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Reprint: THE MEDICAL FORTNIGHTLY, Saint Louis, U. S. A. Reprinted from THE MEDICAL FORTNIGHTLY, Saint Louis: July i, 1892. 
Practical Cerebral Localization. 
Frank Parsons Norbury, M. D., 
JACKSONVILLE, ILLINOIS. 
Assistant Physician Illinois Central Hospital for the Insane, Jacksonville, Illinois; formerly Assistant Physician 
Pennsylvania Institution for Feeble Minded Children, Elwyn, Pa. 
Read before the Central District fledical Society, Springfield, III., January 21, 1892. 
THE odd physiological views regarding the brain and nerves, as held 
by Hunter, and expressed by him in his principles of surgery, compared 
with the modern theory of cerebral localization, is an index of the great 
progress made all along the line of physiological investigation during the 
past century. 
Especially is this true in the physiology of the brain, as demonstrated 
in the establishment of the localization of brain function. The old idea of 
the unity of the organ of the mind has been removed and in its stead an 
assignment of regional location has been given to each individualized func- 
tion. Further, a strong relationship between brain cells has been discovered, 
whereby substitution of action in certain cells takes place when disease or 
accident slowly destroys the physiological functions of their fellows. Such 4 
in brief, are the two essentials of cerebral localization, but their practical use 
to us in removing disease would be nothing, were it not for that greatest of 
modern surgical principles, asepsis. The skull, so long closed to the surgeon’s 
knife, is now opened freely because of the absence of subsequent septic 
dangers, when aseptic measures are thoroughly practiced. To recite the 
various steps leading up to the present status of localization and brain sur- 
gery, would tax your patience and consume time, so we will enter at once 
upon the consideration of the principles of localization and their practical 
application. 
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The brain or that major portion of it which we shall consider, is divided 
into cerebrum and cerebellum. In the cerebellum the middle lobe only 
interests us, for injuries, tumors and abscesses are comparatively innocous, 
unless the middle lobe is affected. The cerebrum, the seat of intelligence, 
is made up of two hemispheres, right and left, subdivided by fissures into 5 
lobes, and these in turn are subdivided into convolutions, which may be 
smaller, larger or reduplicated. The five lobes of the brain are the frontal, 
parietal, temporo-sphenoidai, occipital and Island of Reil, and are separated 
by the primary fissures. As no two brains are alike, we have difficulty in 
locating secondary fissures, but the primary fissures exist in common. The 
fissure of Sylvius separates the temporo-sphenoidai lobe from the orbital sur- 
face of the frontal lobe; its posterior limb separates the temporal from the 
parietal lobe. The fissure of Rolando separates the frontal and parietal lobes. 
The parieto-occipital fissure separates the parietal from the occipital lobe. 
The secondary fissures and the convolutions are important considera- 
tions but are best spoken of under the head of topography, which we will now 
take up. The fissures of Sylvius and Rolando are our base-lines from 
which we will carry on our topographical survey, and it is therefore neces- 
sary that we first locate them with a certainty. As in land surveying, we 
must first determine our land-marks before proceeding in the general sur- 
vey, so 1 will invite your attention to this drawing showing the land- 
marks of the skull. This is copied from Dana’s admirable paper on Cranio- 
cerebral topography as it appeared in The Medical Record, January 12, 1889, 
and reproduced in The Journal of Nervous and Mental Diseases, of June, 
1890. The Glabella-Nason Bregma, Inion, Stephanion, the principal land- 6 
marks, are here well defined. Now, having our land-marks we proceed to 
use them, calling to our assistance this instrument, the cyrtometer. The one 
1 have here is Wilson’s. You see it is a very simple instrument, made of 
flexible metal, and secured in position by use of the tape. 
The broadest .arm passes around the forehead, touching the glabella and 
external angular process, the narrow or longitudinal arm passes backward 
from the glabella in the middle line to the occiput. This arm is marked 
with two scales of figures, one scale being located in the anterior half and the 
other in the posterior half. A narrow strip slides on the longitudinal arm at an 
angle of 67 0 with it, extending towards the transverse arm. To use the cysto- 
meter, we first shave the scalp, apply the instrument so as to touch the two 
land-marks, the glabella and external angular process. Measured from the 
glabella backward the distance of any of the figures in the first scale, is 55.7 
per cent of the distance from the glabella to the corresponding figure in the 
second scale. Now when the instrument is in position, if the figure 1 in pos- 
terior scale falls immediately over the inion, we place the sliding arm at 
figure 1, in anterior scale and we have the beginning of the fissure of 
Rolando, which extends at angle of 67° downward and forward. This is 
the direction of the upper two-thirds of the fissure, or 2% inches. The lower 
third \yi inches is slightly more vertical. To find the lower end more 
exactly, lay off a line from the stephanion to the asterion, and another from 
bregma to the external auditory meatus. The point of intersection will be 
over the lower end of the fissure. The fissure of Rolando is the same in 
children as in the adult. 
