insensibility so that the lower teeth on that side may be extracted with very little pain. Both the prolonged anesthetic effect of the morphine and its general sedative influence are desirable.

The massage generally used after a morphine injection is easily supplied in this procedure by having the patient. open and close the mouth rapidly for a few moments after the injection is made. If the needle be held in the position described and the space between the internal pterygoid muscle and the coronoid process is reached. properly, there will be almost no resistance to the introduction of the needle.'

Under this treatment, using a quarter of a grain of morphine with one two-hundredths of atropine, divided between the two sides of the face, ten teeth were recently removed from the inferior denture with almost no discomfort to the patient.

In operating upon the superior maxillary, it would be possible to produce a considerbale amount of anesthesia by injecting a smaller dose into the antrum of Highmore.

Let us hope that some of our brethren praticing the specialties of aural and nasal surgery will devise a proper syringe needle and give us easy directions for reaching this cavity. This is a simple matter, but of considerable value in certain cases and always appreciated by the patient. The Clinique.

CASE OF LANDRY'S PARALYSIS.

GEO. W. CALE, JR., M. D., F. R. M. S., LONDON, Chief Surgeon, St. Louis & San Francisco Railroad Co,. Springfield, Mo.

Patient, male, age 33, laborer. Entered the hospital September 15, 1901, with diagnosis of tertian malaria, the following symptoms presenting: Headache, nausea, bowels loose, was having chill every other day. Had been sick two weeks. Family history good, with the exception of an attack of scurvy some fifteen years ago. When he was admitted his pulse was 65 and temperature 99. From date of admission until the early morning of the 20th, there was nothing to indicate that malaria was not his only trouble, except the temperature curve, which resembled that of typhoid fever. At this time he complained of great weakness in his hands and arms, and upon examination we found that he had some difficulty in moving his legs. His attention was undoubtedly attracted to the condition of his arms first, as he was in bed and had little occasion to use his legs. On the foliowing day he was not able to use his legs, arms or the lower part of his body. The paralysis did not extend to the shoulders. The reflexes were gone, and only the muscles supplied by the ulnar and radial nerves responded to electrical stimulus. This was noticed only on the right side. The sphincters acted normally. There were no trophic disturbances. Sensation over all the affected parts was not interfered with, nor did he complain of coolness of the extremities. The spleen was enlarged. There was also slight enlargement of some of the lymphatic glands. On the 20th he complained greatly of mucus accumulating in his mouth and throat, and was not able to clear his mouth or throat. We were obliged to turn him on his face to prevent suffocation from collections of mucus in his throat. At this time he was not able to take

rourishment of any kind, or even to drink water. In twenty-four hours the muscles of deglutition improved so that he was able to swallow water and milk in good quantities. After his admission to the hospital he had no more chills, and his temperature ranged from normal to 101.5 and his pulse from 65 to 86. Quinine seemed to have no effect on his temperature. The temperature curve up to the 24th was similar to that of typhoid fever. He denied having had syphilis, and close questioning failed to establish lead poisoning, mercurial poisoning, or trouble from any of the acute infectious diseases. He was given strychnine and iodide of potash without any apparent benefit. On the afternoon of September 23 his pulse went to 135, and his temperature to 102.5. The next morning his pulse had dropped to 95 and his temperature to 99.6. He never complained of pain, in fact always said that he felt pretty well. He died suddenly on September 25, about 7:30 p. m. Less than two minutes before his death he told the nurse that he was feeling pretty comfortable. Death was occasioned by paralysis of the respiratory center, for when the house surgeon, Dr. Newlon, reached his bed, the heart-beat was still

barely perceptible.

While the symptoms in this case do not entirely agree with those laid down in text-books, we are certain that the diagnosis of Landry's paralysis, or acute ascending paralysis, was correct. It was concurred in by Drs. Tefft and Bartlett of Springfield and Drs. Lamphear and Murphy of St. Louis, who chanced to visit us two days before the patient's death. The principal symptom in this case, which differs from the description of a classical case, was the loss of electric excitability of the muscles. The patient's voice was remarkably strong and clear during

the entire course of the disease.

Very little can be said of the etiology of the disease, as the onset is sudden, and the course usually very short. This would seem to indicate that some toxic agent is present, but nothing definite is known. Syphilis, mineral poisons, exposure to cold and acute infectious diseases were all excluded in this case. Remlinger reports a case that followed malaria.

