3 &#C 
 THE GENESIS AND DISSOLUTION 
 
 THETACULTY Or SPEECH 
 
 A CLINICAL AND PSYCHOLOGICAL 
 STUDY OF APHASIA 
 
 JOSEPH COLLINS, M.D. 
 
 Professor of Diseases of the Mind and Nervous System in the New York 
 
 Post-Graduate Medical School; Neurologist to the New York City 
 
 Hospital, to the St. John's Guild Free Hospital for 
 
 Children; and to the Post-Graduate Hospital; 
 
 Attending Physician to the St. 
 
 Mark's Hospital 
 
 Bwaroefc tbe Slvarencia prise of tbc College 
 of pb\>sfcians of pbilafcelpbia, 1897 
 
 Iftevv 
 THE MACMILLAN COMPANY 
 
 LONDON: MACMILLAN \- CO.. LTD. 
 
 1S9S 
 
 All right rexerifd
 
 COPYRIGHT, 1898, 
 
 BY 
 
 JOSEPH COLLINS, M.D.
 
 TO MY TEACHER 
 
 CHARLES L. DANA, M.D. 
 
 AND TO MY FRTKM) 
 
 LIGHTNER WITHER, Ph.D. 
 
 TO WHOM I OWE MY INTELLECTUAL AWAKEMENT 
 THIS LABOR OF A YEAR'S LEISURE IS 
 
 AFFECTIONATELY DEDICATED
 
 PREFATORY NOTE. 
 
 THE MS. of this monograph left the writer's hand in 
 April, 1897. Since that time several important contri- 
 butions have been made to our knowledge of aphasia. The 
 author regrets that time and opportunity have not been 
 granted him to give them the consideration and discussion 
 they merit. Only verbal changes have been made in the 
 text since its completion, but here and there a footnote 
 has been added to call attention to some of the more im- 
 portant facts and striking claims set forth by recent 
 writers. 
 
 47 WEST THIRTY-EIGHTH STREET, New York, Christmas, 1897.
 
 c;- 
 
 CONTENTS. 
 
 CHAPTER I. 
 
 PAGE 
 
 DISORDERS OF INTELLECTUAL EXPRESSION, KNOWN AS APHASIA, . i 
 
 CHAPTER II. 
 HISTORY, ........... 17 
 
 CHAPTER III. 
 AN ANALYSIS OF THE GENESIS AND FUNCTION OF SPEECH, . . 40 
 
 i. General Expressive Reactions ; Mimic Reactions. 2. Articu- 
 
 late Speech. 3. Writing, 4. The Genesis of Percepts. 5. Re- 
 
 marks on Visual Sensation ; Acoustic Sensation, and the Mecha- 
 nism of Articulation. 
 
 CHAPTER IV. 
 CONCEPTION OF APHASIA, ........ 86 
 
 i. Remarks on the Anatomy of the Brain, z. _&Qne.f>f T.gflyuage. 
 
 Site of Revival of Words in Silent Thought. 3. Evidence in 
 Favor of and against the Existence of a Special Graphic Motor 
 Centre. 
 
 CHAPTER V. 
 MOTOR APHASIA, .......... 153 
 
 i Motor Aphasia; General Considerations. 2. Cortical Motor 
 Aphasia ; Articulatory Kinaesthetic Aphasia. 3, Subcortical 
 Motor Aphasia. 
 
 CHAPTER VI. 
 SENSORY APHASIA, . . . . . . . . . . 216 
 
 i. General Considerations 2. Sensory Aphasia: Word Deafness, 
 or Auditor}- Aphasia, and "\Vord Blindness, or Visual Aphasia. 
 3. Subcortical Sensory Aphasia.
 
 via Contents. 
 
 CHAPTER VI.- Continued. 
 
 PAGE 
 SUBCORTICAL SENSORY APHASIA, ....... 2g5 
 
 CHAPTER VII. 
 TOTAL APHASIA, 313 
 
 CHAPTER VIII. 
 DIAGNOSIS OK APHASIA, 324 
 
 CHAPTER IX. 
 ETIOLOGY, ........... 343 
 
 CHAPTER X. 
 MORBID ANATOMY OF APHASIA, ....... 370 
 
 CHAPTER XI. 
 REMARKS ON THE TREATMENT OF APHASIA, ..... 396 
 
 CHAPTER XII. 
 REMARKS ON THE MEDICO-LEGAL ASPECTS OF APHASIA, . . 407 
 
 APPENDIX I. 
 CONDUCTION APHASIA, .. \ ...... 414 
 
 APPENDIX II 
 A CASE OF ARTICULATORY-KIN.KSTHKTIC APHASIA, . . ' . 422
 
 Jlf^M A I 
 
 THE FACULTY OF SPEECH. 
 
 CHAPTER I. 
 
 DISORDERS OF INTELLECTUAL EXPRESSION, KNOWN AS 
 APHASIA. 
 
 Introduction. 
 
 THE possession of the faculty of speech distinguishes 
 the human being from even those animals which stand 
 next to him in biological relationship. Man is in con- 
 sequence inclined to reflect upon its possession, and to 
 speculate concerning its nature and origin. In days when 
 philosophic speculation addressed itself principally to 
 a-priori assumptions of the nature and interrelations of un- 
 analyzed mental phenomena, the function of speech, and 
 that, too, in its fully developed form, was regarded as an 
 essential attribute or inherent faculty of the human mind, 
 manifesting itself with the perfected completeness of a 
 Minerva springing from the brows of Jove. From the 
 vagueness, often the vagaries, of such speculation, there 
 was little relief until attention was directed to the de- 
 velopment of speech in the infant and to its dissolution 
 from disease. Though of recent development, labor in 
 these two fields of observation has extended our knowl- 
 edge of the genesis of speech and thereby given a basis for- 
 the interpretation of its significance. The genetic method
 
 2 The Faculty of Speech 
 
 has rendered relatively a small service compared with the 
 pathological method. In this judgment I am not unmind- 
 ful of the value of many painstaking observations, such as 
 those of Preyer and of Baldwin, that have aided in de- 
 termining the antecedent factors of voluntary articulation 
 and other forms of mental expression ; but it has been 
 chiefly from the study of those disorders of speech in- 
 cluded under the term aphasia, made by many students of 
 human language, physicians, physiologists, and psycholo- 
 gists, that real knowledge of the faculty of speech has 
 been acquired. 
 
 In introducing the term aphasia, Trousseau first ap- 
 plied it to the condition in which there was inability to 
 express thought in words ; in this narrow sense it was 
 used for some time. When the part played by language 
 in the communication of ideas began to be studied, it was 
 not long before it became apparent that this application 
 of the term was wholly inadequate; an:l that a word was 
 needed not only to connote restrictedly an inability to 
 create phonetic symbols, but to include as well the inability 
 to express ideas or to manifest states of consciousness by 
 signs of all sorts, of which speech occupied only the first 
 rank in importance. Disturbance of the power to express 
 a condition of mind manifests itself in speech, writing, 
 pantomime, gesture, drawing, instrumentation, symbols, 
 coloYs, attitudes, etc. To this end the term asymbolia 
 was suggested by Finkenburg. It was improved upon by 
 Kussmaul, who substituted the word asemia, which ad- 
 mitted easy paronymization and the adjective asemic, and 
 which signified literally the meaning that was desired. 
 Nevertheless, the term aphasia, sanctioned by time and
 
 Disorders of Intellectual Expression. 3 
 
 consecrated by usage, has not been supplaced by these 
 technically better constructed terms. On the contrary, 
 aphasia has been given a wider significance, a significance 
 that attaches to it to-day, namely, the total inability or 
 partial disability of an individual to make outward expres- 
 sion of thoughts, feelings, or other states of conscious- 
 ness, whether such disability result from interference 
 with the formation of the mental content or in the emis- 
 sion of it. 
 
 Aphasia has gone through many evolutionary stages. 
 After the first wave of its universal recognition had sub- 
 sided, it came to be looked upon as a symptom with an 
 established seat and an accompaniment of definite lesions. 
 As the literature of the subject grew and the cases with 
 anomalous symptom complexes became more numerous, 
 it was seen that they did not fit in with the simple con- 
 ceptions of those who stood sponsors for its original 
 recognition. This, coupled with the apparent ambition of 
 almost every one who wrote on the subject to adopt a new 
 nomenclature, soon robbed the symptom of its attributed 
 pristine simplicity, and showed it to be in reality one of 
 the most complex subjects with which the physician and 
 psychologist had to deal. 
 
 Former and current nomenclature fostered the obscurity 
 in which the subject of aphasia has been and is still en- 
 shrouded. After aphasia had been recognized as a symp- 
 torn indicative of localized lesion in the brain, the use of 
 the words "ataxic" and "amnesic" aphasia, the one to in- 
 dicate the aphasia of impaired articulation, the other to 
 indicate loss of memory of the word, stood obstinately in 
 the way of ready comprehension of the speech disturb-
 
 4 The Faculty of Speech. 
 
 ances attending given cases. Such classification, how- 
 ever, did not offer material hindrance to those who desired 
 to study the subject of aphasia seriously and scientifically, 
 nor yet did the diagrammatic portrayal which held sway 
 for a long time. 
 
 As time went on, students of the anatomy and physiology 
 of the brain began to unravel the intricacies of its archi- 
 tecture and the mysteries of its functions ; and it became 
 apparent that diagrammatic methods, which necessitated 
 allocating certain functions to definitely and sharply local- 
 ized areas and the connection of these areas, the one with 
 the other, by individual fibres, as well as the representa- 
 tion of such connection in the incoming and outgoing 
 pathways, were inimical to the findings of science. It 
 will be shown in the chapter on the psycho-physiological 
 conception of speech, that the entire speech area, i.e., all 
 that part of the cortex whose functional integrity must be 
 preserved for the production of speech, whether it be con- 
 cerned in the reception of impressions or in the emission 
 of them, is practically a sensory area. Study of the an- 
 atomy of the brain, particularly by the aid of the embryo- 
 logical method, which Flechsig has made so uniquely his 
 own, has thus been of service in interpreting the symp- 
 tomatology of aphasia. 
 
 A glance at the literature register appended to this 
 monograph, 1 and a perusal of the chapter devoted to the 
 history of the subject, will show that delay in establishing 
 a satisfactory explanation of aphasia cannot be attributed 
 
 1 There is appended to the original manuscript of this essay, now in the 
 archives of the College of Physicians of Philadelphia, a bibliography of 
 aphasia which aims to indicate the literature of the subject up to January 
 1st, 1897.
 
 Disorders of Intellectual Expression. 5 
 
 to dearth of reports of cases. In fact, the bare report of a 
 simple case of aphasia is to-day even considered by many 
 writers to be a dignified procedure ; and, although it has 
 been a sort of covenant among medical writers that, as 
 soon as the symptom complex of a disease became uni- 
 versally recognized, nothing was to be gained by putting 
 on record bare reports of cases that offered not the slight- 
 est difficulty in their interpretation and that contributed 
 nothing to the elucidation of the problem to be solved, 
 recalcitrant covenanters are numerous where .aphasia is 
 concerned. To show that this is not an exaggeration, I 
 may refer to an instance of recent date in which the presi- 
 dent of a most learned and dignified European medical 
 society cited a simple case of subcortical motor aphasia, 
 which he referred to as "quite remarkable," as a contribu- 
 tion to " A Discussion on Aphasia" which had been opened 
 by a savant who is known in every medical community and 
 who, in closing the discussion, disposed of the simple case 
 in a few simple words. 
 
 I would not be understood to say that the study of the 
 simplest cases of aphasia is not of value. It is of para- 
 mount importance, and especially study of the morbid 
 anatomy. It is in such cases that the relation between 
 cause and effect is most distinctly traceable. Bare clinical 
 reports have made the literature vast and they have made 
 it a literature that is not of very great value. Compara- 
 tively few cases have been observed in which careful, ac- 
 curate autopsies were made and intelligently reported. 
 This, coupled with the varying nomenclature that has been 
 used by different writers and the different value put upon 
 words, has served to make the subject of aphasia appear
 
 6 Tke Faculty of Speech. 
 
 much more intricate than it really is, and the possession 
 of a knowledge of it more difficult than the phenomena 
 warrant. 
 
 That comparatively few cases carefully observed, prop- 
 erly reported, and accompanied by details of post-mortem 
 findings, go far to unravel many of the apparent mys- 
 teries of aphasia has been shown by the contributions of 
 Wernicke, Dejerine, Vialet, Redlich, Wyllie, Elder, and 
 of many others. 
 