To find the fissure of Sylvius, drawthe vertical line from the stephanion 
to the middle of the zygoma. Draw a horizontal line from the external 
angular process to the highest part of the squamous suture; continue this 
back, gradually curving it up till it reaches the parietal eminence. The 
junction of the two lines will be at the beginning of the fissure of Sylvius. 
The vertical line indicates nearly the position of the anterior or vertical 
branch of the fissure, which is, however, directed a little more forward, and 
is about one inch in length. The posterior part of the line indicates the 
position of the posterior branch of the fissure. The triangular gyrus and 
motor-speech centre lie just anterior to the vertical branch of the fissure. 
The fissure of Sylvius runs nearly horizontally and lies either under or a 
little above the uppermost part of the parieto-squamous suture. This suture, 
the external orbital process, and the parietal eminence are the guiding land- 
marks, by the help of which the surgeon can often operate without marking 
down lines on the scalp. In children, according to McClellan, the fissure is 
higher than in the adult. To carry out our cranio-cerebral topography any 
further would cause a departure from our subject under consideration. To 
those of you who desire further information I take pleasure in referring you 
to the paper of Prof. Charles Dana, before mentioned. From the two base- 
lines we have located, we can by following his concise rules, locate all 
important regions of the brain cortex. 
The relationship between the cranium and cortex is as follows: 
“Beneath the frontal bone lie nearly all the lowest frontal, 5-6 of the mid- 
dle and of the upper convolutions. The temporal bone covers the tern- 7 
poral lobe, except its posterior fifth and anterior extremity. Less than half 
of the occipital lobe lies under the occipital bone. The rest of the cerebral 
cortex lies beneath the parietal bone” (Gowers). The boundaries of the 
areas of the brain have been pretty well established by physical experi- 
ments of Ferrier, Horsely, Schafer, Fritch and Hitsig, and the pathological 
studies of Horsely, Keen, Starr, Park, Mills and others. Especially is this 
true of motor regions, while vision, hearing, etc., are still in dispute. The 
occipital lobe is undoubtedly the seat of vision, the temporo-sphenoidal that of 
hearing, and the higher psychical centers are to be found in the frontal lobe. 
Mills says that for practical convenience the brain may be subdivided 
into five lobes, four of these at least, according to the great general functions 
subserved, these lobes having, in nearly all directions, well defined fissural 
boundaries, i. A higher psychical or inhibitory lobe, in front of the basal 
and anterior branches of the great Sylvian fissure and on the median surface 
in front of the anterior bend of the calloso-marginal fissure. 2. A motor lobe, 
including the posterior parts of the first, second and third frontal, both as- 
cending or central convolutions and the adjoining marginal gyrus on the 
median surface. 3. A lobe for general or common sensation, including the 
gyrus fornicatus, the hippocampal convolution, the precuneus and the pos- 
tero-parietal gyres. 4. A lobe of special senses, including fhe whole of the 
occipital and temporal lobes. 5. The Island of Reil or insular lobe. 
The symptoms of organic brain disease and their relationship to localiza- 
tion are both general and special. General symptoms: Headache or 
cephalalgia is of very common occurrence; we meet it at all times and under all 
conditions. So common is it that its value as a diagnostic symptom is often 
overlooked, In considering it symptomatically we will take it regionally, 8 
first mentioning that its value depends on intensity, permanency and char- 
acter of pain. We know that headaches of the same origin, in different in- 
dividuals present different phases, but taking the headache as an associated 
symptom vve can pretty firmly establish our diagnosis. Frontal headache is 
principally sympathetic in origin, indicating eye strain, or neurotic nasal dis- 
turbance. In migraine frontal headache may be pronounced, but usually it 
attacks one side of the forehead. 
In organic cerebellar disease we find frontal headache as a marked symp- 
tom. In cerebral syphilis, where gumma exists in thefrontal region, we have 
localized frontal headache, which is more severe at night. Temporal headache 
is found in disease of the temporal bone as in caries of the petrous portion; also 
in brain tumor in syphilitic brain disease, and in abscess of temporo-sphen- 
oidal lobes. It may be reflex in origin also. Coronal headache seldom indi- 
cates brain disease but is reflex and calls attention to the digestive tract and 
pelvic viscera. Organic basillar disease of the brain will occasion occipital head- 
ache. Localized headache in organic brain disease only exists when the 
pressure from the lesion involves tissues and nerves. If the deep centers 
of the brain are involved, headache will be general. 