In

With reference to the pathology: In some cases no changes of any kind in any of the affected structures, either nerve cells, nerves or muscles, can be found. other cases, various lesions, especially changes in the meninges and peripheral nerves have been described. Some investigators still hold to the theory of toxemia, largely on account of the enlargement of the spleen and lymphatic glands. In corroboration of this, Baumgarten and Curshmann claimed to have found bacteria in the enlarged glands, but Westphal, Kahler and Pick have looked for them in these glands without success. Centanni found in a typical case of Landry's paralysis a peculiar bacillus, which existed in moderate numbers in the spinal cord and in great numbers in the peripheral nerves, where it formed colonies which had resulted in structural lesions. of the nerve fiber, not in the nature of neuritis, but of a neuromycrosis. This discovery of Centanni has been confirmed by Eisenlohr, who in two cases found a widespread, partially interstitial, partially parenchymatous lesion of the peripheral nerves extending to the extreme end filaments of the nerves, caused by the various forms of micro-cocci, which micro-cocci also existed to some extent in the spinal cord, where they have appeared to have set up a myelitic process. Ross, after an analysis of 93 cases, inclines to the view of acute poly neuritis, in all probability due to one of the causes above mentioned. -Kansas City Med. Index-Lancet.

Notices and Reviews.

"Minor Surgery and Bandaging (Including the Treatment of Fractures and Dislocations, the Ligation of Arteries, Amputations, Excisions and Resections, Intestinal Anastomosis, Operations Upon Nerves and Tendons, Tracheotomy, Intubation of the Larynx, etc."). By Henry R. Wharton, M. D., Professor Clinical Surgery in the Woman's Medical College of Pennsylvania, Surgeon to the Pennsylvania Hospital, etc. Fifth edition, enlarged and revised, with 509 illustrations. Philadelphia: Lea Bros. & Co. 1902. $3.00

net.

This book of 621 pages is devoted to the every-day surgery of the general practitioner. Part first, including 109 pages, describes concisely the application of dressings and the various varieties of bandages. This will be interesting to the student and young surgeon, who is often in doubt in his early practice as to the best form of dressing and bandaging in a given injury, and his ready skill in applying suitable dressings and bandages will greatly contribute to his reputation.

Surgical bacteriology, aseptic and antiseptic treatment of wounds, and the value of the different antiseptic chemical agents are briefly set forth and will be helpful in determining the one best suited to the particular case. The preparation of sponges, suture material, drainage tubes, gauze, and the preparation for aseptic operations, including the dressing of wounds, constitutes an important part of the work.

Considerable space is given to a variety of things in emergency surgical work: Local and general anesthesia, treatment of inflammation. Catheters, bougies and sounds. Varieties of sutures, intestinal anastomosis, treatment of hemorrhage, abscesses, shocks, dressing of wounds, etc.

Parts 3 and 4, comprising 112 pages, are devoted to the treatment of fractures and dislocations. Part 5, operations. These are briefly described and furnish a quick reference to the methods ordinarily employed. The same may be said of the parts devoted to excisions or resections, operations on nerves, tendons, tracheotomy, intubation, etc.

Taken all together, the book serves as a ready handbook of emergency surgery, and may be cordially recommended as such. D. S. F.

"A Nurses' Guide for the Operating Room." By Nicholas Senn, M. D., Ph. D., LL. D., C. M. Chicago: W. T. Keener & Co. 1902. Price, $1.50 net.

This little work is made up largely of abstracts of lectures given by Professor Senn at the St. Joseph's Training School. The preparation of the operation room is first described, then the dressings, methods of sterilization, etc. The latter part of the book contains lists of instruments necessary for various operations. This feature should render it useful to the physician in addition to nurses, for whose use it is well adapted.

PAMPHLETS RECEIVED.

"Local and Regional Anesthesia, with Cocain and Other Analgesic Drugs, including the Subarachnoid Method, as Applied in General Surgical Practice. The Relative Prevalence and Fatality of Fractures in the

The new officers elected September 11, 1902, are as follows:

President-Dr. Henry Waldo Coe, Portland. First vice-president-Dr. F. W. Van Dyke, Grant's Pass.

Second vice-president-Dr. J. A. Geisendorfer, the Dalles.