 Aphasia is a term used to indicate any_ disturbance or 
 perversion of intellectual expression. The significance of 
 the term has expanded from the time when its application 
 was used to designate a defect in the verbal expression of 
 an idea, until now it includes all defects or disorders of 
 intellectual expression, whether such disorders be the re- 
 sult of disarrangement or destruction of the receptive or 
 of the emissive components of speech mechanism, or of 
 anything which may be employed as the analogue of 
 speech. Thus /a person who, despite the integrity of the 
 peripheral speech mechanism, is unable to utter his own 
 name, or to give expression to thoughts which arise in the 
 usual way, has aphasia. If he is incapable of making 
 known his thoughts by the employment of some equivalent 
 of spoken words, such as writing of any sort or by expres- 
 sive mimicry or pantomime, he likewise has aphasia. 
 Moreover, a person has aphasia who, with the extra-cere- 
 bral apparatus intact, is unable to understand the lan- 
 guage in whose use he has been trained ; does not even 
 recognize, although he hears, the sounds of the most 
 familiar nature and words to which he has for a lifetime 
 been accustomed, such as his own name ; although he may
 
 Disorders of Intellectual Expression. 7 
 
 be able to read, is unable to write voluntarily or from dic- 
 tation, or to express his thoughts by words, by symbols, 
 or by pantomime. 
 
 Yet even these shortcomings do not comprise all that 
 is meant by aphasia. If a person with normal ocular 
 apparatus looks upon a printed or written page, and the 
 symbols there with which he has previously been entirely 
 familiar convey no meaning to him in the form of approxi- 
 mate thought or idea, such person has aphasia, even 
 though he may understand all that is communicated orally 
 to him, and though he may himself be able to express his 
 thoughts (incompletely and defectively however) by spoken 
 and written words. 
 
 Thus it will be seen that aphasia, in the broad usage 
 of the term, may be the result of conditions by which the 
 patient is unable to part with the expressive equivalent of 
 an idea which has been properly formed. This failure is 
 not confined to words, but includes all modes of expres- 
 sion. Or it may be caused by any conditions that inter- 
 fere with the reception of impulses or stimuli that enter 
 into the genesis of ideas used in the construction of in- 
 ternal or external language. As movement in some form 
 is requisite for the manifestation of any and all expres- 
 sions, defect of this is the condition to which the term 
 motor aphasia is applied, a condition which is equally well 
 expressed by the term aphasia of emission. In the second 
 form of aphasia, the sufferer is unable to adapt receptive 
 communications and make them fit the idea represented 
 by the verbal symbol, auditory or visual ; that is, he has 
 lost the faculty of adapting the complement of the word 
 to his own idea. It matters not whether these words be
 
 8 The Faculty of Speech. 
 
 spoken or written, or communicated by some equivalent, 
 such as music and pantomime. In a general way, this 
 is the aphasia of reception, or sensory aphasia. 
 
 Motor aphasia, or aphasia of emission, which was de- 
 scribed by Broca as aphemia, and by many writers after 
 him as ataxic aphasia, may be divided into as many forms 
 as there are habitual avenues of exteriorizing thoughts. 
 Ideas are usually exteriorized by spoken words, by written 
 words, by symbols, and by pantomime. Thus, we have 
 aphasia of articulation, or logaphasia; and aphasia of 
 writing, agraphia or logagraphia; asymbolia, and asemia. 
 Aphasia of reception, or sensory aphasia, is also made up 
 of a number of constituents, the two great divisions being 
 auditory aphasia or word deafness, and visual aphasia or 
 word blindness. Each form of aphasia admits in turn of 
 further subdivision. The understanding of the subject of 
 aphasia depends upon a comprehension of the develop- 
 ment of the powers of language and thought. It has 
 seemed to me necessary, therefore, to say something of the 
 conditions under which these are developed, before pro- 
 ceeding to the clinical side of aphasia, although it would 
 be manifestly out of place in a monograph of this kind to 
 trace the evolution of speech in detail from the time of 
 the child's birth to the period when the speech faculties 
 have reached their highest development. Before proceed- 
 ing to this psychological consideration, however, it seems 
 to me desirable to present as succinctly as possible a con- 
 sensus of the opinions furnished by physiology, psychology, 
 pathology, and anatomy as to the location, interconnection, 
 and relative importance of the different speech centres ; or, 
 to be more explicit, the areas by virtue of whose integrity
 
 Disorders of Intellectual Expression. 9 
 
 a person is able to adapt sensations coming through the 
 special senses to the idea represented by such sensations, 
 or to adapt and produce words to ideas which are con- 
 ceived by him. After a brief consideration of the history 
 of aphasia I shall take up the subject in the manner in- 
 dicated. I am aware that this mode of attack may not 
 commend itself, at first sight, to the physician who seeks 
 information of the clinical phenomena of aphasia alone, 
 but I hope that it will to him who would understand the 
 genesis of speech, as well as the phenomena of its disso- 
 lution. 
 
 Classification of Aphasia. 
 
 The externalization of thought requires : 
 
 I. () The production of movements through the muscu- 
 lature of the thorax, the larynx, the tongue, and the lips, and 
 the co-ordination of the respiratory, vocal-cord, lingual, 
 and labial movements, (b} Integrity of the musculature in- 
 volved in writing, generally the muscles of the right hand, 
 but sometimes the muscles of the left hand, and very rarely 
 those of any mobile part of the body, such as the foot, and 
 hence positing specialized motor areas in the opposite 
 cerebral hemisphere, (c) Integrity of the musculature 
 of the face, arms, and hands, and to a lesser extent of 
 other muscles of the body which produce pantomimic ex- 
 pression. 
 
 II. The sense organ of hearing, which is capable of 
 being stimulated differentially by sounds that differ in 
 timbre, pitch, intensity, and duration, and possessing a 
 musculature which is reflexly stimulated so as to bring 
 about a certain degree of accommodation or adaptation of
 
 io Tke Faculty of Speech. 
 
 a sense organ to sounds that differ in the above fashion, 
 and a conduction tract leading from the labyrinth to the 
 oblongata, thence to the internal geniculate body, and 
 to the cortex in the anterior region of the first temporal 
 lobe. 
 
 III. A sense organ of vision capable of differential re- 
 sponse to form, to magnitude, and to distance, with a 
 musculature possessing a high degree of accommodative 
 adaptability to such different stimuli, and a conduction 
 tract which passes directly to the external geniculate 
 body, thence to the anterior quadrigeminal body ; a larger 
 bundle, however, passing directly from the external 
 geniculate body into the pulvinar of the thalamus, and 
 thence to adjacent parts, ultimately reaching the cor- 
 tex of the occipital lobe in the vicinity of the calcarine 
 fissure. 
 
 IV. Sense organs or peripheral sensory nerves in 
 muscles, in joints, and in adjacent parts which are cap- 
 able of differential stimulation by different bodily 
 positions and by differently executed muscular move- 
 ments, and afferent tracts leading from these peripheral 
 parts to the cortex, certainly to the cortex of the Rolan- 
 dic region, the so-called somaesthetic area, and possibly 
 to other locations. 
 
 V. Apperception, a term that is used to indicate the 
 combination of central excitations with any incoming sen- 
 sory stimulus before that stimulus arouses such excitation 
 in the cerebral cortex as to bring into consciousness a 
 completed perception. 
 
 I deem it expedient here to say a few words concerning 
 the use of the term apperception, which, although thor-
 
 Disorders of Intellectual Expression. i i 
 
 oughly familiar to psychologists, is by no means so to 
 physicians. Apperception is a factor that enters into all 
 such processes as understanding, interpreting, identifying. 
 It is not an element of consciousness, but a process that 
 must intervene between the presentation of an object to 
 consciousness and the disposition of such presentation. 
 It cannot be maintained that there are locally separable 
 centres of apperception and of sensation. Apperception 
 involves past experiences acting on the cortex, leaving 
 what are called memory traces. Every perception and 
 every enunciation of speech involves the co-ordinate act 
 of incoming sensory impulses and of these cortical mem- 
 ory traces. The adult consciousness never has a simple 
 sensation which could be supposed to be the resultant of 
 the activity of the ganglion cells of a distinctive sensory 
 centre ; but incoming impulses may evoke few or many of 
 these memory traces, in some cases involving activities 
 which represent memory traces that are the resultant of 
 the actions of different sense organs. A study of aphasia 
 teaches us that this central associating or co-ordinating 
 power may become lost, and the patient's apperceptive 
 powers be restricted, in some cases even to a state ap- 
 proximating simple sensation. 
 
 That an auditory impulse, passing up the acoustic nerve 
 through the oblongata, through the temporal lobe, and 
 thence radiating posteriorly, inferiorly, and dorsally, 
 awakes in temporal succession these associated memory 
 traces, cannot be doubted. Consequently at one point we 
 may assume that we have a simple sensation. That point 
 is certainly under normal conditions not higher than the 
 initial auditory receptive cells in the middle portion of
 
 i 2 The Faculty of Speech. 
 
 the superior temporal convolutions. Whether a simple 
 sensation or any consciousness at all is produced by an 
 activity lower down cannot be determined. 
 
 ,A classification of aphasia is of much service in. con- 
 tributing to a ready understanding of the symptom aphasia. 
 I shall endeavor to give a simple, natural classification 
 that shall be in harmony with the interpretation of aphasia 
 that is expounded in the chapter devoted to " Conception 
 of Aphasia." 
 
 Personally, I am convinced that the time has come to 
 make radical departure from the usual classification of 
 aphasia. We should cease the use of such misleading 
 terminology as ataxic aphasia, amnesic aphasia, etc., and 
 discourage the attitude adopted by British writers, who 
 use the term aphasia only for the condition that most 
 writers call motor aphasia, and the term amnesia for sen- 
 sory aphasia. To illustrate how confusing and mislead- 
 ing the nomenclature of the Britishers may be, I cite an 
 instance of very recent occurrence. A Colonial physician 
 read an excellent paper on " Motor and Sensory Aphasia" 
 before the Royal Medical and Chirurgical Society. On 
 rising to discuss it, a member of the society said that he 
 thought the term aphasia was hardly justified ! He would 
 prefer to call the condition amnesia. It must be granted, 
 I think, that a nomenclature of this kind has not sufficient 
 in its favor to warrant us in retaining it. 
 
 I believe that aphasia should be classified as follows : 
 
 i. TRUE APHASIA. Aphasia of apperception. Due to 
 lesion of any constituent of the speech region, the zone of 
 language. It might be subdivided into (a] visual aphasia, 
 due to lesion of the visual areas and centre ; (&) auditory
 
 Disorders of Intellectual Expression. 15 
 
 Associative or Transcortical Apliasia. 
 
 I shall content myself with mere mention of this sub- 
 division, as its symptomatology is in reality a part of sen- 
 sory aphasia. Variation in the clinical picture is in ac- 
 cordance with the location of the lesion between speech 
 areas in the zone of language. The lesion may be : 
 
 1. In the habitual pathway traversed by impulses going 
 from the auditory to the visual area (the patient can hear 
 a name but cannot write it from hearing; cannot write it 
 from dictation; he has paragraphia). 
 
 2. It may be in the habitual pathway of impulses going 
 from the visual area to the auditory area (the patient can 
 see an object, but he cannot call up its name, because this 
 requires the mediation of the auditory area). 
 
 3. A lesion that interrupts the habitual pathway that 
 impulses take when going from the auditory to the seat 
 of phonetic memories in Broca's convolution (the patient 
 can hear, can interpret from hearing, but cannot talk cor- 
 rectly : paraphasia). 
 
 4. The lesion may interrupt the pathway taken by im- 
 pulses going from the visual area to the auditory area (the 
 patient is dyslexic, paragraphic, and slightly paraphasic). 
 
 Thus it will be seen that the two great divisions of 
 aphasia are sensory aphasia and motor aphasia. As 
 I have said previously, many British writers, such as 
 Bastian, use the term amnesia synonymously with sen- 
 sory aphasia, and a greater number of writers use the term 
 aphemia, originally employed by Broca, as the specific 
 term for the motor form of aphasia. 
 
 Both these forms of aphasia are so complex that it is nee-
 
 1 6 The Faculty of Speech. 
 
 essary to have recourse to a further subdivision ; the most 
 satisfactory basis for which will have reference to the seat 
 of the lesion that produces the speech disturbance. Thus 
 we have cortical sensory aphasia when the lesion is of the 
 speech centre itself, and subcortical sensory aphasia when 
 the perversion of the function of speech is due to a lesion 
 of the sensory tracts leading to it. The same subdivision 
 is made of motor aphasia, i.e., cortical motor aphasia, and 
 subcortical motor aphasia. The designations cortical 
 sensory and cortical motor aphasia are often abbreviated 
 to simply sensory aphasia and motor aphasia and the sub- 
 cortical forms to pure sensory aphasia and pure motor 
 aphasia (Dejerine, Mirallie, et <?/.), thus signifying that 
 sensory and motor tracts alone are involved.
 
