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 RC383.A6 R73 On aphasia, being a 
 
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 Dr. M.A.StARR 
 
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ON APHASIA. 
 
ON APHASIA: 
 
 BEING A 
 
 CONTRIBUTION TO THE SUBJECT OF THE DISSOLUTION 
 
 OF SPEECH FROM CEREBRAL DISEASE. 
 
 JAMES ROSS, M.D., LL.D. Aberd, 
 
 Felloiv of the Royal College of Physicians of London, and Senior Assistant 
 Physician to the Manchester Royal Infirmary. 
 
 LONDON : 
 J. & A. CHURCHILL, 
 
 11, NEW BURLINGTON STREET, 
 
 1887, 
 

PREFACE. 
 
 IN the following pages is collected, with a few alterations and additions, a series of 
 papers that appeared during the past year in the Medical Chronicle. My main 
 object in writing these papers was to record several interesting and instructive 
 cases of aphasia which had come under my own observation, but inasmuch as in 
 none of my cases did the symptoms observed come to the test of a post-mortem 
 examination, I could not enter profitably, either on an analysis of the clinical 
 phenomena, or on an interpretation of them in terms of structure, without 
 availing myself largely of the labours of others. Although previous observations 
 on aphasia will be found described here with tolerable fulness, yet, at the same time, 
 the work does not pretend to be an exhaustive monograph, nor is the subject treated 
 in a strictly systematic manner. In dealing with the opinions of others, I have 
 endeavoured to separate what I conceive to be the true portions of discordant 
 theories from the errors with which they are intermingled, and have then striven to 
 combine the true into one harmonious doctrine. That I have succeeded in separating 
 the true from all admixture of error and in producing an imimpeachable theory of 
 aphasia, I will not for a moment maintain ; but it would be mere false modesty were 
 I to disclaim all credit for the doctrine set forth in this work, or to deny that I 
 believe it to be more harmonious in aU its parts than any which has hitherto appeared. 
 The authors whose works I have laid under contribution are referred to in the body 
 of the work, but I cannot pass over without special mention the names of Broca, 
 Trousseau, and Charcot in France ; Kussmaul and Wernicke in Germany ; 
 Hughlings- Jackson, Gaii'dner, Bastian, Broadbent, and Ferrier in this country. 
 These are the great masters of the subject, and any one who undertakes to write 
 upon it ought to make a close study of their works. 
 
 It will be observed that the closing part of this volume descends almost to the 
 level of a polemic against Dr. Broadbent's views. The distinguished author will, I 
 hope, believe me when I say that this arises, not because I attach little, but because 
 I attach much, importance to his opinions. Some portions of Dr. Broadbent's work 
 on Aphasia must be simply accepted and not criticised, but other portions are open 
 to question. He belongs to a school of psychologists which manifests a tendency to 
 break up the human mind into numerous faculties, with their corresponding cortical 
 centres, and it is as the highest exponent of this school that his views are here 
 singled out for adverse comment. 
 
 JAMES ROSS. 
 Manchester, Januaey, 1887, 
 
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 in 2010 witii funding from 
 
 Open Knowledge Commons 
 
 http://www.archive.org/details/onaphasiabeingcoOOross 
 
CONTENTS. 
 
 PAGF 
 
 Introduction ] 
 
 1. Motor Aphasia 5 
 
 Case 1 (W. D.) 7 
 
 2. Sensory Aphzvsia 12 
 
 Case 2 (Robert Marshall) 13 
 
 Case 3 (James Proffit) 19 
 
 Case 4 (Joseph Lander) 25 
 
 Case 5 (James Lee) 30 
 
 Case 6 (John Morris) 37 
 
 Case 7 (Bouquinefc Marie) 39 
 
 Case 8 (R. B.) 40 
 
 3. Combined Motor and Sensory Aphasia 42 
 
 Case 9 (Louise Jeanniot) 43 
 
 Case 10 (John Handforth) 45 
 
 4. Morbid Anatomy 50 
 
 (1) The Nature of the Lesion 50 
 
 (2) The LocaHsation of the Lesion 53 
 
 5. Morbid Physiology 67 
 
 Clinical Analysis — 
 Motor Aphasia — 
 
 (1) Aphemia 67 
 
 (2) Motor Agraphia 70 
 
 Sensory Aphasia — 
 
 (1) The Aphasia of Recollection 72 
 
 (2) Psychical Blindness 74 
 
 (3) Psychical Deafness ., 77 
 
 Paraphasia 80 
 
 Paragraphia 82 
 
 Paralexia 84 
 
 Theories of Aphasia — 
 
 Kussmaul's Theory 87 
 
 Charcot's „ 89 
 
 Lichtheim's ,, 91 
 
 Broadbent's „ 95 
 
 The Author's Exposition of — 
 
 The Theory of Motor Aphasia 97 
 
 The Theory of Sensory Aphasia 107 
 
 Special Treatment of Aphasia 127 
 
APHASIA. 
 
 Aphasia (d priv., and <f>a.(Tt.s speech) means literally loss of the faculty of 
 intelligent speech, or speechlessness. Before defining more accurately 
 the sense in which the term is to be used in the following pages, it is 
 desirable to make a few general remarks on language, and on the 
 nervous mechanisms which the full use of language presupposes. 
 Language, taken in its widest sense, consists of the various means by 
 which animals indicate and appreciate the mental states of one another. 
 Mental states are divided by psychologists into feelings, cognitions, and 
 volitions. Language is frequently expressive of volitions, but inasmuch 
 as volitions are determined by motives, or in other words by the feelings 
 and cognitions, language of the volitions merges itself into that of the 
 other two mental states. Language may, therefore, be divided into that 
 of the feelings, or emotional language, and that of the cognitions, or 
 intellectual language, and it is to the latter alone that the tei'm speech is 
 truly applicable. The language of the emotions is, as Mr. Darwin has 
 shown, fairly well developed in animals so low down in the scale of being 
 as insects, and it is highly developed in the higher vertebrata. Intel- 
 lectual language, however, is almost exclusively limited to man. Faint 
 indications of this form of language may undoubtedly be observed in the 
 lower animals, but in them it appears only in a rudimentary form, and 
 seldom, if ever, completely differentiated from emotional language. A 
 rook, for instance, perched on a high tree, utters in quick succession, 
 "Caw, caw, caw," and immediately the neighbouring community of 
 rooks take to flight. It is difl&cult to deny an intellectual quality to 
 this act, inasmuch as the given signal had indicated the approach of 
 danger to the community of rooks, and the community had adopted 
 the best means, namely, flight, for avoiding the approaching danger. 
 Scanned more closely, however, it will be seen that the signal cry of the 
 rook belongs chiefly to emotional, and only in a very slight degree to intel- 
 lectual, language. The cry had indicated to the community that the 
 rook giving the signal was the subject of the emotion of fear; the same 
 emotion was communicated to the community at large, and all the rooks 
 immediately took to their inherited mode of escape from enemies. The 
 actions of the rooks were, therefore, determined almost exclusively by 
 emotion, and only in a very subordinate degree by the intellect, or, a."! 
 Professor Huxley aptly expresses it, by a train of feeling, and not by a 
 
train of thought. It is in man alone, therefore, that the language of 
 the intellect becomes more or less completely differentiated from the 
 language of the emotions, and even in him the division between them is 
 by no means always clear and trenchant. When, for instance, a public 
 speaker deHvers an oration, only a small part of what he utters can be 
 regarded as speech. The variations of tone, the melodious voice, the 
 graces of attitude and gesture, the charm of elegant and rhythmical 
 language, and the thousand other ways by which a great orator knows 
 how to sway and influence his audience, belong to emotional and not to 
 intellectual language. And similarly with regard to written language. 
 The separate propositions on a printed page belong to intellectual 
 language, but such methods as accent, italics, and notes of exclamation, 
 by which inflection, and emphasis, and wonder ai'e expressed, as well as 
 the rhythm of metrical compositions, and the diction and imagery of 
 poetry, all belong to emotional language. The distinction, however, 
 between emotional and intellectual language is a radical one, and it will 
 be hereafter seen that the former faculty, which is much the more deeply 
 organised of the two, may be almost entirely unaffected while the latter 
 is almost quite lost by disease. 
 
 Let us now look more narrowly at the structure of intellectual 
 language. This kind of language gives expression to a thought or 
 cognition, and a thought when expressed has the value even when it does 
 not assume the form of a proposition. If I utter the word " book," it 
 may or may not convey any meaning to the listener. But if any thought 
 is conveyed by the word the listener must understand my intention to 
 be to express that the object I am pointing at, holding in my hand, or 
 thinking about, belongs to the class of things known to him and to me 
 by the name of a book, and the word has to both of us the value of a 
 distinct proposition. A proposition, therefore, is the unit of intellectual 
 language. Language is the instrument of the social state, and in order 
 that it may be a means of intercommunication between animals it must 
 possess to each a subjective and an objective value, or in other words it 
 must fulfil an impressive and an expressive function. The signal cry of 
 the rook, already used as an illustration, indicates that the rook which 
 utters it is in a certain mental condition, but this indication would be 
 of no value to the community unless a similar mental condition were 
 excited in all the rooks that listened to the cry. In order that the 
 active rook may be able to communicate his own emotion or thought to 
 the other rooks he must be possessed of outgoing or centrifugal 
 mechanisms, by means of which he is able to give a certain signal ; and 
 in order that the signal may fulfil the function of a language the passive 
 rooks must be possessed of ingoing or centripetal mechanisms, by means 
 
of which they are able to appreciate the meaning of the signal. And 
 each rook, in order to be an effective member of the community, must 
 be possessed of both the outgoing and ingoing mechanisms, so that he may, 
 as occasion requires, be able on the one hand to give warning of 
 approaching danger to the other rooks, and on the other to appreciate 
 the meaning of the warning cry when hearing it from another rook. 
 Now, as the outgoing or expressive function always results in a muscular 
 action of some kind, it may be briefly named the motor function of 
 language ; and as the ingoing or impressive function presupposes the 
 activity of the ear, eye, or one of the other senses, it may be named the 
 sensory function of language. The first step of our analysis therefore 
 shows us that language consists of motor and sensory functions, and 
 that these are regulated by corresponding motor and sensory nervous 
 mechanisms. If the motor function of language, or rather of speech, 
 with which we are now particularly concerned, be further analysed, it 
 will be found to consist of certain articulate sounds and vocalisations 
 constituting articulate or spokeji speech, certain movements of the hand 
 resulting in written speech, and particular movements of the limbs and 
 body constituting pantomimic speech. Each of these kinds of speech is 
 regulated by a mechanism in the spinal cord, or medulla oblongata, 
 with its attached nerves, and by a cerebral cortical centre with 
 its attached centrifugal conducting path. Now, since the spinal 
 mechanism with its attached nerves and muscles acts in subordination 
 to the cortical centre, it may be called the executive department ; and 
 since the cortical motor centre with its attached conducting path 
 gives the final co-ordination to the cortical impulses before they are 
 transmitted to the spinal nuclei, it may be called the emissive depart- 
 ment of speech. If the sensory function of speech be now subjected 
 to analysis it will be found that a certain amount of information about 
 the external world may be communicated by one person to another 
 through each and all of our senses. The senses of taste and smell, 
 however, do not take any prominent part in the appreciation of language. 
 Of all the senses the sense of hearing plays the most important part in 
 the sensory function of language, as the vocal apparatus plays in the 
 motor function. It is in connection with the vocal apparatus on the one 
 hand and the sense of hearing on the other that speech is first organised 
 in the individual, and this statement is doubtless equally true with 
 regard to the race. Written and pantomimic speech are appreciated 
 through the eye, and the deaf and dumb may even be taught to 
 appreciate vocal or articulate speech through the same organ. Written 
 speech may, by means of the device of raised letters, be appreciated 
 through the sense of touch, and every person acquires a considerable 
 
knowledge of the activity of the motor part of his own speech through 
 the nerves of muscular sense. The nervous mechanisms which preside 
 over the sensory function of speech consist of the various peripheral, 
 sense organs with the centripetal conducting paths connecting them 
 with the highest nerve centres, and of the cortical centres themselves. 
 The function of the peripheral sense organs with their centripetal 
 conducting paths may be called the recejotive department of the sensory 
 function of speech, but how to name the function of the cortical centres 
 themselves requires a good deal of consideration. In another place 
 I have named it the regulative department of the sensory function of 
 language, because the impulses conducted inwards through the various 
 senses are reduced to order in the cortical centres before they pass 
 outwards through the emissive to the executive apparatus of speech. 
 This name, however, hardly gives us any idea of the function of the 
 cortical centres in reference to language. The peripheral centripetal 
 apparatus terminates in the cortical sensory centres, but the mental 
 appreciation of the unit of speech or of a proposition must have for its 
 correlative an excitation of a much larger portion of the cortex than an 
 individual sensory centre, and consequently pyscho-sensory would not be 
 a good name for the function of the cortical centres in language. To call 
 the function the perceptive function would answer for some cases, but 
 not for all. If I were to say " This orange is yellow," I utter a 
 proposition which the listener could verify by the exercise of his 
 perceptive faculties, but if I say "The earth revolves round the 
 sun," the proposition is one which could only be verified by a 
 prolonged and complicated process of observation and reasoning. The 
 faculty for the appreciation of complex propositions of this kind, and 
 even of simple propositions, may be named the apperceptive faculty 
 in the wide sense in which Kant^ used the term apperception and its 
 coo-nates. The function of the cortical centres lying between the termi- 
 nation of the sensory conducting paths and the emissive part of the 
 motor mechanism may therefore be named the apperceptive department 
 of the sensory function of speech. The apperceptive faculty is susceptible 
 of being analysed into simpler elements ; but in the meantime we shall 
 speak of it as if it were a simple and homogeneous faculty. Our analysis 
 has, therefore, led us to recognise that speech consists of a motor and of 
 a sensory function, and that the former of these may be divided into an 
 
 1 " Verbindung liegt aber nicht in den Gegenstanden und kann von ihnen nicht etwa durch 
 Walimehmung entlehnt nnd in den Verstand dadurch allererst aufgenommem werden, sondem 
 ist allein eine Verrichtung des Verstandes, der selbst nichts weiter ist, als das Vermogen, a priori 
 zu verbinden und das Mannigfaltige gegebener Vorstellungen unter die Einheit der Apperception 
 zu bringen, welcher Grundsatz der oberste im ganzen meuschUchen Erkenntniss ist." — Kant's 
 Kritik der reinen Vemunft, Herausg. von G. Hartenstein, Leipzig, 1868, p. 117. 
 
emissive and an executive department ; and the latter into a receptive and 
 an apperceptive department, with their corresponding nervous mechanisms. 
 Now the term aphasia is not meant to include disease of all these 
 functions and mechanisms. Disease of the executive department of the 
 motor mechanism of speech gives rise to the symptoms known as bulbar 
 paralysis, or to local diseases of the nerves and muscles by which 
 thoughts are expressed, but these diseases ought to be excluded from the 
 definition of aphasia. And again, disease of the receptive department of 
 the sensory mechanisna gives rise to deafness, deaf-mutism, blindness, 
 anaesthesia, and various other sensory disorders ; but those symptoms also 
 ought to be excluded from any definition of aphasia. Again, every kind 
 of disorder of the higher mechanisms of speech is not an aphasia. The 
 epileptic cry is probably caused by a nervous discharge from the 
 emissive department of the motor mechanism of speech, but this cry is 
 not regarded as an aphasia. The disorder of the nervous mechanism 
 which constitutes an aphasia must be of the nature of a paralysis, 
 although the paralysis need not necessarily be complete. Aphasia may, 
 therefore, be used as a generic term to include diminution or loss of 
 the function of the emissive department of the motor, or of the apper- 
 ceptive department of the sensory function of speech, or of both these 
 departments combined. In accordance with this definition, aphasia 
 may be divided into (1) motor aphasia, (2) sensory aphasia, and (3) 
 combined motor and sensory aphasia. 
 
 1. — Motor Aphasia. 
 
 In cases of complete motor aphasia the patient is unable to com- 
 municate his thoughts by articulate words, by writing, or by pantomime. 
 Certain terms have been employed to designate each of these conditions. 
 Loss of the power of communicating thought by articulate words has 
 been named apJiemia (a priv., and (^yjjjLL I speak), by writing agraphia 
 (d and ypa.(pu) I write), by pantomime amimia (a and fjAfxo'? an imitator), 
 and by all these methods of expression at once asemasia (a and a-r^ixaivw 
 to show by a sign). Loss of the power of expressing thoughts has also 
 been named ataxic aphasia. 
 
 It is important to remember that a patient may be the subject of a 
 complete motor aphasia, and yet be able to utter some words. In Dr. 
 Hughlings-Jackson's language the subject is speechless but not wordless} 
 The words which the patient is able to utter continue, as a rule, the 
 same in the same patient, and have therefore been named "recurring 
 
 ' Hughlings-Jackson (J.). "On affections of speech from diseases of the brain." — Brain, 
 VoL I., 1878-79, p. 313, and Vol. II., 1879-80, p. 204. 
 
6 
 
 utterances." Utterances of this kind, like *'yes" or "no," which 
 are repeated on all occasions, whether appropriate or not, do not 
 possess any intellectual value. In addition to the usual recurring 
 utterances of " yes " or " no " patients sometimes repeat such phrases 
 as "Come on to me," or "I want protection."^ The man who kept 
 repeating the phrase, " Come on to me," was a railway signalman, who 
 had been taken ill on the rails in front of his bos ; while the man who 
 could only say, "I want protection," had his head injured in a brawl. 
 Dr. Hughlings-Jackson makes the very probable supposition that in 
 these cases the frequently repeated phrase were the last words spoken, 
 or which were in a state of mental preparation for utterance, when the 
 damage occurred to the brain. It is not improbable that words spoken, 
 or about to be spoken during a period of great excitement, will leave 
 permanent traces on the organisation of the brain, which renders them 
 liable, to be subsequently uttered as interjectional phrases during 
 emotional states. A patient may also use when excited words and 
 phrases, such as " God bless me," or profane oaths, in an interjectional 
 sense ; but it is evident that these words are expressive of the feelings 
 or emotions, and not of the cognitions or thoughts. A patient may also 
 utter a phrase which is appropriate to the surrounding circumstances, 
 such as "good-bye," when a friend is leaving.^ Words of this kind 
 have been frequently repeated in the previous experience of the indi- 
 vidual, and always under more or less similar circumstances, and have 
 thus become so deeply organised that they possess little more value than 
 a reflex act. The fact that a patient who may say "good-bye," on 
 taking leave of a friend, and is quite unable to repeat the words when 
 asked to do so, shows that the utterance is little more than a reflex act 
 without any intellectual value. 
 
 When the aphemia, or the loss of articulate speech, is not complete, 
 the patient retains the full use of simple words like "yes" and "no," 
 and even when he says " no " to express assent as well as dissent, if he 
 is able to indicate by the aid of pantomime in what sense he wishes the 
 word to be understood, this shows that the word possesses an intellectual 
 value. Although all forms of intellectual expression are often simul- 
 taneously affected in motor aphasia, yet this is by no means always the 
 case. A man may be totally unable to express his thoughts by articu- 
 late words, yet be able to write with tolerable freedom, and to express 
 his wants by pantomime. Loss of the power of written speech while 
 
 ' Hughlings-Jackson (J.). " Remarks on the occasional utterances of speechless patients." — 
 The Lancet, Vol. II., 1867, p. 70. 
 
 -Broadbent (W. H.). "A case of pecuUar affection of speech, with commentary." — Brain, 
 Vol. I., 1878-9, p. 494. 
 
articulate speech is retained or re-acquired is rare, though cases of the 
 kind have been reported ; but a case of loss of intellectual pantomime 
 with retention of the power of articulate speech and of writino: is not 
 known to me. But the functions of language which the subject of motor 
 aphasia retains are just as remarkable and as noteworthy as those he 
 loses. The patient is able to perform all the general movements of the 
 tongue and lips, although he may be totally unable to articulate a single 
 word. There is no difficulty of deglutition, dribbling of saliva, or any of 
 the usual symptoms of labio-glosso-pharyngeal paralysis ; in other words 
 the executive department of the motor function of speech is quite 
 healthy. The language of the emotions is little or not at all affected. 
 The patient can smile, frown, laugh, or sing, and the few words he can use, 
 such as "yes" or ''no," may be uttered with such variations of tone and 
 gesture as to indicate when he is angry or joyful, these words being then, in 
 Mr. Herbert Spencer's language, more akin to song than to speech.^ The 
 sensory function of speech is also quite unaffected. The patient under- 
 stands all that is said to him, and remembers what is said to him or 
 what he reads himself. He will point to surrounding objects, and recognise 
 drawings of them, provided they were known to him before his illness. 
 He also recognises handwriting, and is able to play at cards and other 
 games. The following case is an example of motor aphasia, although an 
 attentive scrutiny shows that the motor disabihty is accompanied by a 
 slight degree of sensory aphasia. 
 
 Case 1. — W. D., aged 24 years, was admitted to the Manchester 
 Royal Infirmary, in June, 1884, under the care of Dr. Eoss. The 
 following history was obtained from his wife. She states that the 
 patient, who was an out-door worker on the railway, was always a strong 
 and healthy man, and never suffered from any serious illness up to the 
 date of the present attack. She does not think that he ever suffered 
 from rheumatic fever, and there is no evidence of syphilis. About 
 twelve months ago, while loading a waggon at the Salford Station, he 
 was seen to turn suddenly round and to fall. He was carried home in 
 an unconscious condition, and it was soon observed that he was com- 
 pletely paralysed on the right side of the body. For the first two 
 months he did not seem to understand anything that was said to him, 
 and did not take much notice of surrounding objects and events; but at 
 the end of that time he began to take an intelligent interest in what 
 was passing around him, and by promptly obeying ordinary requests, 
 such as "put your tongue out," "sit up in bed," &c., he showed that 
 he understood much of what was said to him. He also appeared to 
 
 ^ Spencer (Herbert). "The origin and function of music." Essays — Scientific, political, and 
 speculative. Vol. I., 1S68, p. 221. 
 
take an interest in looking over a ne"wspapei\ He continued, however, 
 quite unable to utter a single word. He gradually recovered from his 
 paralysis, so that in two or three months he was able to walk about on 
 level ground, although he dragged the right leg, and did not use the 
 right hand much. 
 
 Present Condition. — The patient is a short, stiff, and muscular man, 
 and looks very healthy. On close inspection it is seen that his lips are 
 of a rather blueish colour, and his face is somewhat congested. Both 
 hands are of a reddish-blue colour, and always very cold, these pheno- 
 mena being specially well-marked in the right hand. The pulse is very 
 feeble, but regular, and beats 72 in the minute. On examining the 
 chest it is seen that the apex of the heart beats two inches below the 
 nipple, and a little to the inside of the mammary line. The deep cardiac 
 dulness reaches as high as the upper border of the third rib in the left 
 parasternal line, but the deep cardiac dulness does not extend to more 
 than half-an-inch to the right of the right edge of the sternum. On 
 auscultation a soft systolic murmur is heard at a localised spot over the 
 apex of the heart, but it is replaced by an impure first sound at mid- 
 axilla. The second sound is accentuated over the third left costal 
 cartilage. All the other internal organs ai'e healthy. In walking the 
 patient drags the right leg a little, and the patellar-tendon reaction is 
 increased in it, and a little ankle clonus can be elicited by careful 
 manipulation. The grasp of the right hand is fairly good, although 
 weaker than that of the left, and the tendon reactions at the wrist 
 and elbow are increased on the right side. The face is drawn slightly 
 to the left side. 
 
 The patient is unable to utter a single word either in answer to a 
 question or by way of repeating what is said. Asked his name, he 
 shakes his head mournfully to indicate his inability to reply. Asked if 
 his name is William, he nods to give assent. Asked if he is one hundred 
 years of age, he laughs and gives a short grunt which is something like 
 an attempt to say " No." He does not appear to have any kind of recurring 
 utterance. He can write down his own name in a fair hand, but can 
 only write the first half of Manchester when asked to do so, although he 
 can copy the name in full by frequent reference to the printed page. 
 On being requested to show by signs how he would ask a second person 
 to close the door, he laughed and raised his hand and significantly 
 pointed to the door. The patient can protrude his tongue with a 
 scarcely perceptible deviation to the right. He can roll his tongue into 
 a tube and turn the tip upwards towards the nose. He can also blow 
 out his cheeks. There is no dribbling of saliva, and no difiiculty of 
 deglutition. He obeys promptly any ordinary request in articulate 
 
speech, such as '"'Put out your tongue," "Close your eyes," "Show your 
 hand," &c. When shown a simple request, such as " Put out your 
 tongiie," in writing, he cannot be got to obey it, but his wife says 
 that he is fond of looking over the newspaper, and she believes that he 
 understands it, as he sometimes points out to her a paragraph he must 
 know would interest her. His sight, hearing, and all his other senses 
 are normal. 
 
 December 16. — The patient has been under treatment as an out- 
 patient in the Infirmary for upwards of six months, but his condition 
 remains almost unchanged. He has now the full use of " Yes " and 
 " No," and always uses the words correctly. When asked his name, he 
 says it is " Bill." He has also been taught to repeat most of the letters 
 of the alphabet. The explosive consonants were the first letters acquired 
 by him. He generally keeps his lips slightly apart. I first got him to 
 look steadily at my face, and, closing my lips firmly, I touched his lips 
 and pointed to him to do the same. When he closed his lips I then 
 pronounced the letter p, and he immediately followed with a b. He 
 smiled and seemed pleased. After some exercise we got him to pro- 
 nounce many of the letters of the alphabet, and a few monosyllabic 
 words like man and cow, but he has not been systematically exercised, 
 and his vocabulary, even for the repetition of words, is still very limited. 
 To-day he was asked, " Close your eyes," and he immediately obeyed. 
 The same request was now made in writing, and it was instantly obeyed. 
 I now wrote down " Put your tongue out," and he promptly complied 
 with this request likewise, this being the first time that I was able to 
 secure obedience to a written command. In other respects the patient 
 is about the same as he was when he came first under observation. 
 
 Remarks. — When this patient was first seen in June he was the subject 
 of a complete aphemia. The agraphia was not total, inasmuch as he was 
 able to write his name and to copy simple words, while his pantomimic 
 speech was apparently not much impaired ; in other words there was 
 little or no amimia. ISTo defect could be discovered in the sensory side 
 of speech through the ear, but there was a suspicion of the existence of 
 some degree of word-blindness, inasmuch as he could not be got to obey 
 a written request. When examined in December, the word-blindness, if 
 it previously existed, had disappeared. It is, however, important to 
 observe that during the first two months after his attack he appears to 
 have sufi'ered from a more or less complete sensory, as well as motor, 
 aphasia. The patient's wife stated emphatically that during the first 
 two months of his disease he was quite unable to understand anything 
 that was said to him. An opportunity was offered to me to observe this 
 condition of combined sensory and motor aphasia about twelve months 
 
10 
 
 ago, in a boy, who was at first under the care of my colleague. Dr. 
 Morgan, and was subsequently under my own care for many weeks in the 
 Barnes Convalescent Hospital at Cheadle. This boy, who, like W. D,, had 
 a soft systolic murmur over the apex of the heart, was suddenly seized 
 with an apoplectic attack and right hemiplegia. On entering the 
 Infirmary, soon after the attack, he was found to be sufi"ering from right- 
 sided hemiplegia and complete sensory and motor aphasia. He was not 
 only unable to utter a single word, but he also took no heed of any 
 ordinary request, whether addressed to him by means of spoken or 
 written language. At the end of about three weeks he recovered on the 
 sensory side so far as to put out his tongue on being requested to do so. 
 In a few weeks longer he recovered so far as to obey all ordinary 
 requests, and to take an interest in a lesson book, so that the sensory 
 aphasia may be said to have completely disappeared ; but he was still 
 unable to utter a single word. In the meantime the paralysed limbs 
 had recovered their motor power, and scarcely a trace of hemiplegia 
 could be discovered, with the exception of some excess of the tendon 
 reactions at the right wrist and knee. During the whole of this time 
 the patient was unable to utter a single word, a short grunt with a nod 
 for assent, and a shake of the head for dissent, forming the whole of the 
 expressive part of his speech. At the end of about five weeks from the 
 commencement of the attack he was transferred to the Convalescent 
 Hospital at Cheadle, and under the tuition of Dr. Wansbrough Jones and 
 myself he soon learnt to repeat the alphabet, the explosive consonants 
 being first taught him. In a short time he acquired a pretty 
 copious vocabulary of monosyllabic words, such as man, horse, cow, 
 but he was only able to say most of his words by repetition, and 
 was still unable to construct a sentence. He was kept for about two 
 months in the hospital, and on being discharged was lost sight of. This 
 case shows that the early stage of a motor aphasia is sometimes, at least, 
 accompanied by a sensory aphasia, and that after some weeks recovery 
 takes place from the sensory disability, leaving a more or less pure 
 motor aphasia. A combined sensory and motor aphasia is probably 
 always present in all cases in which the loss of speech, if it be persistent, 
 is accompanied by a decided hemiplegia, and it is in those cases 
 alone in which the motor aphasia is accompanied by a slight degree 
 of facial paralysis, without the limbs being much implicated, that a pure 
 motor aphasia is present from the commencement of the attack. In 
 
 the case of W D , the loss of the power of writing was not 
 
 quite so profound as that of the power of articulate speech ; and in other 
 cases the disproportion between the interference with these two functions 
 is still greater than it was in this one. In a case I saw some years ago 
 
11 
 
 with Mr. SutclifFe, of Stretford Road, the patient was quite unable to 
 articulate a single word, but he could write with great readiness pertinent 
 replies, and give instructions about his business on a slate ; and although 
 the writing was not very good, Mr. SutclifFe could decipher it without 
 much difficulty. 
 
 Cases in which the power of speech is retained or soon re-acquired, 
 while the power of writing is lost, are not frequent, but an instance 
 of this kind has been reported by Pitres.-' The subject, a merchant, 
 aged 31 years, who had contracted a chancre ten years previously, 
 was seized with an apoplectiform attack, right-sided hemiplegia, and 
 a certain degree of aphasia. For some weeks after the attack the 
 patient became gradually worse and more comatose, but after energetic 
 anti-syphilitic treatment improvement set in, and the patient regained 
 consciousness, the paralysis gradually disappeared, and the power of 
 articulate speech retiu-ned. The patient was examined by Pitres 
 eighteen months from the beginning of the attack, and only slight 
 traces of the previous hemiplegia could then be discovered, while he 
 could talk freely, and without any evidence of defective articulation 
 or other disorder of spoken speech. The right hand was redder and 
 colder than the left, and it was often covered with chilblains ; the 
 sensibility to contact and pricking was nearly the same in both hands, 
 but with careful testing the muscular sense was found to be slightly, 
 and only slightly, diminished in the right as compared with the left 
 hand. The only other disorder of sensibility that could be dis- 
 covered was a right-sided hemianopsia. All the general movements 
 of the right hand were made with precision, and the patient could read 
 aloud without hesitation. He was, however, quite unable to write a 
 single word or even a single letter to dictation with the right hand, 
 although he had acquired the power of writing fairly well with the 
 left hand. When asked to copy a printed word he began slowly, and 
 after looking frequently at the page he could reproduce the word in 
 printed but not in written characters, and when a written word was 
 presented to him he could reproduce it slowly by copying it letter for letter 
 in written characters, but when the model was withdrawn he was quite 
 unable to write the word in written or printed characters. With 
 numbers it was the same ; the patient could read them without hesitation, 
 and could add, subtract, and make other calculations like any healthy, 
 educated person ; he could also copy slowly with the right hand a 
 number presented to him, whether printed or written, but he was quite 
 unable to write numbers spontaneously or to dictation. The patient 
 
 ^ Pitres (A.). " Considerations sur I'agrapHe a propos d'une observation nouvelle d'agrapMe 
 motrice pvire." — Revue O.e Mededne, Nov., 1SS4, p. 855. 
 
12 
 
 could, however, copy with the right hand geometrical figures, such as a 
 circle or triangle, and he was also able to draw with it a well-proportioned 
 outline of the human figure. There can be little room for doubt that 
 in this case the damage to the brain had occurred on the motor side, and 
 yet, although there was almost complete motor agraphia, the patient had 
 recovered the full use of articulate speech. These remarks on motor 
 aphasia must suffice, and we shall now proceed to discuss the various 
 forms of sensory aphasia. 
 
 2. — Sensory Aphasia. 
 
 In sensory aphasia the chief disorder of speech is to be found in what 
 we have called the apperceptive faculty. The slightest consideration of 
 the mechanism of speech will, however, render it manifest that the 
 disability will not be limited to this faculty, but that all the faculties, 
 the nervous mechanisms of which lie in front of the main lesion, will be 
 thrown into disorder. During the activity of the collective speech 
 mechanisms the currents pass, speaking broadly, from the ear to the cortex 
 of the brain, and from the cortex to the articulatory organs in spoken 
 speech, and from the eye to the cortex of the brain, and from the cortex 
 to the hand in written speech. Interruption of continuity of any 
 portion of these routes will damage not only the function of the local 
 part injured, but will throw into disorder all the parts which lie anterior 
 to the lesion. If a person becomes absolutely deaf in early infancy, he 
 is afterwards, unless subjected to a very special education, mute also; 
 the sensory disorder has prevented the development of the motor 
 apparatus. Similarly, a person born blind is incapable of acquiring the 
 power of writing by any ordinary training ; here also the sensory 
 disorder has placed a bar to the development of the motor capacity. 
 These illustrations will serve to render it clear that in cases of pure 
 sensory aphasia it may be expected that a motor disorder of speech will 
 also be present. In sensory aphasia, therefore, and, indeed, in every 
 form of aphasia, the most valuable indications as to the particular part 
 of the nervous mechanism of speech which is injured is to be found, not 
 in observing the peculiar kind of motor disorder which is present, but 
 in noting how the patient comports himself when certain requests or 
 questions are addressed to him through the ear or eye ; that is, in 
 spoken or written lang-uage respectively. If a patient takes no notice 
 of whistling or other loud noises in his vicinity it is concluded that he 
 is deaf, but if he turns round and scans with intelligent expression the 
 direction from which the sound has emanated, it is concluded that there 
 
13 
 
 is no insuperable barrier to the passage of impulses from the local 
 apparatus in the ear to the cortex of the brain. But if the patient who 
 gives distinct evidence of hearing ordinary noises fails to obey simple 
 spoken requests, such as " Close your eyes," and if his other conduct 
 shows that his not complymg with the request is due to simple perversity, 
 it will be safe to conclude that he has not appreciated the nature of the 
 request, or in other words, that the part of the apperceptive faculty of 
 speech in relation with the sense of hearing is disordered. In the same 
 way, if an educated man avoids obstacles, and takes notice of sur- 
 rounding objects, yet fails to obey simple written or printed requests, or 
 is unable to read, while still capable of expressing his thoughts correctly 
 in spoken words, then it is concluded that the part of the apperceptive 
 faculty which is in relation with the sense of vision is disordered. lu 
 such cases a very valuable test, first proposed by Dr. Hughlings Jackson, 
 is to ask the patient some ridiculous question, such as "Are you a 
 hundred years of age V If the question is understood, it is sure to evoke 
 an emphatic denial on the part of the patient, accompanied by lively 
 evidences of amusement or indignation. But instead of dwelling 
 further upon the tests which are to be applied in cases of sensory 
 aphasia, we shall proceed to show them in operation by describing 
 cases illustrative of the different forms of this disorder of speech. The 
 simplest varieties of sensory aphasia are afforded by the cases, which 
 were first clearly recognised by Wernicke, and which have been named 
 by Kussmaul word blindness and word deafness. Pure examples of these 
 affections are rare. In practice they are most frequently met with 
 variously combined in the same patient. 
 
 The following case is a very good example of uncomplicated word- 
 blindness, the disorder of speech being accompanied by a well defined 
 right-sided bilateral homonymous hemianopsia. 
 
 Case 2. — Robert Marshall, aged 57 years, was admitted into the 
 Manchester Royal Infirmary under my care on July 21st, 1884. 
 
 Previous History. — The following account of the patient was obtained 
 partly fi'om himself and partly from his wife. His occupation was that 
 of engraver on copper, and he was a very well educated man, and fond 
 of reading. He never suffered from exposure or any particular hard- 
 ships, and he was always very temperate and regular in his habits. 
 There is nothing in his history pointing to syphilis. He has suffered 
 for many years from deafness, and his wife thinks that he was as deaf as 
 he is at present for the last two or three years. For some years 
 he has had to micturate frequently, and the quantity of urine passed 
 has been much more copious than in former years. The patient states 
 that he has never suffered much from thirst, bat he acknowledges that 
 
14 
 
 he drinks a considerable quantity of fluid in the twenty-four hours. 
 With these exceptions he has not complained of any symptom worth 
 noting up to within five months of his admission to the Infirmary. At 
 that time he was working very hard on a Saturday afternoon when he 
 was seized with dizziness and a general feeling of illness. Finding 
 himself unable to continue his work he lay down and slept, but after a 
 short time he awoke suffering from a violent headache, and he found 
 that he was unable to speak clearly, and could not define objects. On 
 the following day he was worse rather than better ; he experienced 
 considerable difficulty in expressing his wants. His wife says that he 
 did not give pertinent replies to her questions, while he was unable to 
 see clearly, objects appearing to float before him. Both he and his wife 
 state emphatically that at no time was there any sign of paralysis. He 
 states that his power of speech returned at the end of about a week or 
 ten days, but he does not believe that his sight has in any way improved 
 since the attack. 
 
 Present Condition. — R. M. was in the Infirmary for upwards of five 
 weeks, and during that time the following notes were taken. The 
 patient is a tall and stout man, weighs over fifteen stones, and looks 
 well nourished and healthy. The urine is free from albumen, but it 
 contains a considerable amount of sugar, the quantity as estimated by 
 the fermentation test varying from 25 to 30 grains per ounce. The 
 quantity of urine passed in the twenty-four hours has varied from 20 to 
 80 ounces, the average being about 50 ounces. The apex of the heart 
 is displaced slightly downwards and outwards, and the second sound at 
 the base is highly accentuated and of metallic quality. The arteries at 
 the wrist feel somewhat unyielding and inelastic, but they are not 
 calcareous. The patient is so deaf that he only hears the ticking of a 
 watch on either side when it is brought in contact with the ear. His sight 
 enables him to avoid obstacles in walking, but when be looks at small 
 objects he has to use double convex glasses, as he is the subject of a consider- 
 able degree of presbyopia. He is, however, sufi^ring from a right-sided 
 bilateral homonymous hemianopsia, the completeness of which is testified 
 by the accompanying charts taken on July 29th, by means of Dr. McHardy's 
 perimeter (Figs. 1 and 2). The patient's deafness has rendered him 
 stupid and difficult to examine, but he converses sensibly and freely 
 about himself, and especially about his visual defect, of which he com- 
 plains most. He also names any objects presented to him correctly, and 
 gives rational replies to all questions addressed to him. In short, 
 during his residence of upwards of five weeks in the Infirmary, the fa,ct 
 that he had any special disability of speech had completely escaped the 
 attention of myself and several other very competent observers, who 
 
15 
 
 were led to examine him more or less carefully. He was discharged on 
 August 28th, and made an out-patient. 
 
 Fig. 1. — Left. 
 
 Figs. 1 and 2. — Charts of the Fields of Vision In the case of Robert SCarshall, showing' by the 
 heavy line bilateral homonymous hemianopsia. 
 
 December 16, 1885. — K M. has attended pretty regularly as an 
 out-patient at the Infirmary since the date of the last report, except for 
 a month during last summer, when he was a patient in the Convalescent 
 Hospital, at Cheadle, where Dr. Wansbrough Jones and myself had 
 frequent opportunities of examining him together. The first time that 
 any disorder of speech was observed to be present was one morning soon 
 after he became an out-patient. I was demonstrating the -presence of 
 hemianopsia to some students, when he volunteered the following state- 
 ment : "My sight is very curious, I cannot see things near me so well 
 as those at a distance ; I cannot, for instance, see to read this " — 
 pointing to the heading of "Manchester Royal Infirmary," in capital 
 letters, on the prescription book for out-patients which he held in his 
 
16 
 
 left hand — •' as well as those out there," pointing to signboards on which 
 the names of various mercantile firms are painted in large gilt letters, 
 
 Fig. 2.— Right. 
 
 and which would be about one hundred yards distant from us. I then 
 directed his attention to one of those signboards, and asked him to tell 
 me the name on it. After looking at it for some time earnestly through 
 his spectacles, he said, "Thomson Brothers I make of it ; I do not know 
 whether. I am right." No such name, however, was anywhere to be 
 seen. I tried him with another, and another, and still I got the same 
 reply, "Thomson Brothers." On being asked to spell the name on one 
 of tha signboards, he began, " T, h, o, m," &c., and on being told that he 
 was wrong he began with some other letters, not one of which corres- 
 ponded with the name to which his attention was directed, or with any 
 other visible name. I then got him to write down " Thomson Brothers," 
 which he did in a somewhat tremulous but very readable hand. I now 
 requested him to write his own name. "Do you mean with my eyes 
 open or my eyes closed?" he demanded. "With your eyes open, of 
 
17 
 
 course," I said. His wife interposing, said, " He can write much 
 better with his eyes closed than he can when they are open." He now 
 wrote, with open eyes, somewhat hesitatingly, but without mistake, 
 " Robert Marshall," but on closing his eyes he wrote his name in a much 
 firmer hand, and with less hesitation, than he did while using his sight. At 
 my request he wrote down " Manchester." The paper on which he had 
 been writing was now withdi'awn from him, and presented again after a 
 short interval. Pointing to the first line written by him, he read 
 " Thomson Brothers," which was correct ; but the second hne, which 
 was his own name, the third, which was " Manchester," and the fourth, 
 which was his own name again, were read equally with the first as 
 "Thomson Brothers." On being tried to spell from a printed page, 
 every letter was found to be wrong, but singularly he could read aright 
 two or three out of the nine single numbers, the number 4 being 
 generally correct. The following note was now handed to me by one of 
 the patients, who was the subject of locomotor ataxia, with white atrophy 
 of the optic discs. It was written on a memorandum form, headed 
 "Henshaw's Blind Asylum," and proceeded: "Dear Sir, — I shall be much 
 obliged if you let me know whether or not you consider it likely that A. B, 
 will recover his sight. — Yours, &c." I handed this note to Marshall, and 
 asked him to read it. He immediately took it, scanned it carefully 
 through his spectacles, moving it backwards and forwards a little until 
 he got it to the best distance for his sight, and he then read slowly and 
 deliberately, but without much hesitation : "Manchester Royal Infirmary. 
 Dear Sir, — You are requested to bring this note with you the next time 
 you come to the Infirmary," and ended up with his usual formula, " that 
 is what I make of it, I don't know whether it is right or not." His wife 
 then said : "At home he pretends to read the newspaper, and he reads 
 such stuff, all made out of his o-rni head. Last night he was reading 
 to me aloud, and it was all stuflf made up, you know. After a time he 
 got tired, and asked me to read. I read it as it was in the paper ; it 
 was something about the war (Egyptian). He was very quiet for some 
 time, and then he asked, ' Is that what it says in the paper 1 ' and when 
 I told him it was, he said, 'Well, then, I must be an idiot.'" She then 
 added, "He often says he thinks he must be an idiot now." 
 