In cases of epilepsy, cerebral hemorrhage, abscess, etc., we may have 
a continuous general headache; as a rule, however, the attacks are period- 
ical. Vertigo, optic neuritis and convulsions are other general symptoms of 
great importance. Vertigo, when paroxysmal, is usually associated with 
nausea and vomiting. 1 recall one case where vertigo was always accom- 
panied by a desire to go to stool; the attack would end in free vomiting and 
purging. Vertigo, when continuous, and by this 1 mean, manifested on least 
change of position, is often witnessed in Jacksonian epilepsy, in adults. 
Vertigo is allied to epilepsy; has often an aura and is followed by lassitude and 
even loss of consciousness. Several very pronounced cases of vertigo have 
come under my observation during the past year, one case of cerebellar dis- 
ease (abscess of middle lobe), one of tumor (middle lobe cerebellum). In 
several cases of cerebral syphilis, in one case of abscess of the temporo- 
sphenoidal lobe, and in focal epilepsy I found it a frequent associated symp- 
tom. 
Optic neuritis may be the first symptom leading to the attention of the 
physician being called to cerebral disease. The patient first notices a fail- 
ure of vision and when examined for defect the opthalmoscope will reveal 
neuritis. A considerable degree may exist before vision is affected. The 
neuritis is then probably subsiding as the acuity of vision may not be affected 
during the inflammatory stage. To decide whether the defect in vision is 
the neuritis or the intra-cranial disease, we must compare the degree of neu- 
ritis and the degree of affected vision. Neuritis, says Jacoby, is pathogno- 
monic of brain tumor. Where defective vision exists, let me urge upon you 
opthalmoscopic examination in all cases, especially when cortical disease 
is suspected. Here are presented the first symptoms of grave organic brain 
disease. 
A case in point: A young man, telegraph operator, noticed acuity of vis* 
ion diminishing; could not see to write very well; called on an ophthalmolo- 
gist who diagnosed optic neuritis and referred him to a neurologist in Chi- 9 
cago, for further examination. He diagnosed gummatous brain tumor, which 
diagnosis proved correct; as subsequent history showed. The young man 
denied ever having had syphilis, and as he was then expecting to be mar- 
ried soon, refused constant treatment, recommended to him. He was mar- 
ried, and in due time other symptoms of syphilis appeared; he became insane; 
was under my care three years. He died from extension of paralytic symp- 
toms. His case was one of the most unique and interesting of organic dis- 
turbances of the brain, with heterogenous focal symptoms, 1 have ever 
studied. 
The special cerebral symptoms are either those of irritation, destruction, 
local pressure or reflex, manifested in spasm, or paralysis, or both. Their 
intensity and duration depend greatly upon the manner of onset of the 
lesion, 'whether gradual or sudden. In the former case, partial repair 
may take place during the continuence of the destructive process and the 
symptoms may not be so well defined; in the latter, their extent may in them- 
selves be misleading as to the real value of the lesion, so it is well to be 
observing in the consideration of special symptoms in making our diagnosis, 
keeping in view the fact that the mode of onset indicates the nature of the 
lesion and oftentimes its location as well, “inasmuch as certain lesions are 
more common than others in certain parts.” Mono-spasms are the result of 
local irritative lesions of the cortex, the pathology of which was first clearly 
defined by Hughlings Jackson. The irritation of tissue surrounding a local 
lesion is sufficient to keep up a discharge of nervous energy, and where the 
discharges are frequent, temporary paralysis of the muscles implicated in the 
region follows. The causes of local lesions are variable,butthey are principally 
encephalitis, tubercle, syphilis or spicula of bone. Syphilis causes the 
majority of cases of mono-spasms which ultimately become monoplegia by 
the irritating lesion, becoming destructive by its extension. Spasm may con- 
tinue after paralysis has resulted. The clinical varieties of mono-spasm are 
as follows: Crural (limited to the leg), brachial (limited to the arm) 
facial (limited to the face) oculo-motor (limited to the muscles of the eye). 
Now, where the lesion is such as to cause an extension of the spasm to 
other regions, as where several of the mono-spasms merge together, we have 
then defined epilepsy, for consciousness is then involved. Convulsions do 
not become epileptic until consciousness is lost. This is a diagnostic point 
(but disputed). Where destructive process is extensive, hemiplegia will 
result. Voluntary power is thus lost by involvement of the motor centers 
in the central convolutions. The hemiplegia will be on the opposite side if the 
brain is anatomically normal, that is, if the fibres decussate; if they do not 
the hemiplegia will be on the same side as the lesion. Rigidity generally follows 
as a secondary result,due to degeneration of the pyramidal tract. Partial lesions 
may exist and involve either the face, leg or arm, These are very common, 
first, says Gowers, on account of the wide extent of the central 
region, and secondly because the region is supplied by different arterial 
branches and softening from arterial occlusion is a common lesion. Mono- 
plegia always suggests cortical disease. The leg is an exception, as it can 
be affected only when there is involvement of the paracentral lobule. Lesions 
situated high up in the subdivision of the motor area may affect just special 10 
parts of an extremity, etc., as a lesion in the highest part of the arm region 
affects the shoulder more than the rest of the arm. When irritating lesions 
alone exist convulsions occur, beginning locally, as 1 have before stated, and 
may extend to both regions. By watching for the commencement of the 
convulsion we may localize the lesion, as for instance if the hand or fingers, 
we locate it in the middle third of the central convolution. This local commence- 
ment of spasm diagnoses cortical lesion. Speech defects also mark location 
of lesion. “To express our thoughts we need memory of words, to know 
how to say them, a proper condition of the organs of voice and articulation.” 