 CHAPTER II. 
 
 * 
 
 HISTORY. 
 
 THE real history of aphasia dates from 1861. In that 
 year Broca presented an epoch-making communication to 
 the Paris Anatomical Society, which seemed to prove that 
 the morbid anatomy of aphasia was a lesion of the posterior 
 part of the third convolution. 1 Before that time much 
 speculation had been indulged in concerning the seat of 
 the faculty of language and the location of a lesion that 
 would interfere with its production. In the beginning of 
 the second half of the nineteenth century two patients 
 were admitted into the Bicetre Hospital in Paris whose 
 disorders of speech, thanks to the scientific zeal and 
 clinical insight of Broca, surgeon to that institution, have 
 contributed immeasurably to the understanding of speech 
 in both health and disease. 
 
 The first of Broca's cases was an epileptic who had been 
 for twenty years almost completely bereft of expressive 
 speech, word production being limited to " tan, tan." 
 The receptive faculties that contribute to speech were un- 
 impaired, and he was able to indulge in pantomime. As 
 
 1 Broca : " Remarques sur le siege de la faculte du langage articule, 
 suivies d'une observation d'aphemie." Bulletin de la Societe Anatomique, 
 August, 1861, p. 330. " Nouvelle observation d'aphemie produite par une 
 lesion de la moitie posterieure des deuxieme et troisieme circonvolutions 
 frontales. " Bulletin de la Societe Anatomique, November, 1861, p. 398. 
 
 2
 
 1 8 The Faculty of Speech. 
 
 a slowly progressing right hemiplegia developed, intelli- 
 gence waned and sight became dim. After death an ex- 
 amination of the brain revealed a widespread softening in 
 the left hemisphere. The most ancient softened area, the 
 one to which the aphasia was attributed properly, as this 
 symptom had preceded the hemiplegia for many years, 
 was confined to the middle and sylvian side of the 
 frontal lobe. The second case corroborated in detail 
 the conclusions drawn from the first. This patient 
 understood all that was said, and, although articulatory 
 production was reduced to three or four words, still he 
 used these intelligently and discreetly. He was able 
 to reckon, and in a general way intelligence was 
 unimpaired. Autopsy showed a cavity confined to the 
 posterior third of the second and third frontal convolu- 
 tions, a region which soon became and is still known as 
 Broca's area. The report of these two cases and the 
 discussion to which it gave rise attracted widespread 
 attention, and from that time dates the scientific history 
 of aphasia. 
 
 At first many of the most eminent minds in the pro- 
 fession refused to believe that the emissive speech faculty 
 was confined to the left hemisphere ; indeed Broca him- 
 self looked upon the lesion in the left half of the brain in 
 his two cases as merely accidental, and stated his convic- 
 tion that wider experience would show that lesion of the 
 corresponding part of the right hemisphere was as common 
 as of the left. The French surgeon was scientific but 
 not prophetic, for the scores of cases that were soon 
 studied and reported showed that the lesion was almost 
 invariably in the left hemisphere. From consideration of
 
 History, \ 9 
 
 the reported cases and from wider personal experience, 
 Broca was led to offer in explanation of this seeming para- 
 dox of anatomical selection the hypothesis that the great 
 majority of humanity are right-handed and therefore left- 
 brained; that as the capacity for delicate motor dexterous- 
 ness is most developed in the left brain, so are the ex- 
 quisitely co-ordinated movements which subserve speech; 
 an explanation which has formed the basis for other more 
 comprehensive hypotheses. Indeed Voisin 1 had made an 
 observation which seemed to demand such a conclusion ; 
 a patient with left-sided hemiplegia had no difficulty in 
 interpreting language or in using language. Later he 
 developed a right-sided hemiplegia and complete aphasia. 
 It will be seen in further perusal of this monograph that 
 the aphasia which Broca described and which he designated 
 by the term aphemia, a word hostilely received by purists 
 in etymology, as literally it means " infamy," is but a 
 form or variety of the speech disturbances now included 
 under that heading. 
 
 Broca's communication opened a new era in the under- 
 standing of speech. It was, however, no less epochal 
 than that which marks the direction of Wernicke's master 
 mind toward a solution of the problems of aphasia in the 
 early years of the seventh decade of this century. With- 
 out taking upon myself the invidious task of selecting the 
 name of the one who, next to Broca, has made the most 
 material contribution to the subject of aphasia, it may be 
 said that Broca and Wernicke should be accorded equal 
 parental rights in the interpretation of the complexity of 
 
 1 A. Voisin : " Observation de perte de la parole." Bulletin de 1'Acade- 
 mie de Medecine, p. 1,241, 1862.
 
 2O The Faculty of Speech. 
 
 symptoms included under the term aphasia to-day. Speech 
 disturbances had been recognized clinically and studied 
 even so far back as the time of ancient Grecian writers, 
 who used the term anandia to signify loss of speech; but 
 the first records of serious attempts to study the faculty 
 of speech from the viewpoint of its pathology were 
 made by Bouillaud in France in 1825, by Jackson in 
 this country in 1829, by Dax in 1836, and by Lordat 
 in 1843. The latter designated the disturbance of 
 speech production by the word alalia. Many years 
 before this the brilliant, misguided Gall had located 
 the, faculty of speech in the supra-orbital convolutions. 
 Gall died in 1828, and there can be no doubt that his 
 teachings, which, it should never be forgotten, were 
 based in part upon carefully made dissections of the 
 brain, had much to do with arousing the interest mani- 
 fested in these questions at that time and immediately 
 following. 
 
 Bouillaud advanced the opinion that the anterior ex- 
 tremity of the frontal lobes, despite the contentions of 
 Gall, was the seat of the faculty of speech. He was sup- 
 ported in this contention by Pinel, Grandchamp, and Bel- 
 homme, the latter of whom presented to L' Academic 
 Royale de Medecine a memoir on the " Localization of 
 Speech in the Anterior Lobes of the Brain," in which by 
 a reference to ten cases he endeavored to prove that the 
 cerebral organ which regulates speech is seated in the 
 anterior lobes of the brain. 
 
 Early in the century, Lordat ' seemed to have an 
 
 1 Lordat : Revue Periodique de la Societe de Paris, December, 1820, p. 
 317.
 
 History. 2 1 
 
 astonishingly accurate conception of aphasic speech dis- 
 turbances as they are understood to-day, for he distin- 
 guished between a loss of memory of words, which he 
 designated "amnesic verbale," and inability to pronounce 
 or produce words which are the result of thought, a condi- 
 tion called by him "asynergie verbale." He also recog- 
 nized the speech defect which is now called paraphasia, 
 and he applied to it the term " paramnesie verbale." The 
 Germans were in the field early and made several contri- 
 butions to the study of aphasia, among them being those 
 of Bergmann in 1849, Hasbach in 1852, and Nasse in 
 1853, but none of these was more than a report of cases 
 analyzed and criticised. 
 
 From English observers no contributions of signal im- 
 portance, supported by convincing anatomical proof, were 
 made prior to the publication of Broca's report. Naturally 
 such astute clinicians as Prichard, Crichton, Winslow, 
 and Watson did not allow the striking and withal not un- 
 common symptom to escape their notice and remark, 
 but their contributions did not materially advance the 
 knowledge of the subject. In our own country the ob- 
 servations of Jackson have already been mentioned, and 
 to them must be added those of Rush, 1 Hun, a Bigelow, 
 and others. 
 
 The history of aphasia, dating from the time of Broca's\ 
 first contributions made in 1861 and in 1865, up to the 
 present day, if written in detail, now at the end of the 
 century, would be more replete with references than the 
 history of any other symptom or disease of the nervous 
 
 1 Rush : " Practice of Physic," Philadelphia, 1846. 
 '* American Journal of Insanity, 1851.
 
 22 The Faculty of Speech* 
 
 system. Mention of important contributions alone covers 
 many pages, while to cite the authors who simply re- 
 ported cases corroborating or denying the anatomical 
 seat of aphasia as stated by Broca, and confirmatory 
 of certain forms or types of the disease, would consume 
 an enormous amount of space and be without particular 
 value except to the bibliographer. In the text, I shall 
 therefore mention only a few authors of the different 
 countries who have made such contributions to the 
 subject as are destined to last as long as the science of 
 medicine. To the storehouses of information erected by 
 these writers every one who essays to write on aphasia 
 must go. 
 
 The most important early American contribution made 
 to the subject of aphasia was that of Seguin, 1 who in 1867 
 published an elaborate essay detailing a number of cases 
 personally observed and adding a critical review of a large 
 number gathered from the literature. In this essay he 
 showed that out of a total of two hundred and seventy 
 cases of hemiplegia with aphasia, two hundred and forty- 
 three were paralyzed on the right side of the body. 
 This corresponds practically to the ratio of right-handed 
 to left-handed persons. Several years later Amidon' 2 
 made an important contribution to the pathological 
 anatomy of sensory aphasia, which included a critical 
 analysis of several typical cases reported by European 
 writers. 
 
 1 Seguin : "A Statement of the Aphasia Question, together with a Report 
 of Fifty Cases." Quarterly Journal of Psychological Medicine, New York, 
 1868, vol. ii., pp. 74-179. 
 
 2 Amidon : " On the Pathological Anatomy of Sensory Aphasia." New 
 York Medical Journal, January 3151, 1885, vol. xli., pp. 113, 181.
 
 History. 23 
 
 In England the labors of Russell, 1 Gairdner, 2 Bastian, 3 
 Broadbent, 4 Ogle, 5 and Bateman 6 contributed largely to 
 our present knowledge ; in fact the names of these phy- 
 sicians are landmarks in the history of aphasia. Ogle 
 coined the word agraphia, although the condition was de- 
 scribed first by Marce. Gairdner insisted that a patient 
 with motor aphasia writes at least as badly as he speaks, 
 and that the patient wholly unable to speak is also inca- 
 pable of writing. Bastian, to whose interpretation of 
 clinical phenomena psychology and neurology owe so 
 much, was the first to recognize the relationship of defec- 
 tive auditory perception to speech production. He intro- 
 duced the word " jargonaphasia" to indicate the conglom- 
 eration of syllables, words, and phrases strung together 
 without order or meaning which is the striking feature of 
 certain forms of sensory aphasia. Broadbent was the first 
 to point out, in 1872, the occurrence of the condition which 
 is now known as word blindness, and although very few of 
 the hypotheses advanced by this writer are accepted to-day, 
 I believe, by scarcely an individual aside from a few per- 
 sonal adherents, his writings have been of great service in 
 furthering an understanding of some aspects of aphasia. 
 
 1 James Russell : British Medical Journal, 1864. 
 
 2 Gairdner : " The Function of Articulate Speech, with Observations on 
 Aphasia," Glasgow, 1866. 
 
 3 Bastian : St. George's Hospital Reports, vol. ii., p. 95; British and 
 Foreign Medico-Chirurgical Review, vol. xliii. , 1869, pp. 209, 236, 470, 
 492. " The Physiology of Thinking." Fortnightly Review, 1869. 
 
 4 Broadbent : " Cerebral Mechanism of Thought and Speech. " Medico- 
 Chirurgical Transactions, vol. iv. , 1872. 
 
 5 Ogle: "Aphasia and Agraphia." St. George's Hospital Reports, 
 vol. ii., pp. 83-121. Medico-Chirurgical Transactions, vol. liv., 1871. 
 