 In August, 1885, Dr. Wansbrough Jones and myself, in testing him, 
 gave him the following paragraph to read : " The Bishop of Manchester. — 
 It is stated that the Bishop of Manchester is slightly indisposed, and will 
 be unable to fulfil his engagement to preach at St. Paul's, Brunswick 
 Street, next Sunday morning." After taking considerable time and care 
 in adjusting his spectacles, and getting the point of the index finger of 
 his right hand on the paragraph, he read : " The money market has 
 
 B 
 
18 
 
 been brought to a close, and considered much more easy than it was, 
 and I think it is going to improve." 
 
 December 16. — R. M. was again examined at the Infirmary to-day, and 
 he is found to be practically unchanged. The hemianopsia appears to 
 be as complete on both sides as it was when the patient was examined 
 about eighteen months ago. When asked to read he makes very elabo- 
 rate preparations, and utters a few sentences which have not the 
 remotest connection with anything that is before him on the printed 
 page. He can write a short word to dictation, but cannot complete 
 polysyllabic words or a sentence. Asked to write a word of two or three 
 syllables, he may, by writing very fast, write it correctly; but, if 
 he once raises his pen, he gets confused, and soon gives up the attempt. 
 After raising his pen in the middle of a word, he generally makes several 
 attempts to join the remainder of the word to the last letter, and, 
 not succeeding in this, he begins the word anew, but after one failure 
 he seldom succeeds in completing it. Asked to write "command," 
 for example, he wrote " comma." He then raised his pen, got con- 
 fused, and, after several futile attempts to complete the word, he 
 began anew and wrote "com," when he got confused a second time 
 and gave up the attempt altogether. But if, when he stops writing 
 in the middle of a word, the next succeeding letters are loudly sounded 
 in his ear, he can often complete even a long word. He generally recog- 
 nises his own name, and always reads correctly " Manchester Eoyal 
 Infirmary " as the heading of his prescription book. The next line in 
 the book, " Dr. Ross's patient," is sometimes said to be " Dr. Ross and 
 company." It would, however, appear that his recognition of these 
 words is more or less guesswork, inasmuch as he names other words 
 " Manchester Royal Infirmary," as he did in the case of the letter from 
 "Henshaw's Blind Asylum." He seldom or ever declines to give 
 some name to a word presented to him, but beyond those I have 
 just mentioned I have never known him to have been correct. 
 He is even unable to recognise a single letter. Occasionally he names 
 a letter correctly, but the next time it is presented to him he generally 
 names it wrongly, thus showing that his being right was a mere 
 accident. With numbers he can generally recognise 3, 4, and 7, but 
 with the remaining numbers he is more often wrong than right. He 
 recognises quickly and names geometrical figures, such as a square or a 
 circle, and recognises portraits. I showed him, for example, a photograph 
 of myself, and asked him whom it represented. On getting it at the 
 right focal distance for his sight, he instantly replied, " It is not a very 
 good one, but it should be Dr. Ross." His spoken language is not at all 
 impaired. His deafness makes him a stupid man to converse with, but 
 
19 
 
 there is no recognisable defect of any kind in his spoken speech. He 
 names correctly and promptly all objects presented to him, and seems 
 much amused at being asked the names of his bodily organs. He obeys, 
 without any hesitation or confusion, all spoken requests, and gives 
 rational replies to all questions. 
 
 January 16, 1886. — Mrs. Marshall came to the Infirmary this morning 
 for her husband's medicine — an iron mixture. In speaking of him she 
 volunteered a very interesting piece of information. " He has given 
 over attempting to read the newspaper now," she said. " A short time 
 ago," she continued, " I hardly knew what to do with him. He tried to 
 read the newspaper, and he kept saying, ' I don't know what is the 
 matter with the papers now-a-days, they are filled with such silly stuff.' 
 I frequently had to get him as many as four newspapers in a day to 
 see if it would satisfy him. At last I was obliged to tell him that 
 it was not the newspapers that were wrong, but that it was he who could 
 not read, and now he has given over trying." 
 
 In the following case the word-blindness was at first accompanied by 
 a considerable degree of word-deafness, but the patient is recovering 
 from the latter condition, while the former persists. The speech dis- 
 order is accompanied by an incomplete homonymous hemianopsia. For 
 the notes of the case I am indebted to Mr. Windle, my clinical clerk. 
 
 Case, 3. — James Profl&t, aged 53 years, was admitted as an in-patient 
 to the Manchester Eoyal Infirmary, on October 7th, 1885. 
 
 History. — The following account was obtained chiefly from the 
 patient's wife. They have been married for about 25 years. Twelve 
 months after they were married his wife had a stillborn child, which 
 she thinks was bom at the seventh month. Two other stillborn children 
 followed in succession at intervals of twelve months ; then she had a 
 living child at full time, but it died of convulsions at three weeks old, 
 and another stillborn child followed at the lapse of another twelve 
 months. After this time she has had five living children, all of whom 
 are now alive and healthy. The patient does not own to having 
 contracted syphilis when a young man. The patient has always been a 
 very healthy man, and his occupation — an outdoor labourer — has been, 
 on the whole, a healthy one, although it exposed him to alterations 
 of weather. He has never been a hard drinker, but at times took a 
 moderate quantity of beer. A month previous to the date of his 
 admission, he was suddenly seized, when getting up in the morning, 
 with some kind of attack, of which neither he nor his wife can give a 
 very satisfactory account further than that, as he recovered from the 
 first loss of consciousness, he was found to be speechless, and paralysed 
 on the right side of the body. For the first few days he could hardly 
 
20 
 
 understand anything that was said to him, and his attempts at speaking 
 were almost unintelligible, but he soon showed signs of amendment, and 
 he began to understand better, and to say a few words, which sufficed to 
 make known his ordinary wants. 
 
 Present Condition. — On admission, the patient is found to be a short, 
 strong, muscular man, with a tendency to obesity. The area of cardiac 
 dulness is slightly enlarged downwards and to the left, the second sound 
 at the base is considerably accentuated, and the arteries at the temples 
 and wrists are somewhat tortuous, but not knotty or calcified. The 
 urine is free from sugar or albumen, and, with the exception of some 
 bronchitis and emphysema, the thorax and abdominal organs are free 
 from disease. The patient drags the right leg a little, and there is a 
 slight relative increase in it of the patellar-tendon reaction. The right 
 hand is paralysed, and the fingers are flexed into the palm, and rigid, 
 but the patient can move that extremity pretty freely at the elbow and 
 shoulder joints. The tendon reactions are exaggerated at the right wrist 
 and elbow. There is a slight relative loss of expression of the right side of 
 the face, but so slight as to be scarcely perceptible, but there is no devia- 
 tion of the tongue on protusion. On admission, the patient had 
 complete right-sided bilateral homonymous hemianopsia. He had a con- 
 fused and lachrymose appearance, and when asked his name he drawled out 
 "Ja-a-ames Pro-o-ofit," prolonging the open vowel in each word to a 
 most comical degree. He is unable to give a connected account of 
 himself, but, after manifesting some confusion, and making some 
 mistakes, he ultimately comes to interpret and obey correctly such 
 simple requests as, " Put out your tongue ; " " Close your eyes ; " " Show 
 your hand." To the qviestion, " How old are you 1 " he replies, " I 
 ca-a-a-na te-e-U;" but when asked, "Are you a hundred years old?" he 
 rejoins, with manifest surprise, " Tut ! No-o-a, ma-a-an. I-i-i'm o-o-only 
 a yo-o-oung fe-e-llow yet." Asked if he is 50 years of age, he says, 
 " Mo-o-re," and when 53 is mentioned, he replies^ with evident satisfac- 
 tion, "Tha-a-at's it." Asked the name of his hand, he says, "I c-a-ana 
 just tell, I kno-o-ow it qui-ite we-ell, but I ca-a-ana te-ell." " Is it your 
 headT' «'N>oa, sir." " Is it your foot ? " "No-oa, sir." "Is it your 
 hand?" "Ye-es, sir, tha-a-at's it," he replies, with the usual manifest 
 air of satisfaction. Tried with his head, eyes, and other bodily organs, 
 and with surrounding objects, it was the same ; he was unable to 
 tell the correct name, but he at once recognised whether a name 
 is correct or not when it was uttered in his hearing. He recognises 
 James Profl&t, as written on the bed-ticket, but he is unable to 
 read, or even to spell, my name, or any of the printed words, 
 such as "Manchester Eoyal Infirmary," on the ticket. He is also 
 
21 
 
 unable to make out a single word ■ or letter from a newspaper. He is 
 incapable of identifying written or printed numbers. He can, however, 
 tell whether a particular written or printed letter or number is or is 
 not correctly named in his hearing. Any short and simple word uttered 
 in his hearing he is able to repeat at once, but gets confused when asked 
 to pronounce long words with many syllables such as " Constantinople," 
 
 Fig. 3. — Left. 
 
 
 Pigs. 3 and 4.— Charts of the Fields of Vision in the case of James Proffit showing by the heavy 
 line general restriction of the fields with incomplete bilateral hemianopsia. 
 
 and often sticks at the end of the second syllable. Asked to write his 
 name, he takes the pen in his left hand, his right being paralysed, and 
 makes up and down strokes like a continuous letter m, but he cannot 
 write James, which he is evidently attempting. He also writes from 
 right to left, and slants the strokes from left to right, as in mirror- 
 writing, this being the opposite way to the usual method of writing with 
 the right hand. After struggling painfully with these up and down 
 strokes for a short time, he throws down the pen and declares his 
 
22 
 
 inability to write ; and then adds, " I ne-ever wa-as a goo-od scho-o-olard. ' 
 " But you could always write your name quite well?" I said enquiringly. 
 " Oh ye-e-s, sir," " And you could read the newspaper." " Oh ye-es, sir ; 
 qui-ite we-ell." The fact that the patient's wife had several still-born 
 children rendered syphilis probable, notwithstanding his denial of having 
 had a primary sore ; and he was consequently ordered ten grains of 
 iodide of potassium three times a day, and two grains of bhie pill night 
 and morning. 
 
 Fig. 4.— Right. 
 
 I 
 
 Nov. 19. — During his residence in the Infirmary the patient improved 
 greatly. Almost every trace of hemiplegia disappeared from the right 
 side of the body, even the tendon reactions at the knee and wrist having 
 become almost normal. Soon after his admission it was observed that his 
 fields of vision were rapidly enlarging on the blind sides, and the annexed 
 perimetric tracings (Figs. 3 and 4) which were taken on October 19 — 
 twelve days after admission — show that the bilateral hemianopsia was by 
 no means so perfect at that date as it was when the patient was first 
 examined. At the date of the present report the fields have enlarged still 
 further, and instead of a complete bilateral hemianopsia the fields are 
 
23 
 
 only slightly restricted on the right side. The patient can now name the 
 different parts of his body and the common objects by which he is 
 surrounded, but still hesitates over the name of any unaccustomed 
 object presented to him. The power of naming has, however, come to 
 him only gradually and by a certain amount of training. He expe- 
 rienced a good deal of difficulty in giving a name to his own ear. When 
 the word " ear " was uttered in his hearing, he at once recognised that 
 it was the appropi'iate name for his organ of hearing, and repeated 
 the word readily, while holding the lobule of his ear between his finger 
 and thumb. If asked the name again after a short interval, he would 
 say " There, I've lost it ; I cannot tell," and he would then close his 
 eyes and turn his head now to one side then to the other, as if he were 
 intently listening ; but all in vain, and he would soon give up the effort. 
 After the lapse of a few days, however, when once the word "ear" was 
 uttered in his hearing, he would retain the use of it for the remainder of 
 that moraing, but would forget it by the following day. After another 
 interval of a few days he was able to retain the use of the word perma- 
 nently. When he had made considerable progress in acquiring the 
 names of his own organs and of the surrounding objects, I presented my 
 watch to him and asked him to name it. He was unable to do so. I 
 then asked " Is it a bell ? " to which he promptly replied " ISTo, Sir ! " 
 " Is it a clock ? " I now asked. To this question he replied somewhat 
 dubiously, " That's something like it " ; but when asked " Is it a watch 1 " 
 his expression brightened up and he immediately responded " That's it — 
 a watch." He was now requested to read off the time from the watch. 
 After several futile efforts he placed the tip of the index finger of the 
 right hand opposite the figure one, and carrying it slowly round the 
 dial, he named correctly each figure in succession until he came to 
 twelve ; but even then he was unable to tell the correct hour, and never 
 attempted to read the minutes. I now asked him if the right time 
 were a quarter past six, purposely naming the wrong time, and he 
 immediately answered in the negative ; but on asking if it were twenty- 
 five minutes past eleven— the correct time — he said " That's more like 
 it " ; but his assent was not given with that bright intelligence he 
 manifests when he recognises the forgotten name of an object. He was 
 now discharged from the Infirmary and made an out-patient. 
 
 Jan. 16, 1886. — James Proffit appeared as an otit-patient at the 
 Infirmary this morning. He has improved considerably in his speech 
 since the last report ; there is not much restriction to be discovered now 
 in the fields of vision, and the hemiplegia has almost disappeared. He 
 named correctly most of the objects presented to him, but on being 
 asked the name of one of those table-bells which is rung by striking a 
 
24 
 
 brass knob at the top of the instrument, he hesitated, and for some time 
 failed to recollect it. He closed his eyes, and turned his head, at first to 
 one side, and then to the other, as if he were listening ; he then opened 
 his eyes, and said, disappointingly, "I cannot justly remember it." After a 
 pause, liis face brightened up a little, and, tapping the side of his head 
 with the tip of the middle finger of his right hand, he remarked, 
 laughingly, "I have it here quite well, if it would only come out," 
 and immediately afterwards he became very animated, and brought down 
 his hand on the knob of the bell, ringing it violently, while, at the 
 same time, he shouted out, " Bell ! There, I have got it." He repeats 
 most words very promptly when uttered in his hearing. He even 
 suceeded in pronouncing " Constantinople " fairly well, but stuck 
 in the middle of " hippopotamus." The correct spelling of his surname 
 not being known to us, I wrote on a piece of paper, " James Prophet," 
 and asked him if that were correct. " Yes, I think that's it," he said 
 dubiously. " Do you not think that this is right ? " I asked, and wrote 
 down " Profit." "No, sir," he replied hesitatingly, "I think that's it," 
 pointing with his finger to the first name, but he then pointed to the 
 letter "f" in the second name, and said, "There are two there." I now 
 wrote down " Prophit," and he said promptly, " No, sir ; " and again 
 pointing to the first, he said, " I think that's it." I now spelt the name 
 "Proffit," when he immediately called out, "That's it," and afterwards 
 adhered to this assertion in a very positive manner. On being asked to 
 read the heading of his prescription book, he surprised us by saying, 
 "Manchester Ptoyal," but he failed to make out "Infirmary." I now 
 asked him to spell the word, but he was incapable of telling a single 
 letter, and could not be got to hazard a guess. I pointed to the first 
 letter, and asked him if it were "A." "No, sir," he replied. "Is it 
 ' B ' ? " I asked. " No, sir," he said, laughing. "Is it 'I'V was now 
 inquired. "Yes, sir; that's it," he said, with emphatic assurance. It 
 was the same with all the other remaining letters. He at once knew 
 when they were correctly named in his hearing, and could immediately 
 repeat them, but he was quite unable to name them correctly without 
 prompting. He could not read a single word from a newspaper, or 
 even recognise a single letter. On being asked to tell the time by a 
 watch he at first failed, but after a time he drew, as he did on a previous 
 occasion, his index finger round the dial, and counted from one up until 
 he came to twelve, the hour hand pointing between eleven and twelve. 
 After looking for some time at the hour hand, he drew his finger back to 
 the minute hand, which was pointing between seven and eight, and after 
 another considerable interval, he burst out with "Twenty minutes to 
 twelve ; that's it." 
 
25 
 
 In the next case which I shall report word-blindness is accompanied 
 by word-deafness. The patient is also siiffering from bilateral 
 hemianopsia. 
 
 Case 4. — Joseph Lander, aged 51 years, entered the Manchester 
 Eoyal Infirmary under Dr. Ross, on August 20, 1884. 
 
 History. — The patient is a working engineer, and has been, according 
 to his wife's statement, always a strong and healthy man. He has been 
 married eighteen years, and has three children, all of whom are healthy. 
 There is no evidence of syphilis. The patient has indulged freely 
 in beer drinking, and has been a good deal exposed to cold and wet ; but 
 he has always had a comfortable home and been well fed. Three weeks 
 before he came to the Infirmary he was from home and slept at Shefiield. 
 He Avent to bed in his usual health, but in the morning he was unable 
 to speak. All he could say was " home," " home," and he wanted to 
 go to the station in order to get back to Manchester. He was, however, 
 detained imtil his wife arrived, and she immediately got him to the 
 train and brought him back home. For the first few weeks he was 
 under the care of Dr. Scott, and during that time he could speak 
 but little, and understood very imperfectly what was said to him. The 
 day after he came home he wanted some article of diet. He kept 
 repeating, " I want some of them there," and at the same time he put 
 his hands together, and moved them as if he were breaking a biscuit in 
 two. His wife presented to him every kind of diet she could think of, 
 and even sent out for oysters and various other likely articles, but it was 
 only at the end of five or six hours experimenting that she, aided by 
 her youngest son, hit upon the diet he wanted, which consisted of boiled 
 bacon and beans. 
 
 Present Condition. — The patient is a strong muscular man, and with 
 the exception of the usual signs of arterial degeneration he is free from 
 any organic disease. So far as can be judged, the patient is the subject 
 of a right-sided bilateral homonymous hemianopsia ; but it is so difficult 
 to make him understand the necessary directions, and he is so confused in 
 his replies, that it is impossible to attain to any certainty on this point. 
 When asked to put out his tongue he instantly obeys, but does not 
 comply with any other request unless the spoken demand is accompanied 
 by expressive pantomime. He is incapable of naming correctly almost 
 any object presented to him, or any of his bodily organs. His fingers 
 he calls the first, the second, the third, and the fourth. Shown a bunch 
 of keys, he took a hold of one between the finger and thumb of the 
 right hand, and imitating the unlocking of a door he said, "It's a 
 wheel." Not being satisfied with this name, he made several other 
 attempts to re-name it, and as every fresh effort ended in his calling it 
 
26 
 
 "a wheel," he at last gave up the attempt, and said, "That's the way I 
 am ; I know it quite well, but I cannot say it." When asked to count 
 numbers in succession beginning with one, he always says, " The first, 
 the second, the third," &c., and by no persuasion can he be made to say 
 " one, two, three," &c. He is wholly incapable of breaking in upon the 
 series. When asked to say "three," for instance, he begins by "the 
 first." Shown a shilling, he called it "the first;" then correcting him- 
 self, he named it " Saturday." Shown half-a-crown, he called it " two 
 and two pence ; " but when the shilling was again presented to him, he 
 named it correctly. The half-crown being again shown him, he called it 
 " two and two pence halfpenny f but evidently recognising that he had 
 made a mistake, he said, " That's what bothers me ; I cannot say it." 
 
 Shown a pencil, he said, "It's a pu ■; it's a punt — ; no, that's what 
 
 bothers me," and he gave up the attempt. Asked the day of the week 
 (Wednesday), he said it was " Waterday." He cannot read a word or 
 recognise a single letter or number ; but as he gets very irritable when 
 pressed to read, it is possible that his incapacity may not be so great as 
 it seems. He cannot be induced to attempt to write his name ; and 
 when asked, he protests loudly that he can't. The patient was very 
 unsettled in the Infirmary, and was discharged on September 8th, 1884. 
 January 16, 1886. — Joseph Lander appeared occasionally at the 
 Infirmary as an out-patient for some time after his discharge as an in- 
 patient. About the beginning of 1885 his wife told me that he was 
 "fretting at not getting to his work," and at her urgent request I wrote 
 a note to his employers to say that I thought it likely that he would 
 be found on trial to be quite capable of undertaking his previous work of 
 taking charge of a stationary engine. He appears to have been an old and 
 valued servant, and was accordingly re-instated in charge of his engine, 
 and he has continued to perform his duties, without assistance, from 
 that time until this date. Since he entered upon his old employment 
 I have seen little of him until this evening, when he came for examina- 
 tion, in obedience to a post-card I sent him a day or two ago. In general 
 health he is much the same as he was when he came first under observa- 
 tion, but looks considerably older now than he did then. An examina- 
 tion of his fields of vision shows that he is suffering from a complete 
 right-sided bilateral homonymous hemianopsia, the blind being separated 
 from the sensitive parts of each retina by a sharply-defined vertical line. 
 His speech has improved considerably in several respects since last report. 
 He can now name correctly many common objects, and several of his 
 own bodily organs, but his vocabulary of names is still very limited. 
 His nose, head, eyes, mouth he named correctly and promptly. Asked 
 the name of his finger, he said, " That's my first;" but, on being pressed 
 
27 
 
 still further for a uame, he replied, " That's the way I am ; I've forgotten 
 it again, I know it sometimes quite well." On the name being uttered 
 in his hearing, he recognised its correctness and repeated it. Asked the 
 name of his ear, he replied by the usual formula of failure, " That's the 
 way I am, I have forgotten it." "Is it your nose?" I asked. "This 
 should be my nose," he replied archly, while at the same time pointing 
 to the proper organ. Catching a hold of his ear, I said, " This is your 
 ear. Say my ear." In reply, he said, "My nose, no 3 that's not it," 
 and after many efforts he was still unable to repeat the correct word. I 
 then asked him to say the letter E, but in this also he failed. I now 
 got him to repeat, after me, the alphabet, beginning with A, and when 
 he got to E I stopped him, and asked him to say ear, but it was only 
 after several repetitions of this process that he at last succeeded in 
 getting the word. My first effort to get him to repeat a word after me 
 was to ask him to say " Constantinople." " I could not say it," he replied, 
 "if you were to give it me." On being pressed, he made one or two 
 attempts, but never succeeded in getting the first syllable. Some short, 
 common words, like ink, for example, he repeated after me without hesi- 
 tation. His capacity to understand questions varies a good deal. On 
 interrogating him, for example, about his vision, he gave a graphic 
 account — partly in words and partly by acting — of how his visual 
 defect caused him to come into collision with people on the street. 
 "Little children," he said, "get right under me before I see them; 
 I am frightened of going over them." A few minutes before this 
 he was bemoaning his condition, and said, " If you were to ax me my 
 own name just now I could not tell you." I asked him if he could 
 write it, and, with some reluctance, he took the pen and wrote — 
 
 When he came to the last letter, which was evidently intended for the first 
 letter of his sui-name, he stopped, and, after several efforts to continue, he 
 said, " Ko, I can't manage it." He now made a fresh attempt, and wrote — 
 
28 
 
 but could go no further, and said " T'other part of the name I can't 
 manage at all." During these attempts at writing his nam.e he got very- 
 flushed in the face, and for some time afterwards he was very confused. 
 I asked him, "Where do yon live?" "What, what?" he asked, "my 
 father ? " His wife then asked him the same question in the vernacular, 
 but he still kept asking in a confused manner, "What, my sister? my 
 grandmother?" I then mentioned Ardwick, the locality in which he 
 lived. " Oh, Ardwick ? " he said, " Oh yes, I live in Ardwick," but he 
 could not be got to name the particular street, even after it was told him. 
 I now wrote — 
 
 plainly on a piece of paper, and asked him to copy it, and after con- 
 siderable hesitation and trouble he wrote — 
 
 -.5^^^^^-^^^ 
 
 Finding that the copy had assisted him in writing his name, I asked 
 him to copy the word "contents," which was printed in moderately- 
 large capitals in a newspaper lying on the table. He was, however, 
 imable to copy a single letter from the printed page, but when I 
 wrote the word — 
 
 on a piece of paper, he wrote below it the following — 
 
 0^^^-^^^ 
 
 ^^ 
 
 •f-^^:;2-*n. 
 
29 
 
 which is a fair attempt, althoiigh it would not be easily deciphered 
 if not for the knowledge that it was an endeavour to copy the word 
 "contents." I now drew a square on paper, and he immediately made a 
 very accurate copy of it, but was unable to name the figure, and added, 
 "I know it quite well; I used to do a lot of this at our Avork," meaning 
 that drawing was a necessary accomplishment for an engineer. I then 
 drew roughly the outline of a man's face, and he immediately took the 
 pen and quickly drew another, and laughingly remarked, " I have put 
 plenty of nose on." 
 
 The patient is quite unable to read a single word. He can, however, 
 recognise some letters of the alphabet, but not others. My eye lighting 
 upon the word "whisky," printed in moderately-sized capitals on the 
 cover of the Grajpliic, a word doubtless at one time very familiar 
 to him, I asked him to spell it. He spelt it, "H, h, i, s, h, e." 
 His mistakes having been corrected, he at last succeeded, after many 
 trials, in spelling it correctly, but very slowly. He voluntarily con- 
 tinued the exercise, and at each repetition he spelt the word quicker, 
 and with greater ease, and after several repetitions the letters followed 
 each other as quickly as in the usual spelling of healthy people, when at 
 last his countenance lit up with a smile, and he pronounced " whisky." 
 
 We have already seen that in Case 3, and still more markedly 
 in Case 4, the word-blindness was accompanied by a considerable 
 degree of word-deafness, and we shall now proceed to describe a 
 case of more or less pure word-deafness, or, at any rate, one in 
 which the inability of comprehending spoken speech was not accom- 
 panied by any marked difficulty in understanding written language. 
 It may, however, be. observed that, inasmuch as language is first 
 developed in connection with the sense of hearing, injury of the 
 auditory mechanism may be expected to produce a much more profound 
 disorganisation of the faculty of speech than does injury of the visual 
 mechanism. An imperfectly educated man, for example, scarcely 
 comprehends written speech unless he reads aloud, and in him it is 
 manifest that loss of the faculty of appreciating spoken speech would 
 necessarily carry with it loss, or, at least, great diminution, of the power 
 of understanding a printed page.^ It has already been remarked that an 
 injury of the impressive mechanism of speech will throw into disorder 
 the expressive mechanism, and it is in cases of word-deafness that we 
 meet with the most marked examples of the condition which Kussmaul 
 has called loara'phasia. In this condition the patient applies wrong 
 names to objects, using a word kindred in its meaning with the one 
 intended, as "worm powder" for "cough medicine;" or in its sound, as 
 
 1 See Watteville, Dr. A. de. "Note sur la cecite verbale." — Le. Progres Medical, March 21, 1885 
 
30 
 
 "parasol" for "castor oil," or "butter" for "doctor," A still more 
 profound disorder of the impressive faculty of speech is reached in those 
 cases, which are by no means rare, in which the patient is unable to 
 name his own bodily organs, or any of the common objects by which he 
 is surrounded. Inability to name objects has been called by Kussmaul 
 the aphasia of recollection. We accept the term simply as expressive of 
 certain clinical facts, although it must be admitted that it carries with it 
 somewhat undesirable theoretical implications. With these preliminary 
 remarks we shall proceed to report the following example of ivorcl- 
 deafness, which is accompanied by a profound degree of the aphasia of 
 recollection. 
 
 Case 5. — James Lee, aged 57 years, is an out-patient under me at the 
 Manchester Koyal Infirmary at the date of this report, December 16th, 
 1885. He has, however, been more or less under my observation for 
 the last four or five years, having been two or three times an in-patient, 
 and many times an out-patient, of the Royal Infirmary, as well as a 
 patient several times in the Barnes Convalescent Hospital at Cheadle. 
 
 Previous History. — The patient was born in Rugby, and was a gas- 
 fitter by trade, but for many years he has been a messenger at the 
 Manchester Bankruptcy Court. He was always an unsteady man, and 
 his employment, in serving writs for the last few years, favoured his 
 drinking propensities, and he was a well-known character in all the 
 beer-houses in Manchester and neighbourhood. He has a grown-up 
 family, all of whom are healthy, and there is nothing in his history 
 pointing to syphilis. When he came for the first time under observa- 
 tion, four or five years ago, his wife stated that he had a fit several months 
 previously, and from that time he had been unable to speak correctly. 
 She asserted that he was not completely unconscious or convulsed during 
 the attack, and that he never had any signs of paralysis. On admission 
 to the Infirmary, he was found to have an earthy complexion, his 
 temporal arteries were dilated and tortuous, the radials were hard and 
 knotty, and the second sound of the heart at the base was highly 
 accentuated. The urine was free from albumen or sugar. The grasp of 
 either hand was good, and there was no exaggeration of the tendon- 
 reactions at either knee or wrist, or any other evidence that the patient 
 had suffered from paralysis. He sees imperfectly with the left eye, but 
 we gather from him that this defect is of old date. The media of this 
 eye are transparent, and, with the exception of slight pallor of the disc, 
 no changes are discovered in the back of the eye on ophthalmoscopic 
 examination. The right eye is the subject of a high degree of 
 presbyopia, but there is no restriction of the field of vision, and the 
 optic disc is healthy. On applyiug a piece of camphor to the left nostril, 
 
31 
 
 the right being closed, he gives no evidence that he perceives the smell, 
 but when he sniffs it with the right nostril he immediately draws his head 
 back, and, pointing with the index finger to the right nostril, he says, 
 "This is all right, but," he continues, pointing now to the left nostril, 
 " with this one I can't at all." This test has been frequently applied during 
 the many years the patient has been under observation, and always with 
 the result just described. Ilis sense of hearing for ordinary noises is 
 very acute. He hears the ticking of a watch when it is a foot or more 
 from either ear, and the slightest knocking at a door, or other noise at his 
 back, caitses him to turn round. No other sensory disorders have been 
 discovered. The patient, on being interrogated with regard to his occu- 
 pation, replied, " When gentlemen got into trouble, I brought an action 
 against them, and then they were all right ; " and in order to make still 
 plainer the functions he exercised in connection with the Bankruptcy Court, 
 he generally produced out of his pocket a writ or some such legal 
 document. 
 
 On being asked the nature of his complaint, he replied, "I am all right, 
 if I could only speak it j there is nothing the matter with me. I am quite 
 right, but I cannot speak it at all." He was now handed a bunch of keys, 
 and asked to name one of them. He held one between his thumb and 
 index finger, and said, " It is a public-house." " That is not a public- 
 house," I said. " I know it quite well ; " he replied, " I have seen it 
 thousands of times," and, trying again to name it, he continued, " It 
 is a — it is a public-house. Pooh ! I know it quite well ; " and, by way 
 of further explanation, he added, "When you go to bed at night, 
 you do this," turning the key from left to right, as if he were 
 locking a door, "and when you get up in the morning, and want 
 a drop of beer, you do this," turning the key from right to left, as if 
 unlocking. A latch, key was now placed in his hand, and he was asked 
 to name it. He immediately assumed a very comical expression, and 
 said, " I know it quite well. When gentlemen, you know," he now looked 
 still more comical and knowing, " are out, and when they come iu, they do 
 this," imitating the unlocking of a door, "and then they are all right." 
 He was now asked to name a watch key, which was placed in his hand, 
 and he instantly replied, "It is for your public-house, there," pointing to 
 my watch pocket, "you do this," imitating the movement of winding a 
 watch. Asked to name the index finger of his right hand, he said, 
 " That is the first one." " The first what 1 " I demanded ; to which ho 
 replied, "The first public-house." The middle finger was named 
 "the second," the ring finger "the third," and the little finger "the 
 fourth public-house." He managed to name coins fairly correctly, 
 although not until after several futile attempts. Half-a-crown was 
 
32 
 
 often at first said to be "twopence halfpenny," and a two shilling 
 piece, -'twopence;" but when coppers were shown to him he generally 
 named them correctly, and then sometimes, but not always, he worked 
 up to a sixpence, a shilling, two shillings, and half-a-crown without 
 committing a mistake. Every other object presented to him was 
 " a public-house," or " a glass of beer." A very laughable illustration of 
 the manner in which he used the word "public-house " on all occasions, 
 was afforded in 1883. I brought him over, along with several other 
 patients, to show to the members of the British Medical Association 
 attending the Liverpool meeting. Dr. W. H. Broadbent, who took a great 
 interest in his case, had just finished his examination of him, and we 
 turned away to examine a case of rupture of the brachial plexus. James 
 Lee advanced and tapped me on the shoulder, and pointing to the other 
 patient said, with an air of gi-eat importance, "I know this gentleman, 
 I know him quite well ; he once lived in the next public-house 
 to me." The other patient explained that eighteen months pre- 
 viously he occupied for some weeks the next bed to Lee in the 
 Infirmary. 
 
 The patient is quite unable to repeat any name uttered in his hearing, 
 and does not even seem to appreciate the difference between the right 
 and the wrong name. When, for instance, he holds a key in his hand 
 and is asked whether or not it is a horse, he gets confused and says 
 hesitatingly, "Yes ! Yes, it is a public-house," and when he is next asked 
 if it is a key, he gives the same answer in much the same manner, 
 without giving any evidence that he has recognised the absurdity of the 
 first and the appropriateness of the second designation. He can count 
 in succession numbers iip to twenty or even higher when he starts with 
 one, but he is unable to break in upon the succession. Asked to start 
 with " five " for example, he begins with " one." When asked to put 
 out his tongue in spoken language he promptly opens his mouth and 
 complies with the request, but this is the only mandate he obeys unless 
 the spoken request is accompanied by an expressive look or other sign. 
 He is, however, very quick at interpreting pantomimic speech. Asked 
 his age, he said, " I think I am twenty ; no, that is not it, I think I am 
 twen — . No, I can't speak it at all, I know it quite well." " Don't you 
 think you are a hundred 1" I asked. "No, I don't think I am so old 
 as that," he replied, somewhat dubiously. After being asked his name 
 and age several times, he came one day armed with a small pocket-book 
 in which he had his own name and address, his age, my name, Eugby, 
 which was his birthplace, and the names of several other places and events 
 written down carefully. When now asked his name or age he immediately 
 dived into his pocket and producing his book he pointed to the writing. 
 
33 
 
 " See, that is my name. James Lee is my name ; I was born there — 
 Rugby. That is my age ; I am 57 years of age." Asked now if he does 
 not think he is a hundred, he says, " No, I am not so old ; that is my 
 age," pointing to 57 in his book, but at the same time he does not appear 
 to be in any way sensible of the ridiculousness of the question. When, 
 however, the number 100 is presented to him in written characters 
 and he is asked if that figure corresponds to his age, he imme- 
 diately bursts out laughing and says, " Pooh ! pooh ! nothing of the 
 kind." Pointing again to the 57 in his book he says, " That is my age." 
 Although James Lee will not obey a simple request like " Give me your 
 hand," he understands at other times apparently much more complicated 
 statements and requests. His wife told me that he was very unruly at 
 home, and that he often struck at her and his daughters. For his conduct 
 to his family I gave him a severe reprimand, the nature of which he 
 appeared to understand perfectly. Some time afterwards I asked him 
 "Do you strike those at home yet?" He blushed deeply and said with 
 a forced smile, " Yes, I give them a clout (slap) sometimes." Then 
 getting very angry and losing his self-control he continued, " Yes ! they 
 don't do well to me, but I will kill some of them, I will," he continued 
 with fearful energy and determination, "I will kill some of them 
 yet." "If you kill any of them," I said, "you will be hanged for it." 
 " What do I care ? " he retorted ; " they can't do anything to me ; I don't 
 care a bit, it is nothing to me, it will be done with then," evidently 
 meaning that he did not value his life, and did not care how soon 
 or in what manner it was ended. On now being asked to show his 
 hand he got confused, and after a time put his tongue out. I then 
 repeated the question, and both looked at and pointed to the hand, and 
 he immediately held it out, showing conclusively that his want of 
 compliance with the first request was simply because he did not 
 understand its terms. He evidently understood the nature of my threat 
 that unless he restrained his passions he would get hanged, while he 
 was miable to comprehend the name of his hand. 
 
 James Lee can write in a beautiful round hand, which is singularly 
 free from the tremor of age or from the signs of any other infirmity, 
 and he can copy from a printed or written page without committing 
 mistakes in spelling or punctuation. He is, however, unable to write a 
 single word to dictation except his own name, which he always writes, 
 when asked, with apparent pleasure and pride. When requested to add 
 his address to his name, he produces his little pocket-book, and carefully 
 copies the address. His efforts at spontaneous writing are somewhat 
 ludicrous. A short time ago I sent him a post card to ask him to come 
 to the Infirmary, as I wished to show him along with other cases of 
 c 
 
34 
 
 aphasia to a clinical class, and by return of post I got the following 
 post card : — 
 
 The card was doubtless intended to intimate that I might rely upon 
 his appearing at the appointed time. During the summer of this year 
 (1885) James Lee was an in-patient in the Infirmary in the same ward 
 with a very intelligent patient who became interested in his case, and 
 was very attentive and kind to him. After a time Lee was sent to the 
 Barnes Convalescent Hospital, and soon afterwards the other patient, 
 who remained in the Infirmary, showed me the following letter, which 
 he had received from him : — 
 
 -<^ r^c^-^oa^ ^ -^^ 
 
 
 
 C--tr-o 
 
 The recipient of the letter thought, and I have no doubt correctly, that 
 Lee meant to thank him for his exceeding kindness to him. Along 
 with the letter came an old newspaper entitled The R^ighy, and the 
 
35 
 
 fact that these words were copied from the printed page explains how 
 they came to be correctly spelt. 
 
 The patient reads fairly well, but it is difficult to determine how 
 much, of it he understands. When asked to read a paragraph of a 
 newspaper, he reads on without much hesitation, but he seldom 
 completes a sentence without committing a mistake or two, which 
 completely mars the sense ; but he goes on without trying to correct 
 himself, and when he has finished, he cannot be got to give any 
 indication that he has comprehended the nature of the subject. 
 He cannot also be got to obey written requests, I have tried 
 him with such a simple request as "Put your tongue out" written 
 plainly on a slip of paper. He read the words at once, but put the 
 paper down without giving any sign that he understood the nature of 
 the request, and although he always- gave prompt obedience to this 
 mandate in spoken language, he could not be got to obey it when written. 
 It is probable that on being requested to read before spectators, he 
 regards the simple act of reading as an exercise to be pei'formed without 
 any ulterior aim, and that consequently he makes no effort to compre- 
 hend the meaning of the composition. There can, indeed, be little 
 doubt that he does understand a good deal of what he reads in private, 
 although it is possible that his comprehension of much of it is somewhat 
 dim and obscure. During the public excitement caused by the revela- 
 tions in court at the trial of the Phoenix Park murderers, at Dubhn, he 
 came to the Infirmary one morning and said to me, with fierce energy, 
 " Those fellows over there — I would hang every one of them, every one of 
 them I would hang." I have no doubt whatever that by " those fellows 
 over there " he meant the Irish prisoners, and possibly all their 
 sympathisers, and he must therefore have understood the nature of 
 their crime from reading the newspapers, because his comprehension of 
 it through spoken speech was wholly impossible. 
 
