysis is 
most marked in the region of shoulder and in upper arm, and he 
still has a fairly good grasp. When standing, the right foot is held 
in equino-varus position ; and the knee-jerk is raised on this side. 
No anaesthesia. 
11 am indebted to Dr. R. W. Amidon for many of the notes in this case 
and for opththalmological examinations. 
2 This was the case throughout the illness, an ophthalmoscopic examination 
being made shortly before death. 8 
E. C. SEGUIN'. 
Diagnosis.—Probably a cerebral tumor. It is learned that the 
grandfather and one aunt of patient (both on paternal side) had 
“ cancer.” 
Treatment.—Ord. thirty grains (2 grams) of bromide of potas- 
sium at bed-time. lodide of potassium in large doses three times 
a day. Absolute rest. 
Nov. 27th. More hemiplegia of a peculiar type. The leg is 
completely paralyzed, the upper arm and shoulder more paretic 
than the forearm and hand (grasp 120 on a stiff dynamometer) ; 
right cheek a little flabby. At night, has “ cramps ”in right leg. 
Owing probably to the influence of the bromide of potassium, 
the convulsions did not recur, but there were frequent attacks of 
Fig. 2. 
Fig. 3. 
Fig. 2.—Diagram of convexity of brain—showing location of the (sub-cortical) tumor 
Fig. 3.—Diagram of transection of left hemisphere, showing the exact position of the 
tumor, and of two minute secondary growths. 
painful cramp in the right leg at night (extension of foot and 
flexion of leg on thigh). The next day paralysis extended to the 
hand, but the tongue protruded straight ; speech slow ; no 
aphasia. 
Dec. 4th. More voluntary power in hand and fingers. Marked 
aphasia and alexia (?); attacks of a syncopal nature occasionally. 
In one of these the patient died (Dec. 6th), with a low temperature 1 
and stertorous breathing. 
1 No figures are given in the original notes, but I am very sure that the tem- 
perature was not subnormal; there was simply absence of the hyperpyrexia which 
usually prevails in the last stage of cerebral tumor. STUDY OF LOCALIZED CEREBRAL LESIONS. 
9 
Autopsy.—Dura normal ; arachnoid shows some opacities, more 
over the left hemisphere. The convolutions of the left parietal 
lobe are flattened ; the flattening not extending further frontad 
than one-half of the frontal lobe, and ventrad not reaching the 
inferior parietal lobule. The occipital lobe is slightly flattened. 
The whole hemisphere appears swollen, and larger than the right. 
Transections reveal a sarcomatous globular tumor ventrad of the 
top of the pre- and post-central gyri, and dorso-laterad of the 
paracentral lobule. The growth is mainly in the white substance, 
but invades the cortex, though it does not appear externally. Two 
very small nodules of the same new-formation are found further 
ventrad in the white substance. No other lesions in the brain. 
The lesion interrupted fasciculi of fibres connected with 
the paracentral lobule and with the upper (mesal) ends of 
the pre- and post-central gyri. 
It is very interesting to note the relative immunity of 
the forearm and hand from symptoms. 
From this case we obtain, I think, additional proof 
that the innervating centre for the leg is in the paracentral 
lobule, and perhaps also in the mesal ends of the pre- and 
post-central gyri, in accordance with what has already 
been established.1 
Another conclusion, of more novel interest, which may 
be drawn from this case, is that the cortical centre of 
innervation for the muscles of the shoulder and upper 
arm is probabty in the upper part of the pre- and post- 
central gyri, between the forearm and leg centres. 
We may also infer that the centre for the abdominal 
muscles is in the same area, but nearer to the leg centre.2 
1 desire to add, by way of record, summaries of two 
cases, already published. 
31 have at present under observation, in consultation with Dr. O’Gorman, Jr., 
of Newark, a most interesting case analogous to the above. The attacks of 
“ Jacksonian ” spasm are on the right side and chiefly affect the muscles of the 
shoulder, upper arm, and side of chest (probably only in the serratus and pec- 
torals, but not in the intercostals). In a few attacks the spasm has extended to 
the whole of the right side, and one or two general convulsions with loss of 
consciousness have occurred. No choked disk is present, and there is but little 
headache. The case is improving under mercury and iodide of potassium, 
with some bromide of sodium. 
1 Compare Case 11. of the second contribution, “ Opera Minora,” p. 499. E. C SEGUIN. 
10 
Case 111.—Relating to the visual half-centre. 
Male, aged 46 years ; seen in 1884. Malignant endocarditis ; 
sudden attack of left lateral hemianopsia, with (temporary) left 
hemi-numbness ; no anesthesia or paralysis. Death in May, 1885, 
from progress of endocarditis ; multiple embolisms, pseudo-inter- 
mittent fever, etc. Autopsy showed softening of the right 
cuneus and fifth temporal gyrus, caused by embolism of the occi- 
pital artery (and other visceral lesions). This diagnosis of seat and 
nature of lesion had been made during the patient’s life. 
Published in full in this Journal for January, 1886, p. 25. 
Case IV.—Relating also to the visual half-centre. 
Male, aged 42 years ; seen in October, 1885. Left Internal 
hemianopsia ; slight staggering in gait ; temporary paresis of both 
external recti ; choked disks. Absence of headache, paralysis, 
and anaesthesia. Operation by Dr. R. F. Weir, March 9th, 1887 ; 
removal of an enormous sarcomatous tumor situated on the inner 
aspect of the right occipital lobe, probably connected with the 
ventral part of the falx cerebri and thus injuring the cuneus early 
in its development. The diagnosis of tumor of the right cuneus 
was made by me in November, 1885, sixteen months before the 
operation. 
This case subsequently passed under the care of Dr. W. 
R. Birdsall, by whom and Dr. Weir it has been very ably 
reported in the (Philadelphia) Medical News, April 16th, 
1887.