 6 Bateman : "Aphasia or Loss of Speech in Cerebral Disease." Lon- 
 don, 1868 ; Revised Edition, London, 1890.
 
 24 The Faculty of Speech. 
 
 In Germany the work of Wernicke, 1 Grashey, 3 Licht- 
 heim, 3 and Freud 4 has done much to extend the concep- 
 tion of the term aphasia and to give rational explanations 
 of some of its subdivisions. Wernicke particularly, in 
 1874, furnished a basis for the conception of sensory 
 aphasia. He pointed out that many cases recorded as 
 anomalous examples of aphasia could be explained on the 
 ground that there are several varieties, and that the most 
 typical aphasia can occur with lesion of other parts of the 
 brain than Broca's convolution. He showed clearly that 
 lesion of the first temporal gyrus produced a symptom 
 complex constituting what he called sensory aphasia, and 
 he portrayed the individual on whose ears the words and 
 sentences of his mother language fall like those of a wholly 
 unknown tongue, and to whose eyes the letters that he 
 formerly read with an ease akin to instinct are as hie- 
 roglyphs. In short, he interpreted the phenomena of 
 word deafness and word blindness and made them readily 
 comprehensible by parallelizing them with the phenomena 
 
 'Wernicke: " Der aphasische Symptomcomplex," Breslau, 1874. 
 " Aphasie und Geisteskrankheit." Deutsche medicinische Wochenschrift, 
 p. 445, 1890. " Lehrbuch der Gehirnkrankheiten," Berlin, 1881. " Grund- 
 riss der Psychiatric in klinischen Vorlesungen," 1894. " Aphasie und Anar- 
 thrie." Deutsche medicinische Wochenschrift, p. 163, 1882. " Ueber die 
 motorische Sprachbahn und das Verhaltniss der Aphasie mit Anarthrie." 
 Fortschritte der Medicin, No. I, pp. I, 405, 1884. " Replik auf Dr. Kuss- 
 maul's Entgegnung die Aphasie betreffend." Fortschritte der Medicin, 
 Berlin, 1883, pp. 315, 316. "Die neueren Arbeiten iiber Aphasie." Fort- 
 schritte der Medicin, ii., 1885, p. 24. 
 
 Wernicke and Friedlander : Fortschritte der Medicin, Berlin, 1883, 
 No. 6, p. 177. 
 
 2 Grashey : "Ueber Aphasie." Archiv fiir Psychiatric und Xerven- 
 heilkunde, vol. xvi., 1885. 
 
 3 Lichtheim : "Aphasia," Brain, January, 1885. " Ueber Aphasie." 
 Deutsches Archiv fur klinische Medecin, 1884-85, p. 204. 
 
 4 Freud : " Zur Auffassung der Aphasien," Leipzig, 1891.
 
 History. 25 
 
 of motor aphasia, which by this time had been put on a 
 firm anatomical basis. Another very important service 
 which this writer rendered was to give proper application 
 to the term sensory aphasia and to submerge the term 
 amnesic aphasia, which for a time had found its way into 
 literature. 
 
 Aside from Broca and Wernicke, the three great names 
 that stand out above those of all the others who early 
 increased our knowledge of aphasia are Trousseau 1 in 
 France, Hughlings Jackson 3 in England, and Kussmaul 3 
 in Germany, the latter having written what is to-day the 
 soundest and fullest treatise on the subject of aphasia in 
 any language. 
 
 In his exhaustive and philosophical consideration of 
 aphasia, published in 1877, Kussmaul introduced the 
 terms " word deafness" and " word blindness" to indicate 
 the conditions described by Wernicke, and although the 
 latter and others hesitated to accept some of the conten- 
 
 1 Trousseau : " Discours sur 1'Aphasie." Bull. Acad. Med., February 
 25th, 1861 ; Clin. Med. de 1'Hotel Dieu, vol. ii., 1865, p. 571 ; Bull. 
 Acad. Med., June, 1865. " Lecons cliniques sur 1'aphasie. " Gazette des 
 Hopitaux, February and March, 1864. " Paralysie progressive de la langue, 
 des levres et du voile du palais." Gazette des Hopitaux, January and Feb- 
 ruary, 1863. 
 
 2 Jackson (Hughlings): "Loss of Speech, Its Association with Valvu- 
 lar Diseases of the Heart and with Hemiplegia of the Right Side." Clini- 
 cal Lecture and Report of the London Hospital, Lancet, ii., 1864, p. 
 604. "On Affection of Speech from Diseases of the Brain." Brain, 
 1879-80, t. 2, pp. 203-323. "On Aphasia with Left Hemiplegia." 
 Lancet, 1880, p. 637. " On Slight and Severe Epileptic Attacks with 
 Auditory Warnings ; Slight Paroxysms with Deafness and the Special Im- 
 perception called Word-Blindness ; Spectral (Auditory) Words ; Inability 
 to Speak and to Write." Lancet, July 28th, 1894. 
 
 3 Kussmaul : Article " Aphasia (Disturbances of Speech). " Ziemssen's 
 Cyclopedia, vol. xii., Wm. Wood & Co. " Entgegnung die Aphasie be- 
 treffend." Fortschritte der Medicin, Berlin, 1883, pp. 309-313.
 
 26 The Faculty of Speech. 
 
 tions of this writer, particularly those bearing on the in- 
 dividuality of word blindness and its relation to defective 
 speech production, the experience of innumerable workers 
 hi the field of aphasia since that time has supported Kuss- 
 maul. 
 
 In 1 88 1, Exner, 1 of Vienna, was led, from an analysis 
 of the disturbances of intellectual expression attending 
 cases of aphasia, to allocate a separate area of the brain in 
 which are stored the motor memories of writing, destruc- 
 tion of which caused agraphia. This centre he placed at 
 the base of the left second frontal convolution, and, 
 although to-day no one gives credence to his method of 
 investigation, his conclusions have been a point around 
 which an active war has been waged from that day to 
 this. 
 
 Although not so early in the field as others, the Italians 
 have furnished a number of contributions of the greatest 
 value. Of these mention must be made of the works of 
 Seppilli 2 and of Banti, 3 both of a high standard of excel- 
 lence. 
 
 In France the numerous and worthy contributions of 
 Trousseau were ably followed up by those of Charcot, who 
 in his inimitable way suggested an explanation of aphasia 
 based apparently on a psychological analysis of speech, 
 contrasting the acquisition of speech with the phenomena 
 of dissociation occurring in disease. For a long time this 
 theory seemed to clarify the atmosphere of any haziness 
 
 1 Exner : " Untersuchungen iiber die Localisation der Functionen in 
 der Grosshirnrinde des Menschen," Wien, 1881. 
 
 9 Seppilli : " La sordita verbale od afasia sensoriale." Riv. Sperim. di 
 Frenatr. , Reggio-Emilia, 1884, pp. 94-95. 
 
 3 Banti : " Afasia e sue forme." Sperimentale, Firenze, 1886.
 
 History. 2 7 
 
 surrounding the interpretation of aphasia, while at the 
 same time it furthered the claim of aphasia to accurate 
 anatomical localization. The contributions of Charcot ' 
 had a capable, lucid exponent and commentator in his 
 pupil, Bernard. 2 
 
 It is the first duty of the historian to be truthful and 
 exact in the statement of facts, and that he may be worthy 
 of his task candor compels the historian of aphasia to state 
 without equivocation that Charcot did more to prevent the 
 true interpretation of aphasia as it is understood to-day 
 than did any other writer who essayed to illumine the sub- 
 ject. The scientific position of this deservedly honored 
 and renowned physician was such an exalted one and his 
 utterances were so generally considered ex cathedra, not 
 alone by his disciples but by his contemporaries, that 
 statements from his pen and from his lips were accepted 
 as truth before they had received the corroboration and 
 substantiation of ethers, as the true scientific spirit de- 
 mands. Far be it from me to detract from the claims to 
 immortality of one of the greatest clinicians of the nine- 
 
 1 Charcot : "Cecite verbale. Lejons sur les Maladies du Systeme 
 Nerveux," t. iii., 1887, p. 152. "Observation d'hemiplegie droite avec 
 aphemie et avec integrite des lobes anterieurs et des circon volutions fron- 
 tales." Gaz. Hebd., 17 Juillet, 1863. "Des varietes de 1'aphasie. 
 Cecite verbale." Progres Medical, 1883, pp. 23, 27, 441, 521, 859. " Des 
 varietes de 1'aphasie. Aphasie motrice." Journal de la Sante Publique, 
 1883. " Cas rare de cecite verbale pris a la clinique de Charcot." Wiener 
 medizinische Presse, 1883, p. 834. "Cecite verbale." Gazette Medicale, 
 Paris, 21 Juillet, 1883, No. 29, p. 339. " De Taphasie." Progres Medi- 
 cal, 4 Fevrier, 1888, p. 81. " Le5ons sur les localisations dans les maladies 
 du cerveau recueillis par Bourneville. " Progres Medical, 1876. 
 
 Charcot and Dutil : " Agraphie motrice suivie d'autopsie." Societe 
 de Biologic, Juillet, 1893, p. 129. 
 
 * Bernard . ' ' De 1'aphasie et ses diverses formes. ' ' These Doctoral, 
 Paris, 1885.
 
 28 The Facility of SpeccJi. 
 
 teenth century, but his excursion afield into the subject of 
 aphasia has been a perpetual obstacle to the dissemination 
 of the view of aphasia that passes muster to-day, and that 
 has been endeavoring to get a foothold since Wernicke 
 and Bastian first began their interpretations of aphasic 
 speech disturbances. 
 
 Charcot framed a hypothesis for the explanation of 
 speech, using the word bell, the object bell, the sound 
 bell, the touch bell, to illustrate the various avenues by 
 which sensory impressions arise in the consciousness 
 and to show that the memories of such impressions were 
 stored up in individual centres. The speech centres he 
 taught were in pairs, two for reception of information, 
 the auditory centre and the visual centre, and two for 
 emission of impulses representing ideas, the articulate 
 speech centre and the graphic-motor centre. These 
 centres Charcot asserted, with great assiduity and aplomb, 
 were possessed of striking functional autonomy which 
 they had phylogenetically and as the result of education. 
 A person inherited, or was born with, a tendency to form 
 concepts mainly by arousing them through the visual, the 
 auditory, or the articulatory images, and was destined 
 therefore to be in thought and speech a visuel, an auditif, 
 a motenr, and this predisposition was greatly advanced by 
 education. Charcot adopted early the conclusions of 
 Exner concerning the existence of a separate graphic-mo- 
 tor centre, although the evidence which the latter adduced 
 in support of his claims was about as unscientific as 
 anything could be. Nevertheless Charcot immediately 
 proceeded to speak of the graphic-motor centre as if its 
 existence and individuality were beyond a doubt.
 
 History. 29 
 
 The interdependence of the four centres, and the neces- 
 sity for their harmonious co-operation, in order that intel- 
 lectual expression be complete, was recognized, but the 
 autonomy of each centre was contended for unswervingly. 
 Charcot claimed that from the standpoint of development 
 the centres were independent and separate, and that meth- 
 ods of education as well as natural proclivities tended to 
 the development of one of the centres out of proportion 
 to the others. In this way, those who receive the 
 wealth of their sensory impressions through the hearing 
 apparatus, are preponderatingly auditives ; those whose 
 education is most aided by their organs of vision, visnels; 
 and so on. It was taught, however, that by means of 
 education all of these centres might be developed more 
 harmoniously than they are usually. The conception of 
 the school of Charcot is a simpler one than that of the 
 Germans, and for this reason it has been of service ; but 
 to the latter must be conceded an ability to unravel the 
 intricacies of the complicated forms of aphasia in which 
 the former fails. 
 
 \Yhile Charcot's views were being adopted the reign of 
 diagrams began, an epoch which seems to us to-day to 
 have been attended principally by the construction of 
 schemata by which could be explained theoretically the 
 different forms of aphasia that might occur from interrup- 
 tion in the conductive, receptive, and emissive parts of the 
 various speech centres. To an unprejudiced observer at 
 the time of the present writing, the activity of this period 
 seems to have been directed toward constructing a diagram 
 that would fit all possible forms of aphasia, the builders of 
 the diagrams leaving it for a later task, and for others, to
 
 30 The Faculty of SpeecJi. 
 
 find cases that would fit the theories. The names that 
 are particularly associated with this period are Wernicke, 
 Lichtheim, Kahler, and Pick. 
 
 Lichtheim, 1 for enample, drew a simple triangle, the an- 
 gles of which represented the three speech centres, audi- 
 tory, visual, and kinaesthetic ; and the lines connecting 
 them, the avenues over which stimuli must travel in order 
 to produce perfect speech. In this way he showed that 
 no less than fourteen different areas might be the seat of 
 a lesion producing aphasia. Depending upon the primary 
 seat of destruction and the segment of the speech pathway 
 that is interrupted, the aphasia that results will have indi- 
 vidual and diagnostic characteristics. Construction of 
 such diagrams and speculation as to the form of aphasia 
 that might result soon led to the necessity of positing a 
 central arrangement for the interpretation of the various 
 stimuli received through the different avenues of informa- 
 tion. To this centre the name ideational centre was 
 given. The existence of some such place of central re- 
 ception, interpretation, and dissemination was absolutely 
 necessary when attempts were made to subject the speech 
 defects constituting aphasia to psychological analysis, and 
 although no anatomical proof of the existence of such a 
 centre could be furnished, nor from the conception of the 
 very nature of the centre could it be allocated to any defi- 
 nite area in the brain, yet the reality of such an association 
 area is universally conceded. 
 