 When an in-patient of the Infirmary he is generally found with a news- 
 paper near him, and he frequently scans its columns. One day I remarked 
 to him, " I see you are reading your newspaper." " Yes," he replied ; " but 
 I cannot speak it at all." " But you understand all that you read 1" 1 
 said, enquiringly. "No, I can't," he rejoined; "I can't speak it." He 
 then, byway of correcting himself, pulled a very sorrowful countenance and 
 said, " No, I can't do it ; I can't do it at all. I used to do it very well, 
 but I can't do it now at all." From his manner, which long observation 
 had often enabled me to interpret readily, it was evident that he meant 
 to make a distinction between the " I can't speak it " and "I can't do it," 
 By the last phrase I have no doubt he meant me to understand that he 
 was not able to comprehend the meaning of what he read now as he 
 
36 
 
 once did. His comprehension of some written words was, however, 
 made convincingly clear to me in another way. For some time now he 
 has ceased to name everything presented to him " a public-house," but 
 calls them " a glass of beer," or " a drop of beer " instead. One day I 
 asked him the name of his index finger, and, as usual, he said, " That is 
 the first one," and on being pressed for a further name he called it "the 
 first glass of beer." I then wrote down " finger " on a piece of paper, 
 and on reading it his face lit up with intelligence, and pointing to the 
 index finger of his left hand, he said "That is this — that is my finger." 
 After a short time I again asked him the name of his index finger, and 
 he immediately cast his eyes about in search of the paper, and when his 
 eye lit upon it, he said triumphantly, "That is my finger." The paper 
 was now removed, and after another interval he was asked the name. 
 He now, as before, cast his eyes about him in search of the paper, but 
 on failing to find it, he looked in the distance as if he were in deep 
 thought, and kept repeating at intervals, " It's my fe — fe — fe — ", but 
 on being again urged to name it, he looked down at his finger and gave 
 the stereotyped answer, " It is the first glass of beer." It was found that 
 he could readily identify the written names of key, book, pencil, &c., 
 with their corresponding objects. The request to name his finger being 
 a favourite test and frequently used, it was found after a time that, 
 without being shown the written word, he made a strenuous efibrt to 
 recall the name by repeating "f — f — f — ," but this effort always ended 
 in his calling it the " first glass of beer." When once, however, he saw 
 the printed word he retained its use without refreshing his memory by 
 sight during the rest of the time occupied by that day's examination. 
 There can be little doubt, therefore, that the names of common objects 
 could have been reorganised in this man by the systematic use of 
 printed words. 
 
 .January 9th, 1886. — James Lee came to the Infirmary this morning as 
 an out-patient, and his behaviour forms a striking commentary on the 
 remark just made on the possibility of reorganising in him the names of 
 common objects. On testing him in the usual way, by asking him to 
 name his index finger, he replied by calling it his " hand," instead of " the 
 first glass of beer." I asked him to name his hat, which at the time he 
 held in his hand. "That is," he said with some hesitation, "that is 
 my head," and at the same time he lifted his hat and put it upon his 
 bead. A son-in-law of his, who accompanied him, said, " You should say 
 hat; you knew the name quite well last night." I then said, pointing 
 to the hat, which he now again held in his hand, " That is your hat, and 
 
 not your head." "Yes," he said, "it is my it is my head,"- again 
 
 raising the hat and putting it on his head. The son-in-law again inter- 
 
37 
 
 posed, aud said to me, " If you will write down the name, he will know it 
 at once. I tried him for a long time last night, and by writing down 
 the words for him he got to know hat, head, hand, and various other 
 names quite well ; but he has forgotten them now." The son-in-law 
 also stated voluntarily, " His judgment is very good. He is, indeed, a 
 man of very excellent judgment ; there is nothing the matter with him 
 except in his talk." This shows that a man of ordinary intelligence, 
 and without any special experience or training, may recognise the 
 difference between the mental condition of this patient and that of an 
 insane person. 
 
 January 27. — The patient was once more tested to see if he could be 
 got to obey written requests. I wrote dowu on a piece of paper, " Put 
 out your tongue." He read it at once, but put down the paper as usual 
 without complying Avith the request. I kept pointing to the paper and 
 urging him to do what was wanted. After a considerable time his face 
 lit up with an intelligent smile, and he obeyed. He was now presented 
 in succession with the written requests, "Show me your hand" and 
 "Where is yom' head?" and to these he promptly replied by holding out 
 his hand and pointing to his head ; and on being asked in wi'iting, 
 " Have you got any keys 1 " he put his hand in his pocket and produced 
 one. His ready compliance with these requests shows pretty conclusively 
 that, as I have already remarked, his failure hitherto to obey written 
 commands was owing to the fact that he regarded the words presented 
 to him simply as an exercise in reading. 
 
 In the following case of word-deafness the incapacity of the patient 
 to express his thoughts in spoken language is much greater than in the 
 case just reported. 
 
 Ca.se 6. — John Morris, a man between thirty and forty years of age, 
 entered the Manchester Eoyal Infirmary on July 26th, 1886. 
 
 The patient is unable to give any account of himself, and all that is 
 known of him is that some months ago he had " a stroke," and that for 
 some weeks afterwards he suffered from some degTce of paralysis of the 
 right side of the body, and loss of speech, being unable either to speak 
 himself or to understand what was said to him. He gradually recovered 
 the use of his limbs, and his mouth, which was at first drawn to the 
 left, soon became straight. 
 
 Present Condition. — The patient is, on the whole, a healthy-looking 
 man, but his pulse is found to have the usual typical characteristics of 
 Corrigan's pulse, and his forehead, on being scratched, presents well- 
 marked capillary piilsation. On physical examination of the chest, the 
 apex of the heart is found to be displaced downwards and to the left, 
 the prsecordial dulness is enlarged, and a double murmur is heard in the 
 
38 
 
 aortic area, the diastolic murmur being heard at the top of the sternum 
 but not in the carotids. The patient presents, in short, all the symptoms 
 of a free aortic regurgitation, but in other respects his general health is 
 fairly satisfactory. When a piece of camphor is applied to each nostril 
 in succession he indicates plainly by pantomime that he appreciates 
 the smell with his right but not with his left nostril. The patient piits 
 out his tongue when asked to do so, but he does not obey any other 
 spoken request. To all enquiries about his health he replies in such 
 phrases as "Yes, thank you;" "John, if you please, ma'am;" "All 
 right, thank you;" but his reply never seems to have any kind of relation 
 to the question asked him. On being asked, for example, to name the 
 index finger of his right hand, he says, "John, if you please, ma'am." 
 His attempts at reading are invariably the same. He points with the 
 tip of his right index finger to each word in a line in succession, and 
 repeats, "John nissus, John nissus, John nissus, bree." This jargon is 
 intoned as a kind of chant, and the last word is dwelt upon with an air 
 of much apparent satisfaction, and prolonged to an unusual degree. On 
 uttering " bree " the patient stops, hands back the book or newspaper 
 from which he has been reading, and says, " Thank you, if you please, 
 ma'am," and if urged to continue his reading he repeats the same jargon, 
 beginning as before with "John" and ending with "bree." At times he 
 manifests signs of irritation and disappointment at not being able to 
 read. On these occasions he stops short at "John" or "nissus," utters 
 " Tut ! tut ! " knits his brow, and assumes a lachrymose expression. He 
 at the same time gives a significant jerk of his head to the left, and points 
 with the index finger of his right hand to his tongue or the roof of his 
 mouth, as if he wished us to understand that the cause of his misfortune 
 was to be found somewhere in the cavity of his mouth. But although 
 the patient is tmable to read aloud, he immediately obeys written 
 requests. When such words as "finger," "hand," "head," "ear," 
 "table," tfec, are presented to him he immediately points to the right 
 object, and gives prompt obedience to written requests like " shut the 
 door." He is unable to write any word, either spontaneously or to 
 dictation, except his own name, which he writes in very legible charac- 
 ters. He can, however, copy a printed word in printed but not in 
 written characters, and a written word in a current hand but not in 
 printed characters. He is also able to add up a column of figures, and 
 to write the result in figures correctly. 
 
 Of the few soimds which the patient uttered on attempting to read, 
 the origin of John as being his own name is apparent. The nissus was 
 probably suggested by the hissing sound of the " s " in Morris, but it is 
 hardly possible to give any account of the sound hree. 
 
39 
 
 In the following case, reported by Giraudeau/ the patient could 
 communicate her ideas in writing, but it is not mentioned how far she 
 had the power of naming objects. 
 
 Case 7. — "Bouquinet Marie, aged forty years, laundress, entered 
 L'Hopital Saint Antoine, under the care of Professor Hayem, on February 
 22nd, 1882. The patient had never suffered from any serious disease 
 previous to her present illness, and nothing in her history pointed to 
 alcoholic excess or to syphilis. She never had been regular, and had 
 ceased menstruating for six months. For three months she had suffered 
 from a constant headache, which was diffused over both sides of the 
 head, and was subject to a nocturnal exacerbation of such severity as to 
 have prevented sleep. In the week previous to her admission, the 
 headache was at times so violent as to cause the patient to cry out with 
 pain. The patient had never suffered from vomiting, loss of conscious- 
 ness, or epileptiform attacks. About a month previous to her admission, 
 the pains became so severe as to compel the patient to give up work ; 
 and at the same time it was observed that she was no longer able to 
 understand what was said to her, and did not answer when spoken to, but 
 she never committed any unreasonable action. She passed her time at 
 home bemoaning her condition, and only occasionally went out. These 
 facts were obtained from the person who accompanied her to the hospital, 
 the patient herself being unable to relate her history. 
 
 '■'■Present Condition. — The patient is very stout, there is no fever, the 
 right puj)il is slightly dilated, and the presence of violent headache is 
 attested by the hand being frequently placed upon the head. Asked 
 her name, she raises her head but gives no reply. Asked a second time, 
 she demands, "What do you say?" and on the question being put a third 
 time she says, " I do not understand you ; " but when pressed a fourth 
 time for an answer, she generally gives her correct name, "Bouquinet 
 Marie." On being asked, " How long is it since yoiir illness began % " she 
 manifests the same difl&culty in understanding the question, but after a 
 time she replies, " For three months." If she is now asked her address, 
 she replies, "Probably for three and a half months." Interrogated with 
 regard to her occupation, she presents the prescription of the physician 
 who had treated her in the town, and adds, " A white powder " (sulphate 
 of quinine). The questions addressed to her were varied from time to 
 time, but her replies were always more or less similar to those reported 
 above. After getting her with much difl6.culty to comprehend the first 
 question addressed to her by repeating it frequently, she often answers 
 
 1 Gii-audeau (C). "Note sur un eas de surdite cerebrale (siirdite psychique) par lesion des 
 deux premieres circonvolutions temporo-sphenoidales gauches."— i^'otie de Medeci'iie, Tome II. 
 lSS-2, p. 446. 
 
40 
 
 correctly, but she then follows the idea started, and her subsequent 
 replies have no relation whatever to the questions addressed to her. At 
 times, however, it is impossible to get her to comprehend any idea, and 
 to all questions she replies, "What are you saying ? I do not understand. 
 Cure me." Her sense of hearing is at the same time intact ; there is no 
 discharge from the ear. She hears the ticking of a watch, and turns her 
 head when a slight noise is made near her. Vision is good in both eyes. 
 There is no word-blindness, and it is important to observe that she can 
 easily read the headings of the bed ticket ; and to questions addressed 
 to her in writing she replies, after a short pause for consideration, either 
 in a lively voice or in writing. It is in this way that a knowledge of the 
 fact that she had never been regular, and that she had ceased to men- 
 struate for six months, had been obtained. Tactile sensibility is pre- 
 served, while the senses of taste and smell are normal. Motor power is 
 intact on both sides, and the tendon reactions are normal." 
 
 It is unnecessary to describe the details of this case further, inasmuch 
 as there was no serious alteration in the state of her speech up to the 
 time of her death, which took place from coma about a week after her 
 admission. At the autopsy a sarcomatous tumour was found in the left 
 hemisphere, occupying the position of the first and second temporo- 
 sphenoidal convolutions. The patient, whose case has been reported by 
 M. Giraudeau, appears to have had the power of conveying her ideas in 
 writing in a much greater degree than had James Lee ; but the report is 
 not sufficiently definite to enable us to say Avhether she could name 
 objects at sight. Her inability to give a connected history of her illness 
 in spoken speech indicates that the impressive faculty of speech was 
 profoundly affected, and as the power to name objects is probably the 
 most vulnerable part of speech it was probably lost in this case. 
 
 Although reported cases are not always so definite as could be desired 
 it appears to me that an examination of them will show that word-deaf- 
 ness necessarily carries with it the presence of the condition in which 
 the patient applies wrong names to objects — paraphasia, or in which he 
 is totally unable to give any name to an object, these two conditions 
 being only different degrees of one and the same disability. The con- 
 verse of this proportion is, however, not true. It is possible for a person 
 to labour under at least a considerable degree of inability to name 
 objects, and yet to be free from either word-deafness or word-blindness, 
 as the following case testifies : — 
 
 Case 8. — R. B., a man about 45 years of age, came as an out-patient 
 to the Infirmary, on January 30th, 1866. He said that he had lost his 
 memory, and was unable to give a connected account of himself. We 
 gathered from him that at Christmas he suffered from some cerebral 
 
41 
 
 attack which rendered him unconscious for two or three weeks, and that 
 " ice," a word which he frequently repeated, was apphed to his head. 
 He could not remember the name of the doctor who attended him, and 
 was even unable to recall the name of his wife or of any of his children ; 
 but he told us his own name and the district, but not the street, in which 
 he lived. He told us that he had been married many years, and that 
 he had a large family ; but he was unable "to give us any further trust- 
 worthy information with regard to his history. The tendon reactions 
 were normal, and there were no signs of motor paralysis, while the 
 cutaneous sensibility and all the special senses were found normal. The 
 urine was free from albumen, the cardiac sounds were normal, and the 
 usual signs of extensive arterial degeneration were absent. The patient 
 gave prompt obedience to any spoken request, so that he was free from 
 word-deafness. He was also able to name his bodily organs, although 
 not without considerable hesitation. He likewise named correctly, but 
 always after a long pause for consideration, several objects presented to 
 him ; but he was quite unable to name others. Given a bunch of keys 
 he took one of them between his finger and thumb, and moved it as if 
 he were locking a door ; he then looked in the distance as if intently 
 listening, but not being able to recall the name he again looked at the 
 key, and still not succeeding, he looked in the distance a second time, 
 and after another long pause he burst out with " key," his previously 
 perplexed face hghting up with pleasure. A watch key was now placed 
 in his hand, and he immediately rotated it as if he were winding a watch, 
 and went through the process of looking alternately in the distance and 
 at the key, but all to no purpose. After a time he pointed to my watch 
 pocket and said, " It is for that ; " and he again rotated the key, as if 
 he were winding the watch. I now produced the watch, and without 
 much hesitation he called out "watch." He also read off the time 
 correctly, but was still unable to name the watch key. I purposely 
 suggested wrong names for the key; he promptly rejected them, but 
 joyfully assented when the correct name was given, and he immediately 
 repeated the name. After a short pause the watch key was placed in 
 his hand a second time, and again he was unable to name it. He was 
 now asked if he knew the name of the building in which he was 
 standing, but he was unable to tell. On being told that it was the 
 Infirmary he readily assented ; but on being asked almost immediately 
 afterwards to repeat the name of the building he was unable to do so. 
 He was now requested to read, and when the heading of his pre- 
 scription book was shown to him, he read without the slightest hesita 
 tion, "Manchester Royal Infirmary." The book was now withdrawn, 
 and he was asked to repeat what he had read. He looked in the 
 
42 
 
 distance, as he always did when endeavouring to recall a name, but he 
 was quite unable to recall a single word of the "Manchester Eoyal 
 Infirmary," which he had just read. At the same time he gave prompt 
 obedience to written requests, so that he was not suffering from word- 
 blindness. The age of the patient, his freedom from cardiac or renal 
 disease, and the absence of the usual signs of a cerebral tumour led me 
 to believe that his symptoms might possibly be caused by syphilitic 
 endarteritis, and accordingly he was ordered lOgrs. of iodide of 
 potassium thi'ee times a day. 
 
 February 6. — The patient came to-day for his medicine, and his 
 disorder of speech was found to have undergone much improvement. 
 He now told us that he had been married over 20 years, and that his 
 wife had 14 children, but that only seven of them were living. Of the 
 remaining seven some were still-born, and others died from convulsions 
 in early infancy. The result of the treatment not only confirmed the 
 diagnosis of a syphilitic taint, but also showed that the disorder of 
 speech was most probably caused by a profound anaemia of the cortical 
 mechanism in the absence of any permanent destruction of tissue. 
 The case which has just been reported is a good example of verbal 
 amnesia, or what Kussmaul calls the aphasia of recollection, and with it 
 we must bring to a close our remarks on the clinical aspects of sensory 
 aphasia, and proceed to describe briefly those profound disturbances 
 in which the sensory and motor mechanisms of speech are simul- 
 taneously affected. 
 
 3. — Combined Sexsory and Motor Aphasia. 
 
 In many cases of what turns out after a time to be a pure motor aphasia, 
 the disorder of the expressive faculty of speech is accompanied during 
 the early stages of the affection by a manifest disturbance of the apper- 
 ceptive faculty. In the case of William Davies (Case 1), for example, 
 his wife stated that for the first few weeks after his attack he was not 
 only unable to speak himself, but that he was also incapable of understand- 
 ing the spoken language of others, showing that he was the subject of 
 word-deafness as well as of motor aphasia. And when he came under 
 my observation, some months after the attack which ushered in the 
 aphasia, he could not be induced to obey written commands, so that 
 most probably he was then suffering from some degree of word-blindness. 
 This patient was examined by me a few days ago, when I found that he 
 gave prompt obedience to such simple written requests as " Put yom- 
 tongue out" and "Show me your hand," proving that he has recovered, 
 to some extent, from his word-blindness, and that his case is now to be 
 
43 
 
 regarded as an example of pure motor aphasia. Some months ago I had 
 an opportunity of observing, day by day, the gradual recovery of an 
 aphasic patient from the disorder of the apperceptive faculty of speech, 
 while that of the expressive faculty persisted unchanged for months. 
 The patient was a boy about ten years of age, who was under the care 
 of my colleague, Dr. Morgan. The boy was attacked with a slight 
 apopleptic seizure, and became suddenly aphasic and paralysed on the 
 right half of the body. A soft systolic blowing murmur was audible 
 over the apex of the heart, and consequently the attack was probably 
 caused by embolism of the left Sylvian artery. For the first few weeks 
 the patient was not only unable to utter a single word, but he also failed 
 to obey the simplest request, such as "Put your tongue out," provided 
 the spoken request was unaccompanied by any expressive gesture. When 
 the obsei'ver, however, put his own tongue out, and made signs to the 
 patient to follow his example, prompt obedience was secured, and in a 
 very few days he acquired the power of appreciating and obeying the 
 spoken request without the aid of gesture. And after a process of 
 training, which extended over three or four weeks, the patient came to 
 recognise and to point out his own bodily organs, and the various objects 
 by which he was surrounded, when their names were uttered in his 
 hearing. The patient had been to school and been taught to read, but 
 for the first few weeks he took no interest in one of his school books 
 which was placed on his bed. But after a time he began to turn over 
 the leaves, and from the frequency with which he amused himself with 
 looking over its pages there can be little doubt that he understood the 
 text. In this case the gradual disappearance of the word-deafness and 
 word-blindness could be traced day by day. The motor aphasia remained 
 unchanged for manr weeks. It is worthy of note that the paralysed half 
 of the body regained motor power pari 2mssic with the disappearance of 
 the sensory aphasia, and six weeks from the commencement of the 
 attack scarcely a trace of paralysis could be discovered. It is equally 
 important to observe that, at least in many of the cases in which a 
 motor aphasia occurs without being accompanied by hemiplegia, the 
 disorder of speech is from the first limited to the expressive faculty, and 
 the usual evidences of sensory aphasia are altogether absent. The fact 
 that motor aphasia with hemiplegia is sometimes, at least, accompanied 
 by a sensory aphasia is proved by the statements of patients who have 
 made a complete recovery. A case of this kind, reported by Charcot, is 
 of so much importance that we do not hesitate to give it in detail. 
 
 Case 9. — "Louise Jeanniot, aged 49 years, entered the Infirmary of 
 the Salpetriere, under the care of Professor Charcot, on August 26th, 
 1883. On the previous evening, soon after retiring to bed, she suddenly 
 
44 
 
 lost consciousness. After a time, the duration of which she does not 
 know accurately, she regained consciousness, and then suffered from a 
 pain in the abdomen about the umbilical region, which was so severe 
 that nothing was able to allay it, and which evoked from her piercing 
 cries the whole of the night. The patient is laid upon her back with 
 tympanitic abdomen, and suffering from intense dyspnoea, but she yet 
 gives clear and accurate replies to all questions addressed to her, both 
 with regard to her present condition and her previous diseases, &c. The 
 urine is suppressed. The patient has had many involuntary evacuations 
 from the bowels during the night, while a string of blood flows constantly 
 from the anus. The inferior extremities and the whole of the abdominal 
 walls are livid and cold. The pulse is small, thready, and uncountable 
 at the Avrist, and cannot be felt in the crural arteries. It was concluded 
 that the abdominal aorta was obliterated. Jeanniot is the subject of a 
 right-sided hemiplegia, with contracture, which implicates the side of the 
 face as well as the limbs. Six years previously to her admission she was 
 attacked during the night, and on waking in the morning she found 
 herself paralysed and deprived of speech. For two years she was only 
 able to pronounce 'yes' or *no,' but she gradually regained her speech. 
 The patient is unable to tell the order in which the words became 
 restored to her. At present her speech is as correct and intelligible as 
 that of a person who had never been deprived of it. She writes a little 
 with the left hand, but not in the form of mirror writing. This morning 
 she endeavoured, but without success, to write her name with the left 
 .hand. 
 
 " Jeanniot has always been able to read, and she read very well in 
 our presence, both from a printed and a written page. She understands 
 perfectly all our questions, and her replies do not indicate any incorrect- 
 ness. It Avas not, however, always so. At the commencement of her 
 hemiplegia, and during a period of which she is not able to determine the 
 duration, but which was at the same time much shorter than the duration 
 of her motor aphasia, Jeanniot only occasionally understood the words 
 addressed to her, and therefore it was necessary that they should repeat 
 things to her many times, and that she shoidd fix her look carefully upoti 
 the person who addressed her. Speech was only for her an indistinct 
 noise, similar to that of a conversation in a crowd. She at the same 
 time heard the noise of a step in her room, of articles of furniture and 
 utensils on being moved, and also of the door on being closed or opened. 
 At that time she lived near the Square Parmentier, where the military 
 band played regularly during the summer, and she went there with great 
 pleasure to listen to it. They led her there several times when first she 
 was able to go out. When the music played she heard distinctly that a 
 
45 
 
 new sound became super-added to those which she had before perceived, 
 but it was only a noise which had no musical character. She died at 
 three o'clock in the afternoon." 
 
 At the autopsy, besides obliteration of the abdominal aorta, an 
 extensive softening was found in the left hemisphere of the brain. This 
 softening had destroyed the head and foot of the third frontal convolu- 
 tion, the whole of the Island of Reil, the whole of the first temporo- 
 sphenoidal convolution, and a small portion of the inferior parietal 
 lobule. On horizontal section of the left hemisphere, the claustrum, 
 the anterior portion of the lenticular nucleus, and the anterior two-thirds 
 of the internal capsule, were found to have been destroyed. The right 
 hemisphere was normal. 
 
 In the case just reported, and in other similar cases, the motor disorder 
 of speech persisted for a long time after recovery had taken place from 
 the sensory disability, but in other cases of combined sensory and motor 
 aphasia it appears to me that the disorder of the impressive faculty of 
 speech is even more profound than that of the expressive faculty, 
 although recovery cannot take place from the latter disability so long as 
 the former remains. In the cases we are now about to consider the 
 patient is not reduced to the condition of only being able to articulate 
 one or two simple words like "yes" or "no"; he can give utterance to 
 a large number of syllabic sounds, but he is unable to connect them into 
 any intelligible word, and consequently his vocalisations are mere 
 gibberish. This kind of aphasia, first described by Dr. Broadbent, may 
 therefore be called gibberish cqjhasia ; it is always associated with a 
 profound disorder of the apperceptive faculty of speech, and with a per- 
 sistent hemiplegia and contractures. The following is a good example 
 of this kind of aphasia. 
 
 Case 10. — John Handforth, aged 52 years, appeared for the first time 
 in the out-patients' department of the Manchester Eoyal Infirmary in 
 May, 1885. 
 
 History. — The following brief account of his previous history Avas 
 obtained from his wife. They have been married for upwards of twenty 
 years, and have five children, all of whom are now living and healthy. 
 The patient is a joiner by trade, but for some years has been an over- 
 looker for a firm of contractors. He has enjoyed good health, but has 
 always partaken somewhat freely of alcohol, and been much exposed to 
 wet and cold. On November 12th, 1884, he went to bed apparently in 
 good health, and got up on the following morning at the usual time 
 without making any complaint. Soon after he got on the floor, his wife 
 noticed that his right arm was drawn backwards behind his body and 
 upwards towards the shoulder blade, and on looking at him more 
 
46 
 
 narrowly she found that his face was drawn, and that he was unable to 
 speak. She got hhn to bed as soon as possible, and she soon afterwards 
 observed that the right side of the body was completely paralysed. At 
 first he was unable both to understand what was said to him and to 
 express his thoughts, but she does not think that he was completely 
 unconscious at any time, except, probably, for a very short period during 
 the onset of the attack. He lay in this condition for many weeks 
 without any very material improvement taking place. A few weeks 
 from the commencement he had a severe attack of general convulsions, 
 which lasted from five to ten minutes. During the attack the patient 
 was profoundly unconscious, and bit his tongue, and the wife does not 
 think that the one side of the body was affected by the sj)asms to a 
 greater degree than the other side. He had another attack of the same 
 kind three months after the onset of the disease. After the last attack 
 he gradually improved, so that he was able to get up and walk about a 
 little, but the right leg dragged, and the right hand remained stiff and 
 helpless, though there did not appear to be any drawing of the face. His 
 speech, however, has not undergone much improvement, and the little 
 amendment which has taken place consists in his understanding some- 
 what better than he did at the first what is said to him. 
 
 Present Condition. — On his first appearance as an out-patient he was 
 veiy excited, and by rapidly pointing, in a very animated manner, 
 first to his paralysed hand, and then to his tongue, he made a strenuous 
 endeavour to make me understand the nature of his disabilities, while, 
 in the interval between these gestures, he gave utterance to volleys of 
 unintelligible jargon. His general health appears to be good. His face 
 has a mottled appearance, and his cheeks and nose are covered by 
 dilated capillaries. The temporal arteries are distended and tortuous, 
 and the radials feel knotty and resisting. The heart is found to be of 
 nearly normal size on percussion, and no murmurs are heard on 
 auscultation, but the second sound at the base is much accentuated, 
 and of a ringing, metallic quality. The urine is free from sugar or 
 albumen, and no changes are discovered in the back of the eye on 
 ophthalmoscopic examination. So far as can be ascertained, there is no 
 special defect of vision, and no loss of smell. The right leg drags, and 
 the patellar tendon-reaction in it is exaggerated, while ankle-clonus can be 
 elicited. He can move the right arm fairly well at the shoulder joint, 
 but the forearm is held more or less rigidly at right angles to the arm ; 
 the thumb is flexed into the palm, and the fingers flexed over the thumb. 
 The tendon reactions are exaggerated at the elbow joint and wrist ; the 
 hand is blue and cold, and the patient is unable to use it. Whilst the 
 patient was being examined, he was seized with a severe general convul- 
 
47 
 
 sion, during which he was profoundly unconscious; the tongue was 
 protruded and bitten, and the sj)asnas were distributed over the body 
 generally, the right side being chiefly affected by tonic, and the left by 
 clonic, spasms. The attack lasted about five minutes, and after its 
 cessation the patient remained in an unconscious condition with 
 stertorous breathing. He was consequently made an in-patient, but, 
 on regaining consciousness, he showed signs of impatience at being 
 detained, and after a few days he was again discharged. 
 
 December 16, 1885. — John Handforth has attended regularly as an 
 out-patient since he was discharged from the Infirmary. During the 
 seven or eight months he has been under observation his disorder of 
 speech has imdergone very little change. Asked to put out his tongue, 
 he immediately opens his mouth, and on the demand being repeated, he 
 points to his tongue with his index finger, but never protrudes it unless 
 the examiner renders the request more specific by protruding his own. 
 Asked to close his eyes he generally opens his mouth, but if the 
 examiner should direct his eyes to the patient's, he alternately closes 
 his eyes and opens his mouth in a confused and very comical manner. 
 
 To every question requiring a spoken answer, he replies in unintelli- 
 gible jargon. For the last month or two there appears to be an 
 occasional attempt at articulating a few simple words. Asked his 
 name, for example, he utters two or three unintelligible syllables ending 
 with "futh," which seems to be an attempt at pronouncing the last 
 syllable of his name. Asked how he is getting on, an occasional 
 "better" is heard amongst numerous unintelligible sounds. He is a 
 very passionate man, and when he is vexed, which occurs but rarely in 
 our presence, he gives vent to his feelings in a volley of very uncanonical 
 language, which is very clearly articulated. And although the patient 
 fails to comply with the most ordinary spoken request, such as "Close 
 your eyes," and cannot give an intelligible answer to the simplest ques- 
 tions, he sometimes star-ties his examiner by giving manifest signs of 
 having comprehended what appear to be rather complicated statements. 
 One morning he was being examined along with William Daviii|^ the 
 case of motor aphasia already reported, and each of them seemed to be 
 much interested in the case of the other. At the end of the examina- 
 tion I remarked to some students that the prospects of recovery were 
 much woi-se in the case of John Handforth than in that of William 
 Davies. I forget the exact words used, and I presume that I must have 
 employed some expressive gestures, but, in any case, I had no expecta- 
 tion that the former would understand my remarks, although I knew the 
 latter would. My surprise may, therefore, be easily imagined on 
 finding that Handforth immediately raised both hands and shook his 
 
head, whilst, amongst some jargon, I thought I could detect, "Was, 
 Ah ! Wus, Ah ! " but whether that was so or not, his agitation and 
 expressive gestures plainly indicated that he understood my remarks, 
 and that what I had said had led him to believe that there was not 
 much hope now left for his recovery. On another occasion I finished 
 my examination of him, and, turning round, remarked to some students, 
 in an off-hand, casual manner, "It is a very funny case." I immediately 
 heard him puffing and snorting behind me, as he sometimes did when in 
 a temper, and, on turning round, I at once saw that he was looking 
 very indignant, while he kept repeating, "Fu fu fu-u-nny, damned 
 fu-u-nny, humph ! " When asked his age, he replies, in the usual 
 jargon, in which the "f " sound frequently recurs, the attempt, probably, 
 being to say fifty. When he is asked, "Are you a hundred years of 
 age *? " he does not deign to attempt a spoken reph'', but he pouts his 
 lips, closes his eyes, arches his eyebrows, and jerks his head slightly 
 backwards and to the left, and, with a slight, expressive wave of the 
 right hand, and shrug of the shoulders, he intimates, as plainly as he 
 could do in spoken language, " If you believe me to be a fool, you never 
 were more mistaken." 
 
 On being asked if he can read he gives vent to some gibberish, and 
 by one or two very expressive gestures he indicates that he can do so 
 quite easily. He, indeed, assumes a very airy and off-hand manner on 
 such occasions, just as if he meant to convey the impression that reading 
 is no trouble at all to him, and when the printed page is presented 
 upside down to him he gives a disdainful snort, and immediately turns 
 it right side up. He now places the printed paper upon a table, and points 
 with the tip of the index finger of the left hand (the right being paralysed) 
 to the paragraph to be read, and carrying his finger along each line in 
 succession he gives vent to such a medley of unintelligible sounds that 
 it is impossible for any one to note them down. During this pretended 
 reading his face assumes a serious air, and the sounds are uttered with 
 variations of tone and stops, although these do not appear to depend in 
 any way on the sense or the punctuation of the printed page. When his 
 finger points to the last word of the paragraph, he puts down the 
 newspaper or book from which he was reading in the same airy, off-hand 
 manner he assumed when asked to read, a manner which seems to say, 
 "You see how very easy all this is to me." 
 
 When asked to read slowly, he immediately complies with the request, 
 and pointing with his index finger to each word separately, he at the same 
 time utters sounds which can be readily noted down by the observer. 
 On November 25th, 1885, he was asked to read the following para- 
 graph from a newspaper : — " The Bulgarian troops, after passing the 
 
49 
 
 night of the 22nd inst. on the positions taken from the Servians, com- 
 menced pursuing the enemy yesterday morning, and at four o'clock in 
 the afternoon occupied Tsaribrod. Prince Alexander entered Tsaribrod 
 yesterday." He deliberately pointed with the tip of his index finger to 
 each word in succession, and uttered the following soimds, which were 
 noted down at the time : " Thou for then to visen to ven are the do am 
 they for then thou are they men thro they thro fordis and the thovis are 
 thro and thro the asun am amli thro the then am thro the thro are 
 musen or the they are on bind to vers." During this exercise he 
 assumed an air of as much seriousness and impoi'tance as if he were 
 giving those around him their first lesson in reading a foreign language, 
 and when he had finished he gave a toss to his head and a slight wave 
 of the hand, as much as to say, " You who are listening to me will be 
 a long time before you can read with as much precision and elegance as 
 that." His wife says that at home he frequently looks over the columns 
 of a newspaper, and she believes that he understands the printed page, 
 inasmuch as he often points out to her paragraphs which could only be 
 selected by one who knows what would be likely to interest her. On 
 being asked to write his name, he seizes the pen about an inch and a 
 half from the point, between the finger and thumb of his left hand, and 
 moves it upwards and downwards without resting his hand or forearm on 
 the table. He then writes without hesitation, in a running hand — 
 
 
 cJ(rLrr>* dl tMVv 
 
 Considering the awkward manner in which he holds his pen the 
 result is surprisingly good. He is unable to copy from a printed page, 
 but when I wrote down 
 
 ^^VL 
 
 he wrote under it the following- 
 
 He copies triangles, circles, and other geometrical figures readily, but 
 cannot, of course, name them. On being examined one morning, he 
 
 D 
 
50 
 
 wrote his name, and retui-ned the pen as usual to me ; but almost 
 
 immediately afterwards a sudden thought seemed to strike him, he 
 
 clutched the pen out of my hand, quickly drew the 
 
 annexed figure, and putting down the pen he pointed to 
 
 the drawing with an air of gTeat satisfaction. At first I 
 
 was at a loss to understand what he meant, and he 
 
 tried to explain by the usual unintelligible sounds, but 
 
 of course this kind of explanation was not a success. 
 
 He now pointed to the fig-ure and then to several 
 
 miscellaneous articles lying on the table, but some 
 
 time elapsed before his meaning dawned upon me. 
 
 After a time it occm-red to me that the oblique lines at the 
 
 top of the vertical line were intended to represent the 
 
 feathers of a quill pen and that the imperfect circle 
 
 below was meant for an ink bottle. I now took hold 
 
 of the ink bottle, and placing the pen in it I pointed 
 
 to the figure, and he smihngly nodded assent. Some 
 
 weeks later I placed a pen in the ink bottle, and 
 
 asked him to make a drawing of them. On these 
 
 occasions I had always to supplement my spoken requests by expressive 
 
 gestures. He now seized the pen, and drew a figure, which might 
 
 almost have been an exact copy of his former one, and he even took 
 
 considerable pains to put the hook on the lower end of the vertical line, 
 
 but vrhat he meant by this hook I am still unable to understand, unless 
 
 it be a device to prevent the pen from falling out of the bottle. 
 
 This case must bring to a close what we have to say with regard to 
 the clinical varieties of aphasia, and we shall next proceed to make a few 
 remarks on the morbid anatomy of this interesting affection. 
 
 4. — Morbid AKATOiirY. 
 
 In considering the morbid anatomy of aphasia we shall briefly discuss 
 (1) the nature and (2) the localisation of the lesion, 
 
 (1.) The Nature of the Lesion. — Aphasia may be caused by (a) a func- 
 tional or (h) an organic lesion of the brain. 
 
 (a) The most common functional lesion of the brain that gives rise to 
 aphasia is the condition which precedes or follows an epileptic attack.^ 
 In some cases the warning of an epileptic attack consists of a sudden 
 inability to speak,- and it is very probable that W'Ord-deafness and word- 
 
 1 See Bernard (D.) "De I'aphasie et de ses diverses formes." — These d^ Paris, 1885, p. 256; 
 and Hughlings-Jackson (J.) " Clinical remarks on temporary loss of speech, and of power of 
 expression (epileptic aphemia? aphrasia? aphasia?), and on epilepsies." — Medical Times mid 
 GazeUe, VoL 1., 1SS6, p. 442. 
 
 * Moreau. " Aphasie (aphemie)."— ffaz. des Ho})., Tome XXXVII., 1864, p. 70. 
 
51 
 
 blindness is not by any means an uncommon aura, although the presence 
 of these conditions is not so readily recognised by the observer as a 
 motor aphasia, and in the subsequent descriptions of the patient they 
 can hardly be distinguished from the mental confusion which attends 
 the onset of unconsciousness. A transient aphasia often succeeds to the 
 unilateral convulsions which are caused by gross lesions of the br^in, 
 such as gliomatous and gummatous tumours, and projecting spicula of 
 bone. If the lesion is situated in one or other of the speech cortical 
 centres themselves, then the aphasia is caused by an organic disease, 
 and the symptom becomes permanent. In the cases under considera- 
 tion at present, however, the lesion is situated at some little distance 
 from any of the speech centres, but it gives rise to an irritation of one 
 or other of them, which causes it to discharge its energy periodically, 
 each such discharge being followed by exhaustion of the centre with loss 
 of function until its energy is restored by nourishment. An embarrass- 
 ment of speech, which in some cases may amount to a complete motor 
 aphasia, not unfrequently ushers in an attack of migraine, and patients 
 suffering from cerebral neurasthenia experience much difficulty in 
 recalling names, especially proper names, while in aggravated cases there 
 is a decided embarrassment of the faculty of expression which amounts 
 to a minor degree of motor aphasia. A transient aphasia may also occur 
 after a paroxysm of rage,^ or after a severe fright,- shock,^ or sunstroke,* 
 and loss of the faculty of speech is also a well-recognised symptom of 
 hysteria,'' while in children and impressionable subjects an attack may 
 be determined by the presence of intestinal worms or impacted fseces.*^ 
 It is also met with as a complication of chorea.^ Aphasia is also liable 
 to supervene in the course of the eruptive and continued fevers, inter- 
 mittent fevers, Miabetes,^ gout, albuminuria and ursemiaj^^and saturnism," 
 
 ' Hovel (D. de B.) " On emotional aphasia." — Medical Press and Circular, Vol. II., 1875, 
 p. 203. 
 
 " Habershon. "Case of aphasia consequent on fright." — The Lancet, Vol. II., 1S70, p. 402. 
 
 •■^ Midavaiue. "Parte subite mats momentanee de la parole, suite d'un souffiet sur la joue." — 
 Arch, de la med. Beige, Tome VI., Brux., 1841, p. 243. 
 
 ■'Porter (P. B.) "A case of sunstroke followed by aphasia; death." — Virginia Medical 
 Monthly, Richmond, Vol. I., 1874, p. 421. 
 
 " Davis (H. L.) "De I'aphasie hysterique." Paris, 1884. 
 
 ^ Gibson (D.) "Paralysis, with loss of speech, from Intestinal irritation." — Tlie Lari^et, Vol. 
 II., 1862, p. 139 ; and Mattel.— ^viL de Acad, de Med., Tome XXX., 1864-5, p. 870. 
 
 ' Jackson (J. B.) "Aphasia complicated with chorea." — The Medical Press and Circular, 
 Vol. XXXVIIL, 1884, p. 218. 
 
 " Boisseau (M. E.) " Aphasie transitoire liee k des accfes de fifevre intermittente."— ffas. hebd. 
 de Med., 2, S., Tome VIII., 1871, p. 200. 
 
 » Bernard (D.) et F6r6 (Ch.) "Des troubles nerveux chez les diiibitiquQS."—Archiv de Neu- 
 rologic, Tome IV., 1882, p. 340. 
 
 I" Hlrtz. — Gaz. med. de Strasbourg, 1865. 
 
 11 Heyman (C.) "Ein Pall von Aphasia saturnina."— 5e/-i. hlin. Wochenschrift, Bd. II., 1865, 
 pp. 195, 208, 223. 
 
52 
 
 but as these diseases produce profound changes in the blood and blood- 
 vessels, the disorder of speech is probably caused, not by a functional, 
 but by one or other of the organic changes about to be described. The 
 fact, however, that aphasia may be caused by the venom of serpents^ 
 shows that it may sometimes result from a poison circulating in the 
 blood,- and aphasia has been observed in cases of chronic albuminuria in 
 which no lesion could be discovered after death to account for the 
 disorder of speech. 
 
 (h) The organic lesions which occasion aphasia are all those that 
 produce destructive changes in the brain. The lesion may consist of a 
 depressed portion of bone. The case of a gentleman is reported by 
 Simon^ who became suddenly unable to speak after a fall from his 
 horse, without being paralysed. A small wound with depression was 
 discovered over the left temple, and, death having occurred from 
 meningitis, a piece of bone, which had been detached from the inner table, 
 was found in the left third frontal convolution. More or less similar 
 cases have been reported by Sydney Jones^, MacCormack', Boyer®, 
 Decoudin,'' Oulmont,^ Mayor,® Dejernie,^" and others. Foreign bodies 
 penetrating within the cranial cavity may be the cause of a permanent 
 aphasia. I have myself met with a case in which a permanent motor 
 aphasia, without paralysis, was caused by a gunshot wound in which the 
 bullet entered the skull in the left temple and passed out at the top of 
 the skull on the same side j and a large number of similar instauces 
 might be adduced. Intracranial growths of all kinds may, by com- 
 pressing the central mechanisms of speech, give rise to any of the 
 clinical varieties of aphasia, and every form of inflammation of the 
 brain and of its membranes may also occasion this disorder of speech. 
 Heemorrhage of the brain may cause aphasia, but it is not by any means 
 a frequent cause of the persistent forms of the affection. The reason of 
 this is that the profounder forms of aphasia are caused by disease of the 
 cortes of the brain, and a circumscribed hsemorrhage of the surface of 
 
 '■ Ogle (J. W.) "Loss of speech from the bite of venomous snakes." — St. George's HospUol 
 Reports, VoL III., 186S, p. 167. 
 