Third vice-president-Dr. J. P. Tamiesie, Hillsboro. Secretary-Dr. A. D. Mackenzie, Portland. Treasurer-Dr. Mae Cardwell.

Councilors-Dr. W. J. May, Baker City; Dr. J. Fulton, Astoria; Dr. Wm. Amos, Portland; Dr. C. F. Wilson, Portland; Dr. S. T. Linklater, Hillsboro; Dr. W. T. Williamson, Salem; Dr. Wm. House, Pendleton; Dr. Ellis, Portland; Dr. Coffey, Portland.

BIG FOUR SURGEONS.

The following officers were elected at the late meeting: President, Dr. S. L. Ensminger, Crawfordsville, Ind.; first vice-president, Dr. C. W. Chidester, Delaware, O.; second vice-president, Dr. C. F. Smith, Kankakee, Ill.; third vice-president, Dr. F. R. Belknap, Niles, Mich.; fourth vice-president, Dr. T. W. Moorehead, Terre Haute, Ind.; secretary and treasurer, Dr. T. C. Kennedy. The executive committee follows: Dr. T. M. Wright, Peoria, east division; Dr. S. W. Shenck, Cairo division; Dr. George Beasley, Chicago division; Dr. G. M. Waters, Cleveland and Cincinnati division; Dr. Reymond, Cleveland and Indianapolis division; Dr. Hunt, Anderson, Michigan division; Dr. White, St. Louis division; Dr. Weaver, Columbus and Cincinnati division; Dr. Kimmel, Springfield and Columbus division.

Railway Miscellany.

The Chesapeake & Ohio is planning the establishment of a permanent pension roll for aged employes, the fund to be a gratuitous contribution by the company.

The voluntary relief department of the Pennsylvania lines west of Pittsburg paid benefits during the month of August, 1902, to the amount of $33,203. Out of this $5,000 was paid for cases of accidental death, $6,750 for cases of natural death, $11,485 for cases of accidental injuries and $9,968 for cases of sickness.

Engineman Frank Sisco of Clinton, Ia., has just been placed on the pension list of the Chicago & Northwestern after forty-two years' service. During that time he has kept an accurate account of the miles he has traveled, and his record is a most remarkable one. The total figures up to 1,402,297 miles. During his long period of service, Mr. Sisco has not had an accident of any consequence.

The American Academy of Railway Surgeons elected the following officers at the annual meeting in Kansas City, Mo., on October 4: President, L. Sexton, New Orleans; first vicepresident, A. L. Wright, Carroll, Iowa; second vice-president, J. W. Perkins, Kansas City; secretary-treasurer, T. B. Lacy, Council Bluffs, Iowa; member of the executive board, D. S. Fairchild, Clifton, Iowa: editor, R. H. Reed, Rock Springs, Wyo.; transportation committee, J. E. Owens, Chicago.

Four elephants professionally connected with the wellknown circus of, say, Spangles and Sawdust, were journeying over the Northern Pacific in their private car, the other day, when that particular car, in spite of its ballast, jumped the track near Prescott, Wash., and was wrecked. The four attendants were injured, but the elephants escaped unhurt, saving even their trunks, and began quietly cropping grass along the track-a fine example of self-possession for other passengers in a wreck to imitate.

The relief department of the Pennsylvania Company has been made the target of an unreasonable attack by the prosecuting attorney at Bucyrus, Ohio, who asked the circuit court to oust the company from doing relief work, on the ground that it was exceeding its charter, which did not permit it to do an insurance business. The court has decided in accordance with the petition, but the higher courts may be expected to take a broader view of the purpose and results of this philanthropic work of the railway company and its employes in co-operation.

The relief department of the Baltimore & Ohio during the month of May, 1902, paid out benefits to the amount of $46,324.49. Of this, $11,000 was for cases of accidental death; $10,484.56 for accidental injuries; $1,221.50 for surgical expenses; $12,574.68 for cases of natural sickness, and $11,043.75 for cases of natural death. The statement of the relief department of the Pittsburg & Western for the same month shows a total of $2,045 paid in benefits. Of this, $585.55 was for cases of accidental injuries, $839 for cases of natural sickness, $500 for a single case of natural death and $120.45 for surgical expenses.