 Because of this recognition, and as a result of processes 
 of reasoning analogous to that which led to the establish- 
 
 1 Lichtheim : "Aphasia." Brain, January, 1885. " Ueber Aphasie. " 
 Deutsches Archiv fur klinische Medicin, Leipzig, 1884-85, pp. 204-268.
 
 History. 3 1 
 
 ment of an ideational centre, grew the conception of a pro- 
 positionizing centre on the motor side of the brain and of 
 a naming centre on the sensory side, by Broadbent. 1 The 
 latter has contended unswervingly for the reality and 
 the existence of these centres, but the only convert 
 to his views whose opinion is of great importance is 
 Mills. 2 
 
 This subject is referred to here only casually, as it 
 will be taken up in detail and criticised in another 
 chapter. 
 
 In 1 88 1 appeared an essay, " Word Blindness and Word 
 Deafness," from the pen of Mile. Nadine Skwortzoff, 
 which included an analysis of many cases of sensory 
 aphasia, and which portrayed particularly the teachings of 
 Magnan. Three years later this same side of the subject, 
 sensory aphasia, was handled in a fashion very creditable 
 to the author, Seppilli. 3 In 1886 Ballet 4 contributed a 
 very thoughtful and serviceable article on " Internal Lan- 
 guage and the Various Forms of Aphasia," and in the 
 following year Ross published a series of papers in the 
 Medical Chronicle on "Aphasia" which are to-day among 
 the most lucid and trustworthy expositions of the subject 
 
 1 Broadbent : " Cerebral Mechanism of Speech and Thought." Med.- 
 Chirurg. Transactions, vol. iv., 1872. "Case of Amnesia with Post- 
 Mortem Examination." Lancet, March 2d, 1878, p. 312. 
 
 'Mills: " On the Localization of the Auditory Centre." Brain, 1891. 
 " Disorder of Pantomime occurring among Aphasics." Philadelphia 
 Hospital Reports, 1893, vol. ii., p. 142. 
 
 Mills and McDonnell : "The Naming-Centre." Journal of Nervous 
 and Mental Disease, vol. xx. , 1895. 
 
 3 Seppilli : La sordita verbale od afasia sensoriale. " Riv. Sperim. di 
 Frenatr., p. 94, 1884. 
 
 4 Ballet : " Le langage interieur et les diverses formes de 1'aphasie." 
 Th. Agreg., Paris, 1886.
 
 32 The Faculty of Speech. 
 
 in the English language. In these articles Ross strove 
 to show, and succeeded I believe, that the contentions of 
 Broadbent concerning a propositionizing centre on the 
 motor side of language and a naming centre on the sen- 
 sory side were erroneous. 
 
 After the claims for the separate localization of graphic- 
 motor images had become more universally urged, dia- 
 grams framed to explain the symptoms of aphasia took 
 on the shape of a parallelogram, each angle representing 
 the seat of one of the allocated functions, the auditory, 
 visual, motor, and graphic-motor, but which had the merit 
 of distinguishing between the kinaesthetic and the emis- 
 sive-motor sides of speech. The names of some of those 
 who made special study of agraphia are Charcot, Pitres, 1 
 Wernicke, Lichtheim, and Grasset. 2 
 
 All this time there had been accumulating evidence in 
 the shape of apparently anomalous cases to show that the 
 conception of aphasia as taught by Charcot and his school 
 was largely erroneous, and the labors of Dejerine and of 
 his pupils, of Serieux, and of others to be hereinafter men- 
 tioned, led to the overthrow of the reign of autonomous 
 speech centres. 
 
 1 Pitres : " L'aphasie chez les polyglottes. " Revue de Medecine, 
 November, 1895. Congres Med. Interne, Lyon, 1894; Des Aphasies. 
 " Agraphie motrice pure." Revue de Medecine, Paris, 1884, pp. 855- 
 873. " Recherches sur les lesions du centre ovale."- These de Paris, 
 1877. "Localisations cerebrates. " Gaz. Med., 1876, p. 474. 
 " Aphasie et he'miplegie. " Societe Anatomique, 1875, p. 783. 
 "Rapport sur les aphasies." Journal de Medecine de Bordeaux, 1894, 
 xxiv. , 469-481. Gazette Hebdomadaire de Medecine, Paris, 1894, v., 
 1,365-1,370. 
 
 2 Grasset : " Localisation dans mal cerebral." Montpellier Med., t. 
 xl. etxli., 1878. " Cecite et surdite verbales." Montpellier Med., 1884, 
 pp. 29-50. " Des diverses varietes cliniques d'aphasie." Nouveau Mont- 
 pellier Med., T5th, 22d, 2gth February, 1896.
 
 History. 33 
 
 The contributions of Dejerine' bearing on the subject 
 of aphasia deserve special mention. As early as 1879 ne 
 made an autopsy on a patient who during life had such 
 symptoms that the diagnosis of subcortical motor aphasia 
 was made, and the autopsy fully corroborated it. This 
 contribution was one of the first to show the necessity of 
 differentiating cortical and subcortical aphasia, although 
 perhaps to Pitres more than to any other individual writer is 
 due our knowledge of subcortical motor aphasia, to which 
 he turned his attention as early as 1877. The really im- 
 portant contributions of Dejerine to the subject of aphasia 
 are embodied in a few short communications to the Societe 
 
 1 Dejerine : " Aphasie et cecite des mots." Progres Medical, p. 629 ; 
 Bull, de la Societe Biologic, Juin, iSSo. -"Aphasie et he'miplegie droite. 
 Disparition de 1'aphasie au bout de neuf mois. Lesion du faisceau pediculo- 
 frontal infe'rieur gauche, du moyau lenticulaire et de la partie anterieure de 
 la capsule interne." Societe Anatomique, 1879, p. 16. " De 1'aphasie et 
 de ses differentes formes ; e't'ides de semiotique et de physiologic patholo- 
 gique." Semaine Medicale, Paris 1884, second series, iv. , 421-449. 
 " Contribution a 1'etude anatomo-pathologique et clinique des differentes vari- 
 ete's de cecite verbale." Me'moiresde la Societe Biologic, 1892, p. 61. " Sur 
 un cas d'aphasie sensorielle (cecite et surdite verbales), suivi d'autopsie." 
 Societe Biologic, 1891, pp. 167-173. "Sur un cas de cecite verbale avec 
 agraphie." Autopsie. Societe Biologic, 1891, pp. 197-201. " De 1'agra- 
 phie." Lecon clinique. Annales de Me'decine, 1891. "Contribution a 
 1'etude des troubles de 1'e'criture chez les aphasiques." Societe Biologic Me- 
 moires, 1891, p. 97-113. "Aphasie motrice sous-corticale et localisation 
 cerebrale des centres larynges (muscles phonateurs)." Societe Biologic, 
 1891, pp. 155-162. "Etude sur 1'aphasie dans les lesions de 1'insula de 
 Reil." Rev. Med., 1885, pp. 174-191. " L'aphasie et ses formes." 
 Semaine Med., 1884, Xos. 44et47. " Remarques apropos de la communica- 
 tion de MM. Charcot et Dutil." Societe Biologic, 1893, p. 200. "Aphasie 
 sensorielle." Bulletin Me'dical, March 2oth, 1895. " Remarques a propos 
 de la communication de M. Mirallie." Societe Biologic, March 3Oth, 1895. 
 
 Dejerine and Mirallie: "La lecture mentale chez les aphasiques 
 moteurs corticaux." Societe Biologic, July 6th, 1895. 
 
 Dejerine et Vialet : "Contribution a 1'etude de la localisation anato- 
 miquedela cecite verbale pure." Societe Biologic, 29 Juillet, 1893, p. 793. 
 " Autopsie de cecite corticale." Societe Biologic, 9 Decembre, 1893. 
 
 3
 
 34 The Faculty of Speech. 
 
 de Biologic in the years 1891-95. In these he estab- 
 lished the dependence of sensory agraphia upon loss of 
 visual memories in the angular gyrus, which causes alter- 
 ation of internal language due to loss of visual images, 
 associated with word blindness. He combated success- 
 fully the existence of a separate centre for the registra- 
 tion and storage of graphic images. Moreover, without 
 directly polemicizing against the teachings of Charcot 
 concerning the autonomy of the various centres in which 
 are stored the different memory images, his contributions 
 were of the greatest worth in tending to offset these 
 views. 
 
 Dejerine also did much to establish clearly the distinc- 
 tion between word-blindness due to loss of visual memories 
 in the angular gyrus (which is always associated with dis- 
 turbance of internal language, agraphia, and paraphasia, 
 and never with hemianopsia if the lesion is strictly con- 
 fined) and word blindness due to lesion between the higher 
 visual centres and the primary or true visual area in the 
 occipital lobes. His contentions were in accord with the 
 pathological findings of Henschen and the anatomico- 
 pathological and clinical claims of Seguin, and were of 
 such unique and convincing nature that there has been 
 little hesitation in accepting them. Dejerine had in a 
 pupil, Vialet, one fully worthy of his master. The contri- 
 bution of this brilliant young physician, entitled " The 
 Cerebral Centres of Vision and the Intercerebral Visual 
 Nervous Apparatus," published in 1893, will serve to 
 perpetuate his name. 
 
 The findings and interpretations of Dejerine were 
 corroborated by the cases carefully observed clinically
 
 History. 35 
 
 and fully reported anatomically by Serieux 1 and by 
 Berkhan. 2 
 
 In 1893 and 1894 Wyllie's comprehensive lectures on 
 the disturbances of speech appeared. In these a review 
 of the status of speech disturbances was given, and in the 
 chapters on aphasia particular attention devoted to the 
 separation of the forms of motor aphasia and to an attempt 
 at localizing psycho-motor images and the area in which 
 such are stored. Wyllie's treatise 3 compels admiration be- 
 cause of the evidence of industry and perspicaciousness on 
 every page. But all in all, the chapters on aphasia are not 
 quite so critical as the period and the accessible material 
 would seem to justify. Reference to one chapter may 
 suffice to show this. Although he is duly appreciative of 
 the value of Dejerine's contributions, and apparently up- 
 holds his contentions, he nevertheless proceeds, in a half- 
 hearted way, to indite a chapter on graphic-motor aphasia as 
 an individual condition. But even the believer in such a 
 centre must be disappointed in reading it, for the author 
 does not make so strong a presentation as could be made 
 from the material at hand. In the following year, Freund, 4 
 of Breslau, published a short monograph, the thesis of which 
 was that the conception of so-called subcortical sensory 
 aphasia is entirely too narrow and limited. He furnishes 
 
 'Serieux: " Aphasie ; cecite verbale, agraphie, he'miplegie gauche. " 
 Societe Anatomique, 1891, p. 258. " Sur un cas d'agraphie sensorielle avec 
 autopsie." Memoiresde la Societe Biologic, 1891, p. 195. " Cas de cecite 
 verhale avec autopsie." Societe Biologic, 16 Janvier, 1892. " Cas de sur- 
 dite verbale pure." Rev. Med., 1893, xiii., pp. 733-750. 
 
 2 Berkhan : " Ein Fall von subcorticaler Alexie." Archiv fur Psychia- 
 tric, Bd. xxiii., 1892, H. 2, S. 92. 
 
 3 \Yyllie : " Disorders of Speech," Edinburgh, 1894. 
 
 4 Freund : " Labyrinthtaubheit und Sprachtaubheit," Wiesbaden, 
 1895.
 
 36 The Facility of Speech. 
 
 clinical observations of his own and analyzes others from 
 the literature (one of which is strangely enough a case 
 that Wernicke utilized originally to substantiate the oc- 
 currence of this form of aphasia) to show that the symp- 
 tom complex as originally described by Wernicke must 
 be enlarged to include labyrinthine disease, and perhaps 
 other forms of affections of the peripheral auditory appa- 
 ratus. He supports his contentions by citations from 
 Freud, from Pick, from Adler, from Bleuler, and from 
 other writers. 
 
 In the same year Redlich 1 gave a most detailed re- 
 port, clinical and pathological, of a case of pure word- 
 blindness, which is a model of its kind and which de- 
 serves to be mentioned as an example to be followed in 
 making communications on this subject. In 1896 Mi- 
 rallie," a pupil of Dejerine, reviewed his teacher's work, 
 made an analysis of the cases of sensory aphasia which 
 have been recorded with autopsy findings, published sev- 
 eral new observations of sensory aphasia, and gave a 
 resume of the status as represented by the school of 
 Dejerine to-day. 
 