 2 Dunoyer. " Aphasie ti-ansitoire toxique."— (?a:. raed de Paris, 1, S., 1SS4, Tome I., p. 461. 
 
 = Simon. "Casuistiche Beitriige zur Lehrevon der Aphasie."— iJer. JcUn. Wocfienschrift, 
 Bd. VIII., 1878, p. 959. 
 
 * Jones (Sydney).— r/ic LoMcet, Vol. II., 1873, p. 449. 
 
 5 MacCormack.— Bmi';!., Vol. I., 1877, p. 256. 
 
 « Beyer. "I^tudes cliniques sur les lesions corticales des hemispheres cerebraux." — Paris, 
 1879. 
 
 '' Decoudin. — Bull, de la Soc. Anatomirpj.e, Oct., 1876. 
 
 8 Oulmont. — Svdl. de la Soc. Anat, Avril, 1877. 
 
 » Mayor.— BvM. de la Soc. AnoX., JulUet, 1876. 
 
 10 Dejemie. — Bull. d,e la Soc. Ano.t., Janvier, 1879. 
 
53 
 
 the brain is a comparatively rare accident. An example of aphasia from 
 haemorrhage is, however, reported by B,osenstein\ The case was that 
 of a girl, aged twelve years, who had suflfered from nephritis, and 
 who was suddenly attacked with aphasia and agraphia a few weeks 
 before the fatal issue, and after death a heemorrhagic softening 
 of the size of a hazel nut was found in the third left frontal convo- 
 lution. Of all the lesions which give rise to aphasia occlusion of the 
 Sylvian artery is by far the most frequent. The vessel may be occluded 
 by an embolus, the plug being washed off from a diseased valve of the 
 heart, or from an aorta whose internal surface is roughened by atheroma 
 or injured by aneurism, or by thrombosis, the plug being formed by the 
 deposit of fibrin upon the internal surface of a vessel deformed by 
 atheroma, or by syphilitic endarteritis. It is probable that the aphasia 
 which occurs in the course of the continued and eruptive fevers is 
 caused, sometimes at least, by occlusion of some of the capillaries of the 
 Sylvian artery by means of emigrant leucocytes ; while the aphasia 
 which occurs in the course of albuminuria and saturnism is likely 
 to be caused sometimes by capillary, and at other times by massive 
 hsemorrhages. 
 
 (2.) The Localisation of the Lesion. — It has just been seen that 
 occlusion of one or other of the branches of the Sylvian artery is by far 
 the most frequent cause of all forms of persistent aphasia, or of those 
 from which recovery takes place but slowly. It is therefore desirable, 
 before proceeding to discuss the localisation of the lesion, to describe 
 briefly the distribution of the branches of this artery. 
 
 The middle cerebral or Sylvian artery is the largest and most 
 important branch of the internal carotid artery. As it passes outwards 
 at the base of the brain it gives off small branches (Fig. 2, P) — the 
 perforating branches, or the antero-lateral group of the ganglionic system 
 of arteries — which pierce the anterior perforated space, and supply the 
 corpus striatiim and the anterior part of the optic thalamus. The 
 following branches may be distinguished ■?- — (a) The lenticular hranches, 
 consisting of two or three small twigs, which ascend vertically, and enter 
 the substance of the lenticular nucleus, and are distributed to its two 
 inner divisions and to the adjoining portion of the caudate nucleus 
 (Fig. 1, 5). (&) The lenticulo-striale hranch, which is much larger than 
 
 ? Kosenstein. ' ' Diffuse nepluitis. Urilmische Anf alle von Temperaturerhohung beglietet 
 Aphasie als Tenninalerscheimmgen. Haselnussgrosses Blutcoagulum niit secondarer Erweichimg 
 in der dritten Stimwindung der linken Hemisphiive. " — Berl. klin. Wochenschrift, Bd. V., 1S6S, 
 p. 182. 
 
 2 Buret (H.). " Recherch.es anatomiques sur la circulation de I'encephale." — Arch, de Physio- 
 logic. 2me Serie. Tome I. 1874. Pages 60, 316, 664, et 919. See also Heubner, "Zur Topo- 
 graphie der Ernahrungsgebiete der Einzehren Hirnarterien." — Centrallblait f. d. med. Wissen- 
 schaften, 1872, page 817. 
 
54 
 
 any of the lenticular branches. It ascends along the external surface of 
 the outer division of the lenticular nucleus, traverses the superior part 
 of the internal capsule, and then passes from behind forwards into the 
 substance of the caudate nucleus. It gives branches to the outer division 
 of the lenticular nucleus, the internal capsules, and the caudate nucleus 
 (Fig. 1, 4). (c) The lentimlo-ojytic branch passes, like the lenticulo- 
 striale artery, along the external surface of the outer division of the 
 lenticular nucleus, and through the posterior part of the internal capsule, 
 and terminates in the anterior or external part of the optic thalamus. 
 
 On reaching the outer surface of the brain, the main trunk of the 
 Sylvian arteiy divides into cortical branches, (a) The first, or inferior 
 frontal hranch (Fig. 2, 1) is limited in its distribution to the outer 
 part of the orbital surface and the adjacent inferior or third frontal 
 
 Fig. 1 (after Buret). 
 
 Transverse section of the cerehral hemispkeres, about 1cm. hehind the optic commissure 
 artenes of the corpus striatum. 
 
 Ch. Chiasma ; B — Section of the optic tract ; L — Lenticular nucleus ; I — Internal capsule ; 
 C — Caudate nucleus ; E — External capsule ; T— Claustrum ; K — Island of Riel ; V, V — Section of 
 the lateral ventricle ; P, P — Anterior pillars of the fornix ; O — Grey substance of the third ventricle. 
 Vo.scv.lo.r areas: I. — Anterior cerebral artery; II. — Middle cerebral artery; III. — Posterior 
 cerebral artery ; 1 — Internal carotid artery ; 2 — Sylvian artery ; 3— Anterior cerebral artery ; 
 4,4 — Internal arteries of the coii^us striatum (lenticulo-striato artery); 5, 5— Internal arteries of the 
 corpus striatum (lenticular arteries). The lenticulo-optic artery is not represented in the figure. 
 
 convolution. (&) The second, or ascending frontal branch (Fig. 2, 2) 
 supplies the posterior part of the middle frontal and the chief part of 
 the ascending frontal convolutions, (c) The third, or ascending parietal 
 artery (Fig. 2, 3) passes into the fissure of Rolando, and supplies the 
 rest of the ascending frontal and the ascending parietal convolutions, as 
 well as the anterior part of the superior parietal lobule, (d) The fourth, 
 or parieto-sphenoidal branches (Fig. 2, 4) supply the inferior parietal 
 lobule. The fifth, or s-phenoidal branches (Fig. 2, 5) supply the superior 
 tempero-sphenoidal convolutions. 
 
55 
 
 The ganglionic branches of the Sylvian arteiy are all terminal 
 arteries, and when one of these is occluded the part which it supplies 
 inevitably undergoes softening. The cortical branches, however, are not 
 terminal, but the anastomoses between the different branches of the artery 
 itself, and between its branches and those of the anterior and posterior 
 cerebral arteries are not free, and consequently when one of these branches 
 becomes occluded some degree of softening generally takes place — we say 
 generally, because in young people, in whom the arteries are very elastic, 
 the main trunk of the Sylvian artery may be occluded immediately after 
 the ganglionic arteries are given off without giving rise to softening. 
 The case of a young girl came under my own observation, who, while 
 
 Fig. 2 (after Duret). 
 
 Diagram showing the area of distribution of the middle cerebral artery. 
 
 S — Sylvian or middle cerebral artery ; P — Perforating branches ; 1 — Inferior frontal branch ; 
 2 — Ascending frontal branch; 3 — Ascending parietal branch; 4 — Parieto-sphenoidal branch; 
 5— Sphenoidal branches ; A- -Ascending frontal convolution ; B — Ascending parietal convolution ; 
 Fj, Pj, P:i — First, second, and third frontal convolutions; P^, P,, P^ — First, second, and thii-d 
 parietal convolutions ; Tj, Tj, T3 — First, second, and third temporo-sphenoidal convolutions. 
 OL— Occipital lobe. 
 
 suffering from endocarditis, had first embolus of the femoral artery, and, in 
 succession, embolus of the kidneys, spleen, and left Sylvian artery, occlu- 
 sion of the latter being evinced by an attack of right-sided hemiplegia 
 and combined motor and sensory aphasia. The patient having died from 
 exhaustion about a fortnight after the attack of aphasia, an embolus was 
 found in the main trunk of the Sylvian artery, a little outside the ante- 
 rior perforated space, but before any of the cortical branches had been 
 given off. Not the smallest speck of softening could be discovered, 
 although it is very likely that the nerve cells in the area supplied by the 
 
56 
 
 Sylvian artery had undergone fatty degeneration. There can be little 
 doubt that, had the patient lived, the nutritive and functional activity 
 of the tissues in this area would have been gradually restored. But in 
 most cases of even young people, and in all cases in which the arteries 
 have lost the elasticity of youth, occlusion of the Sylvian artery or of 
 one of its branches is followed by a softening of greater or less extent in 
 the area supplied by it ; and when the embolus is lodged in the artery 
 before the ganglionic arteries are given off, it is inevitable that the 
 greater mass of the middle of the hemisphere must undergo rapid soft- 
 ening, and such cases are generally, if not always, rapidly fatal. Having 
 advanced these anatomical considerations, we are now in a position to 
 examine more narrowly into the localisation of the lesion in cases of 
 aphasia, and to appreciate the relation which subsists between the 
 position of the lesion in the different forms of this disorder and the 
 distribution of the various branches of the Sylvian artery. 
 
 The faculty of language was placed by Gall in the supra-orbital lobes of 
 the brain, but the first serious attempt to determine the localisation of 
 this faculty by means of morbid anatomy was made by Bouillaud,-' who, 
 in 1825, came to the conclusion that speech was the result of the activity 
 of the anterior cerebral lobes. In 1836 Marc Dax^ advanced the opinion 
 that the organ of language was situated in the left hemisphere of the 
 brain, near to the Island of Reil, but this opinion had been neglected 
 and almost forgotten until 1861, when Broca^ localised the faculty of 
 language in the third left frontal convolution. In the subsequent two 
 years Broca^ collected seventeen cases of aphasia in which post-mortem 
 examinations had been obtained, and out of these the lesion was situated 
 sixteen times in the posterior part of the third left frontal convolution, 
 and once in the temporal lobe and Island of Reil. Soon afterwards cases 
 were published by Parrot,® Fernet,® and Charcot,'' in which a destructive 
 lesion of the posterior part of the third right frontal convolution had 
 not given rise to any disorder of speech, these cases affording the negative 
 side of the proof of the assertion that the faculty of language is organised 
 in the left hemisphere ; and to make this proof still more striking, cases 
 
 ' Boiullaud. "Traite d'enceplialit^," 1S25, p. 281. 
 
 2 Dax (Marc). " Lesion de la moitie gauche de I'^nc^pliale, coincidant avec I'oubli des signes 
 de la pens^e."— Montpellier, 1836. 
 
 ^ Broca (P.). " Sur le slfege de la faculty de langage articule, avec deux observations d'aph^mie." 
 Bull, de la Soc. Anat, Tome V., Aout, 1861. 
 
 * Broca (P.). " Remarques sur le sifege, le diagnostik, et la nature de I'apMmie." — Bull, de la 
 Soc. Anat, Julliet, 1863. 
 
 6 Fa,rrot.— Bull, de la Soc. Anat., 1863, p. 372. 
 
 « Fernet.— ^mH. de la Soc. Anat, 1863. 
 
 ' Charcot (J. M.). " Sur une nouvelle observation d'aphemie." — Gaz. hebd. de Med., Tome X., 
 1863, p. 473, et seq. 
 
57 
 
 ■were reported by A'^oisin^ and others, in which patients, who, on 
 being the subjects of left-sided hemiplegia retained their speech, had 
 become aphasic when subsequently attacked with a right-sided hemi- 
 plegia. In reproducing the work of his father in 1863, and again in 
 1878, M. Dax- fils, collected 371 cases of various diseases of the brain, 
 chiefly fi'om the works of Bouillaud and Lallemand. In 87 of these 
 cases a lesion was found in the left hemisphere, and in all of them there 
 was some disorder of speech during life ; while in 53 cases a lesion was 
 foimd in the right hemisphere, but disorder of speech was not found in 
 any of them. The lesion was found in the left hemisphere 243 times 
 out of 260 cases of hemiplegia with aphasia, collected by SeguinV and 
 140 times out of 146 cases collected by Yoisin"*. It was found by 
 Calleuder and Ku'kes that aphasia only failed once out of 13 cases of 
 right hemiplegia, whilst it was only met with once in 13 cases of left 
 hemiplegia. Lohnmeyer' collected 53 cases of aphasia in which an autopsy 
 had been obtained, and out of these the lesion was situated 50 times in the 
 left hemisphere ; it was localised 24 times in the third left fi'ontal convo- 
 lution, and 24 times in it and the neighbouring parts. The Island of 
 Eeil was alone affected sis times, the anterior portion of the frontal lobe 
 twice, the middle lobe near the fissure of Sylvius thrice, the middle and 
 posterior lobes twice, and the posterior lobe four times. Of 34 cases of loss 
 of speech reported by Hughlings-Jackson'^ the paralysis was observed 31 
 times on the right, and three times on the left side ; and out of 25 cases 
 collected by Ogle'' the lesion was situated in all of them in the left 
 hemisphere. The analyses of collected cases made by various authors 
 have now placed beyond any possibihty of doubt that, in by far the 
 majority of instances, the faculty of speech is organised in the left 
 hemisphere of the brain. At the same time it has emerged that in "a 
 comparatively small number of cases the aphasia is associated with left- 
 sided hemiplegia, and consequently it was inferred that disease of the 
 right hemisphere of the brain does sometimes give rise to the disorder 
 of speech. Cases of left hemiplegia with aphasia have been recorded by 
 
 » Voisin. — Gaz. des Hop., 25 Janvier, 186S. 
 
 « Dax (G.). " L'aphasie."— Jlontpellier, 1878, p. 112. 
 
 •■' Seguin. — Qv.o/rterly Jov/raal of Psychological Medicine, Jan., 1868. 
 
 * Voisin. Art. "Aphasie." "Nouvean dictionnaire de Jl^d. et de Chir. pratique." — Tome III., 
 Paris, 1866, p. 4. 
 
 » Lohnmeyer. "Kann Aphasie ziir Trepanation veranlassen?" — Archiv f. klin. Chirurgie, 
 Bd. XIII., 1871-2. p. 309. 
 
 ^ HuEchlings-.Jackson (J.). "Loss of speech: its association with valvular disease of the 
 heart, and with hemiplegia on the right side ; defects of speech in chorea." — Clinical Lecture and 
 Report, Loyid. Hasp. Reports, Vol. I., 1864, p. 388. 
 
 ' Ogle (J. W.). "Aphasia and agraphia."— St George's Hospital Reports, Vol. II., 1867, p. 117. 
 
58 
 
 Pye-Smith, Hiighlings-Jackson\ John Ogie^, and Ferrier^, and post- 
 mortem evidence of aphasia being caused by disease of the right hemi- 
 sphere of the brain was obtained by Wadham* and Habershon^. A 
 negative proof of the occasional organisation of speech in the right 
 hemisphere was afforded by F, Taylor" and Foulis'', who reported cases of 
 destruction of Broca's convolution in the left hemisphere without giving 
 rise to aphasia. Care should be taken not to conclude too hastily that in 
 all cases of left-sided hemiplegia with aphasia the lesion causing the 
 disorder of speech is situated in the right hemisphere of the brain; 
 inasmuch as cases have been recorded by Raymond and Dreyfous^ in each 
 of which a lesion was found in the right hemisphere, causing a left hemi- 
 plegia and another in the third left frontal convolution, which doubtless 
 caused the aphasia. On the whole the observations collected and analysed 
 by various authors prove beyond any possibility of doubt that aphasia 
 is caused in by far the majority of cases by lesion of the left hemisphere, 
 and in a comparatively few cases by lesion of the right hemisphere of the 
 brain. We must now endeavour to localise more accurately the different 
 forms of the affection. 
 
 In motor ai:)hasia the lesion is most usually situated in the posterior 
 part of the third left frontal convolution. Broca thought that all aphasic 
 disorders of speech were caused by disease of this part of the brain, and 
 the cases he adduces in favour of this opinion were, with one exception, 
 in which the lesion was found in the temporal lobe and Island of Reil, 
 all examples of pure motor aphasia. In the first case in which he 
 obtained an autopsy the patient — Leborgne — understood everything that 
 was said to him, but was only able to reply tan, tan, to all questions, 
 and when his interlocutors failed to understand the lively gestures by 
 
 1 Huglilings-Jackson (J.). " Loss of speech with hemiplegia of the right side ; valvular 
 disease ; epileptiform seizvire affecting the side paralysed." — Med. Times and Gazette, Vol. II., 1864, 
 p. 166. " Aphasia with hemiplegia of the left side. — The Lancet, 1S68, p. 316; and Ibid, Vol. I., 
 1868, p. 370. 
 
 * Ogle (John W.). " Illustration of the impairment of the power of intellectual language." — 
 T/ie Lancet, Vol. I., 1868, p. 370. 
 
 ■'' Ferrier. " Left-sided epileptic hemiplegia and aphasia." — The Lancet, Vol. II., ISSO, p. 780. 
 
 * Wadham (W.) " Case of hemiplegia of the left side in an ambidextrous boy ; subsequent 
 occurrence of aphasia which continued complete for three months : gradual but imperfect recovery 
 of speech ; nearly total destruction of the Island of Biel on the right side." — St. George's Hospital 
 Reports, Lond., Vol. IV., 1869, p. 245. 
 
 ^ Habershon. "Aphasia, with hemiplegia on the left side, and tumour on the right side of 
 the brain in the third frontal convolution." — The Lancet, Vol. II., 1880, p. 979. 
 
 '^ Taylor (P.) "Right hemiplegia after scarlatina, with embolism of the left middle cei'ebral 
 artery; destruction of Bovia's convolution without aphasia." — The Lancet, Vol. II., 1880, p. 896. 
 
 '^ Foulis (D.) "A case in which there was destruction of the third left frontal convolution 
 without aphasia." — The British Medical Journal, Vol. I., 1879, p. 383. 
 
 ■'' Raymond et Dreyfous(F.) " Contribution a I'etude de I'aphasia." — Archiv. de Neurologic, 
 Tome III., 1882, p. 80. 
 
59 
 
 which these words were accompanied he gave vent to much imintelhgible 
 jargon, amidst which was clearly articulated, "Sacre nom de Dieu." 
 The lesions found in the brain after death were widely distributed over 
 the surface and in the substance of the left hemisphere, but Broca 
 believed that destruction of the thii"d frontal convolution was the cause 
 of the disorder of speech. A few months later he had an opportunity of 
 examining the brain of Lelong, a man who had the use of only five 
 words, and in his case the lesion consisted of a cavity about the size of 
 a franc piece filled with serous fluid, and which was almost strictly 
 circumscribed to the posterior part of the third left frontal convolu- 
 tion, encroaching to a slight extent upon the posterior part of the 
 second frontal. From these cases Broca, with his usual caution, only 
 concluded that "the integrity of the third and probably of the second 
 frontal convolution appears to be indispensable to the exercise of the 
 faculty of articulate speech." In the subsequent two years Broca 
 collected, as already mentioned, 17 cases of aphasia with post-mortem 
 examinations, in 16 of which the lesion was situated in the third left 
 frontal convolution, and once in the temporal lobe and Island of Eeil. 
 The cases of motor aphasia recorded in which the lesion was situated in 
 the third left frontal convolution are now so numerous and so well 
 known that it is quite unnecessary to quote any of them here. But 
 although it is proved that lesion of the posterior part of the third left 
 and in occasional cases of the third right frontal convolution gives rise 
 to a motor aphasia, it does not follow that this disorder of speech may 
 not be caused by disease of other parts of the brain. And, indeed, it 
 has been found that lesions of the centrum ovale underlying the frontal 
 convolution may give rise to a motor aphasia which is as complete and 
 persistent as that caused by disease of the cortex itself. A man, aged 
 60 years, whose case is reported by Pitr^s^, suffered from right hemi- 
 plegia, with embarrassment and finally complete loss of speech. At the 
 autopsy, two small patches of yellow softening were found in the cortex 
 of the left hemisphere, one being situated in the superior parietal lobule, 
 and the other in the angular gyrus. The third left frontal convolution 
 was normal, but a large focus of softening was observed in the centrum 
 ovale, which extended anteriorly to the part underlying the posterior 
 extremity of the third fi-ontal convolution, and posteriorly beyond 
 the posterior extremity of the optic thalamus. It is possible that 
 the spot of softening in the angular gyrus in this case might have 
 caused word-blindness, but it could not have given rise to complete loss 
 of speech, which, therefore, must have resulted from the softening in the 
 
 1 Pitres (A.) ■' Lesions du centre ovale." (" Obs." xxxviii.) Paris, 1877, p. 94, et seq. 
 
60 
 
 centrum ovale. A case of aphasia is reported by Bouchard,^ in which the 
 lesion, a yellow softening, was situated in the anterior and superior part of 
 the intraventricular portion of the left corpus striatum, which corresponds 
 to the anterior segment of the internal capsule. A secondary degenera- 
 tion was observed in the crusta and the anterior pyramid of the medulla 
 oblongata of the same side. A case of aphasia is likewise reported by 
 Farge," in which the lesion was situated in the centrum ovale, imme- 
 diately above and to the outer side of the caudate nucleus of the corpus 
 striatum,^ almost in the same position as the one reported by Pitres. 
 A case of right-sided hemiplegia, with aphasia, is reported by Hughlings- 
 Jackson,'* in which the lesion was found in the corpus striatum, and we 
 shall hereafter find that most cases of ordinary right-sided hemiplegia, 
 which are most probably caused by haemorrhage into the lenticular 
 nucleus of the corpus striatum, are accompanied by a transient motor 
 aphasia, recovery taking place in a few weeks. A case in which a 
 circumscribed haemorrhage in the pons Varolii produced a slight degree 
 of motor aphasia is reported by Hermann Weber and Altdoerfer.^ A 
 man, aged 35 years, was seized with sudden loss of consciousness and 
 left hemiplegia. He had impairment of the power of swallowing and of 
 articulation. He had difficulty in finding the right words, which, 
 however, when suggested, were readily pronounced. The patient died 
 three weeks after the attack, and at the autopsy a small hsemorrhagic 
 spot was found in the anterior part of the right half of the pons Varolii, 
 with softening of the surrounding substance. 
 
 Motor agra'phia is generally associated with aphemia, and conse- 
 quently it may be inferred that the motor cortical centre for the special 
 movements of writing lies near to that for the special movements of 
 spoken speech. The fact, however, that the disability of spoken speech 
 and of writing are not always present in equal degree in cases of motor 
 aphasia, and that in rare cases the one faculty may be lost while the 
 other is retained, shows that these centres are not identical. The motor 
 
 1 Bouchard (C.) "Aphasie sans lesion de la troisieme circonvolution frontale gauche." — 
 Corii'ptes Rendus des Seances de la Soc. de Biologic, 1864. Paris, 1865. 4, S., Tome I., p. 111. 
 
 = Farge (E.). "Hemipl6gie di-oite, et aphasie sans lesion de la troisifeme circonvolution 
 frontal gauche."— <?as. hebd. de Med., Paris, 1864. 2, S. Tome I., p. 724. 
 
 ^ See also D6jemie (J.). " Aphasie et h^miplegie droite ; lisparition de I'aphasie au bout de 
 neuf mois ; ptrsistance de I'hemiplogie ; mort par plithisie au bout de trois ans (integrite de la 
 troisieme frontale, lesion du faisceau p^diculo-frontale inf^rieur, du noyau lentioulau-e, et de la 
 partie anterieure de la capsule interne." — Progres Med., Paris, 1879, Tome VII., p. 468. 
 
 ■* Hughlings- Jackson (J.). " Disease of the left side of the brain, involving the corpus 
 striatum, &c. Aphasia." — Medical Times and Gazette, Vol. II., 1884, p. 605. 
 
 5 Weber (H.) and Altdoerfer. " Case of aphasia with left hemiplegia. Hsemorrhage and 
 softening in the right side of the pons Varolii."— y/te British Medical Journal, Vol. I., 1877, p. 13. 
 See also Wood, "Tumour at the base of the brain, pressing upon medulla spinalis." — Phild. Med. 
 Times, 1881-2, Vol. XII., p. 648. 
 
61 
 
 centre for writing is placed by Exner^ in the posterior part of the second 
 left frontal convohition. Of the four cases which he adduces in favour 
 of this opinion, the most convincing is probably a case of agraphia 
 reported by Bar,- in which the lesion, consisting of a clot of blood, 
 occupied the posterior part of the second left frontal convolution. In a 
 case of aphasia and agraphia reported by Nothnagel," a spot of softening 
 from embohis was found in the posterior part of the second, another in 
 the corresponding part of the first, and three in the convolutions of the 
 Island of Reil. 
 
 In apperceptive apliada the lesion is localised in the area of distribu- 
 tion of the parieto-sphenoidal and sphenoidal branches (Fig. 2, 
 4 and 5) of the Sylvian artery, and the region of softening comprises the 
 supra-marginal convolution, the angular gyrus (visual centre), the 
 posterior part of the infra-marginal convolution (acoustic centre), and 
 the convolution bounding the parallel and collateral fissures. In the 
 cases of aphasia with autopsies collected by Broca and the earlier 
 observers, the lesion was occasionally observed to be situated in the 
 temporal lobe and the posterior part of the parietal lobe; but these 
 cases were regarded as exceptions to the general rule of localisation in 
 the third frontal convolution, up to the time when Wernicke ^ reported 
 a case of that disorder of speech, which Kussmaul ^ subsequently named 
 word-deafness, and in which the lesion consisted of softening from 
 thrombosis of the first and a large part of the second temporo-sphenoidal 
 convolutions (Fig. 3). In the case of word-deafness reported by 
 Giraudeau, already quoted at length, the lesion consisted of a tumour 
 about the size of a nut, which was situated in the posterior part of the 
 two first temporo-sphenoidal convolutions. A case of word-deafness is 
 reported by Kahler and Pick,^ and another by Fritsch,'' in which the 
 lesion was found in the first and second left temporo-sphenoidal convolu- 
 tions of the left hemisphere. 
 
 In two cases of word-deafness, reported by Petrina,^ and in one 
 
 ' Exner (Sigmund). " Untersucliungen ueber die Localisation der Puuctionen in der Gross- 
 himiinde des Menschen." — Wien, ISSl, p. 57. 
 -' Bar.— i^i-ance Mid., 1S7S, No. 77. 
 - Nothnagel. "Topische Diagnostik der Gehinikrank. "— Bei-lin, 1S79, p. 4-29. 
 
 * Wernicke. "Der aphasische Symptomen complex." — Breslau (Fall. 2), 1874. See also 
 Lehrbv.ch dcv Gehirnkmnkheiten fur Aerzte und Studirende, Bd. II., ISSl, p. 178, et seq. 
 
 ' Kussmavd. Art. " Distm-bances of speech." — "Ziemssen's Cyclopasdia," Vol. XIV., 1S7S, 
 p. 770. 
 
 * Kahler and Pick. "Beitrag zur Lehre von der Localisation du Ilirnf unctiouen. " — Prager 
 VierUljahrschrift, Bd. CXLI., 1879. 
 
 ' Fritsch. — Wiener Medizinische Presse, ISSO. See also Skwortzoff (MUe. N.). " De la eecite et 
 de la siirdite des mots dans I'aphasie." Paris, ISSl, p. 87. 
 
 ^ Petrina (Theodor). "Sensibilitatsstorungen bei Hirnrindlasionen." — Zcitschr. f. Heilkunde, 
 Bd. II., ISSl, p. 375. Abstr. Neurolog. Centralbl., Bd. I., 1SS2, p. 12. 
 
62 
 
 reported by Claus/ the lesion was found in the anterior part of the 
 superior temporo-sphenoidal convolution. A very remarkable case of 
 apperceptive aphasia was communicated by Wernicke^ to the Berlin 
 Physiological Society in 1883. The patient was first affected by word- 
 deafness, and at a subsequent period he became completely deaf; he 
 died from an intercurrent disease, and a spot of softening was found in 
 the first temporo-sphenoidal convolution in each hemisphere of the 
 brain. A careful dissection proved the absence of any local disease in 
 the peripheral organ of hearing. A case is reported by Pitres^ in which 
 the patient, who was the subject of an old left-sided hemiplegia, was 
 seized by a second apoplectic attack, but without paralysis, and although 
 he appeared to take considerable notice of what passed around him, he 
 only replied by an unintelligible grunt on being loudly asked his name. 
 
 Fig. 3. 
 
 He died on the se(!ond day after the last attack, and at the autopsy, 
 besides old lesions in the right hemisphere, a recent clot of blood, about 
 the size of a nut, was found in the medullary substance of the temporo- 
 sphenoidal convolutions. 
 
 A somewhat complicated disorder of speech is reported by Broadbent*, 
 but a very prominent feature of the case was that the patient did not under- 
 stand spoken or written speech, while his attempts at expressing his own 
 thoughts ended in mere jargon. The patient died suddenly, and on post- 
 mortem examination, softening was found, involving a considerable part 
 
 ' Glaus. "Zur Casulstik der Localisation der Grosshirnfunctionen. " — Irrenfreund, 1883, No. 6, 
 Abstr. Ncurolog. Centralbl., Bd. III., 1SS4, p. 205. 
 
 -Wernicke. — Sitzung der Berliner physiologische Gesellschaft, Marz 9, 1SS3. Abstr. "Nature," 
 Vol. XXVII., 1883, p. 593. 
 
 * Pitr6s (A.). "Recherclies sur les lesions du centre ovale des hemispheres cerebraux." — 
 Paris, 1877 (Obs. XV.), p. 55. 
 
 * Broadbent (W. H.) " On a case of aneurism, with post-mortem examination." — Medico- 
 Chirurgical Transactions, Vol. LXI., 1878, p. 147 ; and The Lancet, Vol. I., 1878, p. 312. 
 
63 
 
 of the convex surface of the left hemisphere, the convolutions affected 
 being the supra-marginal lobule, the angular gyrus, the first and second 
 temporo-sphenoidal convolutions, and the adjacent part of the occipital 
 lobe (Fig. 4). It is certain that in this case the patient suffered both 
 fi'om word-blindness and word-deafness. A case of combined word- 
 deafness and word-blindness is reported by Rosenthal,^ which was caused 
 by destruction of the posterior third of the first and second temporo- 
 sphenoidal convolutions, the lesion extending to the point of junction of 
 these convolutions, and the angular gyrus and inferior parietal lobule. 
 A case of partial word-blindness is reported by Dejerine,- in which the 
 patient could read, but did not understand what she read. The autopsy 
 revealed the existence of a tumour, about the size of an orange, in the 
 region of the inferior parietal lobule. The case of a woman is reported 
 by Dr. Shaw,^ of Brooklyn, who had suddenly become, after a slight 
 apoplectic attack, aphasic and perfectly deaf and blind. At the autopsy 
 
 Fig. 4. 
 
 complete atrophy of the angular gyri of both hemispheres was found, and 
 no other lesion either in the brain or peripheral organs. Most cases of 
 word-blindness are associated with right-sided bilateral hemianopsia, and 
 it is now known that this form of hemianopsia* may be caused by lesion 
 of the cortex of the angular gyrus and neighbouring parts, or of the 
 
 1 Rosenthal (Warschau). "Bin Fall von corticaler Hemiplegie mit Worttaublieit."— C««(raJ- 
 blatt fiir Nermnheilhunde, 1884, No. 1. 
 
 * Dejerine (G.). Bull. Soc. de Biologic, 7. S. Tome II., p. 261. See Progres Med., Tome VIII., 
 ISSl, p. 629. 
 
 » Shaw (J. C). Archives of Medicine, Feb., 1882. Absti-. Brain, Vol. V., 1SS2-3, p. 430. 
 
 * See Hii'sohberg. Deutsche Zeitschrift fiir prakt. Med., 187S, Nos. 4 u. 5. Westphal, " Zur 
 Localisation der Hemlanopsie und des Muskelgefuhls beim menschen." — Charite-Annalen. Jahrg. 
 VII. (1880), Bei-1., 1882, p. 466. Marchand, " Beitrag zur Kenntniss der homonymen bilateralen 
 Hemlanopsie und der Faserkreuzung im Chiasma opticum." — Archiv. f. Ophth., Bd. XXVIII., 
 Abstr. 2, 1S82, p. 63 ; and WiUbrand, " Ueber Hemlanopsie und ihr Verhaltniss zur topischen 
 Diagnose der Gehimkrankheiten." Berlin, 1881. 
 
64 
 
 subjacent white substance of the left hemisphere. In most of the cases 
 in which an autopsy has been obtained, the hemianopsia is said to have 
 been accompanied by aphasia, and although the clinical description of 
 the speech disorder is not sufficiently minute to enable us to judge of 
 the form of aphasia present, it may be inferred that it was word- 
 blindness. 
 
 In combined motor and sensory aphasia the lesion is widely distri- 
 buted over the surface of the brain, or two separate lesions may be 
 present. A case is reported by Boyer,^ in which the patient had suiFered 
 for three years from right-sided hemiplegia with contractures, aphasia, 
 and deafness. At the autopsy a spot of softening was found in the 
 posterior part of the first and second frontal convolutions, and another 
 in the convolutions bordering the horizontal limb of the Sylvian fissure. 
 The acoustic and hypoglossal nerves and their nuclei in the medulla 
 were found healthy. 
 
 A very remarkable case of right-sided hemiplegia with contracture, 
 associated with aphemia, word-blindness, and partial word-deafness is 
 recorded by Bernard." At the autopsy numerous spots of softening 
 were found in the left third frontal, the inferior part of the ascending- 
 frontal, and the middle portion of the ascending parietal convolutions. The 
 softening had extended into the substance of the hemisphere and 
 destroyed the anterior segment of the internal capsule. The middle 
 part of the ascending parietal convolution, the angular gyrus, and the 
 posterior part of the first tempero-sphenoidal convolution were occupied 
 by a patch of yellow softening. Another patch of softening was found 
 at the bottom of the sulcus of Eolando below its middle, and the surface 
 of the posterior part of the Island of Reil was destroyed. It is probable 
 that in many cases of verbal amnesia the lesion consists of great local 
 anaemia of the cortex from degenerated arteries, without any destructive 
 disease. A case of verbal amnesia without word-deafness, however, is 
 reported by Rosenthal,^ in a patient suff'ering from general paralysis ; 
 this defect of speech was ushered in by an apoplectiform attack, and 
 persisted unchanged for upwards of two years. At the autopsy, besides 
 evidence of a chronic leptomeningitis, an old focus of softening was found 
 in the second and third temporo-sphenoidal convolutions, the first 
 temporo-sphenoidal convolution being quite free from disease. 
 
 If we now summarise the facts collected in the foregoing pages it will 
 be seen that, in by far the majority of cases, aphasia is caused by a lesion 
 
 1 Boyer (CI. de). " Etude sur les lesions corticales des hemisplisres cer^brales." Paris, 1879, 
 p. 91. 
 
 * Bernard (D.). "De I'apliasie et de ses diverses formes." — Paris, 1885, p. 244. 
 
 ^ Rosenthal (Albert). " Allgemeine Paralyse, mit sensorischer Apliasie anirurt." — Centralblatt 
 fur Nervenheilkunde, Jahrg. IX., April 15, 1SS6, p. 225. 
 
65 
 
 of the left hemisphere of the brain, and that the lesion is situated in 
 aphemia in the posterior part of the third frontal convolution (Fig. 5, 
 Fj) ; in agraphia, probably in the posterior part of the second frontal 
 and the adjoining pai't of the ascending frontal convolutions (Fig. 5, 
 F'^) ; in word-deafness, in the first and second temporo-sphenoidal con- 
 volutions (Fig. 5, T^) ; and in word-blindness, in the angular gyrus and 
 adjoining paii: of the inferior parietal lobule. It would appear from the 
 case just quoted from Rosenthal that the aphasia of recollection, or 
 verbal amnesia, is caused by lesion of the second and third temporo- 
 sphenoidal convolutions (Fig. 5, T" and T^). It has already been stated 
 that occlusion of one or other of the branches of the Sylvian artery is 
 the most frequent cause of aphasia, and if we express the morbid 
 
 Fig. 5. 
 External surface of the left hemisphere of the Brain. — Fissures. 
 
 R — Fissure of Rolando; Sf— Fissure of Sylvius; ipf — Interparietal fissure; pof— External 
 parieto-occipital fissure ; Fi, F,, and F., — The first, second, and third frontal convolutions ; A 
 and B — The ascending frontal and parietal convolutions respectively ; Tj, T,, and T3 — The first, 
 second, and third temporo-sphenoidal convolutions ; Oj, 0„, and O3 — The first, second, and 
 third occipital convolutions ; P^ — The superior parietal lobule ; Pj — The inferior parietal lobule ; 
 P3 — The angular gyrus. The shaded part on F., corresponds to the localisation of the lesion in 
 apherinia ; on F, to motor agraphia; on T^ to tcord-deafness ; on Tj and T3 to verbal amnssia; and 
 on P„ and P~ to 2cord-blindness. 
 
 anatomy of this affection in terms of the arterial supply of the cortex, 
 it may be said that occlusion of the inferior frontal branch gives rise 
 to aphemia, of the anterior division of the ascending frontal branch to 
 agraphia, of the sphenoidal branches, generally the posterior division, to 
 
66 
 
 word-deafness, and of the parieto-sphenoidal branch to word-blindness 
 (Fig. 2). It must not, however, be imagined that the branches of the 
 Sylvian artery are invariably separated so clearly from one another in 
 nature as they are in oiu' diagram. 
 
 The fact, for instance, that aphemia and motor agraphia are so 
 frequently associated, seems to show that the centres for the regTilation 
 of articulate speech and for writing must not only lie near together, but 
 be also supplied by the same vascular system, and it is therefore 
 probable that the inferior frontal, and the anterior division of the 
 ascending frontal branch are not so trenchantly separated from one 
 another as they are in the diagram. It must also be remembered that 
 the spot of softening which occurs after the occlusion of the main 
 trunk of the Sylvian artery, or of one of its branches, is by no means 
 co-extensive, especially in young people, with the area of distribution of 
 the vessel William Davies (Case 1 ), for instance, suffered from a 
 right-sided hemiplegia and complete sensory and motor aphasia, and 
 taking the symptoms in association with the fact that he had a systolic 
 murmur over the apex of the heart, it is very likely that the main 
 trunk of the Sylvian artery was occluded by an embolus imme- 
 diately after the perforating branches are given off. In this case, 
 however, the patient made a comparatively rapid recovery from the 
 sensory aphasia and from the hemiplegia, and even the faculty of 
 writing has undergone considerable improvement, but he is still, twelve 
 months from the onset of the attack, the subject of almost complete 
 aphemia ; and it may consequently be inferred that the posterior part 
 of the third, and to a less extent the posterior part of the second, and 
 the adjoiniug part of the ascending frontal convolution was the only 
 part of the cortex which had become permanently disorganised. In 
 combined sensory and motor aphasia which becomes persistent, the 
 softening is widely distributed in the area of distribution of the anterior 
 and posterior branches of the Sylvian artery. Such cases usually occur 
 in persons advanced in life, and the aphasia is generally associated 
 with hemiplegia and permanent contractures. It is possible for a pure 
 motor or a pure sensory aphasia to be associated with persistent hemi- 
 plegia, but it is probable that in such cases the aphasia is caused by a 
 circumscribed lesion in the cortex, and the hemiplegia by a second 
 lesion, which injm-es the pyramidal tract in its passage through the 
 internal capsule, cms cerebri, or pons. "When, however, a persistent 
 hemiplegia and aphasia are caused by one and the same lesion, the 
 disorder of speech is likely to implicate both the apperceptive and the 
 motor functions, and the disease probably extends widely over the 
 greater part of the area supplied by the branches of the Sylvian artery. 
 
67 
 
 5. Morbid Physiology, 
 
 It now remains for us to interpret the symptoms of aphasia by means 
 of the knowledge we possess of the physiology of those portions of the 
 cerebrum which have been found diseased in the different clinical 
 varieties of the affection. We have already been led to the conclusion 
 that loss of the expressive faculty of speech is, speaking broadly, caused 
 by disease of the motor area of the cortex of the left hemisphere, and 
 that loss of the impressive or apperceptive faculty is caused by disease 
 of the sensory area of the same hemisphere. But in order to justify this 
 conclusion, and to make our interpretation more detailed and minute, it 
 is desirable to subject the symptoms of the different forms of aphasia to 
 a still further analysis. And let us begin our examination with the 
 aphasic disorders of the expressive faculty of speech. 
 
 Motor aphasia may, as we have already seen, be divided into 
 (1) aphemia, (2) agraphia, and (3) amimia. It must at once be admitted 
 that nothing is known of amimia as a separate affection, and not even 
 sufficient is known of it in its association with other speech disorders to 
 enable us to enter profitably upon a further analysis of it. Passing over 
 amimia, therefore, aphemia and agraphia remain for consideration, and 
 although these disorders are usually found combined in various degrees 
 in the same person, it will be found useful to subject each to separate 
 analysis. 
 