A defect, involving any one of the above qualifications will produce aphasia 
in some form. Amnesic aphasia, or loss of the memory of words, is a com- 
mon form and often seen in organic brain disease. Occasionally we find 
word-blindness, familiar objects lose their identity or their name, the noun, 
may be lost and in its place we have the verb to express its peculiarity, like 
the word “tire” is forgotten and “that which burns” is used to express it. 
Or the wrong word is used because of a similarity of objects in shape, size, 
etc., as in a case 1 saw in consultation recently, the patient, in trying to 
speak of capsules which her physician had left her, called them “potatoes.” 
Her case involved more than word-blindness, however, but on the aphasic 
symptoms depended the diagnosis, which subsequent history proved correct. 
Word-blindness is not the only sensory disturbance we have, for now 
deafness is noticed as well, certain sounds are lost, or all sounds are lost or per- 
verted. The sound of words may be heard but may be utterly unintelligible. 
1 have seen such cases among feeble minded children, and on one or two 
occasions, in insane patients. The lesion in such cases is to be found in the 
posterior half of the first and second temporal convolutions of the left hemis- 
phere in right-handed persons. The lesion in word-blihdness is probably in 
the angular gyrus. Most cases of amnesic aphasia have associated motor 
aphasia or ataxic aphasis. This form of aphasia (motor) is most frequently 
seen. The patient understands what is said to him, remembers it, remem- 
bers what he reads, recognizes his friends, objects, etc., but cannot express 
his ideas. He may be able to use a simple word or a sentence which he is 
apt to use on all occasions. This form of aphasia is frequently seen in em- 
bolism of the middle cerebral artery. It is also a symptom in cerebral tumors, 
traumatic injury to the brain, when hemorrhage by compression causes it. 
It is noticed in double athetosis, sometimes in adult chorea. In porenceph- 
alus or congenital defect it is a frequent associated symptom. Embolism in 
elderly people is heralded first by loss of consciousness, then with return 
of consciousness, hemiplegia with aphasia is noticed. 
Frequently some poor fellow, the victim of embolism, is found on the 
street, taken in by the police, and because he cannot speak, is locked up 
for being drunk. He may be found dead in his cell in,the morning. I knew 
of such a case. It is interesting to note in most aphasiacs, the connection 
between disease of the left hemisphere and ataxic aphasia. It is explained 
because of the development of the left hemisphere in right-handed people 
and the reverse in the left-handed. The localization of motor aphasia is to 
be made carefully; we will find the third frontal or Broca’s convolution always 
involved, together with the Island of Reil in complicated cases. Aphasia is 11 
an important consideration from a medico-legal standpoint in cerebral disease 
and should be thoroughly investigated. 1 have thus briefly reviewed the import- 
ant points of cerebral localization, and in closing, ask that in the examination 
of all cases presenting focal symptoms, plenty of time be taken and com- 
parisons made, so that localization may have the credit it deserves in the 
diagnosis of cerebral diseases. 
Hunter’s Leetures, delivered 1786-1787. 
Cerebral Localization in its Practical Relations- C. K. Mills; Brain: July and October, 1889. 
Cranio-Cerebral Topography; Chas. Dana; Medical Record, January 12, 1889. 
On the Anatomy of Children; Geo. McClellan; Keating’s Cyclopedia, 1889. 
Diseases of Nervous S' stem; Gowers, 1888. 
Diseases of Nervous System; Ross. 
Diseases of Women; Saken. 
Epilepsy; Hare, 1890. 
Convulsive Seizures; J. H. Hughlings Jackson; Wood’s Monographs, Vol. 1. 
Sensory Aphasia; M. Allen Starr; Brain, July, 1889. 
Aphasia; C. K. Mills; Review of Nervous and Mental Diseases; September, December, 1891. 
Cerebral Syphilis; F. P. Norbury; Medical News; January, 1891. 
Diagnosis of Intra-Cranial Syphilis; L, C. Gray; American Journal Medical Sciences; January, 1892, 
BIBLIOGRAPHY.