 In the following year appeared an apologist for the 
 contentions of Brissaud, echoing the teachings of Char- 
 cot. Lantzenberg 3 aims, apparently, in his brochure on 
 " Motor Aphasia" to do for his teacher what Mirallie did 
 for Dejerine. This opuscle, which contains nothing new 
 or original, as well as three important English contribu- 
 tions, appeared after the completion of the writer's mono- 
 
 1 Redlich : " Ueber die sogenannte subcorticale Alexie." Jahrbuch fiir 
 Psychiatric und Neurologic, vol. xiii., 1895. 
 
 4 Mirallie : " L'aphasie sensorielle," Paris, 1896. 
 3 Lantzenberg ; " L'aphasie motrice," Paris, 1897.
 
 History. 3 7 
 
 graph, and reference to them is here interpolated to show 
 that interest in the phenomena of the dissolution of speech 
 is not on the wane. Of these contributions in the Eng- 
 lish language, Bastian's 1 was most eagerly awaited. One 
 of the pioneers in the subject, one whose early utterances 
 on aphasia have been shown by time to be astoundingly 
 unerring, has had opportunity to look over the entire field, 
 to review the subject, and to modify, to reiterate, and to 
 recant. In another part of this work I shall approach 
 some of his claims with the deference and criticalness to 
 which they are entitled. Another English writer, Bram- 
 well, 2 of Edinburgh, one of our most trustworthy expound- 
 ers of the intricacies of neurology, reviewed in the same 
 year a number of extremely interesting cases, and illumi- 
 nated in discussing them some of the most obscure and 
 debatable points on the subject. On the whole, his con- 
 clusions are very much in accord with those of Dejerine, 
 Mirallie, and the present writer. The last of the three 
 above-mentioned contributions is that of Elder, 3 who has 
 made a painstaking and careful study. His conclusions 
 reflect the teachings of Wyllie and evidence his disciple- 
 ship. 
 
 Thus even a general view of the history of aphasia 
 suffices to show that this symptom has attracted the at- 
 tention of many men and minds during the past third of 
 the nineteenth century. It shows also that aphasia, the 
 
 1 Bastian : " The Lumleian Lectures on Some Problems in Connection 
 with Aphasia." Lancet, April 3d, loth, 24th ; May ist, 1897. 
 
 '-' Bramwell : " Illustrative Cases of Aphasia." Lancet, March 2Oth 
 and 27th, 1897. 
 
 3 Elder: "Aphasia and the Cerebral Speech Mechanism," London, 
 1897.
 
 38. The Mechanism of Speech. 
 
 explanation of which seemed so clear and so little liable 
 to variation, after the publication of Broca's cases, is in 
 reality one of the most complex problems to which the 
 physician can direct his attention. The brief survey that 
 I have taken gives inadequate consideration to the writ- 
 ings of some whose work has been of the most important 
 kind, and leaves unmentioned the names of many who have 
 contributed materially to the understanding of aphasia and 
 the interpretation of its intricacies, and without mention 
 of which the history of aphasia should not be written. 
 Such names include those of Pick, 1 Hammond, 2 Ferrier, 3 
 Eskridge, 4 Wilbrand, & Berlin, 6 Grashey, 7 Soury, 8 Sachs 9 
 (Breslau), Starr, 10 Henschen, " Thomas and Roux, 12 
 
 1 Pick : Archiv fur Psychiatric, t. xxiii., p. 896. " Beitrage zur Lehre 
 von den Storungen der Sprache," 1892. " Zur Lehre von der Dyslexic." 
 Neurologisches Centralblatt, 1891, pp. 130-132. " Ein Fall von transcor- 
 ticaler, sensorischer Aphasie." Neurologisches Centralblatt, 1890, pp. 646- 
 651. ' ' Xeue Beitrage zur Pathologic der Sprache." Archiv fur Psychiatric, 
 vol. xxviii. , 1896. 
 
 2 Hammond : " Treatise on Diseases of the Nervous System." 
 
 3 Ferrier : " Lectures on Localization in the Brain." Brain, May, 1898. 
 Croonian Lectures, London, 1890. 
 
 4 Eskridge : ' ' Symptoms of Speech Disturbance as Aids in Cerebral 
 Localization." University Medical Magazine, January, 1897. 
 
 5 Wilbrand : "Die Seelenblindheit als Hirnerscheinung," Wiesbaden, 
 1887. 
 
 6 Berlin : " Weitere Beobachtungen liber Dyslexic mit Se'ctionsbefund." 
 Archiv fiir Psychiatric, 1887, pp. 289-292. 
 
 1 Grashey : " Ueber Aphasie und ihre Beziehungen zur Wahrnehmung. " 
 Archiv fur Psychiatric, vol. xvi., 1885. 
 
 8 Soury : " Les fonctions du cerveau," Paris, 1892. 
 
 9 Sachs : " Ueber Bau und Thatigkeit des Grosshirns und die Lehre von 
 der Aphasie und Seelenblindheit," Breslau, 1893. 
 
 10 Starr : " Sensory Aphasia." Brain, 1889, .pp. 82-101. 
 
 "Henschen: " Klinische und anatomische Beitrage zur Pathologic des 
 Gehirns," Upsala, 1890-96. 
 
 14 Thomas and Roux: " Aphasiques moteurs corticaux," etc. Societe 
 Biologic, 1895, pp. 531, 731, 733; and 1896, p. 210.
 
 History. 39 
 
 Strieker, 1 and many other writers in the three great 
 languages of science. They in their own ways and in 
 their own times have added facts that prevent their 
 names from being forgotten. 
 
 'Strieker, S.: " Zur Lehre vender Aphasie." Wiener medizinische 
 Blatter, 1881, iv., 1,477-1,509, 1,565.
 
 CHAPTER III. 
 
 AN ANALYSIS OF THE GENESIS AND FUNCTION OF 
 SPEECH. 
 
 I. General Expressive Reactions ; Mimic Reactions. 
 2. Articulate SpeecJi. J. Writing. 4. The Gen- 
 esis of Percepts. 5. Remarks on Visual Sensation; 
 Acoustic Sensation, and the Mechanism of Articu- 
 lation. 
 
 AN introductory analysis of the so-called faculty of 
 speech, from the psychological point of view, must con- 
 sider : (i) the function of vocal articulation and of 
 writing as phenomena of bodily movement ; and (2) the 
 sensational, ideational, and other antecedents or stimuli 
 provocative of these exhibitions of complex motorial co- 
 ordination; and (3) the development of the function of 
 speech. I shall limit the inquiries at the outset to vocal 
 speech, considering the faculty of writing as subsidiary 
 and as following upon the analysis that I shall now pro- 
 ceed to make of the relationship of speech to other forms 
 of expression, and of its mental and physical antecedents. 
 
 Vocal speech must be regarded as one, and that the 
 most important, mode of expression. In addition to 
 words, articulate and written, the human being expresses 
 his thoughts and feelings by gesture, by pantomime, of 
 which the conventional signs of the manual language
 
 The Genesis and Function of Speech. 41 
 
 taught to deafmutes is a variety, or by means of inarticu- 
 late cries. A wave of the hand, a contraction of the mus- 
 culature of the face, the expanding or contracting aper- 
 ture of the eye, the cry of pain, the start of fright, are 
 all manifestations or expressions of bodily condition. The 
 most highly developed and most exact form of expression 
 is found in words ; but the individual who says, " I am 
 angry," has given expression, it is true, to a state of mind 
 in set phrases which require for their exclamation a much 
 more far-reaching examination of nervous and mental 
 processes than does the note of anguish ; but nevertheless 
 the two present analogies, and we may safely consider the 
 former as a development and outgrowth from the latter- 
 simpler mode of mental expression. 
 
 It must be remembered that these externalizations or 
 expressions, whatever they may be, are manifestations of 
 the reaction of the individual organism to its environ- 
 ment. So far as concerns our present analysis the en- 
 vironment acts upon the individual through his sense 
 organs. In this preliminary treatment, I shall consider 
 only the group of sensations that are known as the visual, 
 the auditory, and the kinaesthetic. 
 
 A stimulus acting upon sense organs tends to the pro- 
 duction of bodily changes. These bodily changes to a 
 certain extent depend in character upon the nature of the 
 stimulus. The organism reacts with different bodily move- 
 ments to a strong and to a weak light. It makes differ- 
 ential responses to the color red and to the color blue. 
 The organism of the child will react differently to the 
 objects of its environment than will that of the man. In 
 the life of the individual, the reacting organism is there-
 
 42 The Faculty of Speech. 
 
 fore modified so that certain differences in the resultant 
 responses to stimuli must be considered as dependent 
 upon its stage of ontogenesis. Again, the reacting or- 
 ganism of the human being responds in a different man- 
 ner to the same stimuli of the environment that act upon 
 it than does that of a dog or a pigeon, a lizard or an amceba ; 
 in other words, the character of the reacting organism is 
 dependent upon its stage of phylogenesis. Biology is the 
 science to which we must have recourse for an explana- 
 tion of these variations of type. Again, the sight of the 
 bottle produces upon the hungry child different responses 
 from those brought out by the same object acting upon 
 a child whose appetite is satisfied. Thus the organism 
 at every stage of phylogenesis and ontogenesis is subject 
 to characteristic modifications which manifest themselves 
 in the differences of reaction. In substance, therefore, 
 the expressive movements of the organism made in re- 
 sponse to external excitation are subject to variations 
 that are referable in part to differences in the stimuli, 
 the stage of organism development, and to temporary 
 changes in its condition. The nervous system is the 
 centre for the production of these reactions ; certain parts 
 of it seem to be of greater importance than others. In 
 the human being the cerebral cortex is the portion of 
 the nervous system which is chiefly modified by succes- 
 sive ontogenetic variations. It is that portion, conse- 
 quently, which is most educated in the lifetime of an indi- 
 vidual, and in an adult its destruction in whole or in part 
 is fraught with the most serious consequences to his men- 
 tal life. The cerebral cortex enregisters, perhaps as 
 changes of its substance, effects of past stimuli. These
 
 / 
 
 The Genesis and Function of Speech. 43 
 
 have been called by the name of memory residua. With- 
 out such memory residua and the association or grouping 
 of past experiences with present experiences, modification 
 of the organism would be impossible. Therefore, if a 
 visual stimulus acts upon the eye, and produces some 
 bodily change, the result of that stimulus is to produce 
 some mark or trait which is left upon the cells of the 
 cerebral cortex. If after innumerable stimulations the 
 organism of the child reacts to the face of its mother in 
 a manner different from that which it did in the first few 
 days or months of its existence, it does so because that 
 same visual stimulus now acts upon a brain which has 
 been modified to such an extent that past visual stimuli 
 of a similar nature are evoked simultaneously, and to- 
 gether with them are auditory and kinaesthetic impres- 
 sions and recollections of bodily well-being, such as being 
 fed, and so on. Although all parts of the organism re- 
 spond more or less intensely to every excitation, still 
 certain portions of the body and, more narrowly, certain 
 regions of the cerebral cortex seem to be foci of the bod- 
 ily disturbance evoked by a stimulus, and loci for those 
 modifications that we have called memory residua. Thus, 
 there are centres for visual impression locally differen- 
 tiated from those of auditory impression, and these 
 two again locally differentiated from those of muscular 
 impression. 
 
 The simplest mental consequence of the stimulation of 
 a sense organ by an external object may be assumed to 
 be the arousal of a sensation. A more complex resultant 
 is the arousal of a perception of an external object. The 
 flower violet may call up a simple sensation of color, or it
 
 44 The Faculty of Speech. 
 
 may arouse in the mind the perception of an object of 
 certain form, color, odor, taste, and even of certain habitat. 
 The arousal of a perception requires the conjoint action 
 or simultaneous association of disparate sensation groups. 
 To perceive the purple violet requires the conjoint action 
 of kinaesthetic, visual, tactile, and olfactory sensory groups. 
 To perceive bell requires most of these, with the addition 
 of the auditory group. If we, without the stimulation of 
 a sense organ, call up in mind the flower violet, we evoke 
 through central excitation the same sensory group. To 
 ideate requires the successive and simultaneous grouping 
 of these after-images of perception, the so-called memory 
 images. No one can carry on a train of thought for any 
 length of time without being aware of the sensory origin 
 and basis of the contents of most of his ideas. In some 
 persons one group predominates in initiating in the zone 
 of language the process that results in internal or external 
 speech. If the auditory group predominates, such a person 
 may be called an auditif, it being understood that the 
 auditory images are relatively and not absolutely pre- 
 dominant. For instance, if I am an anditif, and in my 
 mind I fail to observe the visual and articulatory ele- 
 ments, it is not because these are not acting at all, but 
 because they are not acting with sufficient intensity to 
 arouse consciousness or to stimulate the frontal lobes to 
 activity, while the auditory images are acting with suffi- 
 cient intensity and stimulatability. In a similar way, one 
 may be a visuel, an articulomoteur, etc. The latter indi- 
 vidual is fairly well represented by the person who has 
 to think aloud, and who, as he thinks, has to articulate 
 that upon which he cogitates. Ability to reason, to
 
 The Genesis and Function of Speech. 45.
 