 (1.) A2yhemia presents many degrees, from a slight defect in the power 
 of expressive speech up to absolute wordlessness. In the first or the 
 least degree of the disorder the patient has either partially recovered or 
 has never altogether lost the expressive faculty of speech. The subject 
 of aphemia who has been master of two or more languages may, for 
 example, recover the use of one of these, while he remains totally unable 
 to express himself in either of the others. The case of a Russian 
 gentleman is reported by Charcot, who, besides his mother tongue, spoke 
 French fluently, and German less readily. A friend addressed him in 
 French, and he readily comprehended what was said to him, but found 
 himself quite unable to reply in the same language. The German 
 language he found difficult to understand, and was totally unable to 
 speak in it. Numerous examples of this kind might be quoted from 
 other authors. In some cases the disorder of speech is manifested 
 by an uncertain and hesitating speech. Slowness of utterance may, 
 indeed, of itself be taken as a sign of a slight degree of aphemia, just 
 as slowness in the execution of the " devil's tattoo " on the table may be 
 taken as a sign of partial paralysis of the fingers. In other cases the 
 disability is declared by the misplacement or mutilation of words. The 
 
68 
 
 patieut may, to quote the examples adduced by Dr. Hughlings Jackson,, 
 use a word kindred in its meaning with the one intended, as "worm 
 powder" for "cough medicine," or in its sound, as "parasol" for 
 "castor oil." It is, however, in sensory aphasia that the most marked 
 forms of the misplacement of words are observed, and the condition will 
 be subsequently described under the name of ^^aropAasia. 
 
 In the second degree of aphemia the patients have lost the power of 
 expressing their thoughts in spoken words with the exception of a few 
 monosyllabic replies to simple questions. Such patients, hovfeyer, are 
 able to repeat most words uttered in their hearing, and they may be able 
 to read aloud without committing any serious mistakes. A boy, who 
 was the subject of aphemia, and to whose case we have already alluded, 
 was in the Convalescent Hospital at Cheadle last summer. He could 
 only utter spontaneously "Yes" and "No," his own name and a few 
 other words imperfectly, but he could repeat a large number of mono- 
 syllabic names, such as horse, cow, keys, book, etc. When, however, the 
 corresponding objects were shown to him he was unable to name them, 
 but instantly recognised the right name, and repeated it, when it was 
 uttered in his hearing. In other cases the power of repeating words and 
 of reading aloud is retained or recovered in even higher degree than it 
 was in the case of this boy, Avhile the power of spontaneous vocal speech 
 remains very limited. 
 
 In the third degree of aphemia, the power of repeating words oi- 
 reading aloud is lost, but the patient can give monosyllabic replies to 
 two or three simple questions. The unit of emotional language is, so 
 far as it is expressed in vocalisation, an exclamation or an interjectional 
 Avord or phrase, but the unit of intellectual language is a proposition, 
 and if the monosyllabic reply of an aphemic patient possess any speech 
 value it must be equivalent to a distinct proposition. If, for example, 
 a patient says "Yes ! " as an exclamation, the word belongs to emotional 
 language ; but if he says " Yes," with the full understanding that he is 
 giving an affirmative answer to a question, then the word is equivalent 
 to a distinct proposition. Suppose the patient is asked "Are you better 
 to-day?" and he replies "Yes," with a full comprehension of the meaning 
 of his answer, it is equivalent to the proposition " I am better to-day," 
 and the reply itself becomes part of intellectual language. When 
 William Davies (Case 1) was asked his name some months after his 
 attack, he answered " Bill," which is the equivalent of the pi'oposition 
 " My name is Bill," and therefore a part of intellectual language. In 
 this degree of aphemia, therefore, the patients retain or recover the use 
 of a few simple words which possess real speech value. 
 
 In the fourth degree of aphemia, the j)atient has completely lost the 
 j)ower of giving expression in vocal language to any thought, but 
 
69 
 
 ^although he is speechless ho is not wordless. The words which the 
 patient can use continue, as a rule, the same in the same patient, and 
 ■consequently they have been named "recurring utterances." These 
 utterances usually consist of such simple words as " Yes " or " No," but 
 whatever the word may be it is used on all occasions, whether appro- 
 priate or not, and it consequently possesses no speech value. At other 
 times the recurring utterances consist of a phrase, such as "Come on to 
 me," or, " I want pi'otection." ^ The man whose recurring utterance was 
 "Come on to me," was a railway signalman, who had been taken ill on 
 the rails in front of his box ; while the man who could only say " I want 
 protection," had his left cerebral hemisphere injured in a brawl. Dr. 
 Hughlings-Jackson makes the very probable supposition that in these 
 •cases the recurring utterance constituted the last words spoken, or which 
 were in a state of mental preparation for utterance, when the damage 
 occurred to the brain. It is not improbable but that words uttered, or 
 about to be uttered, during a period of great excitement might leave 
 permanent traces on the organisation of the brain which would render 
 them liable to be afterwards uttered as interjectional phrases during 
 •emotional states. Besides these recurring utterances, the patient may,^ 
 under certain circumstances, give vent to "occasional utterances." 
 When the patient becomes vexed with his interlocutor for not under- 
 standing his recurring utterance, or at himself for his inability to express 
 himself, he may find relief in a volley of oaths. On rare occasions a 
 patient may even utter a phrase which is appropriate to the occasion, 
 such as " Good-bye," ^ when a friend is leaving. Now, of these occasional 
 utterances, swearing is a purely emotional expression, and even the 
 phrase " Good-bye " may be regarded as expressing a state of mental 
 regret rather than an intellectual appreciation of the surrounding 
 ■ circumstances. That these recurring and occasional utterances must be 
 regarded as belonging to emotional rather than to intellectual speech is 
 shown by the fact that the patient is unable to repeat, when asked, his 
 favourite oath, his formula of leave-taking, or the simple recurring 
 uttei-ance of " Yes " or " No." The few words which the patient uses may 
 Hbe accompanied by such variations of tone and gesture as indicate when 
 he is angry or joyful. The words are indeed, in Mr. Herbert Spencer's * 
 language, more akin to song than to speech, and belong to emotional 
 and not to intellectual language. 
 
 1 See Jackson (Hughlings). "On affections of speech fi-om disease of the brain." Brain, 
 Vol. I., 1878-9, p. 313 ; and Vol. II., 1879-80, p. 204. 
 
 = Jackson (Hughlings). " Remarks on the occasional utterances of 'speechless' patients." — 
 The Lancet, Vol. II., 1867, p. 70. 
 
 ^ Broadbent (W. H.). " A case of peculiar affection of speech, with commentary." Brain, 
 Vol. I., 1878-9, p. 494. 
 
 Spencer (Herbert). "The origin and function of music." Essays scientific, political, and 
 • speculative. Vol. I., 1868, p. 221. 
 
. 70 
 
 In the Jjffh or highest degree of aphemia the patients, so far as vocal 
 speech is concerned, are both speechless and wordless. Such patients 
 may, however, endeavour to reply to questions by grunting noises in 
 the throat, or by the continuous repetition of a meaningless syllable, 
 like the "tan, tan'' of the patient Leborgne, whose case was reported by 
 Broca. The affection of speech, which has been named in these pages 
 jargon aphasia, must, in so far as the expressive faculty is implicated, 
 be included in this category. In these cases the patient, instead of 
 continuously repeating the same syllable, gives utterance to a rapid 
 succession of different syllables ; but it may be noted that two, or at 
 most three, favourite sounds frequently recur. This form of aphasia is, 
 as already stated, frequently a compound disorder, and the expressive 
 disability is then accompanied by a considerable disorder of the apper- 
 ceptive faculty of speech. 
 
 (2) Motor agraphia may, like aphemia, be divided into five varieties, 
 according to the degree of the affection. 
 
 In the first or least degree the patient either has acquired or has 
 never completely lost the power of writing spontaneously a few words, . 
 phi'ases, and simple sentences, although he makes egregious mistakes in 
 spelling and diction. 
 
 In the second degree he has lost the power of giving spontaneous 
 expression to his thoughts, but he can write to dictation, and copy from 
 a written or printed page. The power of writing to dictation varies 
 greatly, and is often very limited and imperfect. The capacity to copy 
 also varies within extreme limits ; the patient at first may only be able 
 to copy slowly and imperfectly a written word in written and a printed 
 word in printed characters, but after a time he may reacquire the power 
 of writing in a running hand from a printed page. 
 
 In the third degree of agraphia the patient is unable to write to 
 dictation or to copy sentences, but he can still write somewhat imper- 
 fectly his own name, and probably a few simple words, especially if 
 aided by a plain copy of them. 
 
 In the fourth degree, or what Kussmaul calls verbal agraphia, the 
 patient can write rows of letters, which may be separated here and 
 there in the form of words, but which do not convey any meaning. He 
 is also able to copy geometrical figures, but is unable to copy letters and 
 figures. 
 
 In the fifth degree, or what Kussmaul calls literal agraphia, the 
 patient is iinable to write a single letter, and, a fortiori^ he cannot write 
 a word. In such cases even geometrical figures are only imperfectly 
 copied. 
 
 Although the sensory mechanism of speech is not much affected 
 in pure motor aphasia, there can be no doubt that the disorder of the 
 
71 
 
 expressive faculty does interfere to some slight extent with the full 
 exercise of the apperceptive faculty. Some persons, especially those 
 who are only half-educated, when reading a written or printed page, 
 pronounce each word half-aloud, or at any rate the most important 
 words in each sentence, and when the poAver of articulation is lost to 
 these persons the capacity of comprehending what is read is consider- 
 ably impaired. A clergyman once said to me, " I can only study when 
 the pen is in my hand ;" and it is manifest that had this gentleman 
 become the subject of a motor agraphia, his power of comprehending 
 a difficult subject would have been much lessened. 
 
 Patients affected with motor aphasia are able to frown, laugh, and smile 
 as usual, and can also play whist and other games requiring skill. In 
 many cases of aphemia the patient is able to sing simple airs, but generally 
 without words, although on rare occasions persons have been known to 
 sing with the accompanying words a few lines of a favourite song, while 
 quite unable to utter any other word. The chief disabilities from which 
 the subjects of motor aphasia labour are brought together and repre- 
 sented in the following table : — 
 
 APHEMIA. 
 
 The Faculties of Spoken 
 Speech. 
 
 Varieties. 
 
 1st deg. 
 
 2nd deg. 3rd deg. 4tli deg. 5th. deg. 
 
 1. Spontaneous vocal speech \ Tiv,vj„iv.o(j 
 
 in sentences / ^ 
 
 2. Eepetition of words and | ^^^^^^^^_ 
 
 reading aloud J 
 
 3. A few intelligent replies^ j 
 
 to questions in single J-j Retained, 
 words J 
 
 4. Occasional and recurring ^ | 
 
 utterances of no speech |- : Retained, 
 value J 
 
 5. Grunting sounds, and^ 
 
 syllabic utterances, not |- Retained, 
 forming any word J 
 
 Lost. 
 Retained. 
 
 Retained. 
 Retained. 
 Retained. 
 
 Lost. 
 
 Lost. 
 
 Lost. 
 
 Lost. 
 
 Retained. 
 
 Lost. 
 
 Retained. 
 
 Retained. 
 
 Retained. 
 
 Retained. 
 
 Lost. 
 Lost. 
 
 Lost. 
 
 Lost. 
 
 Impaired 
 
 MOTOR AGRAPHIA. 
 
 The Faculties of Written 
 Speech. 
 
 1. Spontaneous writing in 1 
 
 sentences J 
 
 2. Writing to dictation and 1 
 
 copying sentences J 
 
 3. Writing and copying im-" 
 
 perfectly a few single 
 words 
 
 4. Writing letters of the \ 
 
 alphabet J 
 
 5. Copying geometrical \ 
 
 figures J 
 
 Varieties. 
 
 1st deg. 
 
 2nd deg. 
 
 3rd deg. 4th deg. 5th deg. 
 
 Impaired. 
 Retained. 
 
 Retained. 
 
 Retained. 
 Retained. 
 
 Lost. 
 Retained. 
 
 Retained. 
 
 Retained. 
 Retained. 
 
 Lost. 
 
 Lost. 
 
 Lost. 
 
 Lost. 
 
 Retained. 
 
 Lost. 
 
 Retained. 
 
 Retained. 
 
 Retained. 
 
 Retained. 
 
 Lost. 
 Lost. 
 
 Lost. 
 
 Lost. 
 Impaired 
 
72 
 
 Sensory aphasia is much more difficult to analyse than the motor 
 disorders of speech. Leaving the compound forms of sensory aphasia 
 out of consideration for the present, the simple varieties of the aflFection 
 may be divided into (1) the aphasia of recollection; (2) psychical 
 blindness; and (3) psychical deafness. The reason for selecting these 
 words will appear in the sequel. 
 
 (1) In the aphasia of recollection the idea of an object, property, or 
 event is represented in consciousness, but it fails to revive the cor- 
 responding word in memory ; or a person, object, or action may be 
 actually perceived without the corresponding name being recalled to 
 memory. Proper and general names are the words which are most 
 usually forgotten, and the reason for this is not far to seek. As 
 KussmauP remarks "the more concrete the idea the more readily is 
 the word to designate it forgotten, when the memory fails." We 
 not only can, but we constantly do, think of a friend, mentally see 
 his face, hear his voice, observe his attitudes and gestures, without 
 even recalling his name. We may even think of his particular good and 
 kind actions in the absence of verbal signs, but we pan hardly contem- 
 plate " goodness " in an abstract sense without the corresponding word 
 being revived in memory. To state the case more generally, it is 
 possible to think about concrete objects by means of mental images 
 without names, as we may suppose to be done in a rudimentary manner 
 by the lower animals, but abstract thought is impossible in the absence 
 of verbal signs. 
 
 The aphasia of recollection, or verbal amnesia presents many degrees. 
 Almost every person who has reached middle age, and even most 
 young persons who have suffered from overwork, anxiety, loss of 
 sleep, or from any cause which leads to imperfect nourishment and ex- 
 haustion of the brain, must have experienced the slighter degree of this 
 affection. The most common form of the disorder is when the subject 
 of it meets a person with whom he is well acquainted but is 
 unable to recall his name. In the slighter degrees the correct name 
 emerges in consciousness after the lapse of a short time, or a wrong 
 name somewhat similar in sound with the right one, such as Stewart for 
 Stead, rises in the memory. The subject is often aware that the name 
 in his mind is not correct, but the wrong one occupies his attention to 
 the exclusion of the other, or it is only after he is corrected, or ceases 
 to think of the name of his friend altogether, that the right one emerges 
 in consciousness. 
 
 In the second degree of verbal amnesia, the patient is not only 
 
 ' Kussmaul (A.) art. " Disturbances of speech." Ziemssen's " Cyclopoedia," 1871, Vol. XIV., 
 p. 759. 
 
73 
 
 unable to recall the name of his wife and children, probably not 
 even his own, but he is also unable to name most if not all of the 
 objects by which he is surrounded, including his bodily organs. The 
 case of R. B. (Case 8) is a good example of this form of the affection. 
 Some patients are quite unable to name most objects presented to them, 
 others name correctly common objects, but a comparatively long time 
 elapses before the name is recalled to memory, while still others give a 
 wrong name, this last condition being subsequently described under 
 the name of paraphasia. In the first degree of verbal amnesia the 
 power of abstract thought is not at all impaired ; and, indeed, it is a 
 matter of common observation that those who contemplate the pro- 
 founder problems of philosophy are what is called absent-minded, and 
 often the subjects of the slighter degrees of verbal amnesia. In the 
 second degree of the affection, however, there can be no doubt that all 
 the faculties of the mind, including the power of abstract thought, are 
 profoundly injured, and that the idea of things, and the laws which 
 govern them, have, in a great measure, faded from the memory, as well as 
 the words by which these are represented. In such cases, however, 
 when a name is either spoken in the hearing of the patient, or presented 
 to him in writing or printed type, he immediately recognises whether or 
 not it is the appropriate designation of a particular object. 
 
 Several other varieties of amnesia have been observed, but inasmuch 
 as in these the memory for ideas fails in corresponding, or even in higher 
 degree than that for words, they can hardly be regarded as examples of 
 a special speech disorder, and therefore do not belong to the subject of 
 aphasia. These varieties of amnesia will, consequently, not be discussed 
 at any great length in this place. The verbal amnesia which is. so 
 common in middle age increases with advancing years, and in old age it 
 is not imusual to find that the ideas fade from memory even in greater 
 degree than the words by which ideas are expressed. It not unfrequently 
 happens that old people completely forget recent occurrences, while 
 events which occurred in their childhood remain fresh in their memory. 
 In senile amnesia the recent marriage of a friend may be completely 
 forgotten, while the words necessary to describe such an event may be 
 retained and used to describe a similar event which occurred fifty years 
 previously. A partial amnesia of this kind is liable to occur after severe 
 cranial injuries.^ It is not uncommon to find that a patient after a fall 
 on the head has completely forgotten not only all the events which have 
 occurred for several weeks after the injury, but also those that happened 
 
 1 See Azam " Traumatismes C^r^brales," Arch, genh: de mkl., Feb. et'Mars, 1881; Ferr6 
 " L'amnesie traumatique isol6e," These de, Paris, 1881 ; and Bell (J.), on "A form of loss of memor 
 following cranial injuries," Edin., 1883, 
 
74 
 
 several "weeks before it, or the facts of a favourite science or other subject 
 may completely fade from the memory. The faculty of speech is not, 
 however, particularly affected ; the patient is quite able to describe 
 adequately other occurrences more or less similar to those which are 
 forgotten, and the appropriate words fail, not from any special damage 
 to the speech mechanism, but only because the events themselves have 
 become obliterated from the memory. 
 
 (2) FsycJiical-hlindness admits of being divided into several degrees or 
 varieties, and it is indeed because word-blindness constitutes only one of 
 these varieties that psychical-blindness has been selected as the generic 
 term. In recalling to memory the words read in a book some men 
 employ chiefly visual and others chiefly acoustic images. It was said of 
 Macaulay that he could read and remember an article of a review by 
 simply looking at each page as he turned over the leaves. His mind 
 took in the meaning of the text at a glance, and he could afterwards 
 remember the relative positions of the words on the printed page. 
 Persons who are gifted in a high degree with the faculty of thinking by 
 visual images have the power of remembering with marvelloias accuracy 
 a large number of simultaneous facts, such as the position, form, and 
 colour of the various objects in a landscape, the traits which charac- 
 terise each man in a large company, and the direction and relative 
 position of the streets, with the details of the architecture of the public 
 buildings, of a large city. There can be little doubt that Macaulay 
 owed his intellectual eminence in great measure to the high develop- 
 ment in him of the power of thinking by visual images, and if disease 
 had destroyed this power, even without injuring perceptibly any other 
 part of the structure of his mind, he would have been reduced to the 
 level of a very ordinary person. Now in the first or slighter degree of 
 psychical-blindness this is what actually happens. The case of a 
 gentleman is recorded by Charcot^ who had in a high degree the power 
 of picturing in his mind the minutest details of the physiognomy of 
 absent friends, the plan of each town he visited, and the least important 
 features of the scenery through which he passed; but who suddenly 
 discovered that he had lost this power during a time of great mental 
 anxiety and sleeplessness. Before the attack he could add up several 
 columns of figures at a glance, but in order to obtain the sum of a 
 column of figures after the attack, he had to look at each figure in 
 succession, and to pronounce them in a medium voice ; and even in 
 ordinary reading, each word had to be accompanied by slight movements 
 of the lips and other muscles of articulation. The visual memory of 
 
 1 Charcot. "Un cas de suppression brusque et isolee de la vision mentale des signes et des 
 objets (formes et couleurs)." — Le Progres Medical, Tome XI., 18S3. Paris, 1SS3, p. 568. 
 
75 
 
 forms and of colours had almost completely disappeared subsequent to 
 the attack ; he was quite unable to recall the plan of the town in which he 
 lived, the faces of his wife and children, or even the traits of his own person, 
 and he was known to apologise to a supposed individual in a public gallery 
 for barring the way, that turned out to be his own image reflected in a 
 mirror. This gentleman was highly educated, and was perfect master 
 of German, Spanish, and French, as well as of classical Latin and Greek, 
 and although he could still read fairly well in all of these languages, a 
 certain degree of word-blindness was observable in some of them, notably 
 in the German and Greek. The patient was myopic, and his colour 
 vision was slightly defective, but there was no restriction of the field of 
 vision, and no other defect of sight. 
 
 The seco7id degree of psychical blindness is the disorder already 
 described under the name of word-blindness. In this affection the 
 patient is unable to read a single word either from a printed page 
 or in writing; but in most cases he recovers after a time so far as 
 to recognise his own name, the name of the town in which he lives, and 
 a few other simple and very familiar words. In aggravated cases the 
 patient is not only unable to read a single word, b\it he is also incapable 
 of recognising a single letter, a condition named literal-blindness. He 
 can, however, still distinguish geometrical figures and recognise portraits. 
 A person suffering from word-blindness may re-acquire the power of 
 reading without recovering from his visual disability. It is well known 
 that a person who is absolutely blind may be taught to read through the 
 nerves of tactile sensibility by the device of raised letters, and one who 
 remains word-blind may teach himself to read through the nerves of the 
 muscular sense. In a case of word-blindness described by WestphaF the 
 patient, at first unable to read his own writing, acquired the power of 
 deciphering it by passing the tip of his index finger over each letter 
 as if he were writing the word a second time. The case of a very 
 intelligent gentleman is recorded by Charcot", who was suddenly 
 attacked with complete word-blindness ; after a time he taught him- 
 self to decipher written or printed words with considerable rapidity 
 by moving the index finger of his right hand in the air as if he were 
 writing. When his right hand was fixed at his back he moved the tip 
 of the index finger over the nail of his thumb and thus deciphered the 
 word. 
 
 A third degree of psychical blindness may be named 2^ctrtial 2^erceptive 
 blindness. This disorder is best illustrated by the condition to which 
 
 ' See Kussmaul, op. cit, p. 776. 
 
 2 Charcot. "Des differentes formes de I'aphasie." " De la c6cit^ verbale." — Le Progres 
 Medical, Tome XI., 18S3, p. 441. 
 
76 
 
 Goltz reduced dogs by washing out with a jet of water large portions of 
 the cortex of the brain. The animals operated upon manifested a 
 peculiar imperfection of vision ; they could still see and avoid obstacles, 
 but failed to recognise that some of the objects by which they were 
 surrounded were endowed with special properties which constituted 
 them food. The mental condition to which these dogs were reduced 
 was named by Munk psychical blindness, but as we have already 
 said, it will be . most convenient to use this term in a generic sense. 
 The foundation of every perception by sight is to be found in the 
 connection between certain lights and shadows falling upon the eye and 
 the feeling of resistance. Rudimentary sight may be regarded, according 
 to Mr. Herbert Spencer, as anticipatory touch. Suppose a man to be 
 seated at a table, and certain lights and shadows fall upon his eyes, which 
 he knows to be cast by a loaf of bread. The knowledge that the 
 sensation of certain lights on the eye is cast by a loaf implies the 
 further knowledge that on stretching out his hand a certain distance he 
 can grasp the object, and that it will offer a certain degree of resistance 
 to his hand. This is the primary or fundamental part of the perception, 
 but it is only a very small part of the ideas called up in men of ordinary 
 intelligence by the sight of a loaf of bread. Every person knows that 
 the loaf can be cut into slices by a knife, and that when a portion of it 
 is taken into the mouth and chewed, it has an agreeable taste, and that 
 it nourishes the body when swallowed. The more educated a man is 
 the larger will be the number of ideas which cluster round a perception. 
 The sight of a loaf, for instance, may revive in the memory of some men 
 the idea of the mill in which the grain was converted into flour, the 
 wheat from which the grain was derived, and the fields in which the 
 wheat was grown ; while in persons who have had a special training in 
 chemistry, the sight of it may revive a large mass of knowledge about 
 the properties of gluten and starch, and the physiology of digestion. 
 Most of my readers will know to their sorrow the extreme facility with 
 which the knowledge of the chemical properties of gluten and starch 
 fade from the memory even in the absence of any disease, and a mental 
 condition may be induced by injuries of the head or severe disease of the 
 brain, in which a visual sensation fails to arouse in the mind any of the 
 properties of the object except the fundamental one of its inertia, and if 
 this, the most profound of all relations, viz., that between the sight of an 
 object and the idea of its resistance, is once broken, a person would be 
 regarded as having lost either his sight or his reasoning faculties. If, for 
 example, a person were seen moving his hand over a table as if the light 
 reflected by a loaf were a shadow instead of indicating a resisting 
 substance ; or if he were seen walking in an apartment without taking 
 
any notice of the shadows cast by objects, and without arresting his 
 movements imtil he came into collision, with the objects themselves, it 
 would be concluded that he was either completely blind or mad. The 
 mental condition to which Goltz reduced the dogs on which he operated 
 was one in which the fundamental relation between the sight of an 
 object and the idea of its resistance was retained, but in which the 
 sight of an object failed to arouse the idea of any of its remaining 
 properties, and consequently such dogs were unable to make any prac- 
 tical distinction between the leg of a table and a leg of mutton, both 
 objects being regarded as obstacles to be avoided. A more or less 
 similar mental condition to that of these dogs has also been observed in 
 man. A peculiar defect of sight was observed by Fllrstner^ in cases 
 of general paralysis of the insane in which the occipital lobes were 
 particularly involved in the disease. The patients could still see large 
 objects and avoid obstacles, but they failed to count small things 
 correctly, or to appreciate the special properties of oojects. A coin, for 
 example, when placed in the hand, was recognised as a piece of metal, 
 but the knowledge of the special characteristics which constituted it 
 into a money tender was lost. Partial perceptive blindness can hardly 
 be regarded as an aphasia, but it is mentioned here because it forms the 
 connecting link between true word-blindness and the results obtained 
 in animals by experiments on the sensory cortical centres. 
 
 (3) Psychical-deafness is used here, like psychical-blindness, as a. 
 generic term including various disorders in the intellectual appreciation 
 of words, while the faculty of hearing sounds is not necessarily interfered 
 with. We have already seen that in the recollection of language some 
 persons chiefly employ visual and others acoustic images. It is well 
 known that some men, for instance, have a marvelloas faculty of recog- 
 nising, at first sight, persons whom they had casually met some years 
 previously, whilst others recognise their long-absent acquaintances most 
 readily on hearing them speak. Persons in whom the acoustic word- 
 imagery is highly developed recall to memory the voices of their friends 
 rather than their physiognomy and gestures, the singing of birds and 
 the roaring of cataracts rather than the form and colouring of the objects 
 in the scenery through which they pass, and the hum and bustle of a 
 large town rather than the style of its architecture and the plan of its 
 streets, while they are likely to be more appreciative of music than of 
 painting and sculpture. In most persons, ho'.vever, both the acoustic 
 and visual imagery are sufficiently developed to find the loss of either 
 faculty a great deprivation. A case of loss of the acoustic word- 
 
 * Fiirstner. " Ueber erne eigenthlimliche Sehstorung bei Paralytikern." — Archivfiir Psycliiatney 
 
 Bd. VIII., 18S7, p. 162. 
 
78 
 
 imagery has neither been , observed by ourselves nor have we met 
 "with one recorded in medical literature, but we have no doubt that 
 cases of the kind will soon be discovered when a careful search is made, 
 and in the meantime we will name this acoustic disability the first 
 degree of psychical-deafness, and give it a place in our subdivisions of 
 this disorder. 
 
 Word-deafness constitutes the second degree of psychical-deafness. 
 In this condition the patient is not only unable to name correctly 
 any object presented to him, but the names of objects and persons 
 uttered in his hearing also fail to revive in his memory corre- 
 sponding ideas. The degree in which spoken words fail to call up 
 appropriate ideas differs greatly in different cases. In some cases the 
 patient replies readily to most simple questions so long as the names 
 of objects are avoided, while in other cases the disorder is so profound 
 that the patient fails to comprehend almost every question addressed to 
 him, however simple it may be. In some cases of word-deafness the 
 patient can both comprehend reading and read aloud quite well, but in 
 others the auditory disability is accompanied by a considerable degree 
 of word-blindness. The word-blindness is in some of these cases accom- 
 panied by bilateral hemianopsia, and such must be regarded as a 
 compound variety of the two affections ; but in other cases bilateral 
 hemianopsia is absent, and in these the word-blindness must be looked 
 upon as being secondary to the word-deafness. That word-deafness 
 should carry with it a certain degree of word-blindness is not difficult to 
 understand.^ In the acquirement of language spoken speech takes 
 precedence of written speech. An association is first formed between 
 the spoken word and its corresponding perception or idea, and when 
 subsequently the word comes to be seen in writing the association is 
 formed not directly between the written word and the idea, but 
 indirectly through the spoken word. A half educated person can only 
 comprehend what he reads when the words as uttered by himself fall 
 upon his ear, and it is manifest that in such a person word-deafness 
 would entail almost complete word-blindness. And even educated 
 persons, when reading a difiicult subject, are much aided in compre- 
 hending it by muttering half aloud the principal words of each sentence; 
 and in such persons also word-deafness would cause some difficulty in 
 understanding written language, although not complete word-blindness. 
 The degree of deafness to words varies greatly in different cases. A 
 case of fracture of the brain is reported by Ore,^ in which the 
 patient failed to understand questions addressed to him in French, 
 
 • See De Watteville (Dr. A.) " Note sur la cecite verbale." Le Frogres McOAcal, 21, Mars, 1S85. 
 - Ore. Ball. Acad, de Med., 2 S., Tome VII., 1S7S, p. 1183. 
 
79 
 
 but replied at once when the question was asked in patois. In 
 other cases a still less degree of disability is present. The case of 
 a Russian gentleman is recorded by Charcot/ who, besides his native 
 tongue, was master of French and German. After a cerebral attack he 
 failed to comprehend questions asked him in German, but understood 
 quite well when addressed in Russian or French. In some cases the 
 patient understands many questions so long as concrete nouns are 
 avoided, while in other cases the patient fails to give evidence that he 
 understands any word uttered in his hearing. In some few cases the 
 deafness extends even to letters and figures, constituting literal deafness 
 corresponding with the literal blindness already described. The percep- 
 tion of music is sometimes preserved even in complete word-deafness, 
 but in most cases the appreciation of music is much impaired. It is, 
 however, abundantly proved that word-deafness does not entail deafness 
 to ordinary sounds ; a slight knocking at the door, for instance, being 
 readily heard and its significance quickly interpreted. 
 
 Partial-perceptive deafness is not so well known as the corresponding 
 visual affection. The dogs operated upon by Goltz took no notice of 
 calls to which they readily responded prior to the injury, yet they were 
 not deaf, inasmuch as they were observed to start at noises. Now the 
 fundamental relation in an auditory perception is to be found in the 
 association between certain noises and the feeling of danger, and of 
 other sounds and something, such as prey or food, to be enjoyed, and of 
 these the former is probably the more profound of the two. If, for 
 example, a loud or sudden noise be made close to the ear of a person 
 and it fail to cause a start, it would be concluded that the subject was 
 absolutely deaf; but if a person, who affords the usual indications of 
 hearing sounds of moderate intensity, fail to understand the significance 
 of a loud tapping at the door of his apartment, it would be concluded 
 that he is the subject of the partial-perceptive deafness under considera- 
 tion. Examples of this form of partial deafness are doubtless to be 
 found in our asylums, although the condition has not yet, so far as we 
 know, been adequately described. 
 
 In motor aphasia the apperceptive faculty of speech is, as we have 
 seen, not much affected, but the converse of this proposition is very far 
 from being true, inasmuch as in the various forms of sensory aphasia 
 the expressive faculty of speech is the subject of a profound disorder. 
 The different derangements in articulate expression which are observed 
 in sensory aphasia may, following Kussmaul, be grouped together under 
 the term " paraphasia." 
 
 ' See Bernard (Desir^). " De I'aijliasie et de ses divei-ses formes." Thhe de Paris, 1S85, p. 154. 
 
80 
 
 Paraphasia presents several degrees according to the intensity of 
 the sensory disorder, and to the nature of the apperceptive faculty 
 which is injured. The first or slightest degree of the affection hardly 
 oversteps physiological limits, and is liable to occur in persons exhausted 
 from fatigue or hunger, or who are excitable or nervous. A person 
 absorbed in thought, or whose brain is exhausted from some cause,, 
 will often find that on meeting a friend a wrong name starts in 
 his memory to the exclusion of the right one. In many cases the 
 wrong name is connected with the right one by similarity of sound, 
 like the example already given of Stewart for Stead, or the familiar 
 Brown for the less familiar Barrett, while in other cases the connection 
 is formed by some more hidden link of association. At other times 
 mistakes are made in grammar and diction, or there may be a transpo- 
 sition of the syllables of two words in the same sentence, a condition 
 which has been named by Kussmaul " syllable-stumbling," but which is. 
 doubtless a variety of paraphasia. As an example of syllable-stumbling 
 Kussmaul mentions the case of an absent-minded professor who, before 
 his class, spoke of "the two great chemists Mitschich and Liderlich, 
 meaning Liebig and Mitscherlich." Those who studied medicine in the 
 University of Aberdeen some years ago, will remember that one of our 
 most respected professors was constantly in the habit of committing 
 ludicrous mistakes of this kind, " cus porcuscles" instead of "pu^. 
 corpuscles," being an example of which we have been recently reminded. 
 It may here be remarked that great hesitation in recalling the correct 
 names of objects and events is of itself a sign of the presence of some 
 degree of sensory aphasia, just as slowness in the execution of certain 
 movements, such as beating the devil's tattoo on the table, is a sign of 
 motor paralysis. 
 
 The second degree of paraphasia is met with in the second degree of 
 verbal amnesia. The patient being unable to recall to memory the- 
 names of objects, is compelled to substitute for the correct word a 
 paraphrase of it or a wholly inappropriate term. A person, for example,, 
 Avho forgets the name of "scissors," may say "the thing you cut with," 
 or of a " chair " " that you sit on." When a wrong name is substituted 
 for the right one, the former is generally connected with the latter by 
 similarity in sound or meaning, or by frequent association in the use of 
 the objects represented by the words. The patient may, for example, 
 say "butter" instead of "mother," "pencil" instead of "pen," or 
 "pepper" instead of "salt." 
 
 The third degree of paraphasia is observed in those cases of word 
 deafness in which the patient is not only unable to give an appropriate 
 name to any object, but also fails to appreciate the right name when it 
 
81 
 
 is uttei'ed in his hearing. In cases of this kind the patient often 
 employs one word, which by long use and frequent association had 
 become automatic in him before the attack, as the designation of every 
 object presented to him. James Lee (Case 5), for example, named 
 every object "public-house." His index finger was "the first public- 
 house," and the remaining fingers, "the second," "third," and "fourth 
 public-house" in succession. His thumb was "the public-house there," 
 and his head " this public-house," at the same time pointing to it. The 
 workhouse, in which he Avas on several occasions an inmate, was " the 
 public-house up yonder," and so on. At other times the patient may 
 substitute for the appropriate name an unintelligible sound instead of a 
 word. Joseph Lander (Case 4) for example, named a pencil a "punt," 
 and although he knew that this was incorrect every fresh endeavour to 
 name the object ended in it being called a "punt." 
 
 A fourth and last degree of paraphasia is met wdth in certain cases of 
 gibberish aphasia. It is very probable that in some cases of this kind 
 of aphasia the derangement of the expressive faculty of speech is caused 
 by a direct injury of the motor mechanism. In the case of John Hand- 
 forth (Case 9), for example, word-deafness was present in a marked 
 degree, but inasmuch as the patient was the subject of a persistent 
 hemiplegia, it is probable that the motor mechanism of speech was like- 
 wise injured. A too exclusive consideration of this case led us to assert 
 that gibberish aphasia is always associated with persistent hemiplegia, 
 but Dr. Clifford Allbutt, whose opinion on such a question is so well 
 deserving of confidence, has, in a private communication, kindly pointed 
 out that this association is not invariable. A further examination of the 
 subject has convinced us that Dr. Allbutt is right. The case of a man, 
 aged 60 years, is reported by Broadbent,^ who, after a fit of some kind, 
 sufiered from paresis of the right side of the face, but no hemiplegia. 
 His speech was mere inarticulate jargon, while he was almost com- 
 pletely word-blind and word-deaf. At the autopsy a large focus of 
 softening was found in the left hemisphere of the brain in the area of 
 the parietal and parieto-sphenoidal branches of the Sylvian artery. In 
 this case the motor mechanism of speech was uninjured, and yet vocal 
 expression was reduced to mere jargon. It is evident, therefore, that 
 the gibberish resulted not directly from injury of the motor, but indi- 
 rectly from injury of the sensory mechanism of speech, and it must 
 consequently be regarded as a paraphasia. The disorder may, therefore, 
 in such cases be named syllabic paraphasia. In a very remarkable case 
 
 ' Broadbent. "On the cerebral mechanism of speech and thought." Medico-Cldrurgical 
 Transactions, Vol. LV., lSi2, p. 162 et seq. 
 P 
 
82 
 
 reported by Dr. Osborne^ the patient, after an apoplectic attack which 
 left no trace of paralysis, gave utterance to a rapid succession of unin- 
 telligible sounds when he attempted to speak, while his efforts at reading 
 aloud ended in mere jargon. The patient, however, is said to have 
 understood all that was said to him and also what was written, and was 
 even able to express his thoughts, in writing, only using incorrect words 
 rarely. In this patient the apperceptive faculty of speech appears to 
 have been intact, and his speech disability must consequently be 
 regarded as a variety of aphemia, which may be named syllabic apTiemia, 
 and corresponds to our fifth degree of aphemia. The case shows that 
 even the gibberish aphasia which results from injury of the motor 
 mechanism of speech may occur in the absence of hemiplegia. 
 
 The power of repeating words is lost in cases of complete word- 
 deafness, but it is preserved in uncomplicated cases of word-blindness, 
 as, for example, in the case of Robert Marshall (Case 2). 
 
 The subjects of sensory aphasia make mistakes in writing, which 
 correspond more or less with those made in speaking, the affection being 
 named by Kussmaul " paragraphia." 
 
 Paragraphia admits, like paraphasia, of being divided into several 
 varieties, according to the degree of the affection. The first degree 
 of paragraphia occurs in most healthy persons when the brain is 
 exhausted from any cause. It shows itself sometimes by errors in 
 spelling simple words, and at other times by elision, or transposition 
 of words or of whole phrases in a sentence. 
 
 The second degree is met with in those cases of verbal amnesia in 
 which the patient is unable to recall the names of persons and objects. 
 The patient being unable to recollect most of his concrete nouns, he 
 cannot write them, and he is consequently unable to write continuously 
 anything beyond a few simple sentences, although he can write readily 
 to dictation, especially if the words are frequently repeated in his 
 hearing. 
 
 The third degree of paragraphia is met with in word-deafness. In 
 this form of aphasia the patient is almost wholly incapable of completing 
 a sentence in writing. The letter written by James Lee (Case 5) to one 
 of his fellow patients is a good example of this degree of the affection. 
 
 K fourth degree may possibly be constituted by some at least of those 
 cases in which the patient writes whole lines of letters without being 
 able to form a single intelligible word. The case of a woman is men- 
 tioned by Hughlings-Jackson^ who, after a slight attack of aphasia with 
 
 ' Osborne. The Dublin Journal of Med. and Chemical Science, 1834, Vol. IV., p. 157, quoted by 
 Bastian, Bi-it. tb For. Medico-Chir. Review, Vol. XLIII., 1869, p. 229. 
 
 2 Jackson (Hughlings), London Hospital Reports, Vol. I., p. 432, quoted by Bastian (Charlton), 
 British and Foreign Mediro-Chirurgical Revieto, Vol. XLIII., Jan., 1869 p. 232. 
 
83 
 
 transient hemiplegia, on attempting to write her name, wrote, " Sunnil, 
 Siclaa, Satreni," and gave her address as "Sunesr Nut Ts Mer Tinn-Lain." 
 It is, however, probable that, as the patient is said to have been very 
 intelligent, the disorder in this case was due to injury of the motor 
 mechanism. The case of a man was reported by myself,^ who, after 
 an injury to the head, named objects indifferently "two," "tooth," 
 and " measures," and understood but imperfectly what was said to 
 him, while his attempts at reading aloud ended in little better 
 than gibberish. This man fell from the top of an omnibus, and the 
 right side of his forehead was the first part to strike the ground, so that 
 the angular gyrus and the posterior part of the first and second temporo- 
 sphenodial convolutions of the left hemisphere would be the parts that 
 would suffer from the contre-coup ; and, as there was no paralysis, the 
 motor mechanism of speech was not likely to have been injured. Both 
 the synaptoms and the nature of the injury therefore pointed to the 
 conclusion that his speech disability was a sensory aphasia. On being 
 asked to write his name — William Abson — he took hold of the pen with 
 the air of one accustomed to its use, and in a bold hand, but with con- 
 siderable hesitation, wrote, " Wuagageng Abreaghrer." As he wrote 
 each letter he named one aloud, but the written and spoken letter never 
 corresponded with one another, and very few of either corresponded with 
 the letters of the name he was attempting to write. Prom this case it 
 may be concluded that a sensory aphasia may give rise to so great a 
 disorder in writing that every syllable and almost every letter of the 
 writing fails to correspond with the word attempted to be written, and 
 the disorder may consequently be named syllabic or literal paragraphia. 
 Other disorders emerge when the subject of a sensory aphasia attempts 
 to write to dictation. In cases of verbal amnesia patients can write 
 correctly to dictation, but in aggravated cases the words have to be 
 frequently repeated to them. The word-deaf, of course, are unable to 
 write to dictation. A few days ago James Lee (Case 5) was asked to 
 write down " This is a fine day," and, after taking some time for con- 
 sideration, he wrote " whiskey," which at present has replaced " public- 
 house," and " glass of beer " as his favourite name for all objects. The 
 word-blind can, if educated, write to dictation, but they write better 
 with their eyes closed than open, and are unable to read what they have 
 written. Kobert Marshall (Case 2) could write a few words to dicta- 
 tion, but if he raised his pen while writing a polysyllabic word, he got 
 confused and was afterwards unable to complete it. 
 
