Ruptures of the Viscera and Their Connection with Surgical Shock

1897 Boston Medical and Surgical Journal  
very naturally opposed to operation on such a discouraging report as we were forced to give them, and to the patient the subject was never broached. The autopsy certainly established the uselessness of operative interference, as the removal of the tumor would have involved practically the removal of a very Fio. I. ShowiDg seat of tumor. considerable portion of the temporo-sphenoidal lobe, as will appear from the accompanying cut. If attempted, the operation would probably have resulted in an
more » ... e resulted in an extensive brain hernia, with its attending inconveniences and discomforts, thereby increasing rather than diminishing the patient's distress. Fig. II. Diagram showing order of involvement of leg, arm, anil face librea by lesiona of the temporo-sphenoidal lobe (Maoewen). The most interesting point in connection with cerebral localization is that of the order in which the limbs were affected, a point upon which Macewen lays much stress. In case the lesion extends along the surface of the brain from the temporal lobe, involving successively the Rolandic areas from below upwards, the paralysis begins with the face, and the arm and leg become successively involved. If, on the other band, the process extends inward and encroaches upon the internal capsule, this order is reversed, because the Bbres from the leg and arm centres cross before reading the internal capsule. A glance at the diagram used by Macewen a (Fig. tl) will make this point clear. A practical applica-;ion of this knowledge bears on the question of operalive interference. In case we have to do with an abicess, paralysis commencing with the leg tends to show ;hat the lesion is very deeply seated, though it is true :hat abscesses sometimes cause symptoms by indirect pressure, as shown by the improvement after evacuation of their contents. In the case of tumors, the involvement of more or less remote regions by pressure is juite characteristic, as evidenced by the case here reported, in which the order of paralysis indicated pressure upon the internal capsule, although the postmortem examination showed that the tumor had not itself invaded that region. Nor had the tumor directly invaded the optic tract, though the marked hemianopäia showed pressure upon that tract, posteriorly to the optic commissure. This unique case, while offering an excellent illustration of the present status of cerebral localization, only emphasizes the difficulty of determining the exact nature of hidden lesions.
doi:10.1056/nejm189708191370802 fatcat:kudej7bwjfhw5grnkt5je2euca