 46 The Faculty of Speech. 
 
 carry on a train of abstract thought, to recognize, and to 
 remember, are dependent for their full preservation and 
 for their development upon the integrity of these several 
 sensory systems. It is probable, however, that the subtle 
 and complex co-ordinations requisite for the processes of 
 abstract thought are dependent upon ganglion cells having 
 a different location, whose activity is superadded to that 
 of those which are functional in the less complicated 
 processes of sensory perception. 
 
 There are many facts, biological, physiological, anatomi- 
 cal, and pathological, which point to the frontal lobe as 
 the seat of those neural processes whose function subserves 
 the purposes of a physical basis for the higher or more 
 complex processes of the mind ; and although it is believed 
 by the writer that there is no special centre of attention, 
 or of thought, or of apperception, or of morality, in the 
 frontal lobes, it can be, nevertheless, truthfully main- 
 tained that the integrity of the frontal lobes is essential 
 to the full exercise of the human being's powers of com- 
 plex thought. 
 
 If we designate (Fig. i) by V the centre for visual 
 memories, by A the centre for auditory memories, and by 
 K the centre for kinaesthetic memories, we may connect 
 these three centres by a line which will indicate, first, 
 that for full and complete perception the integrity of these 
 three centres is essential, so that, even if a stimulus 
 reaches the brain through the eye, it will not evoke per- 
 ception unless it succeeds in passing through appropriate 
 channels from the visual to the auditory and to the kinaes- 
 thetic centres. Let us further represent by C a hypo- 
 thetical centre or area for conception ; we shall then draw
 
 The Genesis and Function of Speech. 47 
 
 FIG. 2. Diagram o Speech Centres and Conception Area.
 
 48 TJie Faculty of Speech. 
 
 a line from C to V, another from C to A, and another 
 from C to K (Fig. 2). In ideation it is probable that 
 all of these centres, C, V, A, and K, are co-ordinated in 
 action, and that the various halves must be unbroken. In 
 a case of visual conception, that is, if full recognition of 
 an object that is seen is to be had, it is most important 
 that the tract from F"to C be kept open ; and for an audi- 
 tory recognition, that the tract from A to C be kept open. 
 It will be observed that we make no sharp distinction be- 
 tween the centre for ideas and the centre for visual impres- 
 sion. They are not in reality separated, as represented 
 here for purposes of demonstration, with fibres connecting 
 them. The centres are rather to be looked upon as the 
 end of a series, the abstract idea being at one end and 
 the simple sensation at the other. I might illustrate it 
 better by comparing it to the waves in a pond into which 
 a stone has been cast. At the centre of the irradiating 
 waves is the simple sensation ; the waves farthest from 
 the centre represents the concept or abstract ideas. For 
 convenience' sake, and in nowise to be considered a defi- 
 nite centre, we let the letter C represent the area for the 
 formation of concepts, and V, A, and K represent re- 
 spectively the centres for visual, auditory, and kinses- 
 thetic perceptions. We shall now add, to complete the 
 figure, other points along the line of conduction to these 
 several centres. Adjacent to V (Fig. 3) we place, 
 joined thereto by a line, the circle marked/' V. This 
 circle represents the primary visual centre, or the 
 centre of simple visual sensation. From this tract run 
 two others, v, v, and from them we lead by two tracts 
 V R, which we shall assume to represent the retinae.
 
 The Genesis and Function of Speech. 49 
 
 . 3. Diagram of Speech Centres and their Projection.
 
 50 The Faculty of Speech. 
 
 /The intermediate v and v we assume to represent the basal 
 ganglia. The construction is similar for the acoustic tracts 
 and for the kinaesthetic tracts. If we now add to the 
 figure a motor tract, the central portion represented by 5 
 and its termini by s, s, s, s, which are supposed to rep- 
 resent the several parts of the several nerves or neuraxons 
 going to the musculature involved in articulatory speech, 
 we have the figure complete. The muscles of speech 
 are induced to contract by impulses that start from the 
 lower end of the Rolandic area, to which impulses have 
 been sent from the zone of language directly or indirectly 
 from the higher intellectual areas, but always through the 
 speech area. In other words, the frontal lobe cannot 
 act on the part of the projection tract which func- 
 tionates in externalizing speech, without first sending 
 its impulses to the speech area. The impulses from the 
 cortex go to the end of the primary motor neurons, 
 that is, to the motor nuclei in the oblongata or in 
 the basal ganglia. 
 
 believe that the first cries of an infant are purely 
 automatic, nearing reflex acts ; the same, for instance, as 
 respiration. Their occurrence is conditioned by peripheral 
 stimuli which manifest their excitation in the pons, ob- 
 longata, and basal ganglia, in which lie the nuclei of origin 
 of the cranial nerves innervating the musculature which 
 must contract in order to produce crying sounds. Such 
 cries and sounds are produced as well by an anencephalic 
 child as by a child with a cerebrum. In fact, at its birth 
 a child is practically without a functioning cerebrum, and 
 in this respect it is no better off for the time being than 
 its anencephalic brother. Shortly after birth the brain
 
 The Genesis and Function of Speech. 51 
 
 begins to mature, and it does so by the protons of the 
 neurons developing myelin sheaths ; in other words, by 
 the medullation of fibres. The fibres passing to and from 
 the brain develop myelin sheaths and functionability 
 synchronously; in fact, the latter is entirely impossible 
 without the former. The first paths to become medul- 
 lated are those destined to carry sensory impulses. This; 
 is in fullest accord with psychological teachings that sen-( 
 sation conditions motion. Gradually the individual fibres 
 of these sensory pathways become medullated one after 
 another, the first being the olfactory and the last the 
 auditory. The lateness of development of the audi- 
 tory pathway has important ontogenetic significance and a 
 direct bearing on the monitorship of auditory over other 
 images, which is referred to in another chapter. If one 
 studies the anatomy of the brain according to the develop- 
 mental method, each sensory pathway can be traced dis- 
 tinctly to its termination, which is not diffuse, but lim- 
 ited to sharply circumscribed areas, such as witnesses the 
 visual area, limited to the occipital cortex in the imme- 
 diate vicinity of the calcarine fissure. These areas may 
 be looked upon as internal sense organs, or as areas that 
 mirror the activity of the peripheral sense organs. De- 
 struction of them causes total destruction of the corre- 
 sponding sense. Thus, destruction of the visual area pro- 
 duces blindness ; destruction of the auditory area produces 
 deafness ; destruction of the somaesthetic area 1 produces 
 loss of the bodily feeling. Each one of these strictly de- 
 limited areas is in relation with a higher area, which one 
 may call an association area if he is satisfied with Flech- 
 
 1 Flechsig's Korpergeflihl-Area.
 
 52 The Faculty 'of Speech. 
 
 sig's nomenclature. In a portion, at least, of such areas 
 are stored the memories of previous experiences, of pre- 
 vious functionings, and the materies of storage is called 
 memory images. Before such memory images can be 
 \ stored or enregistered they must be produced, and before 
 they are produced the pathways that conduct the impulses 
 must have been finished. 
 
 /When the newborn child utters a scream or a shriek, 
 At does so reflexly; the sound is neither an emotional nor 
 / a cognitive expression, and no anatomical structure above 
 V^the brain ganglia is necessary. As it grows older and 
 the brain ripens by the development of sensory pathways 
 and of terminal areas that have already been mentioned, 
 impulses begin to be conducted along these pathways. 
 ,Vhen the child screams after these pathways are devel- 
 oped, a kinaesthetic impulse going from the muscles that 
 externalize the scream (which by the way are in part the 
 muscles that externalize speech : the muscles of expira- 
 tion and of laryngeal action) is sent along this pathway to 
 the Rolandic-area cortex, and memories of it are stored 
 up in an adjacent sensory area, the foot of the third fron- 
 tal convolution. Later, when the auditory conducting 
 fibres ripen and the auditory area becomes a reality, these 
 impulses, likewise, are conducted to its area, in which 
 they are enregistered as sounds, but not as differentiated 
 sounds ; for not until the child begins to develop intel- 
 lectually does its auditory word area develop. Neverthe- 
 less, these autogenetic and slightly differentiated sounds, 
 as well as heterogenetic sounds, are making their impress 
 upon the general auditory field and are the outrunners to 
 prepare it for the reception of articulate sounds, which
 
 The Genesis and Function of Speech. 53 
 
 the child makes later in response to auditory and to visual 
 stimuli. 
 
 It is not alone kinaesthetic memories that such inarticu- 
 late sounds store up in the speech area. The inco-ordi- 
 nate contraction of muscles causes some change in the 
 motor cells of the Rolandic cortex (to which the great 
 central sensory pathway goes) which may have a decided 
 bearing on the readiness with which these same peripheral 
 muscles contract later in life in externalizing emotional 
 and cognitive states when the child becomes possessed of 
 consciousness and intellect. 
 
 Every contraction of the musculature of speech sends 
 impulses along the tract KK (Fig. 3), which are carried to 
 the sensory and percept centre and are there joined in si- 
 multaneous association or co-ordination with sensations or 
 percepts that were aroused by the original stimulus passing 
 up the tract Ww AA. At a later period, after these asso- 
 ciations have become well fixed, we find inarticulate cries 
 giving place to persistent articulated ones. We find, fur- 
 ther, the beginning of speech imitation, which is prob- 
 ably due, in the first instance, to a stimulus that, passing 
 from the tract AA, gives rise to a motor impulse running 
 down the tract SS, which in turn causes such articu- 
 late co-ordination that the resultant vocal response is 
 more or less an approximation to the sound that causes 
 it. This vocal response is, of course, the source of two 
 ingoing impulses, one up the tract KK, the other up 
 the tract AA, both of them giving rise to appropriate 
 sensations and perceptions which in the consciousness 
 of the child supply the material for a comparison, and 
 under the renewed stimulus of imitation lead to a
 
 54 The Faculty of Speeck. 
 
 constantly nearer approximation to the original sound. 
 It is not necessary for us to regard the centres that in 
 this diagram are represented as being located within the 
 cerebral cortex as taking part in the production of this 
 responsive adaptation. The action is probably more or 
 less reflex; it is a condition of echolalia, and the cross- 
 connection between the sensory and motor tracts is prob- 
 ably made very low down, certainly not above the tasal 
 ganglia. At the same period of the development of the 
 child we find evidence of visual imitation as the child 
 copies the expressions, gestures, and bodily positions of 
 those about him : it points as they point, just as it enun- 
 ciates the words which it hears them enunciate. This is 
 accomplished through the reflex co-ordination of the visual 
 with the appropriate mental tracts. Thus we have com- 
 plex adaptive movements, gesture and speech, provoked 
 through the instinct of imitation, due to the constitution 
 of the reactive organism. They require no volitional or 
 even ideational antecedents, and yet they gradually build 
 up and develop perception, memory, and the association 
 of these into what will be the framework of a system of 
 conceptual ideation. 
 
 As a result of these processes, there are stored up in the 
 kinaesthetic centre for articulation motor images that are 
 the result of reflexly or automatically excited contractions 
 in the musculature of articulation, which serve as memory 
 images and which are the immediate mental antecedents of 
 the words that are to be enunciated. The central motor 
 speech mechanism consists therefore of a purely sensory 
 centre for motor memory images, a centre that is built up 
 as the result of receptive processes, and an emissive centre
 
 The Genesis and Function of Speech. 55 
 
 motor in function but which has, so far as we know, no 
 conscious accompaniment of its activity ; which is, in short, 
 a part of the general motor area of the brain, the part from 
 which proceed motor impulses externalizing speech, which 
 external ization is the product of definite muscular contrac- 
 tion. Next we have formed at the end of the acoustic 
 tracts a general auditory area for the reception of all 
 forms of acoustic phenomena. A definite part of this 
 area is destined for the reception of sounds having precise 
 and limited significance. These sounds are deposited 
 there partly as the result of the words of others and partly 
 as the result of the words of the individual himself, and 
 constitute acoustic verbal images. As the reflex centres, 
 so the cortical centres are probably closely bound together, 
 and these connections are known as association tracts. 
 At the same time there have been forming in the visual 
 centre and in the general auditory centre visual percep- 
 tions and auditory perceptions related to the objects of 
 the external world, and these again related to the motor, 
 auditory, and articulatory verbal images that have been 
 invariably associated with these visual and acoustic per- 
 ceptions. Each one of these centres is in its turn con- 
 nected with the area of conception in the frontal lobes, 
 to which the zone of language (a designation used to 
 indicate the part of the cortical surface which contains 
 the speech centres or areas) always sends impulses 
 with conscious accompaniment, and elements from each 
 centre are inextricably interwoven with the processes of 
 ideation. 
 