 The power of copying written or printed words is also deranged in 
 
 1 Ross (J.) " A case of amnesic aphasia occasioned by a fall on the head." The Lancet, Vol. 11^ 
 1S81, p. 904. 
 
84 
 
 many cases of sensory aphasia, while it is preserved in others. James 
 Lee (Case 5), who was word-deaf, and could not write a word to 
 dictation, could copy correctly in a beautiful running hand from a 
 written or printed page. Robert Marshall (Case 2), who was word- 
 blind and could write to dictation, was unable to copy a single letter of 
 a written or printed word. Some patients suffering from word-blindness 
 can copy words very slowly, taking letter by letter, and forming it as it 
 is in the copy, whether written or printed, just as if it were a geometrical 
 figure. In other cases of sensory aphasia a still greater success in 
 copying is attained ; but it still continues to be very imperfect. William 
 Abson, tlie case just alluded to, who was word-deaf, and, most likely, 
 word- blind, on being asked to copy "With deep feeling," wrote with 
 great deliberation, and with frequent glances at the copy, " Weeth deap 
 flneearer." 
 
 Some of the subjects of sensory aphasia commit mistakes on 
 attempting to read aloud, this condition being named by Kussmaul 
 "paralexia." 
 
 Paralexia admits also of being divided into several varieties, accord- 
 ing to its degree of intensity. The first degree of paralexia occurs in 
 absent-minded and nervous people, and consists of slurring over some 
 words altogether, transposing others, and similar ludicrous mistakes. 
 In the profound verbal amnesia, in which the names of most objects are 
 lost, the patient is able to read aloud and generally correctly, or only 
 makes slight mistakes like an absent-minded person; but he forgets 
 what he has read immediately afterwards. 
 
 In the second degree mistakes are so frequently committed that the 
 sense of what is read is almost completely lost to the listener, although 
 it is possible that the patient himself may understand the meaning of 
 what he is reading. Considering the extreme degree of the speech- 
 disorder from which James Lee (Case 5) suffered, he read aloud with 
 wonderful correctness; but he hardly ever read a sentence without 
 mispronouncing some of the words, and thus marring the sense to the 
 listener. 
 
 In a third degree of paralexia every word, or almost every word, is 
 represented by syllabic sounds to which no definite meaning can be 
 attached, as in cases of gibberish aphasia. The disorder observed in 
 Robert Marshall (Case 2), in which the patient composed his own 
 reading, but not a word of which corresponded with any in the text, is 
 doubtless allied to the profounder degrees of paralexia, although it is 
 somewhat difiicult to classify. 
 
 In partial perceptive blindness the patient must commit serious 
 mistakes in conduct, a condition which has been named by Kussmaul 
 
85 
 
 *' apraxiii." A patient, for example, "who fails to recognise that a piece 
 of metal he holds in his hands is a money tender of a certain specified 
 value must necessarily commit gross mistakes in purchasing commodities. 
 The case of a young man is reported by Gogol "v\-ho, after an injury to 
 the head, suffered from a complicated form of aphasia, manifestly 
 including word-blindness. Kussma\il,^ who quotes the case, says of this 
 patient, " he urinated iu the wash-basin, bit a morsel out of a cake of 
 soap, and did other things of a like character, which proved that he 
 confounded material objects with one another. He performed prepos- 
 terous acts, or, iu other words, suffered from apraxia." Corresponding 
 mistakes in conduct may doubtless be committed by those suffering from 
 word- deafness, but an example of the kind is not known to me. 
 
 Paraminua is a word used by Kussmaul to designate the disorders 
 of intellectual gesture, which may occur in sensory aphasia. A patient 
 may, for example, nod assent when he wishes to give a negative answer, 
 or vice versa. Those disorders of gesture are,, however, not well ascer- 
 tained, and consequently they need not detain us longer. 
 
 Tlie chief disordei*s, both of the apperceptive and expressive faculties 
 of speech which occur in sensory aphasia, are broiTght together iu the 
 following table : — 
 
 1 Kussmaiil. Op. cit., p. 797. 
 

 
 
 
 
 
 
 
 
 
 <B tS 
 
 O.g . . 
 
 
 _, > tn 
 
 
 
 13 
 
 Ti 
 
 13 
 
 
 
 
 P'S! '^ 
 
 gn3 T3 cS 
 
 
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 a: 
 
 -p 
 
 02 
 
 ^1 CQ QJ 
 
 bo 5 -p s^ 
 
 0) ,3 02 -.3 
 
 I'^^-.g-a 
 
 
 is S's 
 
 
 o 
 
 "c3 
 
 ■rf 
 
 "S 
 
 
 
 
 
 
 
 13 Ph C g 
 
 13 r„ cs 2 
 
 09 
 
 H 
 P 
 
 TO o ra 
 
 
 y^ 
 
 
 0) 
 
 P5 
 
 -p 
 P^ 
 
 hJ 
 
 1-3 
 
 H-1 
 
 2 g^ §^^ E^^ »^ 
 
 
 
 
 '6 
 
 is' 
 
 13 
 
 
 
 13 
 
 S.| ^ 
 
 QJ j3 13 13 
 
 nil 
 
 
 ^• 
 
 .9 
 
 0) 
 
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 -p 
 
 <B 
 
 a 
 
 IB -3 CQ •" 
 
 
 <) 
 
 o>*- 
 
 
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 "cS 
 
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 T3 a. j^ 
 
 13 tu ce ?? 
 
 ^1 
 
 
 H^ 
 
 
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 h:i 
 
 i-:i 
 
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 ■B 
 
 -raj P' " 3^ J -P i-^ 
 
 O 
 
 W 
 
 fi 
 
 
 
 P^ 
 
 P5 
 
 P5 
 
 
 
 Ph 
 
 -p c« a 
 
 ^1 «- 
 
 .„o^-^ 
 
 
 rd 
 
 T3 
 
 la' 
 
 tj 
 
 
 13" 
 
 ^6 
 
 IB cS . 
 
 ■73 13 is'-TJ 
 
 oB3 g m 
 
 
 <P 
 
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 a> 
 
 OJ 
 
 
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 h, rf i^ I' 
 
 0) 0) <B IB 
 
 
 
 .3 
 
 fl 
 
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 .9 -".g.g 
 
 
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 c« 
 
 13 a * cc 
 
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 hJ 
 
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 ^ ^hSp: 
 
 CO pLi'^ '^ 
 
 <B 3 IB IB 
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 ^ 
 
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 "^ 
 
 
 ■^^ 
 
 
 
 
 ■73 
 
 13 
 
 13" 
 
 13' 13" 
 
 13 ^3 ce 
 
 
 f— 1 ,ll CO 
 
 
 (D 
 
 
 
 
 <U 
 
 CB 
 
 IB 
 
 a> IB 
 
 IB IB . .5 
 
 
 
 t-i 
 
 -P 
 
 -ti 
 
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 ^ 
 
 p 
 
 a 
 
 U 3 -P 
 
 i^ u -t^ yi 
 
 
 'Ji QiO 
 
 
 
 
 
 
 
 
 .a 
 
 •S •!= If 
 
 ■§ "^ § 6 
 
 
 1; tUT3 
 
 
 cS 
 
 O 
 
 
 
 
 
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 '(^ 
 
 ce 
 
 2 cS C 
 
 03 
 
 00 
 
 ci P rj 
 
 
 ft. 
 
 s 
 
 1— 1 
 
 ^A 
 
 h:i 
 
 yA 
 
 (B 
 P5 
 
 P5 
 
 -p 
 
 <B 
 
 P5 
 
 ^1 p^ 
 
 a a^^ 
 
 « 
 
 
 ^ 
 
 ^-^ 
 
 
 
 '6 
 
 'd 
 
 13" 
 
 13" 
 
 13 13" 
 
 13 '^ ^3 
 
 
 
 
 n3 Q, 
 
 
 
 <o 
 
 IB 
 
 IB 
 
 a> 
 
 <B (B 
 
 IB IB . IB 
 
 m 
 
 ii 
 
 
 
 o 
 
 
 
 '3 
 
 .g 
 ■3 
 
 '3 
 
 .9 
 '3 
 
 .a .9 a 
 
 '3 '3 c 
 
 ce cc ce 
 
 s 
 
 
 
 
 h-5 
 
 a 
 
 h- 1 
 
 IB 
 
 Ph 
 
 -p 
 
 IB 
 P^ 
 
 -p -p t^ 
 
 IB "^ 
 
 P5 p^ 
 
 &, p,j p< 
 
 a g^ a 
 
 1— 1 h-H h-H 
 
 n 
 
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 ?H 
 
 
 
 
 
 
 
 
 
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 3 J 
 
 
 TS 
 
 
 TS 
 
 TJ 
 
 13 
 
 13 
 
 13 
 
 13 'C 'C 
 
 ^ 13 T3 13 
 
 •|3Ss 
 
 
 ai 
 
 
 <u 
 
 CU 
 
 IB 
 
 m 
 
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 <B IB <B 
 
 IB IB IB <B 
 
 
 
 B 
 
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 ^ggg 
 
 
 
 02 
 
 
 
 
 
 
 
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 O 
 
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 ■3 
 
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 3 '* 'i 
 
 
 SsS.^ 
 
 
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 1-5 
 
 © 
 
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 IB 
 
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 <B 
 
 (B 0) a. 
 
 aj aj 3 IB 
 
 p^ ph)5p5 
 
 
 
 
 Ph 
 
 
 pi; 
 
 P5 
 
 P5 
 
 P^ 
 
 P5 
 
 P^ (A^ 
 
 
 
 
 
 
 
 
 
 
 
 <B ^- 
 
 g-i-ai: 
 
 «^ rS .3 .^ 
 
 13 a cS c^ 
 
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 CD 
 
 
 
 13 
 
 'O 
 
 t: 
 
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 13* 
 
 13" 
 
 g ;a 13 -73 'd 
 
 i 
 
 
 
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 0) 
 
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 "S, 
 
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 2 1" S'- '^ 
 
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 ■^ 
 
 a> 
 
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 IB 
 
 IB 
 
 IB 
 
 lll««^ 
 
 <S 
 
 
 
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 P5 
 
 p:5 
 
 « 
 
 P5 
 
 Ph 
 
 3 ce Qi cr 
 
 
 
 
 
 
 
 
 
 
 IB ce 
 
 a>.d . . . 
 
 <) 
 
 CJ 
 
 
 T3 
 
 13" 
 
 '6 
 
 TJ 
 
 'd 
 
 -c 
 
 TJ 
 
 0) -^ 13 13 
 
 y.al 
 
 aj ^ 13 T3 13 
 
 N 
 
 
 
 (D 
 
 <o 
 
 a> 
 
 <B 
 
 2 
 
 a> 
 
 IB 
 
 h, P. aj a) a> 
 
 « 
 
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 ^ 
 
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 .9 
 
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 _a 
 
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 a 
 
 bp 3* 3 3 3 
 
 1> 
 
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 % 
 
 •3 
 
 •3 
 
 13 &< ca 3 
 
 05 -^ .^ .3 "^ 
 13 tio_g J 4§ 
 
 -P 2 0) 05 0) 
 
 
 
 ->i 
 
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 -p 
 
 
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 cS -P -P 
 
 
 
 
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 (B 
 
 aj 
 
 <u 
 
 IB 
 
 tt) 
 
 IB 
 
 -P >^ IB IB 
 
 
 45 
 
 
 Ph 
 
 P^ 
 
 p^ 
 
 P^ 
 
 p^ 
 
 P5 
 
 ^ a=^Pi 
 
 ^ 3Pip^« 
 
 
 
 
 tj^ 
 
 >> : 
 
 t>i 
 
 05 
 
 >iiS 
 
 >a 
 
 >i : 
 
 ^-Y-' 
 
 
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 ^4 
 
 t^ : 
 
 ^ 
 
 ^ 
 
 u 13 
 
 ^ 
 
 fa • 
 
 
 
 
 
 
 
 
 
 
 
 
 o 
 
 • 
 
 
 
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 a 
 
 
 
 • 
 
 
 
 
 
 
 
 
 
 
 
 
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 a : 
 
 a 
 
 >1 
 
 a S 
 
 a 
 
 a '■ 
 
 
 
 
 
 
 
 
 
 
 
 
 a> 
 
 m 
 
 a> 
 
 ;-i 
 
 IB g 
 
 <B 
 
 <y> m 
 
 
 
 
 
 
 
 
 
 
 w 
 
 
 a 
 
 
 a 
 
 
 
 a 
 
 a "« 
 
 
 a 
 
 al 
 
 
 
 
 
 
 
 
 
 
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 a 
 
 0) 02 
 
 t< a 
 
 a 
 
 2 w 
 
 
 a 
 
 3.2, 
 
 
 
 
 
 
 
 
 
 pet 
 
 o 
 
 
 > ■? 
 
 > 
 1, 
 
 at 
 
 .r-H tjj 
 
 
 •i-i 
 
 IB 
 
 > 
 
 .3^ 
 
 IB 
 
 •- 
 
 IB to 
 ^ IB 
 
 
 
 
 
 
 05 
 
 a5 
 
 Ph 
 m 
 
 
 
 
 
 05 
 
 Eh 
 
 1 
 
 1 
 
 a - 
 
 02 i^ 
 
 ,1 £ ^ i 
 
 02.2 
 
 „ a -t= 
 
 H <B .-H 
 
 13 1 
 
 02 
 
 H§| 
 
 .2 
 
 ■p 
 
 OJ IB 
 
 a (B 
 bpi: 
 
 _ ta 
 
 '3 a 
 
 IB a 
 
 > § 
 ; 
 
 ■-P <B 
 
 ° 
 
 a'^ 
 .2 ^ 
 
 IB O-4 
 "•^ 
 
 IB ce 
 
 &i 
 ^S =0 02 
 
 E r^ tJ 
 
 ^ cS !-, 
 
 03 
 
 •1 ? ^^ 
 
 ig 3 • r3 bi 
 ■o 3 IB 13 
 
 PI a' 
 ^ .2 
 
 11 
 
 '1 ^.9 
 a '-p > 
 
 3 
 
 
 
 
 « 
 
 
 Ph 
 
 CS ° 
 
 a :: 
 
 IB ^ 
 
 -a 
 
 ;<; P' cS 
 
 p "e: p- y 
 
 
 
 1 
 
 £ 
 
 
 .2 "^ 
 
 8 " 
 
 § -P 
 
 1 CO Ph Ph 
 
 d^ kT P 
 
 
 
 1 
 
 rH 
 
 (m" 
 
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 1>^ 
 
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 -* 10 CO t>l 
 
 
 
 '>^* 
 
 
 
 
 
 
 
 
 '^ 
 
 
87 
 
 Having subjected the chief symptoms of aphasia to analysis, it now 
 remains for us to connect the clinical varieties of the affection with 
 disease of certain parts of the nervous mechanisms of speech. Attempts 
 have been made, from time to time, by different authors to accomplish 
 this end by means of a diagram. The first attempt of the kind was 
 made by Baginsky,^ and he was soon followed by Wernicke- and 
 Spamer,'^ but those schemes, being somewhat crude, need not detain us, 
 and we shall at once proceed to describe briefly the very important 
 diagram constructed by Kussmaul.'*= In Figure 6, J represents the 
 ideational centre or centre of conceptions ; B, the acoustic sensory 
 centre, and B' the visual sensory centre for words. C is the motor 
 centre for the co-ordination of the movements required for spoken speech, 
 
 Fig. 6. 
 and C the corresponding centre for written speech ; a is the acoustic, and 
 the optic nerve ; a h c h d is the collective acoustic track for spoken 
 speech, and o 2^ q 2^ ^ ^he coiTesponding optic track for written speech ; 
 a 6 c^ is the track for the imitative speech of children and o ^:) r is the 
 track for the copying of uncomprehended words. 
 
 1 Baginsky (D.). "Aphasie in Folge scliwerer Nierenkrankungen. — Urajmie." Bevlbur lUn. 
 Wochensch,:, Bd. VIII., IS71, p. 441. 
 
 2 Wernicke (C). "Der Aphasische Symptomen-coniplex." Breslaw, 1S74. 
 
 ' Spamer (C). " Ueber Aphasieund Asymbolienebst VersucheinerTheoriederSprachbildung," 
 Arch. J. Psychiatric, Bd. VI., 1S75, p. 507. 
 
 * Kussmaul (A.). "Disturbances of speech." Ziemsseii's Cyclopcedia of the Practice of Medieine, 
 Vol. XIV., 1878, p. 779. 
 
c b d is the track for giving utterance to thoughts, and q p r for 
 "writing down thoughts. 
 
 c X q represents the connection between acoustic and visual word 
 images, and by means of it the translation of written into spoken words 
 is rendered possible, and vice versd. 
 
 h r and 2^ ^ represent respectively the tracks between the centre for 
 spoken images and the motor centre for writing, and that between 
 the centre for written images, and the motor centre for spoken speech. 
 
 a & 7- is the track for writing down an uncomprehended spoken word, 
 and p d the one for reading aloud an uncomprehended written word. 
 
 ah ch r is the path for writing down dictated words that are under- 
 stood, and p qp d the one for reading aloud comprehended written 
 words. The dotted lines indicate paths from the nerves of sense passing 
 to the ideational centre through other centres than those of acoustic and 
 visual word images; such, for example, as a tract through the optic 
 nerve leading to a centre for the appreciation of gestures and panto- 
 mimic speech generally, and through the acoustic nerve to a centre for 
 the appreciation of music. The arrows indicate the direction of the 
 conduction. 
 
 Such, then, being Kussmaul's diagram of the nervous mechanisms 
 of language, let us see how he explains the various speech disorders by 
 disease of particular paths and centres. 
 
 The deaf-mwte is incapable of using the tracks ah ch d and ah ch r, 
 but the centres C and C can be reached through 0, and thus the 
 power of writing and speaking can be acquired. In writing he can 
 copy without understanding the text through the path p r, and with 
 understanding of it through the path p q p r. In learning to speak, 
 the acoustic centre B for spoken words cannot be reached, and conse- 
 quently a visual centre B" for the appreciation of the movements of the 
 lips and the other parts of the articulatory apparatus must be developed 
 to take its place. When the patient mimics the movements of articu- 
 lation without comprehension, he uses the track %t, d, and with compre- 
 hension %i z u d. By the use of the central connection z x' q, it is 
 possible to translate mimic word-images into written word-images, and 
 vice versd. 
 
 In complete motor aphasia the centres C and C are injured, and 
 the paths passing through them cannot be used. In aphemia the centre 
 C, and in motor agraphia the centre C, is alone injured. 
 
 In those cases in which the patient has lost the faculty of spontaneous 
 speech while retaining the power of reading aloud, the path & c? is injured, 
 while the centre C with the path p d are unaffected. In the a2oliasia of 
 recollection the path c h is temporarily blocked, and the patient is unable 
 
89 
 
 to name objects spontaneously. When, however, the sound of the name 
 falls on a, the impulses passing through the path a h d enable the 
 patient to utter the word in a reflex manner, and the extra stimulus 
 caused by the word suffices to re-establish the arc h ch. The extra 
 stimulus necessary to open the path c h may also be supplied through 
 p q X, by means of the written name. 
 
 In word-deafness the centre B, and in luord-hlindness the centre B' is 
 injured, and the tracks leading to and from these centres are injured in 
 varying degrees. In word-deafness luith jiaraiiiJiasia the track a 6 c is 
 injured, while the track c h still permits conduction to the more or less 
 disordered centre B, and the track h d'\^ intact. In luord-hlindness, with 
 retention of the ability to copy writing, but without comprehension, the 
 track jj qp i^ obstructed, while the track o p r is uninjured. In ivord- 
 blindness, with retention of the ability to write spontaneously and from 
 dictation, the track p q is obstructed, while the tracks q 2^ r and ab r are 
 preserved. The case of word-blindness recorded by Westphal, in which 
 the patient was enabled to read writing by passing his finger over each 
 letter, seems, in Kussmaul's opinion, to prove that there is not only a 
 track leading from b to r, but also from r to b. At this stage of our 
 enquiry it is scarcely necessary to add that this assumption is superfluous^ 
 inasmuch as the knowledge is acquired through the muscular sense. 
 
 Another very important diagram has been constructed by Charcot,^ 
 and although his plan is similar in its main outlines to Kussmaul's 
 scheme, he has, with his usual illustrative power, rendered it more 
 striking to the senses, and more easily comprehended at a glance than 
 any hitherto devised. The author believes that the word bell (cloche), 
 with its corresponding object, is particularly well adapted for the study 
 of the development of language and its subsequent disorganisation by 
 disease. The object is shown at the lower part of the diagram, and its 
 sound is represented by a wavy line passing to the left, and upwards 
 through the auditory nerve to the acoustic centre C A C for common 
 sounds. After a time the sound of the word bell (cloche) falls on the 
 ear, and is conducted to the special centre for spoken words CAM, 
 which lies near to, or is part of, the common acoustic centre. By 
 frequent repetition an inseparable association is formed between these 
 two sounds, so that the presence of the one revives the idea of the 
 other in consciousness, an operation which is represented structurally by 
 the union of the paths of the separate sounds in the common centre of 
 conceptions or the ideational centre I C. The subject is now in 
 possession of two means by which the idea of the object may be revived 
 in memory, namely, the sound of the bell itself, or the sound of the 
 
 1 See Bernard (Dfesir6). " De I'aphasie et de ses diverses forraes." These de Paris, 1S85, p. 45. 
 
90 
 
 word. But in order that the individual may be enabled to awaken in 
 others the idea of the object, it is necessary that a new centre should be 
 developed — the centre C L A — for the regulation of the movements of 
 the organs of the articulation of words. If the impulse to action comes 
 to the motor centre of articulation C L A directly through the path 
 marked 1 from the sensory centre CAM, then the word is merely an 
 imitative sound, without meaning to the person uttering it ; but if it 
 comes from the ideational centre I C, through the conducting path 2, 
 then the word is uttered with full comprehension of its meaning. On 
 
 the visual side of the development of language, the object and the printed 
 word cloche give rise to impulses represented by the dotted lines, which, on 
 passing through the optic nerves, make a first impression on the common 
 visual centre CVC and the special visual centre for words CVM 
 respectively. The organisation in these centres, caused by the two 
 separate visual impressions, becomes united after a time in the 
 ideational centre I C, and this in its turn becomes connected with the 
 motor centre for the regulation of the movements of the hand in writing, 
 CLE. The arrows indicate the direction of the conduction, and it will 
 
91 
 
 be observed that on the lines which connect the mouth and the hand with 
 the centres for the regulation of the movements of articulation C L A, and 
 of wi'iting CLE, respectively, and the lines connecting these centres with 
 the ideational centre I C, the arrows point both upwards and down- 
 wards. This is to show that when a person utters or writes a word he 
 becomes conscious of the operation through, the nerves of muscular 
 sense, without the aid of the special senses. It is unnecessary to give 
 a further description of this diagram, inasmuch as the reader who 
 has mastered our discussion of Kussmaul's scheme will readily interpret 
 for himself the kind of speech disorder that will be caused by disease of 
 pai'ticular centimes and conducting paths. 
 
 In a very elaborate and able paper on aphasia by Lichtheim, 
 translated into English by de Watteville,^ several diagrams, or rather 
 
 Fig. 7. 
 
 several modifications of the same diagram, are given to illustrate the 
 various speech disorders, and of these we select Fig. 7 as being the 
 simplest, if not the most complete. In this diagram B represents the 
 centre for conceptions, or the ideational centre. A is the centre of 
 acoustic, that of visual, word-images ; M is the motor centre for 
 the regulation of the movements of articulatipn, and E for the regulation 
 of the movements of the hand in writing. The commissural fibres 
 connecting these centres will be readily intelligible without fui-ther 
 description. The author believes that the different clinical forms of 
 aphasia may be reduced to seven types, and that each of them is caused 
 by lesion of one of the centres, A and M, or of one of the five conducting 
 paths, A M, B M, M m, A B, and a A, 
 
 1 Lichtheim (Prof. L.). "Ueber Aphasie." Aus der medicinischen Khnik in Bern. Deutsches 
 Archiv f. Bin. Med., Bd. XXXVL, Leipzig, 1SS5, p. 204. De Watteville (Dr. A.) "On aphasia." 
 Brain, VoL VII., Lond., 1SS5, p. 433. 
 
92 
 
 The annexed table, borrowed from a very excellent abstract of 
 Lichtheim's paper by Thomsen/ gives at a glance the author's seven 
 types of aphasia, with the centre or conducting path injured in each : — 
 
 
 
 
 •« 
 
 tj 
 
 -d 
 
 
 
 
 nS rQ 
 
 
 
 
 a> 
 
 <L> 
 
 0) 
 
 
 
 
 03 d) 
 
 
 
 03 
 
 
 a 
 
 •J 
 
 -+3 
 
 1 
 
 o 
 
 o 
 
 a a 
 
 3 J 
 
 4) cU 
 
 
 
 
 P5 
 
 ^ 
 
 P^ 
 
 
 
 
 P5 P^ 
 
 <1 
 
 
 
 
 
 
 
 
 
 
 
 _cS 
 
 d 
 
 * 
 
 *. 
 
 * 
 
 
 
 O 
 
 
 
 02 
 
 S 
 
 d 
 
 n3 
 
 d 
 
 
 'd 
 
 
 
 1 
 
 '1' 
 g 
 
 1 
 
 0) 
 
 ID 
 
 a 
 
 a 
 
 -ij 
 
 o 
 1-:! 
 
 l-< 03 
 
 o 
 
 
 
 Ah 
 
 p-i 
 
 p:3 
 
 Ph 
 
 P5 
 
 
 P^ 
 
 
 
 
 
 
 
 
 
 
 
 
 •id 
 
 
 
 '^* 
 
 nS 
 
 n3 r^ 
 
 IJ) 
 
 
 
 
 <u 
 
 
 
 O) 
 
 a> 
 
 <U 03 
 
 o 
 
 
 -J 
 
 
 
 o 
 
 -p3 
 
 o 
 
 .a 
 
 'c3 
 
 •i 
 
 a a 
 '3 "cs 
 
 
 g 
 
 kI 
 
 
 ^A 
 
 1-^ 
 
 
 ^ 
 
 HJ -li 
 03 03 
 
 m ■ 
 W E2 
 
 
 
 
 P5 
 
 
 
 P^ 
 
 P^ 
 
 P? P^ 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 o Ph 
 
 
 
 
 
 TS 
 
 TJ 
 
 TJ 
 
 TJ 
 
 'd 13 
 
 
 
 
 
 
 a> 
 
 OJ 
 
 a> 
 
 <u 
 
 03 03 
 
 
 
 ^^" 
 
 -ti 
 
 += 
 
 fl 
 
 .a 
 
 a 
 
 • rH 
 
 .a 
 
 •§ -2 
 
 
 O 
 
 o 
 
 "3 
 
 "3 
 
 CS 
 
 "3 
 
 o3 <A 
 
 
 
 pq 
 
 1-1 
 
 ij 
 
 
 
 03 
 
 <o 
 
 OJ (B 
 
 -5 g 
 
 
 
 
 
 Ph 
 
 P^ 
 
 Ph 
 
 Ph 
 
 P5 P? 
 
 . P 
 
 
 
 
 
 
 
 
 
 
 n o 
 
 
 
 
 
 
 
 
 
 
 
 
 .S 
 
 A 
 
 .^ 
 
 .2 
 
 .2 
 
 02 
 
 ^ 
 S 
 
 -s 
 
 -d rd 
 
 CO 
 
 
 ^^ 
 
 i 
 
 
 ,i3 
 
 t 
 
 .a 
 
 03 03 
 
 ,a a 
 
 D 
 
 
 CO 
 
 Ph 
 
 1 
 
 -' Ph 
 
 p. 
 
 Ph 
 
 '3 
 
 'cs '3 
 
 
 
 ->i 
 
 OS 
 
 Ph 
 
 2 
 
 ® 
 
 -4J -p 
 
 03 0) 
 
 CQ 
 
 
 
 Ah 
 
 Ph 
 
 P5 
 
 « P^ 
 
 
 
 
 
 
 
 
 
 s 
 
 
 
 ■d 
 
 tJ 
 
 
 
 
 
 n3 
 
 p-l 
 
 
 
 0) 
 
 dj 
 
 
 
 
 
 03 
 
 <J 
 
 
 (M-^ 
 
 
 .3 
 
 o 
 
 -+= 
 
 o 
 
 1i 
 
 o 
 
 -P d 
 
 o 3 
 
 O 
 
 
 
 ■s 
 
 03 
 
 hJ 
 
 h^ 
 
 i-:i 
 
 i-:i 
 
 ^ ^ 
 
 TO 
 
 
 
 P5 
 
 P^ 
 
 
 
 
 
 p^ 
 
 P3 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 ■^ 
 
 o 
 
 
 
 
 
 
 
 
 
 
 Pm 
 
 
 
 
 
 
 
 
 
 ^6 'd 
 
 03 03 
 
 
 
 
 -|i 
 
 -t^ 
 
 -(j 
 
 -ti 
 
 ^ 
 
 sa 
 
 a a 
 
 
 
 -^^ 
 
 O 
 
 O 
 
 o 
 
 O 
 
 o 
 
 "3 
 
 
 
 
 
 ^^ 
 
 J 
 
 >A 
 
 h:i 
 
 1-q 
 
 <A 
 
 03 <D 
 
 Ph P^ 
 
 w 
 
 |H £ ai 
 M W ^ g; 
 ^ W w o 
 
 S ^ H S 
 i P3 S o 
 
 R § 6 ^ 
 
 w to i? P 
 » fife 
 
 a 
 
 pq 
 
 pq 
 
 a 
 
 a 
 
 H 
 S 
 ^ 
 
 pq 
 <! 
 
 eS 
 
 2" «■ 
 
 
 
 
 o 
 
 C3 
 
 c3 
 
 
 
 
 
 
 
 
 » 
 
 q 
 
 , 
 
 , 
 
 
 
 
 
 
 
 
 'd 
 
 o 
 
 CHH 
 
 ^ " ^ 
 
 
 
 rfs 
 
 .s 
 
 
 o 
 
 1 
 
 .2 
 
 O 
 bJO 
 
 _a 
 
 o : 
 
 °„=.a 
 
 
 to 
 
 1 g 
 
 EH fi, H 
 
 g ° ? 
 
 ^ Oh 
 
 o 
 
 <v 
 
 (Ll 
 
 H 
 
 h3 
 
 a 
 o 
 
 bo 
 
 a 
 
 o 
 a 
 .2 
 
 60 ITS 
 
 IS 
 
 .9 P o 
 
 
 
 
 
 Pi 
 
 a> 
 
 P^ 
 
 '■+3 
 
 m o 03 -r; 'Th 
 
 a « a ^ § 
 t> 1:3 fe 
 
 A careful study of this 
 
 > Thomsen. " Ueber Aphasie. 
 1885, p. 417. 
 
 table will show that the clinical analysis of 
 
 " — CmtralblaU fur Hinische Medicin, Bd. VI., Leap2dg, 
 
93 
 
 cases is carried out only to a very imperfect degree. It will be at once 
 seen that the first and fourth types are only different degrees of aphemia 
 in association with motor agraphia, while the fifth represents aphemia 
 without motor agraphia. The seventh type represents a moderate 
 degree of word-deafness, while the second and sixth represent word- 
 deafness and word-blindness variously combined. The third type now 
 remains for consideration. In the example which Lichtheim gives, 
 the patient on being asked "' What was there for supper?' answered, 
 ' Bread, meat, potatoes,' with only two mistakes."^ On being asked to 
 i-elate his history he strung together numerous words, of which only one 
 now and then could be made out, such as " evening, five and twenty 
 and." The patient could understand spoken and written language, and 
 could also repeat correctly short words uttered in his hearing, but in the 
 repetition of words generally and in loud reading he committed the 
 same kind of mistakes as in voluntary speech. This case is doubtless 
 allied to our first degree of aphemia, a condition in which the patient 
 comprehends both spoken and written speech, and is able to utter a great 
 many words, but cannot complete a sentence. The fact, however, that 
 at the autopsy the lesion was found chiefly in the area of distribution of 
 the posterior branches of the Sylvian artery, shows that the sensory 
 mechanism of speech was injured. It will suffice at present to say that 
 Lichtheim's third type corresponds with the disorder of speech which 
 Dr. Broadbent has named "inability to express the relations between 
 things," and which he believes to be caused by disease of an assumed 
 propositionising centre. Such cases are believed by Wernicke^ to be 
 caused by injury of the fibres which connect the sensory with the 
 motor centres of speech, and he has consequently named them commis- 
 sural aphasia. But we shall return to the consideration of these cases 
 after giving a brief account of Dr. Broadbent's views of the sensory 
 disorders of speech. 
 
 Dr. Broadbent^ sets out in his explanation of speech disorders with 
 the proposition that all muscular movements are performed under the 
 direction of a "guiding sensation." If, for example, the palm of the 
 hand of a person asleep be tickled, impulses are conducted inwards to a 
 particular level of the spinal cord, and thence are reflected outwards to 
 the muscles which close the hand. When, however, the individual is 
 
 ' Lichtheim, Brain, loc. cit, p. 4.45. 
 
 ^ See Wernicke (0), Lehrbuch der Gehinih-ankheite-n filr Aei-zte VMcl Sfudirende, Bd. II. , 1S81, p. 205. 
 
 ^ Broadbent (W. H.) "A case of peculiar affection of speech with commentary." Brain, 
 Vol. I., London, 1879, page 484 et seq. ; see also, "On a case of amnesia, with post-mortem 
 examination." Medico-Chirurgical Transactions, Vol. LXI., 1878, p. 147 ; ' On a particular form 
 of amnesia ; loss of novms." Ibid, Vol. LXVIL, 1884, p. 249. 
 
94 
 
 awake, the outgoing portion of the reflex arc can be utilised by the 
 cortex of the brain, and then voluntary closure of the hand takes place. 
 The nuclei of the motor fibres of the peripheral nerves in the spinal cord 
 are, therefore, subservient both to centripetal impulses coming from tha 
 periphery, and to centrifugal impulses from the cortex of the brain. 
 But the centrifugal impulses from the cortex are initiated and 
 controlled by centripetal impulses going from the periphery to 
 the cortex. It thus appears that each movement is represented 
 in the anterior grey horns of the cord by a group of con- 
 nected cells, and that this group may be called into activity 
 either by centripetal impulses going from the periphery to that 
 level of the spinal cord in which these cells are situated, or by centri- 
 fugal impulses descending to this level from a higher nerve centre. In 
 Dr. Broadbent's words, " a motor cell-group is formed under the guidance 
 of a sensory cell-group on the same level, and when formed is made use 
 of by a higher centre." In the case of speech the " motor cell-group "■ 
 must combine into orderly action — the thoracic muscles to obtain an 
 expiratory current of air, the laryngeal muscles for phonation, and the 
 muscles of the lips and tongue for articulation. This motor cell-group 
 Dr. Broadbent names for convenience the word group, and he believes- 
 that it is organised in the corpus striatum. When the cells of the word- 
 group are called into activity by centripetal impulses on the same level 
 the action is reflex, and the resulting contractions simply represent a 
 complicated muscular adjustment without any reference to intellectual 
 expression ; but on the activity of the group being evoked from the 
 cortex, then the movement becomes subservient to speech. The cortical 
 outlet for speecb is situated in the third left frontal convolution, and the 
 cortical guiding sensory centre for spoken language is situated in the 
 superior temporo-sphenoidal convolution (auditory centre). In accord- 
 ance with the annexed diagram, lesion of S (the motor centre for speech) 
 will cause motor aphasia, while lesion of A (the auditory perception 
 centre), or of a s (the fibres which connect the inlets and outlets) will 
 cause different forms of sensory aphasia. A hypothetical explanation is 
 thus afforded for three disorders of speech. In lesion of S, the "way 
 out" for all the muscular adjustments concerned in intellectual expression 
 is destroyed. In lesion of a s, the line of communication between the 
 guiding sensory centre and the motor outlet is damaged, and mistakes in 
 words recognisable by the patient occur; while in lesion of the sensory 
 centre A, mistakes in words occur of which the speaker remains uncon- 
 scious. But still higher centres than those named are brought into use 
 in intellectual expression, and disease of these produces various compli- 
 cated disorders of speech. " The formation of an idea of any external 
 
95 
 
 object," says Dr. Broadbent,^ " is tbe combination of the evidence respect- 
 ing it received through all the senses ; for the employment of this idea in 
 intellectual operations it must be associated with and symbolised by a 
 name. The structural arrangement corresponding to this process I have 
 supposed to consist in the convergence from all the ' perceptive centres ' 
 
 of tracts of fibres to a convolutional area (not identified), which may 
 be called the 'idea centre' or 'naming centre.' This will be on the 
 sensory, afferent, or upward side of the nervous system ; its correlative 
 motor centre will be the propositionising centre, in which names or nouns, 
 are set in a framework of other words for outward expression, and in 
 
 which a proposition is realised in consciousness or mentally rehearsed. 
 If we are to have a seat of the faculty of language, it would be here 
 rather than in the third left frontal convolution, with which, however, it 
 may possibly be in close proximity. Expressing this by a diagram, we 
 
 I Broadbent (W. H.) Brain, Vol. I., 1879, p. 494. 
 
96 
 
 have V, A, and T, the visual (angular gyrus, Ferrier), auditory (infra- 
 marginal Sylvian gyrus), and tactual (uncinate gyrus), perceptive centres, 
 sending converging tracts of fibres, v n^ an, t n, to N, the ' naming 
 centre.' Here the perceptions, from V and T (smell and taste are 
 omitted for the sake of simplicity), are combined with an idea, which 
 idea is symbolised by the name reaching N through A, which has always, 
 in the experience of the individual, been associated with the object. P 
 is the propositionising centre, in which the phrase is formed, its relations 
 with N and S being sufficiently clear." 
 
 According to this scheme, lesion of the naming centre N would 
 cause loss of the memory of names or nouns, leaving the patient able to 
 express himself imperfectly in words indicative of relations and attributes. 
 Lesion of P, the propositionising centre, would render the patient unable 
 to construct a sentence, although retaining the use of names. This 
 condition Dr. Broadbent^ illustrates by the case of a patient, who, in 
 endeavouring to explain that he had two brothers in America, said — 
 " Brother — New York — brother — "Merica — letter — two brothers in 
 America — letter." The patient could understand spoken and written lan- 
 guage, but his attempts at reading aloud ended in gibberish. He was 
 unable to write to dictation, and, with the exception of his own name and 
 the names of his brothers — which he wrote quite well — he was also unable 
 to write spontaneously. He could copy short words quickly and 
 correctly, but a long word he took down slowly and in schoolboy 
 characters, and as he wrote each letter he named it aloud, and always 
 wrongly. This form of speech disorder Dr. Broadbent regards as an 
 " inability to express the relations between things " ; it corresponds with 
 Lichtheim's third type, and with Wernicke's commissural aphasia, but we 
 reserve further consideration of it at present. 
 
 Lesion of the visual perceptive centre V, or of its channel of com- 
 munication V n with the naming centre N, would explain cases of word- 
 blindness, while lesion of the auditory perceptive centre A, or of its 
 channel of communication a n with the naming centre would explain 
 word-deafness. 
 
 A very good diagram illustrative of the disorders of speech is given 
 by Professor Grainger Stewart,^ and although I believe that he postulates 
 too many centres both on the ingoing and on the outgoing side of the 
 speech mechanism, his scheme, taken in conjunction with his remarks on 
 aphasia, is well worthy of careful study. No good, however, would result 
 from dwelling at greater length on this part of our subject. 
 
 1 Broadbent (W. H.), Brain, Vol. I., 1879, p. 486. 
 
 2 Stewart (T. Grainger). An introduction to the study of the diseases of the nervous system." 
 Edin. 1884, page 181 et acq. 
 
97 
 
 Instead of entering upon a criticism of the diagrams figured and 
 described in the foregoing pages, we prefer to indicate briefly our own 
 views of the nature of the connection existing between the various 
 speech disorders and the lesions which underlie them. In the first place 
 we shall deal Avith motor aphasia, because it is more simple, and conse- 
 quently more easily handled, than the sensoiy forms of the affection. 
 
 The first and most important proposition which we will endeavour to 
 establish is that motor aphasia is the result of a genuine paralysis. Some 
 pathologists have offered much opposition to this view. They assert, and 
 with truth, that the subject of a pure motor aphasia is often capable of 
 moving his lips freely, of protruding his tongue and employing it in 
 the act of deglutition, and of using his vocal apparatus in singing, 
 without giving evidence that the muscles engaged in these actions are 
 suffering from any degree of paralysis. They also point to the well- 
 ascertained fact that in cases of pure motor agraphia all the other move- 
 ments of the hand may be effected with ease, and without the gross 
 strength of the grasp being diminished. Those who urge these objections 
 believe aphemia to be caused by a want of motor co-ordination, and 
 they have consequently named the affection ataxic aphasia. That 
 aphemia is due to a motor inco-ordination we do not deny ; so is 
 diplopia, but in most cases it is paralytic also. In paresis or paralysis 
 of the sixth nerve, for instance, the patient is unable to direct the axes 
 of vision to one object, and he consequently sees two objects instead of 
 one, and so far there is an inco-ordination of the ocular muscular 
 movements, but it is caused by paralysis of one of the muscles 
 of the eyeball. And to call aphemia by the name of ataxic aphasia is only 
 less absurd than it would be to call cases of double vision from paralysis 
 of one or more of the ocular muscles by the name of ataxic diplopia, 
 because the paralysis is not always so easily discovered in the former as 
 in the latter affection. The brain is, indeed, so far as its motor functions 
 are concerned, an organ by means of which the simple movements which 
 are regulated by the spinal cord are variously combined and co-ordinated 
 so that complex bodily adjustments are produced, and when the cerebral 
 motor organisation is "wholly destroyed by disease the co-ordination is 
 altogether lost, or when it is partially destroyed the co-ordination is so 
 disordered that the balanced muscular contractions which are requisite 
 for effecting delicate movements fail to take place. In every case of 
 partial paralysis from cerebral disease, therefore, there is a want of 
 motor co-ordination ; but this motor disorder is in no way comparable 
 with the genuine ataxia of tahes clorsalis, in which not a trace of 
 paralysis is to be discovered. 
 