To head off the reported intention of American financiers to secure both the railways between the capital and the gulf the Mexican government has purchased control of the Interoceanic Railway. This is an excellent narrow-gauge road, running from Mexico City to Vera Cruz, 340 miles, with 258 miles of branches. The line to Vera Cruz is 76 miles, longer than that of the standard-gauge Mexican railway, of which control is reported to have been acquired by the Mexican Central. The new owners of the Mexican National were negotiating for the Interoceanic and the government apparently feared a combination of the two outlets to the gulf, which might control rates and perhaps deflect traffic disadvantageously to Mexican interests. It does not seem probable, however, that the government will undertake the direct operation of the purchased road. All the Mexican roads have

been built and are managed under American or British auspices to the advantage and satisfaction of the national authorities.

One case in which the ticket scalper did not "protect his customer" occurred in Buffalo recently. One O'Brien went to the office of Ticket Scalper Callahan to sell two return tickets to Rochester, a distance of 68 miles. He was offered 25 cents. resented the proposition, calling the maker "a cheap guy," was knocked down and died from the effect of a fractured skull,

The Chicago Burlington & Quincy has placed in service a new style passenger car. It is a combination car, containing a parlor with observation platform at the rear end, two sleeping sections, a smoking room and a dining room and kitchen. The car is attached to the fast mail train which makes a day run between Chicago and Omaha. The car supersedes the parlor car which has heretofore been attached to the mail train. The use of the parlor car and the demand for first-class accommodations on this train have so steadily increased that the passenger officials have deemed it expedient to provide for these wants in this novel combination.

new

For many years the Illinois Central road was commonly spoken of as "owned in England," and its conservative methods seemed thus to be accounted for. At the present time of the 7,447 registered shareholders, representing $79,197,000 of stock, only 1,920, owning $14,352,000 of stock, are credited to Great Britain, and the road is about as thoroughly American in make and management as may be. A similar change in ownership has taken place in very many other roads. The securities of our railways have been steadily coming home in recent years by purchase-to say nothing of those that have been invited back by foreclosure-and American railways, as a general thing, are now owned by Americans, and the interest and dividends which they pay are largely for home consumption.

Some interesting data concerning the workings of the piecework system are contained in a semi-official statement emanating from the mechanical department of the Union Pacific and published in The Railway Age of September 19. It may be said also that though only semi-official, there is no reason for questioning its accuracy, for the conclusions that must be drawn from the facts contained therein tally closely with results reported occasionally from other sources. It appears, as might be expected, that large numbers of the men who are working under the system earn a considerable excess over the amount of their former wages under the hour rate system, the amount of excess varying from a few cents an hour up to, in a few cases, twice and nearly three times the former pay. Of course the latter are exceptional cases and should not be relied upon as a basis for a general statement. But experience in this and in numerous other instances seems to show that men can and do earn larger wages under the piecework system than the same men have been accustomed to earn under the old rate. Even a difference of a cent or two an hour in favor of the new system is worth while-at least it has been in times past considered sufficient cause to form a basis for trouble between employer and employe. The chief difficulty in the introduction of this method of payment seems to be that any system that gives scope for individual development or improvement is diametrically opposed to the practice, if not the principles, of labor organizations whose basis on the work side of the question is the leveling of all to the datum of him who can or will do the least. Even with this in view, it is difficult to understand the attitude that has for so long a time been assumed in the case of the Union Pacific, for the reason that in the statement referred to it is shown that if under the new system a workman fails to make the wages realized under the old scale, he is paid at the old rate. It looks very much like a case of "heads I win tails you lose," in which the employe has the call. The source of his objection to such a game is beyond the comprehension of thinking men.

VOL. IX.

SOME REMARKS ON CEREBRAL SURGERY.*

BY A. I. BOUFFLEUR, M. D., CHICAGO, ILL., CHIEF SURGEON C., M. & ST. P. RAILROAD.

Mr. President and Gentlemen: It is with considerable diffidence that I attempt to speak on the subject of cerebral surgery this evening, for two reasons: (1) Because the subject has been presented before the association several times in the recent past, and (2) because the comparatively short time which I have had has not enabled me to prepare a paper which I feel would do justice to the association or be a credit to myself.

