Extracted from The American Journal of the Medical Sciences, November, 1894. 
A CONTRIBUTION TO THE LOCALIZATION OF THE 
MUSCULAR SENSE. 
By M. Allen Starr, M.D., 
AND 
A. J. McCosh, M.D., 
OF NEW YORK. 
There has been some discussion in regard to the existence of a 
muscular sense, or sense of the position of the limbs as .derived from 
sensations arising in the surface, joints, and muscles, which can serve as 
a guide to movement. It has been claimed by some that a perception 
of movement is an inherent power of the motor area. It has been held 
by others that a muscular sense is separate from the voluntary motor 
function, and that it has a different cortical localization. 
Without entering fully into this discussion, we desire to record the 
following very interesting case, which seems to give conclusive proof 
that the muscular sense has a localization of its own entirely indepen- 
dent of the motor impulse. The case is quite comparable to an accurate 
physiological experiment upon the cortex of the brain, although, as will 
be evident to the reader, no such experiment was intended. We have 
not been able to find in the literature of the subject any similar case. 
Traumatic epilepsy characterized by psychical attacks; headache; 
trephining; removal of small angioma; loss of muscular sense in the right 
arm, lasting six weeks; recovery.-S. F., aged twenty-one, is the son of 
healthy and intelligent parents, with a personal and family history free 
from any rheumatic or syphilitic taint or alcoholic habit. Up to his 
fifth year he was a bright and healthy child. He then received a severe 
fall on his head, followed by unconsciousness for twelve hours. Since 
that accident he never completely regained his mental balance, and has 
suffered from pain on the left side of his head. He seemed fairly bright 
at his lessons, and was willing to study, but was very easily excited and 
accustomed to give way without adequate cause to emotional impulses, 
either of joy or anger. When sixteen years of age he received a second 
fall on his head, followed again by unconsciousness for several hours. 
Since the second accident all his symptoms have been decidedly aggra- 
vated. The headache is located by him in the left parietal and occipital 
regions, and the maximum point of pain seems to be at a point half-way 
from the parietal boss to the median line, and at this spot a small scar 
can be seen, and there can be felt a slight irregularity of the surface of 
the skull, suggestive of a fracture. The pain from which he suffered, 2 
STARR, MCCOSH: THE MUSCULAR SENSE. 
though continuous, was subject to exacerbations. In connection with 
the sudden increase of pain, the boy would develop a maniacal con- 
dition, in which his actions were extravagant, his speech abusive and 
profane, and in which he at times indulged in acts of violence toward 
his family and employers. In consequence of these attacks, which 
occurred every few days, or, when under treatment by bromides, every 
three or four weeks, he was unable to keep up with his classes at school 
or to pursue any steady employment. 
He was not particularly bright or intelligent, though he could not be 
said in any sense to be demented. Between the attacks he had no clear 
recollection of what had occurred during an attack, and on several occa- 
sions he had lost consciousness; he had never had any convulsions. All 
K 
remedies having failed to produce any relief of these distressing symp- 
toms, it was thought justifiable to trephine him at the site of the pain. 
It was thought that in all probability there had been a fracture of the 
skull at the time of the fall and a local pachymeningitis beneath the 
fracture, as well as some injury of the brain substance. Very careful 
tests made before the operation failed to reveal any disturbance of the 
special senses or any disturbance of motion. 
Operation, February 10, 1894. After reflection of the scalp flap, con- 
siderable thickening of the tissues was noticed, especially of the peri- 
cranium, which was very adherent to the skull. Directly under the 
cicatrix was a slight linear depression upon the surface of the bone. 
With an inch trephine a button of bone was removed, its centre being 
one and a quarter inches to the left of the median line, one and three- 
quarters inches behind the fissure of Rolando, and an inch above the pari- STARR, MCCOSH: THE MUSCULAR SENSE. 
3 
etal bone. There was no evidence of fracture on the inner table, and the 
dura mater appeared normal. The opening in the skull was enlarged 
by rongeur forceps. When the dura was incised and reflected there 
was no evidence of any internal pachymeningitis, but the surface of the 
brain and pia presented an abnormal appearance. A large number of 
veins of the pia mater appeared to be distended and increased in size, so 
that a vascular mass consisting exclusively of veins was present just 
under the trephine opening. This mass of veins, covering a space three- 
quarters of an inch in diameter, contrasted very markedly with the 
normal appearance of the pia at adjacent portions. The larger veins 
leading into this mass of vessels were tied with catgut, which was passed 
in a needle under the vessels, and probably at four points the superficial 
layer of the brain cortex was slightly lacerated by the passage of the 
needle and the tying of the ligature. The brain cortex about this 
mass appeared to be normal, but it was explored by the hypodermatic 
needle with a view of the possibility of finding some cyst beneath; 
nothing was found. The wound was then closed. Recovery from the 
surgical operation was steady and progressive. He was fit to be dis- 
charged from the hospital in ten days. 
Immediately after the operation the boy noticed a peculiar awkward- 
ness in his right hand and arm. When examined this was found to 
consist of a most pronounced condition of ataxia, all finer co-ordination 
of movement being impossible. Thus any attempt to grasp a pencil or 
a glass of water, or to pick up a pin, resulted in most excessive motions 
without the possibility of carrying out the desired movement; the attempt 
to place his finger upon his nose with his eyes closed failed, the finger 
frequently being carried up above the head or far to one side. When 
his eyes were closed he was absolutely unable to tell what position had 
been given to his fingers or hand by the examiner. He did not know 
whether his hands were closed or opened. When his hand was placed 
in a position and he was requested to put the other hand in the same 
position, his eyes being shut, he was totally unable to do so. There was 
altogether a complete loss of muscular sense in the hand and wrist. At 
the same time his actual power was greater in the right hand than in 
the left; there was no disturbance whatever of tactile sense or the sen- 
sations of temperature and pain. There was no similar disturbance in 
the leg, and his gait was perfect; there was no affection of the face or the 
eyes. It was evident that the effect of the operation upon a spot in the 
brain about at the junction of the superior and inferior parietal convo- 
lutions, clearly posterior to the posterior central convolution, had resulted 
in a loss of muscular sense in the opposite hand and forearm without any 
disturbance of other sensations or of the power of movement. 
This condition of ataxia remained stationary for about three weeks, 
and then gradually subsided. On April 10th, when he was last ex- 
amined, no trace whatever remained, and the boy is practically well, 
being free from his old headache, feeling much brighter and more active, 
and having had no return of his attacks of epileptic nature.