 In order to illustrate the theory that aphemia is a paralytic 
 disorder, let us attend to the course of the development of the 
 
 G 
 
98 
 
 movements of the hand. In the infant at birth the hand closes 
 on anything that touches lightly the palm, this movement being 
 altogether reflex and regulated by the spinal cord. When the 
 infant is a little older he begins to use the hand as an organ of prehen- 
 sion, and the acquired movements, which are now voluntary and 
 regulated from the brain, become more and more complicated by use, 
 each complication of movement being represented by a new complica- 
 tion of structure in the cerebrum. Let us now suppose that the faculty 
 of writing is not developed until after the infant has reached adult age 
 and has acquired the full strength of manhood. This supposition is 
 made in order to show that the delicate muscular adjustments which 
 have to be acquired in learning to write have added nothing to the 
 strength of the hand as an ordinary prehensile organ, and it is easily 
 conceivable that disease may destroy the new organisation in the brain 
 which is the structural correlative of those delicate movements, without 
 diminishing in the slightest degree the strength of the hand for ordinary 
 purposes. Now this is what occurs in pure cases of motor agraphia. In 
 most cases loss of the faculty of writing is accompanied by impairment 
 of the power of the hand as an organ of prehension, and it is then said 
 that the agraphia is accompanied by more or less of |iemiplegia, but it 
 is important to recognise that motor agraphia is itself an indication of a 
 slight degree of hemiplegia, even in those rare cases in which the gross 
 strength of the hand is not perceptibly diminished. Similar remarks 
 apply to aphemia ; it is of itself an indication of hemiplegia even in the 
 rare cases in which it is unaccompanied by any perceptible paralysis of 
 the face or tongue. 
 
 If further proof be required of the paralytic nature of aphemia and 
 motor agraphia, it is found in the fact that these speech disorders are 
 accompanied, except in the rarest instances, by some degree of hemi- 
 plegia. And again, in experiments on animals, electrical excitation of 
 the posterior part of the third frontal convolution, which is the seat of 
 the lesion in aphemia, gives rise to opening of the mouth, with protru- 
 sion and retraction of the tongue, thus showing the essential identity of 
 function of this part of the brain with the other motor centres of the 
 cortex. The phenomena which attend unilateral convulsions teach the 
 same lesson. It is now well recognised that an attack of unilateral 
 epilepsy is followed by some degree of paralysis of the parts which 
 were the seat of the spasm. When the spasm begins in the foot, the 
 leg, and when it begins in the hand, the upper extremity, are found 
 to be more or less paralysed for some time after the cessation of 
 the spasm ; and when the spasm begins at the angle of the mouth, 
 the attack, when right-sided, is not only followed by a considerable 
 
99 
 
 loss of expression on the side of the face that was the subject of 
 spasm, but also by a decided aphemia. From these considerations it 
 may be concluded that aphemia and motor agraphia are a paralysis of 
 highly specialised movements ; that in rare cases the special movements 
 of articulation, and of the hand in writing, are paralysed without the 
 general movements of the respective organs being interfered with ; but 
 that in most cases not only the special but the general movements also 
 suffer to some extent, and then only is it popularly recognised that the 
 speech disorder is accompanied by, or is a part of, hemiplegia. Before 
 proceeding further, therefore, it is desirable for us to study somcAvhat 
 minutely the mechanism by which hemiplegia is produced, and the 
 phenomena which attend it, for it is in this way alone that we can hope 
 to throw light upon several obscure problems connected with aphasia 
 and motor agraphia, which still remain unconsidered. 
 
 It may be stated as a general proposition that the muscles of one 
 lateral half of the body are regulated from the cerebral hemisphere of 
 the opposite side. The centres for the regulation of the movements of 
 the opposite side of the body are situated on the outer convex surface of 
 the cerebral hemisphere — the so-called motor area of the cortex. These 
 centres are connected with the anterior grey horn of the spinal cord of 
 the opposite side, and to a less extent with that of the same side by the 
 long fibres of the pyramidal tract. Now hemiplegia of the opposite side 
 of the body may be caused by extensive disease of the motor centres 
 themselves, but the ordinary form of hemiplegia is usually caused by 
 compression or rupture of the fibres of the pyramidal tract, as they come 
 together to form one bundle between the basal ganglia in the internal 
 capsule. It is found, however, that interruption of conduction through 
 the whole of the fibres of the pyramidal tract of one hemisphere does 
 not paralyse all the muscles of the opposite side of the body. In pro- 
 found hemiplegia some of the muscles are completely paralysed, while 
 others are scarcely, if at all, affected. It was first pointed out by 
 Dr. Broadbent^ that the muscles which remain comparatively unaffected 
 by paralysis in hemiplegia are those which, like the muscles of respira- 
 tion, are associated in their actions with the corresponding muscles of 
 the opposite side. In cases of severe hemiplegia the muscles of the 
 hand, the actions of which are independent of the muscles of the other 
 hand, remain persistently paralysed, while the muscles of respiration, 
 which always act in conjunction with the corresponding muscles of the 
 opposite side, may show a slight degree of feebleness at first, but recover 
 completely in a few days. The explanation offered by Dr. Broadbent for 
 the fact that the muscles which are bilaterally associated in their actions 
 
 ' Broadbent (W. H.), British and Foreign Medico-Chir. Review, 1S66, p. 477. 
 
100 
 
 have a relative imnmnity from paralysis is that these muscles are inner- 
 vated from both cerebral hemispheres, and consequently vi^hen the motor 
 centres or conducting paths of the one hemisphere are injured, the 
 muscles in question receive their impulses to action from the uninjured 
 hemisphere. He believes that the connection between the motor nervous 
 mechanisms of the two sides of the body is effected by means of com- 
 missural fibres in the medulla oblongata and spinal cord. 
 
 In the annexed diagram B and B' represent the cortices of the right 
 and left hemispheres of the brain, M M' represent motor centres, and 
 N and N' nerve nuclei in the medulla oblongata or spinal cord. P and P' 
 represent the conducting paths in the pyramidal tracts which form a 
 crossed connection between the cortical motor centres and the spinal 
 nuclei, while m and m represent the nerves which pass out to the 
 muscles. 1, 2, 3, 4, and 5 represent lesions in different situations. When 
 
 the muscles of the one side of the body, as those of the hand, act inde- 
 pendently of the corresponding muscles of the opposite side, the above 
 centres and conducting paths constitute the whole of the motor 
 mechanism, and when a lesion at 1 injures the motor centre, or at 3 the 
 conducting path, the muscles on the opposite side become permanently 
 paralysed. When, however, the muscles are bilaterally associated in 
 their actions, another mechanism is superadded. It consists of com- 
 missural fibres connecting the"nerve nuclei — the one (c) cond acting from 
 right to left and the other (c') from left to right — and now when a 
 lesion 1 or 3 injures the motor centre or the conducting path in the one 
 hemisphere, impulses pass from the uninjured motor centre M of the 
 other hemisphere to the nerve nucleus N' of the opposite side, and then 
 across and through the commissureV to the other nerve nucleus N, and 
 to the muscles, through the motor nerves m and m'. In this manner 
 the muscles of both sides receive impulses to action from the one 
 hemisphere B. The principle which has just been described has been 
 
101 
 
 happily named by Dr. Broadbent the "bilateral association of the nerve 
 nuclei of muscles bilaterally associated in their actions." 
 
 The laryngeal muscles belong to the group of muscles which are 
 bilaterally associated in their actions, and they escape almost entirely 
 in ordinary hemiplegia ; and although the other muscles of articulation, 
 such as those of the mouth and tongue, are implicated in the paralysis, 
 yet they are not profoundly affected, and the loss of power which they 
 undergo only gives rise to slight articulatory difficulties. In left-sided 
 hemiplegia, for instance, in which the special mechanism of speech is 
 not usually affected, the voice of the patient remains almost entirely 
 unaltered after the attack, wdiile the paralysis of the facial and lingual 
 muscles which is present only gives rise to some thickness of speech and 
 a difficulty in pronouncing polysyllabic words. When hemiplegia occurs 
 in infancy, before the development of speech, and in the lower animals, 
 the muscles of the vocal apparatus are not, any more than those of 
 respiration, affected by the occurrence of paralysis on either side, but 
 subsequently to the evolution of speech in man the conditions are entirely 
 changed. To the simple nervous mechanism which we have just been 
 considering, a highly complicated structure has become gradually deve- 
 loped, and by means of it the simple movements of the lips, tongue, and 
 vocal apparatus which are alone possible in early infancy and in the lower 
 animals, are now combined into the complicated movements of articulate 
 speech. The chief characteristic of this superadded mechanism is that it is 
 unilateral. It has already been seen that speech disorders are caused, 
 except in rare cases, by disease of the left hemisphere of the brain, and in 
 the annexed diagram the special motor centre M' for speech is situated in 
 the left hemisphere B', while the corresponding centre M in the right 
 hemisphere regulates the general actions, which the articulatory muscles 
 would have been capable of performing even if the faculty of speech had 
 never become developed. It is scarcely necessary to observe that in the 
 speech centre M' both the general and special movements of the articula- 
 tory muscles are organised, although we shall find it convenient some- 
 times to call it the special motor centre of articulation in opposition to 
 the centre M of the other hemisphere, which may be named the general 
 motor centre. In the diagram the special motor centre M' is connected 
 by a continuous line P' with the nerve nucleus N of the opposite side, 
 and through the commissural fibre c' with the nerve nucleus of the same 
 side, so that the muscles of both sides of the articulatory apparatus are 
 regulated from a centre in one hemisphere. The general motor centre M 
 in the right hemisphere is also connected with the nerve nuclei of both 
 sides, as is represented by the dotted lines P and C, but as already 
 remarked the complex combinations of contractions requisite to articula- 
 tory speech cannot be effected by it. 
 
102 
 
 From the foregoing remarks it will be at once apparent that complete 
 destruction of the special motor centre M' will abolish the faculty of 
 the expressive facility of speech, but the general movements of the 
 articulatory muscles on both sides will still be effected by means of 
 the centre M. From this statement, it almost follows as a corollary, 
 that partial damage of the special articulatory motor centre will give rise 
 to a partial disorder of the expressive faculty of speech. Now in all 
 partial lesions of nerve centres, the latest evolved structure is the most 
 liable to injury. The inroads of disease conform, both as regards 
 structure and function, to the law of dissolution ; the mode of invasion 
 being from the complex to the simple, and from the special to the general. 
 On examining the structure of the cortex of the brain, it will be seen that 
 it is composed of several super-imposed layers of cells ; and that the cells 
 near the surface are destitute of processes, and therefore do not form 
 any definite connection with one another, while the cells of the internal 
 layers have numerous processes, by means of which they become connected 
 with one another, and some of them even with the motor ganglion cells 
 of the medulla oblongata and spinal cord. Now the nervous impulses 
 regulating actions, which are frequently repeated in the experience of 
 the individual and of the race, tend to pass more and more with each 
 repetition through the caudate cells of the cortex, and these being, as 
 we have seen, definitely connected with one another, the nervous 
 impulses pass through them without meeting much resistance, and the 
 less the resistance offered to the passage of the impulses, the less is the 
 resulting action attended by consciousness. Such actions are sometimes 
 called automatic and at other times reflex actions of the brain, but they 
 really are psychical actions which are efiected in an unconscious manner. 
 But the impulses which regulate unaccustomed actions must pass 
 through unused channels, or in other words, must pass through the 
 round cells near the surface of the cortex which have not formed definite 
 connections with one another. In passing through these cells, the 
 impulses meet with a considerable degree of resistance, and much of the 
 force generated is expended, not in effecting the desired action, but in 
 producing a new organisation in the round cells of the cortex, and this is 
 the process which is the correlation of consciousness. It follows, there- 
 fore, that a superficial lesion of the cortex of the brain will abolish in a 
 motor centre the power of performing unaccustomed actions, while 
 leaving intact the power of performing the actions which have been 
 so frequently repeated that they have become automatic, or are efifected 
 in an unconscious manner. The application of this theory to the 
 explanation of the motor disorders of speech is manifest. A superficial 
 lesion of Broca's convolution may destroy the power of uttering all 
 
103 
 
 unaccustomed words, while leaving intact the power of uttering a con- 
 siderable number of the words which have been early acquired and have 
 been so frequently repeated that their utterance has become automatic. 
 A lesion passing somewhat deeper in the cortex may entirely abolish the 
 power of giving utterance to spontaneous speech while leaving 
 unaffected the automatic power of repeating words uttered in the 
 hearing of the patient. A still further degree of injury may arrest the 
 power of repeating words, while leaving intact the power manifested by 
 infants in their first endeavours at speech of uttering a large number of 
 vocables or syllabic sounds, amongst which no word having a definite 
 meaning can be detected, this forming one variety of gibberish aphasia. 
 It is very pi'obable that the power of giving expression to " recurring 
 utterances" and oaths, which is so frequently left to persons who are 
 otherwise the subjects of a complete aphasia, is, as Dr. Hughlings- 
 Jackson conjectures, organised in the general articulatory motor centre, 
 and may, therefore, be preserved in cases in which the special centre is 
 thoroughly disorganised. 
 
 But if destruction of the special motor centre M' in the annexed 
 diagram gives rise to aphemia, it may be expected that the same dis- 
 order of speech will be caused by a lesion (3) which ruptures the motor 
 conducting path, and thus severs the spinal nuclei from the centre. 
 Now right-sided hemiplegia is almost always at first accompanied by 
 some degree of aphasia,^ but when the lesion is situated, as it usually 
 is, in the lenticular nucleus, and compresses or ruptures the motor con- 
 ducting path in the internal capsule, the power of speech is recovered 
 sometimes in a few days, and at other times in a few weeks or months. 
 When, howevei', the speech centre itself is disorganised, the speech 
 disorder remains more or less permanent in old people, while 
 in young persons the power of speech is only slowly acquired, 
 most probably by a new organisation being formed in the motor 
 centre of the opposite hemisphere. How, then, can we explain 
 the persistency of the speech disorder in the cases in which the 
 centre itself is diseased, as compared with the relatively speedy 
 recovery which occurs when the conducting path is alone injured? The 
 most common form of hemiplegia is that which is caused by haemorrhage 
 into the lenticular nucleus. The • speech motor conducting path is now 
 proved to pass in the anterior segment of the internal capsule, and in 
 many cases of haemorrhage into the lenticular nucleus this portion of 
 the capsule remains almost uninjured, while the conducting paths for 
 the limbs which pass in the anterior part of the posterior segment are 
 
 1 See Broadbent, " Cases of Spurious Ai>h3.sia.."— Transactions of the Clinical Society, Vol. XI., 
 1878, p. 37. 
 
104 
 
 considerably damaged. Immediately after the occurrence of the 
 hsemorrhage conduction through the speech motor path is impaired 
 partly by the shock of the injury and partly by the pressure of the clot, 
 and consequently aphemia results ; but as the effects of the shock pass 
 away, and the fluid portion, of the effused blood is absorbed the con- 
 ductivity of the fibres is restored, and the speech disorder rapidly 
 disappears. But even in the cases in which the anterior segment of the 
 capsule is seriously damaged, recovery from the speech disorder appears 
 to be more rapid than in the cases in which the centre is destroyed. The 
 difference between the results of injury to the centre and the conducting 
 path may be illustrated by the electric telegraph. Suppose that the 
 central ofiice in Manchester were blown up by dynamite, all communi- 
 cation from the centre of the city to other towns would be interrupted 
 until a new structure of some kind was formed ; but if the conducting 
 wires from Manchester to London were alone injured by a snow storm 
 communication would be immediately restored, as messages could be 
 sent from Manchester to Liverpool, and thence to London. Now, Dr. 
 Broadbent believes that something of this kind occurs in the aphasia 
 which is caused by injury of the motor conducting path. The corpus 
 callosum is still believed by most anatomists to be a great hemispherical 
 commissure, although the recent observations of Professor Hamilton, of 
 Aberdeen, appear to cast some doubt upon the theory, and its fibres are 
 supposed to connect symmetrical parts in the two hemispheres. It 
 has been suggested by Dr. Broadbent that when the speech motor 
 conducting path P' in the annexed figure is interrupted by lesion at 3, 
 the impulses from the special speech centre M' find their way through 
 the fibres C of the corpus callosum to the corresponding motor centre M 
 of the opposite hemisphere, and thence through the conducting path P 
 and the commissure c to the nerve nuclei in the medulla. A process of 
 this kind will occupy some time, because the nervous impulses have to 
 make their way through channels which have been more or less unused, 
 but the time occupied will be much shorter than that required for the 
 formation of a completely new organisation in the general motor centre 
 at M. As an additional argument in favour of this theory, Dr. Broad- 
 bent urges the fact that a lesion (2 in the figure), which is situated so high 
 up in the white substance of the hemisphere that it will interrupt both 
 the speech motor conducting path and the fibres of the corpus callosum 
 which connect the posterior parts of the third frontal convolutions, will 
 cause an aphasia which will be as persistent as that resulting from 
 destruction of the centre itself.^ 
 
 ' See Pitres. " Lesures du centre ovale." Paris (Obs. XXX., vi.), 1S77, p. 94 et seq. 
 
105 
 
 But if the theory of motor aphasia which has been advanced in 
 these pages be true, destruction of the two motor centres M and 
 M', or of the two motor conducting paths P and P', ought to give 
 rise to a complete paralysis of the muscles of articulation. Now this 
 is what actually happens. A large number of cases of this kind 
 have now been reported under the titles of pseudo-bulbar paralysis, 
 labio-glosso-laryngeal pai'alysis of cerebral origin, and other names, but 
 I can only allude here to one or two examples. Perhaps the most 
 remarkable case hitherto reported in which the centres themselves were 
 destroyed is one recorded by Dr. Barlow.-' The subject was a boy, aged 
 ten years, who was suffering from aortic regurgitation, and had an 
 attack of right hemiplegia with aphasia, from which he made a good 
 recovery. Four months afterwards he had an attack of left hemiplegia, 
 which was accompanied not only by aphasia but also by paralysis 
 of the muscles of mastication, of those concerned in the first act of 
 deglutition, and of those of articulation. The patient died from 
 the results of the aortic lesion, and at the autopsy the anterior 
 branch of each Sylvian artery was found blocked by an embolus, and 
 a focus of softening, about the size of a shilling, was observed in the 
 cortex of each hemisphere, involving the interior extremity of the 
 ascending frontal and the posterior extremities of the second and third 
 frontal convolutions. Many cases of labio-glosso-laryngeal paralysis, 
 from disease of the motor conducting paths of the cerebrum, are now 
 recorded, and we have oiirselves reported several cases of the kind." 
 The first which came under our observation was kindly sent by Dr. 
 Leech. The patient presented all the symptoms commonly observed in 
 cases of progressive labio-glosso-laryngeal paralysis, but at the autopsy, 
 conducted by Prof. W. H. Young, "each cerebral hemisphere presented 
 a single well-defined cystic cavity, containing clear straw-coloured fluid, 
 and occupying the position of the lenticular nuclei," while the medulla 
 oblongata was free from disease. As these cavities, especially the one 
 on the right side, were larger than the normal size of the lenticular nuclei, 
 the fluid doubtless compressed and injured the motor conducting paths 
 of the internal capsules. No more striking proof than these cases afford 
 could well be imagined in favour of the theory, that Broca's convolution 
 is functionally identical with the other motor centres of the cerebral 
 
 1 See Lepine : " Xote siir la paralysie glosso-labiee cerebrale en forme pseudo-bulbaire." — Rev. 
 mens, de Med., Tome I., 1877, p. 909. Kirchoff : " Cerebrale glosso-pharyngo-labial-paralyse mit 
 einseitigem Herd," Arch. f. Psychiat., Bd. XI., ISSO, p. 132. Barlow: "On a case of double 
 hemiplegia, with symmetrical lesions." — The British Medical Journal, VoL II., 1S77, p. 103. 
 
 - See Ross (J) "On labio-glosso pharyngeal paralysis of cerebral origin." — Brain, VoL V., 
 1SS2-3, p. 143; also Raymond (F) et Artaud (G). "Contributions a I'etude dea localisation 
 cer6brales." — Arch, de Neurologic, Vol. VII., Mars, 1SS4, p. 145. 
 
106 
 
 cortex, and of the corollary, which is deducible from it, that the speech 
 disorder — aphemia — caused by destruction of this convolution, is a 
 genuine paralysis, and what is true of aphemia is equally true of motor 
 agraphia. 
 
 Motor aphasia is, as we have seen, a paralysis of the special movements 
 of articulation constituting aphemia, and of those of the right hand in 
 writing, constituting motor agraphia. Some pathologists, however, 
 believe this statement to be imperfect, and they supplement it by saying 
 that this form of aphasia is a loss of the memory of those special move- 
 ments. Now if this theory of loss of memory be true as applied to the 
 explanation of the inability of a patient suffering from aphemia to execute 
 the articulatory movements necessary to the expression of words, it must 
 be equally true as an explanation of the inability of a hemiplegic patient 
 to execute the movements necessary to normal locomotion. But were 
 we to say that the inability of a patient suffering, for example, from a 
 crural monoplegia from cortical disease, was due to a loss of memory of the 
 movements of locomotion on the affected side, the absurdity of the state- 
 ment would be immediately recognised, and yet it is not a whit more 
 absurd than the statement that aphemia is due to a loss of memory of 
 the movements of articulation. For our part we agree with Dr. Bastian^ 
 in thinking that outgoing currents from the cortex to the muscles are 
 free from all subjective accompaniments, and arrest of these currents 
 will consequently not interfere directly with the memory, although it 
 may do so indirectly. The memory of the contractions of the muscles of 
 articulation has doubtless played an important part in the development 
 of the expressive faculty of speech, just as the memory of the contrac- 
 tions of the muscles of the lower limbs has played in the development of 
 the power of locomotion, but the memory in both cases is correlated with 
 the activity of a cortical centre in relation with afferent fibres from the 
 muscles, and therefore the centime is endowed with a sensory and not a 
 motor function. It is possible that the sensory cortical centre of 
 muscular sense may so far coincide with the motor centre for the muscle 
 that the former is constituted by the outer layers of small cells, the 
 activity of which we have already seen to be the correlative of conscious- 
 ness, while the latter is constituted by the inner layer of caudate cells, 
 the activity of which is not accompanied by any feeling. But if the 
 sensory and motor centres of a muscle or group of muscles are super- 
 imposed so as to occupy the same area of the cortex, is it not an excess 
 of refinement to make a distinction between them 1 Our reply is that 
 nature makes such a distinction. A cerebral paralysis is not always 
 
 1 Bastian (H. Charlton). " The Brain as an Organ of Mind," p. 529 ; and "Paralysis : Cerebral, 
 Bulbar, and Spinal," London, 18S6, p. 107. 
 
107 
 
 accompanied by loss of the musculai* sense in the affected muscles, and 
 loss of the muscular sense may be present, as in profound hysterical 
 hemi-ansesthesia, without being accompanied by muscular paralysis. 
 And as loss of the muscular sense in one of the lower extremities pro- 
 duces only a slight disorder of locomotion without entailing paralysis of 
 the limb, so loss of that sense in the muscles of articulation might 
 produce a slight disorder of the expressive faculty of speech, but it 
 certainly would not arrest the articulatory movements to the extent 
 observed in aphemia, and loss of the muscular sense in the muscles of 
 the right upper extremity would not paralyse the special movements of 
 the hand to the extent observed in motor agraphia. We have no hesita- 
 tion, therefore, in coming to the conclusion that aphemia and motor 
 agraphia are forms of motor paralysis, and that the speech disability 
 present in these affections is not accompanied by loss of memory of words, 
 this infei'ence being fully attested by the fact that the subjects of these 
 disorders understand vocal and written speech, although unable to give 
 expression to their thoughts in words. 
 
 Let us now turn our attention to apperceptive aphasia. The different 
 forms of speech disorder comprised in this category are caused by 
 disease of the sensory mechanisms of speech, and now that the symptoms 
 of these affections have already been subjected to a detailed analysis, 
 the interpretation of the clinical phenomena in terms of structure need 
 not detain us long. The first assertion which we will venture to make 
 is that as aphemia and motor agraphia are a motor paralysis, so apper- 
 ceptive aphasia is a sensory paralysis. Considerable difficulty has already 
 been experienced in realising that motor aphasia is a paralytic disorder, 
 and the conception of apperceptive aphasia as a sensory paralysis will 
 not by any means be found to be easier. There is, however, no difficulty 
 in comprehending that complete blindness is a sensory paralysis ; and it 
 is also comparatively easy to realise that the profound amblyopia, in 
 which the subject sees the form of an object without being able to 
 appreciate its colour, is a partial sensory paralysis. Now, suppose that 
 a person has his eyes directed to a piece of soap on the table, which is 
 not in any way disguised so as to appear to the healthy eye other than 
 it is, and yet he grasps it and puts it to his mouth as something to be 
 eaten, would it not at once be suspected that that person was partially 
 blind ? This action might, of course, result from moral perversity, with- 
 out any degree of blindness ; but defective vision might lead to such an 
 error of judgment as would give rise to it in the absence of any other 
 mental peculiarity. In other words, a certain patch of colour falling 
 upon a defective organ of vision failed to arouse in consciousness certain 
 qualities belonging to the object, while it suggested other qualities 
 
108 
 
 which did not belong to it, and thus led to a serious error in judgment. 
 When, therefore, the presentation of a common object to the eye fails 
 to revive in consciousness certain previously well-known qualities belong- 
 ing to the object, this may be taken as a sign of a partial paralysis of 
 vision. When, for example, the general paralytic patient described by 
 Ftirstner failed to recognise that a coin placed in his hand was a money 
 tender, he manifested partial blindness. His conduct, doubtless, also 
 revealed loss of memory and defective judgment, but it did not differ in 
 any essential respect from the conduct of a person who, from having lost 
 the sense of colour owing to advancing white atrophy of the optic discs, 
 mistakes a sovereign for a shilling. In the case of white atrophy, it is 
 at once recognised that the mistaken conduct was the result of partial 
 blindness ; biit when we pass from the non-revival of the more common 
 properties of matter, sach as is met with in cases of achromatopsia, to 
 the non-revival of the less common properties, such as is met with in 
 the disorders already named partial perceptive blindness and deafness, 
 and in word-blindness and word-deafness, we only pass from a general to 
 a special form of partial sensory paralysis. That word-deafness is a partial 
 sensory paralysis may be aptly illustrated by my own mental condition 
 with regard to the French language. I can read French, especially 
 French medical literature, with nearly as much facility as English, but 
 in listening to a conversation in French I am almost absolutely word-deaf. 
 I can detect a few common verbs, pronouns, and adjectives, but hardly 
 ever a noun, and, on the whole, the conversation is to me a series of sounds 
 which blend with one another in inextricable confusion. Another pecu- 
 liarity is that if I were asked to give the French name of any object 
 presented to me, even including my bodily organs, I would fail, without 
 considerable time for thought, in probably nine trials out of ten ; but if 
 the French name were pointed out to me on a printed page, I would 
 instantly identify the object. I am also unable to write French to 
 dictation, but can copy from a written or printed page, and with a full 
 understanding of the meaning of what is written. My condition with 
 regard to the French language is closely analogous to the condition of 
 James Lee (Case 5) with regard to the English, and, indeed, all 
 forms of language. He understands scarcely any word uttered in his 
 hearing, and cannot name correctly any object presented to him ; but 
 when he sees the name in written or printed characters, he immediately 
 identifies the object. He can also copy from a written or printed page, 
 and understands the meaning of what he has written, but he is unable 
 to write to dictation anything beyond his name and address. My 
 disabilities with regard to the French language are manifestly due to 
 the fact that my ear has not been educated, or in other words, to the 
 
109 
 
 fact that the necessary structure has not been organised in my auditory 
 cortical centre ; while the disabilities of Lee are due to the fact that the 
 structure which had been organised in his auditory cortical centre is 
 now destroyed by disease ; in the one case there is a want of evolution 
 of the necessary organisation, in the other there is a dissolution of a 
 previously acquired structure. Similar remarks apply to word-blindness, 
 although I am unable to illustrate the condition from my own expe- 
 rience so adequately as word-deafness. It appears to me, however, that 
 the condition of Robert Marshall (Case 2), when looking at a printed 
 page of English is, in some respects, similar to my own when looking at 
 a page of Hebrew test. On scanning a page of Hebrew text, I not only 
 cannot decipher a word, or even a letter, but I have even difficulty in 
 imagining how any other person can attach a definite meaning to such a 
 confused assemblage of dots and dashes. It is quite conceivable that I 
 might have acquired the power of thinking and conversing in Hebrew 
 without having learnt to read the language, and had I done so, my 
 mental state would have been closely analogous to that of Marshall, 
 with regard to English. I should then be able to name all objects 
 presented to me, and to converse in Hebrew as Marshall does in English, and 
 like him, I should be unable to read a printed page or to decipher a single 
 letter. I should be able, like some of the subjects of word-blindness, to copy 
 printed words in Hebrew in printed and written in written characters, 
 and without being capable of attaching any meaning to what I had copied, 
 though, unlike most of those who suffer from word-blindness, I should be 
 unable to write to dictation. But notwithstanding the great similarity 
 existing between cases in which there is a dissolution of one of the 
 sensory mechanisms of speech and those in which the mechanism has 
 been imperfectly evolved, yet the former present mental peculiarities 
 which are not paralleled in the latter. For instance, if I were asked to 
 write down the French phrase of " It is a fine day," I should never 
 write anything so totally unlike it as "whiskey," as James Lee (Case 5) did; 
 and if I were asked to read from a printed page of Hebrew, I should not, even 
 supposing I were able to converse in the language, give utterance, like 
 Robert Marshall (Case 2) to my own composition, fully believing that I was 
 interpreting correctly the text before me. It need hardly be expected, 
 however, that the brutal dissolution of nerve centres by sudden disease, 
 like the softening caused by the occlusion of an artery, will ever exactly 
 parallel in its results a simple arrest of the organisation of the same 
 nerve centres at a particular stage of their evolution. On the whole, 
 then, it may be concluded from physiological considerations, conjoined 
 with the results obtained from post-mortem dissections, that word- 
 blindness and word-deafness are a partial sensory paralysis, resulting 
 from damage of the visual and auditory cortical centres respectively. 
 
no 
 
 We must now proceed to interpret as far as possible those 
 minor cases of apperceptive aphasia which we have named verbal 
 amnesia. The slighter degrees of verbal amnesia are met with whenever 
 the brain becomes exhausted from over- work, loss of sleep, or from being 
 imperfectly supplied by a sufficient quantity of healthy blood. In such 
 cases the lesion is a functional one, and is widely distributed over the 
 whole brain, especially over its surface, where the nutritive processes are 
 most active. Manifestly such cases are not well calculated to throw 
 much light on the disorders of the speech mechanisms which underlie 
 aphasia. The severer forms of verbal amnesia are, however, caused most 
 probably by a destructive lesion, and consequently these disorders demand 
 detailed examination. The second degree of verbal amnesia, as already 
 described, consists of those cases in which the patient understands what 
 is said to him, and is able to read, but cannot name any object presented 
 to him, and consequently is unable to use nouns in his conversation. 
 In the case of R. B. (Case 8), the patient was either unable to name the 
 objects presented, or could only name them after a long pause for 
 consideration, but he instantly recognised the correct name when it was 
 uttered in his hearing, or when it was presented to him in writing, and 
 he could at once repeat it. In a case described by Dr. Broadbent,-' the 
 patient, during the five years in which he was under observation, was 
 unable to name any object presented to him, and although he under- 
 stood all that was said, and promptly obeyed when told to say "one, 
 two, three," during an examination of the chest, he was unable to 
 repeat any noun uttered in his hearing. It is quite manifest that 
 Dr. Broadbent's case is a degree of apperceptive aphasia intermediate 
 between the speech disorder of R. B. (Case 8) who, although unable to 
 name objects, understood the name, and could repeat it when uttered in 
 his hearing, and that of James Lee (Case 5), who could neither name 
 objects, understand the name when uttered in his hearing, nor repeat it. 
 Dr. Broadbent believes that in his case the communication between the 
 ideational or naming centre and the propositionising centre^ was 
 destroyed. Before endeavouring to account for the clinical variety of 
 apperceptive aphasia which Dr. Broadbent has named " loss of nouns," 
 we ought to ascertain whether such a disorder of speech has ever been 
 observed, or is possible. Is it true that an individual may lose the use 
 of concrete nouns while the other parts of speech remain unimpaired ? 
 We do not believe it. The ease described by Dr, Broadbent as " loss of 
 nouns," and other similar cases, merely show that the whole structure of 
 
 ^ Broadbent (W. H.)- " On a particular form of amnesia. Loss of nouns." — Medico-ChirurniccU 
 Transactions, Second Series, Vol. XLIX., Lond., 1884, p. 249. 
 
 = Broadbent (W. H.). loc. cit, p. 258. 
 
Ill 
 
 language has been damaged, and in such cases the only words left to 
 the individual are those which have been most frequently used in his 
 experience, and which have, therefore, become most deeply organised 
 in him. In these cases there is a dissolution of language, in 
 which the most special parts are the first, and the most general 
 the last to disappear, and if concrete nouns disappear in greater 
 degree than other parts of speech, it is chiefly because they form a very 
 special part of language. Dr. Broadbent's patient gave expression to 
 such phrases as " I am very glad to see you," " I am very much better 
 to-day, thank you," " Oh ! yes, very well indeed," while James Lee's (Case 
 5) conversation consisted of such statements as " I am quite well, there 
 is nothing the matter with me, if J could only speak it ; but I cannot 
 speak it at all." Now, although these phrases are couched in the 
 developed language of civilisation, it is manifest that the thoughts 
 expressed in them are hardly above the level of the first expressions of 
 infancy, or of the thoughts which may be supposed to have been uttered 
 by aboriginal man in his first attempts at articulate speech. There is a 
 widely prevalent belief, even amongst cultivated psychologists, that nouns 
 are the first parts of speech to be developed. This notion is due most pro- 
 bably to the fact that 7na-ma is the first articulate sound of the infant, 
 and from this it is inferred that the infant's first step in the acquisition 
 of language is to call its mother by name. But in so far as the infant 
 associates the sound ma with its mother it is only a particular name, and 
 is more like to a nickname than to our developed conception of the 
 general name, mother; and in the earliest stage of the acquirement of 
 speech by the infant, it is doubtful if the exclamation ma has even the 
 signification of a particular name. It is probable that it is associated in 
 the infantile mind with the pleasant sensations which contact with the 
 naother, and especially with the breast of the mother, brings along with 
 it, and consequently the signification of the word ma in the mind of the 
 infant is more nearly expressed by the imperative mood of the verb "■ to 
 come " than by our general name " mother." The signals of the social 
 animals teach us a similar lesson. When a rook, for example, utters 
 "Caw! caw ! caw !" as a danger signal to his fellows it cannot be sup- 
 posed that he uses a noun having a meaning corresponding to our 
 abstract word " danger," or to our words for the usual causes of danger, 
 such as man, gun, gunpowder, &c. The nearest interpretation to the 
 signal in our language would be the imperative mood of the verb " to fly." 
 And when language, as a whole, is subjected to analysis, it is found that 
 all words are derived from simple predicative roots, signifying, to go, 
 to come, to divide, to eat, &c., and demonstrative roots such as, this, 
 that, I, he, it, which are simply used to point at an object or person. 
 
112 
 
 The rudiments of the demonstrative pronoun may even be recognised 
 in the signal cry of the rook when taken along with the movements of 
 the one giving the signal, inasmuch as the direction of his own flight 
 indicates their course to the other members of the flock, so that the cry 
 and movements are tantamount to our phrase "fly in this direction." 
 The devices which persons sufiering from apperceptive aphasia employ 
 to overcome their disability, remind us of the manner in which aboriginal 
 man used his few scanty words to convey his thoughts. "Were James 
 Lee (Case 5) to be presented the object hay — the present staple food 
 of cattle — we have no doubt but that he would describe it in the 
 following terms : — "I know it quite well; it is a glass of beer;" and on 
 being remonstrated with for this answer he would add, "I have seen that 
 thousands of times ; they eat that." In aboriginal times the staple food 
 for cattle was acorns and beech-nuts, and it would become necessary to 
 have a name for these fruits at a very early period in the development 
 of speech. In the Sanskrit there is a root hhag, meaning to divide, and 
 from the act of making a division of the fruits which had been collected 
 for the cattle, the word came to be used also for the act of eating them, 
 as is shown by the Greek w^ord <^ay, to feed, to eat, and, after a time, 
 the same root was used to designate the trees from which these 
 fruits were derived, as in the Latin fagus, the Greek <f>rjy6s, oak, and 
 the English beech} The science of language teaches unmistakably that 
 the language of aboriginal man consisted almost entirely of verbs, 
 demonstrative pronouns, and a few adverbs of time and place, 
 and that the names of even common objects are always derivative, 
 and, consequently, of much later growth^ than the roots them- 
 
 1 See Max Miiller (F.) "On the Origin of Reason." The Coniempormy Review, Yol. XXXI., 
 1877-78, p. 490. 
 
 2 In a discussion whioli followed the reading of a paper on aphasia by Dr. Gairdner before the 
 Philosophical Society of Glasgow, March 7th, 1866, the Rev. H. W. Crosskey is reported to have 
 said, " that naming objects was an exceedingly difficult thing, and involved a process of thought 
 difficult for a child to accomplish ; and, therefore, it was found that the verb, of all utterances, 
 was the first object, and that to give a name to an object showed a considerable amoimt of predi- 
 cation and will, so that the arrest of the faculty of the mind to grasp proper names, instead of 
 being an arrest of a primeval quality of the mind, was an arrest of one of the latest and most 
 elaborate actions of it." — (Gairdner (W. T.). " On the Function of Articulate Speech," p. 39, Glas- 
 gow, 1866.) It is to me a matter of regret that Dr. Gairdner's remarkable paper did not come 
 uuder my notice until after the series of papers, which are here collected in one volume, had 
 already appeared in the Medical Chronicle. Its perusal has convinced me that I have not done fuU 
 justice to the share which my own countrymen have taken in differentiating motor and appercep- 
 tive aphasia. The distinction between the two forms of speech disorder is suggested by 
 Dr. Gairdner, as an alternative to some other hypothesis, when he says, " or we must admit two 
 perfectly distinct kinds of aphasia, only one of which affects the ideation of language, so to speak, 
 while the other affects, in some complicated way, as yet imperfectly studied, but perhaps differing 
 from paralysis properly so-called, the innervation of language, or rather of speech, while it leaves 
 the ideation of it, on the one hand, and the mechanism of it through the writing hand, on the 
 other, absolutely, or nearly, intact." — {Op. cit., p. 20.) About the same time with Dr. Gaii-dner, 
 his friend, the late Professor Sanders of Edinburgh, gave expression to a similar view in still more 
 
113 
 
 selves, and it is only what might have been expected that in the 
 dissolution of language caused by disease, nouns should disappear 
 from the vocabulary of the patient before the parts of speech which 
 have been first developed, and, thei'efore, most deeply organised. It 
 will thus be seen that, in the cases of apperceptive aphasia in which 
 the patient is unable to use nouns, the whole structure of language is 
 profoundly injured, and that the subject of this disability is reduced, so 
 far as language is concerned, to the condition of the infant or the 
 remote savage in their early attempts at giving articulate expression to 
 their thoughts, or in understanding the articulate expressions of others. 
 This view is, however, very different from Dr. Broadbent's theory that 
 the patient has lost the use of nouns by the destruction of conducting 
 paths between a naming and a propositionising centre, while the remain- 
 ing parts of speech have remained unimpaired. 
 