However, I have thought it would be well to continue keeping this subject before the association, as I have had the matter impressed upon me a number of times that we do not operate often enough in a certain class of cases, and that we operate too frequently in a certain other class of cases which should be let alone. And why it was that we do not operate in one class of cases often enough and too frequently in the other class, was something which seemed to me this association ought to be in a position to settle. Too frequently useless operations are done upon the skull for supposed lesions of the brain. Operations have been performed and no lesions found, and it frequently occurs that we operate, finding our diagnosis is not confirmed, and at the post-mortem examination it is shown that an entirely different lesion is present from that which we had supposed existed in the beginning. This is positive proof of our ignorance as to the condition. This is an accusation which may be applied generally, for no one presumes that he is able to make a positive diagnosis of intercranial conditions in every instance. I think there are one or two neurologists who claim to be able to do this, but no surgeon that I know of. There are a few typical lesions that should be recognized and treated surgically, others which should be left entirely alone, and it is in calling attention to a few of these that I will ask your indulgence for a few minutes.

Successful cerebral surgery depends upon three conditions: (1) (1) Accurate diagnosis of the character and location of the condition. (2) Timely rational treatment, and (3) the technique of the operative procedure itself. It would be useless for me to attempt to go through the whole list of intracranial lesions, but I shall simply take up those which result from trauma; to emphasize, as well as I can, the importance of cerebral localization; to urge operation in suitable cases, and to favor a more simple technique than is commonly practiced. Traumatisms of the brain comprise by far the larger percentage of lesions of the brain which we are called

*Stenographic report.

No 6

upon to treat. Unconsciousness is considered an alarming condition by the laity, and for that reason, if a person sustains an injury and is unconscious for more than a few moments, a surgeon is called. When he is called he assumes responsibility as to treatment. At times he is greatly opposed if he decides not to do much, because the laity object to calling a physician, who, finding a patient in an unconscious condition, claims it is not a case for operation or for the administration of some heroic plan of medical treatment. On the other hand, if the surgeon does operate and the patient should die, he is apt to be blamed for being too hasty with his operative measures. Traumatisms vary in degree, and patients vary materially as to their reaction to traumatisms. Therefore, the symptoms which we have following trauma vary considerably. The character of the force, the area of its application, its velocity, as well as the thickness and condition of the cranium, the elasticity of the brain, and also of the vessels themselves within the brain naturally constitute important etiological factors in the production of brain lesions. If we have, for instance, an object, moving slowly, which comes in contact with a large area of the brain, we would naturally expect some concussion, but not a serious lesion of the brain itself. On the other hand, if we have the same object moving with great velocity, we would expect considerable destruction of the brain substance. If the object or missile is more pointed, we would expect fracture of the cranial vault, with a tendency to local damage and extensive damage of the brain substance. So it is in children, for instance, whose brain substance is elastic, we may have an injury to the side of the head or over the motor areas, which is not followed by symptoms, except those of slight concussion; whereas. if an adult sustains the same injury, the same degree of force being applied, it may cause serious disturbance of the brain, because in the adult the brain is much less elastic, and therefore, it is much more liable to laceration. And the same may be said with regard to the cerebral blood vessels. Traumatism of the skull may cause one of three conditions: (1) Simple concussion with or without fracture. (2) Contusion of the brain with minute lacerations, with or without fracture of the skull, and (3) Compression.

Fractures of the skull are of importance only on account of their immediate and remote effects upon the brain. A traumatism which produces a fracture is likewise productive of some form of cerebral disturbance. A simple fracture, unattended by depression or evidence of compression, is of itself of very little significance, and deserves no special consideration or attention on the part

of the surgeon. Of course, there might possibly be an exception to that as to the after-effects, in that hemorrhage sometimes results from a fracture, after an hour or so, that is, an appreciable hemorrhage. But, as a general proposition, simple fractures of the skull are of no significance whatever unless they are attended by cerebral symptoms. When hemorrhage does occur, it ceases to be a simple fracture and becomes a complicated one. Fractures attended by depression, except in children, or open wounds, even though unattended by symptoms of compression, are always serious on account of the secondary pathological changes which may result, namely, not only hemorrhage, which I have mentioned, but particularly infection, suppuration, abscess formation, epilepsy,

etc.