 " Another derangement of speech," says Dr, Broadbent,^ " is where 
 names are more or less remembered, but there is loss of the faculty of 
 constructing a sentence which shall convey the ideas to be expressed 
 regarding them — that is, of the power of framing a proposition. The 
 lesion here will be in the propositionising centre." The case by which 
 Dr. Broadbent illustrates this form of aphasia is one in which the patient, 
 in endeavouring to express that he had received a letter from a brother 
 in America, said — " Brother — brother — 'Merica — letter — New York — 
 two brothers in America." The same patient, however, in describing 
 the mode of onset of his attack, said, " Evening, evening — put down 
 my cigar — smoking, smoking not a quarter of an hour — all at once 
 couldn't speak." These broken sentences are a very imperfect statement 
 
 definite language. "Two kinds of aphasia," says Professor Sanders, "have accordingly been 
 distinguished. First, amnesic aphasia, loss of speech depending on a defective memory of words, 
 and, therefore, to some extent, a psychical defect ; and, second, ataxic aphasia, where the loss of 
 speech is due to lesion of a supposed cerebral apparatus of co-ordination for the movements of 
 articulate speech — a defect of nervous mechanism only." — (Edin. Med. Journal, Vol. XI., 18S5-6, 
 p. 813.) But not only did Professor Sanders distinguish these two forms of aphasia clinically, he 
 even went so far as to suggest a possible difference in the position of the lesion in each disorder. 
 In the case (Mackie) reported by him, the symptoms of motor (ataxic) and apperceptive (amnesic) 
 aphasia were combined, and at the autopsy one focus of softening was found in Broca's convolu- 
 tion, and a second near the posterior extremity of the fissure of Sylvius — the superior marginal 
 convolution. Referring to the second focus, Professor Sanders says, " Probably this additional 
 lesion may account for the greater loss of memory seen in Mackie than is observed in other 
 cases." — (Zoc. cit., p. 822.) The distinctions between motor and apperceptive aphasia are clearly 
 recognised by Dr. W. Ogle ("Aphasia and Agraphia," St. George^s Hospital Reports Yol. 11, 1S67, 
 p. 117), but the next great advance in the appreciation of the differences between these two forms 
 of speech disorder was made by Dr. Bastian, in an altogether remarkable paper, entitled "On the 
 Various forms of Loss of Speech in Cerebral Disease." — (British and Foreign Medico-Chir. Review, 
 Vol. XLIII., 1869, pp 299, 470. See also, Bastian, " The Physiology of Thinking," The Fortnightly 
 Review, January, 1869 ; "On the Muscular Sense," British Medical Journal, April, 1869 ; "The Brain 
 as an Organ of Mind," Third Edition, p. 601, et seq. ; and "Paralysis : Cerebral, Bulbar, and Spinal," 
 
 » Broadbent (W. H.) "A case of peculiar affection of speech, with commentary." — Brain 
 VoL I. (Lond. 1879), p. 496. 
 H 
 
114 
 
 of facts, but they contain several parts of speech besides the names of 
 things. The speech disorder of this patient was ushered in by an 
 attack of right-sided hemiplegia, from which he made a rapid recovery ; 
 he is said to have understood both spoken and written speech, and had 
 been able to name some objects, and not others, but his attempts at 
 reading aloud ended in mere jargon. A case of this kind of disorder of 
 speech, so far at least as vocal expression is concerned, was sent to me 
 a few weeks ago by Dr. Harris, but as I had only one short interview 
 with the patient I was unable to take full notes of his symptoms. He 
 was a man of about 45 years of age, and I gathered from him that 
 while on a visit to London, about ten years ago, he was suddenly seized 
 with some kind of fit, and was conveyed to Guy's Hospital, where he 
 was fattended by Dr. Taylor. On regaining consciousness he found 
 himself paralysed on the right side of the body and unable to speak, 
 but he insisted on leaving the hospital and came back to Manchester 
 the same night. Sometime afterwards he returned to Guy's Hospital, 
 and remained there for three weeks under the care of Dr. Goodhart. 
 He had almost entirely recovered from his paralysis, but had now given 
 up all hopes of his power of speech being restored, and was undergoing 
 treatment at the Hospital for Diseases of the Chest, not with the view 
 of obtaining a cure for his "tongue," but for an attack of pleurisy, from 
 
 1886, p. 103, et «cg.) The subject is approached by Dr. Bastian from the double standpoints of 
 the physiology of thinking and clinical analysis, and his main thesis is that " words are revived 
 in the cerebral hemispheres as remembered sounds," in opposition to the hypothesis advanced by 
 Bain, and adopted by Hughlings-Jackson, that the material of oiir recollection is a suppressed 
 articulation. If the latter hypothesis were true, both the amnesic and so-called ataxic disorders 
 of speech would necessarily be caused by lesion of the motor mechanism of speech ; while, if the 
 former be accepted, the amnesic disorders will be caused, as we now know they are caused, by 
 lesion of the cortical cerebral centres. Dr. Bastian's theory is tacitly adopted throughout these pages; 
 It has, indeed, become so much the common property of psychologists that we are apt to forget to 
 whom we owe its first enunciation, or rather, its first application to the explanation of the phenomena 
 of aphasia. The theory itself had already, as is acknowledged by Dr. Bastian, been briefly, but 
 very distinctly, stated by Mr. Herbert Spencer. — (" Principles of Psychology," 1870, Vol. I., p. 187.) 
 The next great advance in the differentiation of motor and sensory aphasia was made by 
 Dr. Broadbent, in a paper entitled, "On the Cerebral Mechanism of Speech and Thought." — 
 •{Medico-Chirurgical Transactions, Vol. LV. , 1872, p. 162.) In this paper the author reported a case 
 of what is now recognised clinically as word-blindness, and in which, after the death of the 
 palient, the lesion was found in the angular gyrus, and neighbouring convolutions. In this 
 ■contribution, as well as in all his subsequent writings, Dr. Broadbent sees clearly that the dis- 
 orders of speech which had hitherto been described under the name of amnesic aphasia, are 
 ■caused by lesion in the area of the posterior branches of the Sylvian artery, and that they result 
 from injury of the sensory mechanism. In the text the recognition of apperceptive or 
 sensory aphasia is attributed chiefly to Wernicke ; but, without wishing to detract from the great 
 value of his work, it is only right to point out that it did not appear until 1874, and, therefore, 
 subsequently to the writings which have just been quoted. It is unnecessary for me to speak of 
 the immense strides which the hypothesis of amnesic aphasia, as a disorder of the sensory 
 mechanism of speech, has made since Perrier's first experiments on the sensory cortical centres, 
 but inasmuch as the second edition of his great work on "The Fimctions of the Brain" was not 
 published until after these papers had appeared in the Medical Chronicle, I shall content myself 
 with saying that it contains a profoundly interesting article (p. 441, et seq.) on the subject of 
 .aphasia generally. 
 
115 
 
 Tvhicli he had recently suffered. The language in which this informa- 
 tion was imparted may be gathered from the following note which he 
 handed to me, and which was evidently a carefully prepared account of 
 his seizure and subsequent symptoms : — 
 
 Done 10 years Dr. Taylor Guy's Hospital London, but same night back to Man- 
 chester. Last month Guy's Hospital 3 weeks Dr. Goodhart and no better and now 
 near done, only my Health little longer, and see my Lungs and Throat and four 
 weeks bad Pluracy. But try no more tonge. 
 
 The vocal speech of this patient was more disconnected, if possible, 
 than his written speech. During my examination of him nothing could 
 restrain his volubility ; he poured forth volley after volley of words, 
 many of which I was quite unable to understand, but aided by my 
 knowledge of the symptoms which usually usher in and accompany 
 aphasic disorders, and by his expressive gestures, I have no doubt I 
 formed a tolerably correct idea of the information he intended to impart. 
 This patient, with his incessant and disjointed talk, reminded me 
 forcibly of an active and restless child who from his continuous prattle 
 earns the name of " chatterbox," and indeed a careful examination, shows 
 that the vocal speech of the former is by no means unlike that of the 
 latter. In both instances the articles, conjunctions, prepositions, and 
 auxiliary verbs are omitted, while nouns are generally used in preference to 
 pez'sonal pronouns. The vocal speech of this patient is also very similar in 
 its construction to languages, like the Chinese, which have only reached 
 the radical stage of development. The Chinese-'- language has neither 
 declensions nor conjugations, and it depends upon the position which a 
 word occupies in a sentence whether it has the signification of a verb, a 
 substantive, an adjective, an adverb, or a preposition. It is clear that 
 in a language of this kind the meaning which the speaker intends to 
 convey must be interpreted largely by means of his intonations and 
 gestures. It appears to me, therefore, that the vocal speech of the 
 patient whose case has just been mentioned, manifests a dissolution of 
 language to the level of the forms which preceded the inflexional stage 
 in the development of all languages, or to the level of the vocal speech 
 of early childhood." And, indeed, the post-mortem records of cases of 
 
 1 See Mtiller (Max), "Lectures on the Science of Language," 2nd Series, Lecture IL, p. 84 et 
 seq.; and Eussmaul (A.)., Art. " Distur-bances of Speech." — Zienisse'ii's Cyclopoedia, Vol. XIV., 
 1878, p. 791. 
 
 = The relation subsisting between the Chinese language and that of childhood is thus 
 clearly stated by Prof. Max MUller : "If -we -watch," he says, "the language of a child, which is 
 in reality Chinese spoken in English, we see that there is a form of thought and of language 
 perfectly intelligible to those who have studied it, in which, nevertheless, the distinction between 
 noun and verb — nay, between subject and predicate — is not yet realised. If a child says up, that up 
 is, to his mind, noun, verb, adjective, all in one. It means, 'I went to get up on my mother's 
 lap. ' If an English chUd says ta, that ta is both a noiui, thanks, and a verb, I thank you. Nay 
 •even if a child learns to speak grammatically it does not yet think grammatically ; it seems in 
 
116 
 
 what Dr. Broadbent calls " loss of nouns," and " loss of the power of 
 expressing the relation between things," shows that the lesion occupies 
 nearly the same position in the brain in both cases, proving that there 
 cannot be any essential difference between the two affections. In the case 
 of "loss of nouns," reported by Dr. Broadbent,^ the two posterior of the 
 six convolutions of the Island of Reil " had entirely disappeared, leaving 
 a smooth surface of a pale fawn colour, formed apparently by the 
 external capsule, itself somewhat degenerated, but overlying grey 
 substance of the lenticular nucleus, which was not appreciably altered. 
 The angular gyrus round the extremity of the Sylvian fissure, and the 
 supra-marginal lobule forming its upper margin posteriorly, were under- 
 mined by an extensive area of degeneration continuous with that which 
 had destroyed the posterior convolutions." Other spots of degeneration 
 were found in the basal ganglia and the substance of the left hemisphere, 
 but these had evidently not taken part in causing the disorder of speech. 
 A good example of the speech disorder, which Dr. Broadbent names 
 " inability to express the relation between things," and in which a 
 post-mortem examination was obtained, is the case reported by 
 Lichtheim,^ which we have already mentioned. The patient had 
 suffered from an attack of right-sided hemiplegia and aphasia, from the 
 former of which he made a partial recovery, but the latter persisted. 
 He understood both spoken and written speech, and could repeat short 
 words correctly, but made mistakes in repeating sentences. His writing 
 was very imperfect, but he could copy correctly. " When asked to 
 relate his history," says the report, " he strings together in a fluent 
 manner numerous words, of which scarcely one now and then can be 
 made out. The following were noted : ' Evening, five and twenty, and.' 
 Patient is aware of the incorrectness of his diction, and tries to assist 
 himself with gestures. He succeeds better with single short words and 
 answers ; thus, in answer to the question, ' What was there for supper 1 ' 
 he answered, ' Bread, meat, potatoes,' with only two mistakes. His own 
 name he mutilates." The following were the chief changes found at the 
 autopsy. " There is considerable depression of the convolutions bordering 
 the upper and posterior part of the left Sylvian fissure, as well as of the 
 ascending frontal and parietal convolutions. The Island of Reil is sunken, 
 
 speaking to wear the garments of its parents, though it has not yet grown into them. A child 
 says, 'I am hungry,' without an idea that it is different from 'hungry,' and that both are united 
 to an auxiliary verb, which auxiliary verb again was a compound of a root as, and a personal 
 termination mi, giving us the Sanskrit asmi, I am. A Chinese child would express exactly the same 
 idea by one word, slii to eat, or food. The only difference would be that a Chinese child speaks 
 the language of a child, an English child the language of a man." — Loc. cit, p. 86. 
 
 1 Broadbent (W. H.) " On a particular form of amnesia. Loss of nouns." — Medico- 
 Cliirurgical Transactions, 2nd Series, Vol. XLIX., 1884, p. 249. 
 
 = Lichtheim (L.) "On Aphasia." Translated by Dr. A. de Watteville. Brain, Vol. VII., 
 1884-5. p. 445. 
 
117 
 
 forming a depression into which the second frontal convolution falls 
 suddenly to a depth of 1|- cm. ; the third frontal convolution terminates 
 into it likewise. Here the pia is inflamed with yellow discoloration. 
 The depression is bounded posteriorly by the fissure of Sylvius. The 
 middle portion of the first temporal convolution is somewhat sunken 
 opposite the depression of the Insula, in which the consistence of the 
 cerebral matter is soft, with harder patches around. . . . Ttie 
 softened patch occupies the bottom of the Sylvian fissure and extends to 
 1| cm. from the posterior part of the inferior frontal convolution, and to 
 the neighbouring portions of the ascending frontal convolution. A 
 fragment of the cortex of the ascending temporal is also wanting, but 
 there is no yellow discoloration here." If we now compare the results of 
 the post-mortem examination in these cases, reported by Drs. Broadbent 
 and Lichtheim, it will at once be apparent that the lesion in the one 
 occupies almost the same position as it does in the other. The only 
 differences in the localisation of the lesion that we can discover, are that 
 the area of the softening extended rather further back, roimd the 
 posterior ends of the horizontal branch of the Sylvian and the parallel 
 fissures (the angular gyrus) in Dr. Broadbent's than it did in Lichtheim's 
 case, while it extended rather further forwards over the inferior portion 
 of the ascending parietal and frontal convolutions in Lichtheim's than in 
 Dr. Broadbent's case. It is also expressly stated in the report of Dr. 
 Broadbent's case, that the angular gyrus and supra-marginal lobule were 
 undermined by degeneration, while it would appear from the report of 
 Lichtheim's case, that the cortex of the supra-marginal lobule was itself 
 softened, and it is, as we have seen, doubtful if the angular gyrus was 
 implicated. But surely such minor differences as have just been noted, 
 would not warrant us in concluding that in Dr. Broadbent's case the 
 lesion had injured the conducting path between a naming and a pro- 
 positionising centre, while in Lichtheim's case the propositionising centre 
 itself was destroyed. In the case of verbal amnesia, already mentioned 
 as having been reported by Rosenthal, the area of softening was found 
 in the second and third temporo-sphenoidal convolutions, and yet this 
 patient also was imable to name objects at sight, and had, therefore, lost 
 the use of concrete nouns, but in Dr. Broadbent's case the lesion was 
 found in the supra-marginal lobule and angular gyrus. If then the 
 clinical form of aphasia, named " loss of nouns," is caused by ruptm-e of 
 the conducting path which unites a naming centre with a propositionising 
 centre, this path is capable of being injured either by a lesion in the second 
 and third temporo-sphenoidal convolutions, or in the supra-marginal 
 lobule and angular gyrus. Nothing in the structure of the brain, 
 or in the direction of the association fibres, is known to me which could 
 be held to justify such a supposition. 
 
118 
 
 The following appears to me to be a much more reasonable interpre- 
 tation of the symptoms of these forms of aphasia. The first temporo- 
 sphenoidal convolution (the auditory sensory centre) is in direct relation 
 with the central end of the fibres of the auditory centripetal conducting 
 paths, and the supra-marginal lobule and second and third temporo- 
 sphenoidal convolutions are in indirect relation with them. Now 
 the understanding of spoken speech is first developed in healthy 
 persons in connection with the sense of hearing, and consequently partial 
 damage of that portion of the centre which is connected with the 
 auditory conducting paths will give rise to partial disorders of speech, 
 while complete disorganisation of this portion of the centre will give rise 
 to complete loss of the faculty of understanding vocal speech. Now the 
 least damage to the centre will be done by lesions of those portions of 
 the cortex which are indirectly connected with the auditory conduct- 
 ing paths — the second and third temporo-sphenoidal convolutions and 
 the supra-marginal lobule, and the greatest damage to the centre will be 
 done by lesions of that part which is directly connected with this path — 
 the first temporo-sphenoidal convolution. Lesions of the second and 
 third temporo-sphenoidal convolutions will, according to this supposition, 
 only damage the more special part of the great function which has been 
 developed in connection with the sense of hearing, and as the names of 
 individuals, concrete nouns, and highly abstract nouns like "virtue" are 
 the most special part of language, they are the parts of speech which 
 suffer most by such a lesion The case of R. B. (Case 8) is a good 
 example of the kind of speech disorder which is most probably caused 
 by a lesion in these convolutions. The supra-marginal lobule may be sup- 
 posed to be more intimately connected with the auditory conducting paths 
 than the second and third temporo-sphenoidal convolutions, but the con- 
 nection between them is still indirect and not direct. Lesion in this locality 
 will therefore leave the fundamental structure of language intact. A 
 lesion of a certain intensity may be supposed to cause loss of all highly 
 abstract and concrete nouns and individual names, and to render the 
 patient incapable of using correctly the moods and tenses of verbs, 
 the inflexions of nouns, and the articles and connecting particles which 
 give definition and precision to language. The patients, however, 
 still retain, as in Lichtheim's case, the use of a few familiar concrete 
 nouns, the names of the simpler qualities and ordinary numerals, 
 a considerable number of verbs, and some other parts of speech 
 which enable them to express their meaning fairly well, especially 
 when aided by gesture. ■ A more profound lesion of the supra- 
 marginal convolution may be supposed to cause loss of all abstract 
 and concrete nouns, like the case reported by Dr. Broadbent. It 
 
119 
 
 ought, however, not to be forgotten that a lesion of the supra- 
 marginal convolution often encroaches upon the motor area of the 
 cortex, as in Lichtheim's case, and it is, therefore, probable that in the 
 cases which Dr. Broadbent names " inability to express the relations 
 between things," the sensory disorder of speech is accompanied by some 
 injury of the motor mechanism, a certain justification being thus 
 afforded to Wernicke for giving to such cases the name of commissural 
 aphasia. But although we believe that cases of this kind form a sort of 
 transition between the sensory and motor disorders of speech, we find no 
 warrant for the opinion that they are caused by isolated disease of 
 any particular bundle of the association system of fibres, even in spite 
 of the fact that the fasciculus uncinatus which passes across the bottom 
 of the Sylvian fissure to connect the temporo-sphenoidal with the frontal 
 lobe is likely to be involved in the lesion. There is no case known to 
 me in which disease of this bundle of fibres caused a disorder of speech 
 when the cortex was intact. 
 
 The first temporo-sphenoidal convolution has so far been supposed 
 to be intact, and although the patients had lost the power of naming 
 things they still understood the noun when uttered in their hearing. 
 When, however, this convolution is itself diseased word-deafness 
 is superadded to the other disorders of language. If the convolution 
 is only partially destroyed the patient can understand much of 
 what is uttered in his hearing, so long as the sense of the statements 
 does not depend upon concrete nouns, and he is also able to express many 
 of his own thoughts by means of pronouns, simple verbs, and adverbs 
 of time and place, aided by gestures. The case of James Lee^ 
 ^Case 5), is a good example of this speech disorder. If the first 
 temporo-sphenoidal convolution is thoroughly disorganised, the patient 
 fails to understand almost all words which are uttered in his hearing, 
 and he is likewise unable to express his thoughts in articulate speech, 
 although he is still able to repeat "recurring utterances," like the 
 
 1 Such patieuts have also the use of a few general and abstract nouns. James Lee (Case 5), 
 ■whose speech disorder is a very good example of the one \inder consideration, made frequent use 
 of matter and gentlemen, but those words were "generally used when he was endeavouring to 
 describe his own bodily feelings and previous experiences, and seldom in reference to any one 
 thing or person presented to him. The words were never, indeed, used singly, but always as part 
 of a sentence. It seems clear, therefore, that the patient is aided in his utterance of such words 
 by their association with others, and it is probable that it is this association which revives them 
 in memory, and not any external impression. The power of association in suggesting complex 
 words to persons suffering from sensory aphasia is well illustrated by the capacity James Lee 
 manfested of counting from one up to a hundred, although unable to utter one word of the series 
 unless he started with the first. Dr. Gairdner believes that in associations of this kind the words 
 are set free "very much as one wholly unskilled in music might let loose the tunes of a barrel- 
 organ without any direct cognisance of the music he is playing, or the precise combinations of 
 movement he is calling into action." But whether this be the explanation or not, there can be 
 no doubt that the patient is, as Dr. Gairdner says, capable of uttering phrases en masse which he 
 is incompetent to utter in detail. — Loc. cit., p. 19, and British Medical Journal, Vol. II., 1S85, p. 310. 
 
120 
 
 phrases "John, if you please," "thank you, ma'am," used by John 
 Morris (Case 6). When the first temporo-sphenoidal convolution is 
 completely disorganised, the patient is quite unable to understand any 
 word uttered in his hearing, and even the power of repeating recurring 
 utterances fail him, but he is still capable of uttering a larger number of 
 vocalisations to which no definite meaning can be attached, this 
 speech disorder constituting the variety which we have already 
 named syllabic paraphasia. When, however, gibberish aphasia is 
 caused by a lesion in the sensory area of the cortex, without any damage 
 being at the same time done to the motor mechanism of speech, it is 
 probable that disease of the angular gyrus must necessarily be associated 
 with that of the first temporo-sphenoidal convolution. At any rate, in a 
 case reported by Dr. Broadbent,^ in which the patient talked incom- 
 prehensible gibberish, he was unable to comprehend either written or 
 spoken language, and at the autopsy an extensive area of softening was 
 found in the angular gyrus, supra-marginal lobule, and first temporo- 
 sphenoidal convolution. 
 
 In the conditions already described under the names of partial 
 perceptive blindness, and partial perceptive deafness, it is highly 
 probable that the angular gyrus and the first temporo-sphenoidal 
 convolutions respectively are diseased in both hemispheres. These 
 affections would, therefore, bear a similar relation to the other forms of 
 sensory aphasia, that the bulbar paralysis which results from lesion of 
 the posterior part of the third frontal convolution on both sides bears 
 to the other forms of motor aphasia. A disorder of the apperceptive 
 faculty of speech is, so far as we know, not caused by disease of the 
 sensory conducting paths, in correspondence with the motor aphasia and 
 bulbar paralysis, which result from injury of the motor conducting 
 paths in their passage through the internal capsules, crura cerebri and 
 pons. Hemiansesthesia is, however, not an unfrequent accompaniment 
 of sensory aphasia, but this symptom is certainly caused in some cases, 
 and probably in all, by a second lesion in the optic thalamus or lenti- 
 cular nucleus, whereby the sensory conducting path is injured in its 
 ascent to the cortex in the posterior part of the internal capsule. 
 
 The theory which has just been advanced still encounters one serious 
 difficulty. In the second degree of verbal amnesia^ the patient, as in the 
 case of R. B. (Case 8), is unable to name most objects presented to him, 
 but he immediately identifies the object when the name is uttered in 
 his hearing, or presented to him in writing. Why then should the 
 object fail to revive the idea of the verbal sign, while the verbal 
 sign revives the idea of the object? The reply to this question 
 
 ' Broadbent (W. H.) "On a case of amnesia, with post-mortem examination." — Medico- 
 CUrurgical Transactions, Vol. LX., 1878, p. 147. 
 
121 
 
 is to be found in an analysis, not of language, which is the 
 prodiict as well as the instrument of thought, but in an examina- 
 tion of the process of thought itself. Our thoughts may be said 
 roughly to move on two extreme, and a middle plane, with 
 every intermediate level. On the low level our thoughts corres- 
 pond more or less to the thoughts which may be supposed to pass 
 through the minds of the lower animals. We shall not waste time in 
 proving that animals think. A dog, for example, on seeing his master 
 from a distance, infers that if he will run some paces he will experience 
 certain sensations of resistance, of touch, and of smell, or in other words, 
 the presented sensation caused by the impression of certain rays of light 
 falling on the dog's eye has revived a large group of represented sensations 
 which have always been associated with the presented one in his expe- 
 rience. This shows that the dog has formed a perception of his master, 
 just as a fellow man would have done had the same rays of light fallen 
 upon his eye. The perceptions which a dog and a human being looking 
 at a man from the same distance form of him will differ doubtless 
 greatly in detail, but the fact that the respective perceptions prove 
 adequate for the practical guidance of both animals under similar 
 circumstances shows that they must be fundamentally alike. A dog 
 not only forms perceptions of objects, but there can be little doubt that 
 ideal revivications of perceptions previously experienced pass through 
 his mind. Dogs not unfrequently bark excitedly in their sleep, and it is, 
 therefore, highly probable that they are dreaming of being engaged in 
 the pleasures of the chase, or in resisting an attack from an enemy. 
 And if dogs dream it may be inferred that reminiscences of previously 
 experienced pleasures and dangers, with all their attendant circumstances, 
 pass through their minds in the waking state. It may, therefore, be con- 
 cluded that animals think, not only in trains o^ feelings, as Professor Huxley 
 asserts, but in trains of perceptions. Now a great part of our thinking con- 
 sists of perceptions experienced at the moment, and of reminiscences of 
 previously experienced perceptions. Suppose one takes a walk in a 
 green field, he perceives the greensward, the trees, and the foliage, from 
 which rays of hght are reflected to his eyes, and the cattle and birds, 
 whose lowing and singing fall upon his ear, and the more vivid of these 
 perceptions start a train of reminiscent perceptions, probably from 
 scenes in his childhood, while there is with him an ever-present feeling 
 of the great conditions of all our sensuous perceptions — time and space. 
 It is possible that in addition to these thoughts he may carry on a train 
 of reasoning in words, but whether that be so or not, there can be no 
 question that the greater part of his thinking has consisted of percep- 
 tions actually experienced, and trains of perceptions ideally revived. 
 Thinking by means of percepts is, therefore, common to man with the 
 
122 
 
 lower animals, and although the thoughts of the former, even on this 
 level, are much more varied and complex than those of the latter, yet 
 there is no essential difference in principle between the two. 
 
 Let us now pass at once to the consideration of the other extreme 
 plane of thought. Thinking, on the high level, has for its subject- 
 matter the relations in which phenomena are presented to us when they 
 are detached from all individual perceptions, and it can only be carried 
 on by means of mathematical symbols and abstract nouns. It is quite 
 manifest that thinking of this kind is beyond the reach, not only of the 
 lower animals, but also of the lower races, and the youth and uneducated of 
 the higher races of mankind. Such words as "function" and "co-efficient" 
 in mathematics, and "virtue" and "benevolence" in morals, are not even 
 capable of being expressed in the languages of the inferior races, and 
 can only have a vague meaning to all except those whose mental faculties 
 are fully developed and highly educated. Thinking on the middle level 
 is possible to every healthy man who has passed the age of early infancy, 
 but not to any animal. It is carried on by means of words, and chiefly 
 by the aid of general names, or concepts, and it is scarcely necessary to 
 add that thinking of this kind admits of innumerable degrees. In the 
 early stages of development the concept and the precept must have 
 almost been identical. Aboriginal man, even before he had any general 
 name for his fellow man, was, no doubt, able to form a perception of him 
 as the lower animals do. On hearing a footstep, for example, the image 
 of one of his fellow men, or of sevex*al of them in succession, would 
 arise in his mind, and the rapidity with which images of different people 
 passed through his mind gave to the perception an element of generality. 
 But let us suppose that an aboriginal man had advanced so far in 
 the acquirement or construction of language as to have a word man, as in 
 the Sanskrit, signifying to think, and that he had now applied it to designate 
 the animal who is pre-eminently endowed with the power of thinking, 
 the word, on being uttered by himself or another, would not only call 
 up an image of a fellow man, as the footstep did, but by the aid of 
 it the power of generalising would be indefinitely increased. The verbal 
 symbol would now stand for generations of men yet unborn, and for 
 those that had already died just as well as for the men that were living 
 around him. Once the concept man had become detached from the 
 percept man the meaning of the former has gone on widening in intent, if 
 not in extent, along with the growing knowledge of our own minds and 
 of the universe by which we are surrounded, while the signification of 
 the latter has remained comparatively, although not altogether, stationary. 
 In order to prove this we have only to glance at the meaning which an 
 educated biologist would attach to the general name man. According 
 
123 
 
 to Prof. Huxley/ man is one of the orders of mammalia having a discoidal 
 deciduate placenta, the hallux provided with a flat nail, a particular dental 
 formula, and certain other peculiarities. It will at once be apparent 
 that this definition can have no meaning to anyone except he is possessed 
 of a wide knowledge of the structure of other animals, and this presup- 
 poses a knowledge of the properties of the substances which enter into the 
 composition of the bodies of animals ; in short, the definition can have 
 no meaning except as a part of a complete scheme of knowledge of 
 man and of the universe in which he lives. And although only a very 
 few men can form such a conception of man as Prof. Huxley, yet the 
 conception which each man forms of his kind is determined by his 
 particular scheme of knowledge of the universe at large. Concepts as 
 embodied in general names are generalisations of innumerable percepts of 
 various orders, and as such they are altogether on a higher plane of thought 
 than the individual percepts aroused in our minds by the exercise of 
 our senses, Man lived upon this planet thousands upon thousands of 
 years before it was possible for him to regard himself in the light of 
 Prof. Huxley's definition, and the definition itself was only rendered 
 possible by the accumulated knowledge of ages. It will thus be seen 
 that the passage from the joercejoi to the concept has been an exceedingly 
 slow and gradual process ; but each step in the growth of the latter pre- 
 supposes that it can be readily applied for the practical purpose of 
 recognising the former when presented to the senses. In other words, 
 the passage from the low level of thinking in percepts to the middle 
 level of thinking in concepts has been a slow and difficult one, but each 
 acquirement on the middle level presupposes a ready and easy transition 
 to the low level. 
 
 Let us now apply this somewhat crude theory of the process of 
 thinking to the elucidation of the phenomena of sensory aphasia. We 
 may at once state our disbelief in the possibility of parcelling out the 
 nervous structure in the cortex of the brain, the activity of which is the 
 correlate of the process of thought, into distinct centres, each having a 
 separate faculty, such as naming, ideation, and propositionising. There 
 is nothing in the structure of the brain to warrant such a supposition. 
 The cortex is spread out like a mantle over the surface of the hemi- 
 spheres, and to this structure fibres ascend from the surface of the body 
 and terminate in or amongst the superficial cells, while other fibres 
 emerge from the inner layer of the cortical cells and pass out to end in 
 the muscles. The centripetal fiibres are gathered into groups, which ter- 
 minate chiefly but not entirely in the posterior and inferior portion of 
 the cortex of each hemisphere ; and the centrifugal fibres, also collected 
 
 1 Huxley (Thomas Henry). "An introduction to the classification of animals." Lond., 
 1869, p. 99. 
 
124 
 
 into somewhat indefinite groups, emerge from the middle and anterior 
 portions of the cortex, and consequently we have no objection to call 
 the portions of the cortex in which the former groups terminate, and 
 from which the latter emerge, sensory and motor centres respectively. 
 In addition to the ingoing and outgoing fibres, the cortex is furnished 
 by a system of association fibres which connect different parts of the 
 cortex with one another. 
 
 The annexed diagram, sketched for me with his usual kindness by my 
 friend, Prof. A. H, Young, will help the reader to understand this view of 
 the cortex. From the eye and ear centripetal fibres (v and a) ascend to 
 
 terminate in the angular gyrus (V) and first temporo-sphenoidal convo- 
 lutions (A) respectively, but in reality these fibres are directly connected 
 with a much larger area of the cortex than is here indicated. In addition 
 to these, fibres of muscular sense (s s' and s"), indicated by dotted lines, 
 ascend from the muscles of articulation, from those of the hand, and 
 from those of the eyeball to reach the cortex. These fibres are repre- 
 sented as terminating on the surface of the motor centres of the cortex, 
 but it is doubtful whether they ought not be made to terminate along 
 with the cutaneous sensory nerves — not represented in the figure — in the 
 hippocampal region. The dotted lines which connect the sensory centres 
 
125 
 
 with one another and with the motor centres represent the association 
 system of fibres, but they have no pretensions to anything like accuracy 
 of representation. The centres of vocal and written expression are 
 represented at E and W, and these are connected by means of centri- 
 fugal fibres m and m' with the vocal apparatus and hand respectively. 
 According to this scheme it is possible to speak of motor and sensory 
 centres, but at most there can be only one perceptive centre. A 
 moment's consideration will make this plain to any one. Suppose that 
 the rays of light which are reflected from the surface of an orange fall 
 upon the eye. As long as these rays arouse in the mind a sensation of 
 colour alone, so long is the cortical excitation restricted to the visual 
 centre. But if once a perception of the cause of the colour is formed, 
 then the object is thought of as having a peculiar smell and taste, as 
 being solid and having weight, and as being a certain distance from the 
 eye, which shows that the excitation has extended from the visual 
 centre to the sensory centres of smell and taste, and of the muscular 
 sense of the hand and of the eyeball respectively. The act of perception, 
 therefore, is correlated with the active excitation of one sensory centre — 
 say the visual — and faint excitation of several other sensory centres, and 
 consequently the perceptive centre must be formed by the union of all 
 the sensory centres. The simple relations between things are perceived 
 in the same way, and they also are correlatives of the activity of the one 
 perceptive centre. If the eye be directed from the orange on the table 
 to a book, the new excitation of the perceptive centre gives to the mind 
 the shock of difference, and if it be directed from the one orange to another 
 the sensation of sameness is experienced, although these relations are not 
 thought of apart from the perception of particular objects, until the 
 middle and high levels of thinking are attained. 
 
 And on passing from thinking by percepts to thinking by concepts, 
 and from that to thinking by abstracts, there are no new centres intro- 
 duced, but only a complication upon complication of the one perceptive 
 centre. All that can be said is that the correlative of perceptive 
 thinking is excitation of that portion of the cortex of the brain which is 
 directly connected with the sensory inlets, of conceptive thinking ex- 
 citation of portions of the cortex which are indirectly connected with 
 them, and of abstract thinking excitation of portions which are still more 
 remotely connected with them, It must, however, be remembered that 
 the effective working of the portions of the cortex which are remotely 
 connected with the sensory inlets will, in a great measure, depend upon 
 the integrity of those which are in direct relation with them. 
 
 Let us now attend to the effects of dissolution of this structure. A 
 destructive lesion of the portions of the cortex which are most remotely 
 connected with the sensory inlets would destroy the capacity of the 
 
126 
 
 patient for highly abstract reasoning, and would no doubt inflict con- 
 siderable damage on the language in which abstract thought is em- 
 bodied, but this condition would not be recognised as an aphasia ; and 
 even the intermediate portions of the cortex in which conceptive thought 
 is carried on might be seriously damaged without giving rise to a special 
 speech disorder, inasmuch as any impairment of speech which might be 
 present would only be regarded as a part of a general decay of the 
 reasoning faculties. When, however, the lesion is situated in or near to 
 the sensory inlets, a disorder of language results which is out of all 
 proportion to the general impairment of the reasoning faculties. There 
 are several reasons why the power of thought is comparatively spared 
 under such circumstances. Thinking by means of percepts is correlated 
 with the activity of both hemispheres, and consequently one hemisphere 
 will carry on thought on the low level when the other is injured. And 
 although speech is organised in one hemisphere, a destructive lesion of 
 one of its sensory inlets does not cut oflF the patient altogether from 
 communication with the external world. The portions of the cortex the 
 activity of which is correlated with thinking by concepts and abstracts 
 can be reached in the word-deaf through the eye, and in the word-blind 
 through the ear, and in those who are both word-deaf and word-blind 
 through the nerves of muscular sense and those of the other special senses, 
 so that thinking on the middle and high levels is not completely arrested, 
 Inasmuch as speech is first organised in connection with the sense of 
 hearing, a lesion in or near the auditory cortical centre will cause, as 
 already remarked, a greater disorder of speech than does disease of the 
 sensory centres. Now, suppose that the auditory centre itself is spared, 
 and the lesion is situated in the cortex near to it. The patient can 
 now appreciate a general name uttered in his hearing as an acoustic 
 image, and he can immediately repeat it. The verbal sign has, how- 
 ever, never sounded in his ear without reviving some kind of concept, 
 the two being inseparable. The concept evoked by the verbal sign 
 may be, indeed, and probably is, a very undeveloped and imperfect one, 
 but it sufi&ces for the purposes of identifying the corresponding percept. 
 When, however, the excitation of what remains of the auditory centre, 
 which is caused by the falling of the verbal sign on the ear, fades away, 
 the percept is not capable of reviving in memory either the concept or the 
 general name which embodies it. We see nothing in this except that 
 less resistance is offered by the nervous structures to the passage of 
 nerve currents from the less organised structure representing the con- 
 cept to the more organised one representing the percept, than from the 
 more organised to the less organised, but this is only a particular example 
 of a general law. There is no occasion, therefore, to postulate the 
 
127 
 
 existence of a coixiplicated mechanism of centres and conducting paths 
 for what can be so simply accounted for. 
 
 The diagnosis of the nature of the lesions which give rise to aphasia 
 is most profitably considered in treatises on nervous diseases or on 
 general medicine, and the subject will consequently be passed over here. 
 The prognosis in different cases, and the general treatment of the 
 patient, depending as they both do on the nature of the lesion, will also 
 not be discussed in these pages. In bringing the work to a close we 
 shall content ourselves with making a few remarks on the special treat- 
 ment of aphasia considered as a symptom and without reference to the 
 lesion which has given rise to it. In pure motor aphasia the patient 
 understands what is said in his hearing, or presented to him in written 
 or printed characters, but he is unable to express himself in articulate 
 speech or in writing. So far as writing is concerned the left hand is 
 capable of being educated by a series of exercises, just as the right was 
 educated in childhood. With articulate speech the process of education 
 must be conducted on the same principles as in writing; that is, by 
 imitating the method adopted by the mother, often more or less uncon- 
 sciously, in training her infant to speak. The first lesson consists in 
 getting the patient to utter almost any kind of vocalisation, and the 
 hearing of the sound of his own voice gives him so much pleasure and 
 encouragement that he soon learns to utter and recognise many of the 
 vowel sounds. The patient should then be led to imitate the move- 
 ments of the lips of his instructor, and no great difficulty will be 
 experienced in teaching him how to utter the explosive consonants first, 
 and other consonants subsequently.-^ After some of the vowel sounds 
 and consonants are mastered the patient can then be taught to articulate 
 short monosyllabic words ; and in selecting the words to be taught to 
 the patient care should be taken to use pronouns and monosyllabic verbs, 
 these being the most useful for the construction of short phrases. 
 
 In sensory aphasia, the kind of training which will be found most 
 suitable will depend upon whether the visual or auditory functions are 
 damaged. In word-blindness the patient may learn to read by the aid 
 of tactile and muscular sensations. A case of word-blindness is recorded 
 by Westphal,^ in which the patient re-acquired the power of reading his 
 own writing by passing his finger over each letter as if he were re-writing 
 them, and Magnan taught a patient to read by the device of raised 
 letters.^ The case of a gentleman, recorded by Charcot, has already 
 been mentioned in these pages,* who, after an attack of word-blindness, 
 
 ' See Bristowe (John Syer). "The Physiological and Pathological Relations of the Voice and 
 Speech." London, 1880, p. 114, et seq. 
 
 ^ See Kussmaul (A.) Zienissr/i's Cydopcedia, Vol. XIV., 1878, p. 770. 
 
 3 See Skwortzofi (Nadan). "De la Cecity et de la Surdity des Mots dans I'Aphasie." Paris, 
 1881, Obs. VII., p. 84. Also Ferrier (David). "The Functions of the Brain," Second Edition, 1881 
 P- 456. 4 Page 75. 
 
128 
 
 taught himself to decipher written or printed words with considerable 
 rapidity by moving the index finger of his right hand in the air as if he 
 were writing. 
 
 In word-deafness the education of a new faculty is carried on with 
 considerable difficulty, but such patients soon become very proficient in 
 interpreting gesture language, and systematic education would doubtless 
 greatly increase the range of this power. James Lee (Case 5) was word- 
 deaf, but the power of naming familiar objects, at first altogether lost, 
 had to some slight degree been re-organised in him, and his education 
 might have been carried much further by systematic training. He was 
 so quick in recognising the names of objects when the word was pre- 
 sented to him in writing that had his clothing, and the ordinary objects 
 by which he was surrounded, such as articles of furniture, been distinctly 
 labelled, he would very soon have re-acquired the names of these objects. 
 The patient had jotted down for himself in a pocket-book the names 
 which were most urgently required by him, and a carefully selected list 
 of concrete nouns, alphabetically arranged, would doubtless have been 
 of much service to him. The service which such a list may render to 
 the word-deaf is well illustrated in a man whose case was reported by 
 Graves.^ This man had lost his memory for proper names and sub- 
 stantives in general, with the exception of the first letter of the noun ; 
 but he prepared for himself an alphabetically arranged dictionary of the 
 substantives required in his home intercourse, and whenever it became 
 necessary for him to use a noun he looked it up in his dictionary. When 
 he wished to say " cow " he looked under C, and as long as he kept his eye 
 upon the written name he could pronounce it, but was unable to do so 
 a moment afterwards. While examining James Lee (Case 5) one day an 
 incident occurred which shows that he also was sometimes aided in 
 recalling a name by remembering its first letter. He was asked to name 
 his hand, and, as usual, he looked in the distance as if he were listening 
 intently, but after a time he applied the tip of the index finger of the 
 right hand to the palm of the left, and moved it as if he were writing 
 the capital letter H in a current hand, and he immediately called out 
 " Hand ! that is my hand, the whole of it." " The whole of it " was 
 doubtless meant to imply that the name applied to the hand in contra- 
 distinction to the fingers, which he was frequently asked to name 
 separately. In the combined forms of sensory and motor aphasia the 
 treatment becomes difficult and uncertain, but the education of the 
 impressive must necessarily precede that of the expressive faculty. 
 
 ^ Graves. Dublin Quarterly Journal, Vol. XI., 1851, p. 1, quoted by Kussmaul, Zeimssen's 
 Cyclopedia, Vol. XIV., 1878, p. 758. 
 
 John Heywood, Excelsior Steam Printing and Bookbinding Works, Hulme Hall Eoad, 
 
 Manchester. 
 
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