Fracture attended by evidence of compression demands operation. The diagnosis of a fracture of the skull, in the absence of a wound, is frequently impossible, and when made is not infrequently pure conjecture. The presence of a well-defined swelling, with sharp borders, due to blood clot or exudation into the scalp, has been taken for depressed fracture, and a correct diagnosis made when the scalp was incised for the purpose of elevating the depressed bone. I remember seeing a case, when I was an interne, of that character, in which there was apparently a depressed fracture of the frontal bone. The man was hit by a hammer. The surgeon, instead of resorting to the measure of introducing a needle horizontally to determine whether or not there was depression, operated, and was very much chagrined to find that it was nothing but an exudation, with hemorrhage into the periosteum and scalp.

Open wounds admit of fairly accurate diagnosis, and in doubtful cases, attended with cerebral disturbance, exposure of the skull under proper precautions is indicated. Therefore, I should say, that as far as fractures are concerned, they are not the essential features of head injuries, and we should not base our treatment upon the condition of intactness of the skull, but rather upon the condition. of the cranial contents. From the paper which I presented at the Toronto meeting of this association, most of you know that I believe cerebral contusion is a very common condition, and from a greater experience which I have had since that time, I have no reason whatever to change the position I then took. Contusion of the brain is, I think, very easy of demonstration. Only two weeks ago I asked to have a number of cases of head injuries brought into the clinical amphitheater of the Cook County Hospital, for the purpose of holding a clinic, and that evening several patients were brought in who had sustained injuries to the head, with concussion of the brain, so-called. I believe all of them were diagnosed as cases of concussion of the brain.

I think but few of them were suffering from that condition alone, for the reason that we should limit cerebral concussion to those temporary disturbances in the circulation of the brain. We have two degrees of it: (1) Simple concussion, that condition which you and I have experienced, perhaps, where we have fallen on the ice or bumped our head and have been dazed for a moment and slightly confused. That is the simplest variety of cerebral concussion. It is simply a disturbance of the equilibrium of the circulation within the brain. (2) If, how

ever, this concussion is greater, and we have the vaso-motor system involved in the injury, then we have a disturbance in the vaso-motor control, and we have a greater degree of mental disturbance, with general systemic symptoms. That is true concussion, to which, I believe the term should be limited. This is the condition in which we get pallor, cold sweating, a general blanched appearance, yawning, dilated, but always equal, pupils, sighing respiration, sometimes paralysis or paresis, with possible relaxation of the sphincters. In addition, we may or may not have unconsciousness; frequently we do. By careful observation, however, you will notice that these symptoms are identical with those of shock in every single particular. Such being the case, they should be treated as shock; and when treated as shock, patients recover from these symptoms as they recover from those of shock, and when they have recovered, there are no ill effects resulting. This condition is practically always transitory. It is never productive of any permanent effects or changes. There is never any indication for operative treatment. The condition being identical in all respects with that of shock, its treatment should likewise. always be identical with that for shock. Some may say that a person may have shock, as from fright, and die. That is very true. The condition of the patient and of the circulatory apparatus of the individual may be such. that the shock incident to a severe fright from witnessing an accident, or fright as induced by a patient about to take an anesthetic, may be sufficient to disturb the vasomotor and vital centers so markedly as to suspend their action and cause death. But that is no proof in itself that simple shock ever leaves any permanent cerebral lesion, certainly none which we can demonstrate. This condition never requires operative intervention.

Where great force is applied with great velocity, we are likely to have a contusion of the brain. If we will just imagine for a moment what the phenomena of contusion would be in any other part of the body, we will have a good conception of what contusion of the brain means. First, a disturbance in the circulation locally from vasomotor disturbance, with slight laceration of the soft parts, the small capillary blood vessels, extravasation of blood, followed by swelling, and exudation. If these occur in the brain substance, they will produce brain symptoms. If they occur in any part of the brain which has a special function, we will be able to localize the lesion. If they occur in a part of the brain whose function we do not know, they may not produce any symptoms except those of shock. The first symptoms may be those of irritation in the cortex, from slight hemorrhages into the cortical substance of the brain. If the injury or trauma has been sufficient to destroy one of the cerebral centers, then, of course, we would have paresis or paralysis, depnding upon the extent of the lesion. The twitchings, contractures, paralyses, are all of great value in making a diagnosis as to the character of the lesion. Symptoms of irritation may come on first, and be followed by those of destruction, which is not uncommon in progressive hemorrhage into the cortex of the brain. These phenomena vary in accordance with the part of the brain involved. Our ignorance of brain centers renders localization often impossible. Mental disturbance is observed