 The development of abstract thought is to a great de- 
 gree dependent upon the development of language, internal
 
 56 The Faculty of Speech. 
 
 or external. The name of an abstract quality is fre- 
 quently the only definite content of an idea. Many per- 
 sons do their thinking in words. As I have mentioned 
 before, it depends largely upon individual constitution 
 whether it be in auditory verbal signs or in kinaesthetic 
 verbal symbols. 
 
 We are now in a position to consider one or two points 
 of special interest connected with the use of language. 
 To see, recognize, and name an object, requires an intact 
 ^visual-conduction tract extending from the retina through 
 the external geniculate body, the anterior quadrigeminal 
 body, and the pulvinar, to the cortex of the occipital lobes 
 by means of the optic radiations, and thence to the left 
 angular gyrus. In a general way, to see the object re- 
 quires only that part of the visual mechanism extending 
 to the cortex of the occipital lobe. ATo recognize and name 
 it requires all or part of the remainder of the visual mech- 
 anism. The recognition and complete apprehension of 
 the object requires, further, that the lower visual centre 
 be in intact relationship with the centre of visual images, 
 so that images of the object can be contrasted with past 
 experiences. If there have been no such past experi- 
 ences, then the object is seen but not recognized or named. 
 In order that the use, function, and wider relations of the 
 object may be recognized, the centre of visual images must 
 be in intact relationship with the concept centre. To 
 name the object apprehended, the concept centre must 
 either be in unbroken connection with the kinaesthetic 
 motor centre or with the auditory verbal centre, which last 
 must then be in connection with the kinaesthetic verbal 
 centre, or else the connection must be made through the
 
 The Genesis and Function of Speech. 57 
 
 visual centre to the auditory and kinaesthetic, or to the 
 kinaesthetic direct. It is highly probable that the first 
 is nearest to the real condition. These connections being 
 intact, with the connection between the visual and concept 
 centre unbroken, we shall have the perception of the object, 
 followed by the naming of it. Similar conditions obtain 
 in naming objects which impress themselves upon the 
 sensorium through the ear. It is true also of the under- 
 standing of spoken language.' To hear and answer a 
 question intelligently requires that the acoustic conduct- 
 ing tract to the auditory area and to the centre of audi- 
 tory verbal images be intact, and that the connection with 
 the concept centre be undestroyed. It requires next that 
 the outgoing tract from the area of conception to the 
 kinaesthetic verbal centre, or to the acoustic and thence to 
 the kinaesthetic centre, be intact. This leads to one remark 
 concerning spontaneous speech, which is understood to be 
 speech induced by a train of ideas an oration, for example. 
 In delivering an oration we ordinarily find involved only the 
 concept centre and its connection with the kinaesthetic and 
 articulatory centre. But, nevertheless, in every instance 
 the area of cognition calls up the complete formula of 
 speech product. The train of ideas, however, is the vivid 
 content of the mind, in virtue of which the auditory ver- 
 bal portion functionates below the level of consciousness. 
 
 The Genesis of Percepts. 
 
 In considering the development of the functions of 
 speech from the psychological point of view it is necessary 
 to speak briefly of the constitution of percepts and of ideas, 
 of their relation to sensation upon the one hand and to
 
 58 The Faculty of Speech. 
 
 memory images on the other, and, lastly, to make inquiry 
 as to the significance of the verbal symbols for our ideas 
 and percepts, and of the mode of their acquirement. 
 
 The percept of an object is formed of the collocation in] 
 our minds of different sensory impressions that have been 
 aroused in consciousness through the action of the object 
 upon the special organs of sense. Sensations are there- 
 fore the material out of which a percept is formed. All 
 the sensations that are capable of being aroused by an 
 object need not be present in consciousness at one time. 
 In becoming acquainted with some object of the environ- 
 ment (let us suppose a bell) the object has appealed at 
 different times to eye, ear, and touch ; from these experi- 
 ences of various senses we have formed our idea of the 
 nature of a bell, its appearance, the sound that it will 
 emit on being struck, and its hardness or resistance. If 
 our past sensory experiences with the object bell have 
 been well preserved in memory, impingement of one sin- 
 gle quality of a bell on the consciousness, through one 
 sense organ only, will be sufficient to arouse in our minds 
 the total percept of bell, which will really be an aggregate 
 of the present sensation and of the memories of the sen- 
 sory impressions of the past, and to revivify every quality 
 of a bell and all it stands for. 
 
 The sensations of hearing and seeing are the most im- 
 portant sources of perception, and are those upon which 
 we depend principally to obtain our knowledge of the 
 world about us and what goes on in it. The other sensa- 
 tions are used more for corroborative or supplementary 
 information. The formation of a definite composite per- 
 cept of an object is generally followed by giving to it a
 
 The Genesis and Function of Speech. 59 
 
 name. The name usually indicates some quality of the 
 object, and in the beginning the child calls the stove 
 "hot," the dog "bow-wow," or it expresses a generality 
 of occurrences that a single conventional expression does 
 not even suggest, such as " baba," meaning not only sleep, 
 but the paraphernalia with which mothers of modern 
 civilization surround the transition from consciousness to 
 unconsciousness in their children the nurse, the rocking 
 of the cradle, the lullaby, and all the other things that the 
 child has been accustomed to at this time. In the very 
 beginning it is probable that the names applied to things 
 are entirely imitative and the association between the 
 name and the thing comes only after the child's attention 
 has been repeatedly called to it. The more frequently 
 and persistently his attention is directed to it, the sooner 
 does the child learn to associate the sound with the thing. 
 This is well illustrated by the early acquisition and under- 
 standing of, that is, the application of, the words " papa" 
 and " mama." These sounds are uttered by the mother, 
 and, as they are easily imitatively produced, and as the 
 mother repeats them persistently, the child very early 
 learns to say them, and moreover early learns to use them 
 but not discriminatingly, for in the beginning every man 
 is "papa." In a very short time the sound of the word 
 " papa" calls up in the child's mind the visual memory of 
 its father, and this is accompanied by numerous expres- 
 sions of joy. Thus we have association of ideas as the 
 basis of intellectual process and the originator of purpo- 
 sive speech. 
 
 Every one has had opportunity to observe young chil- 
 dren, busy with their toys, repeating over and over sounds
 
 60 The Facility of Speech. 
 
 or words to which they attach no significance, and which, 
 if addressed to them directly, call up no memory pictures 
 in their minds of the objects of which they are the names. 
 This condition of echolalia indicates the existence of an 
 automatic speech mechanism in the production of these 
 words. The word is produced because some sensory 
 impression has been caught up and is influencing the 
 emissive centres to activity. Each time that the child 
 repeats the word, memories of a sensory and motor nature 
 are being stored up and held in readiness to be associated 
 with their proper percepts. 7 Thus speech is the product 
 of the revival of memory in one or more sensory and motor 
 areas simultaneously, the two memories blending into a 
 ..^single consciousness. As I have said previously, before 
 the proper name has been associated with the object, as, 
 for example, the word dog with a barking animal, the 
 child for a long time may associate some prominent sense 
 impression which the dog makes on its auditory centre, 
 namely, its bark, with the sight of the dog. In this con- 
 dition it recalls the memory of dog and refers to it as 
 " bow-wow." It is thus seen that the giving of a specific 
 name to an object is a more complicated mental process, 
 and therefore one more easily destroyed, than is the giv- 
 ing of expressive or suggestive designation to a sensory 
 impression. 
 
 The name of an object, as well as the names of quali- 
 ties of the object, is stored up in definite parts of the 
 brain, and its retention by the brain constitutes a word 
 memory or name memory of the object, which can be 
 drawn upon for purposes of perception or thought or 
 speech, as are other memories. The sound of a church
 
 The Genesis and function of Speech. 61 
 
 bell, which to an aborigine would call to mind no image 
 of belfry or church building, no thought of the material 
 from which it was cast, nor of its size, color, and shape, 
 nor of the purpose of its ringing, and thus would bring 
 to his mind no memory picture of all the environmental 
 associates of the bell, starts a sequence of associations in 
 the mind of one who has learned of a bell, which may be 
 of religious worship, of death, of marriage, of public calam- 
 ity or rejoicing, and along with them it calls up the name 
 which he has heard others give to the object which is the 
 immediate cause of the sensation. 
 
 If a normally developed adult person were to have that 
 part of the auditory cortical areas destroyed in which are 
 stored up the memory images of all percepts obtained 
 through the sense of hearing, he would be unable to rec- 
 ognize the sound of the bell, as a bell, although the sensa- 
 tions which the ringing of it produced might be the same 
 as before, and heard quite as acutely. His auditory cen- 
 tres have been reduced to the simple untutored state of 
 the aborigine. An exactly analogous condition maintains 
 for percepts that are formed through other sense organs, 
 as, for example, through the eye, as in learning to read; 
 and for the expression of language in motor visual form, 
 for example, in writing. 
 
 An individual who has learned to speak transforms 
 memory images of words and ideas into spoken or written 
 or other forms of conventional language. To accomplish 
 this there must have been stored up in the brain cortex, 
 in the centres of vision, of audition, and of kinaesthetic 
 perception, a large number of sense impressions which 
 are the symbolic representatives of percepts. These come
 
 62 The Faculty of Speech. 
 
 from without and are first presented through the sense 
 of hearing. 
 
 Although speech is not absolutely essential to thought, 
 still it is probable that most persons find it necessary to 
 use words internally in order to think. For some persons, 
 at least, thinking is always accompanied by and dependent 
 upon internal speech. A knowledge of the psychology and 
 physiology of internal speech is very helpful to the under- 
 standing of some aspects of aphasia. Internal speech is 
 dependent upon a revival of auditory, visual, and articu- 
 latory memories ; its integrity depends upon the united 
 action of these three centres, but that one which is most 
 highly cultivated is revived most vividly. This special 
 one in some cases reaches such a stage of development 
 that it seems to overtop the others; for instance, some 
 persons find it necessary in speaking to call up the visual 
 images of the words, others depend largely upon the au- 
 ditory, and still others upon the articulatory kinaesthetic 
 images. Nevertheless, internal speech is imperfect when 
 the speech centre considered of least importance in any 
 given individual is in any way deranged. The first is the 
 most common and the second least. As I have said be- 
 fore, Charcot and his followers refer to those who in 
 speech depend upon visual memories as visuels, to those 
 who depend upon auditory memories as auditifs, and to 
 those who depend upon motor memories as moteurs. This 
 division is fanciful and has but slight practical application 
 as has before been suggested. I shall have occasion to 
 revert to this point in the chapter on " Conception of 
 Aphasia." 
 
 All of the centres entering into word production are
 
 The Genesis and Function of SpcecJi. 63 
 
 intimately connected with one another, and a variety of 
 combinations is possible. With these combinations I 
 shall not concern myself here. 
 
 Clinical experience teaches that occasionally visual im- 
 ages of letters and words are lost, while those for ciphers 
 and other graphic symbols are preserved. It is necessary, 
 therefore, to say a word here concerning the acquisition of 
 such symbols. Ciphers and other forms of notation are, 
 like words, symbols devised by mankind to represent cer- 
 tain definite values, which are used to facilitate human 
 intercourse. As symbols they are very much less differ- 
 entiated in their application than letters are, and unlike 
 letters, which vary in their value with every varying com- 
 bination and change of position, ciphers have given to 
 them a very definite, limited, and unvarying value which 
 remains unchanged, it matters not their combination. 
 Moreover, they are not complex as words are, but may be 
 looked upon as simple, unvarying substitutes for words. 
 This graphicness of registration on the visual areas is 
 shown most convincingly by a study of arithmetical prodi- 
 gies. Such persons, as a rule, have well-defined intellec- 
 tual limitations in a number of directions. In fact, many 
 of them belong to the class of idiots savans. Such per- 
 sons are enabled to perform the most stupendous arith- 
 metical problems usually calling only for primitive 
 methods of computation. When the method by which 
 they accomplish this is analyzed, it is seen to be very 
 simple and in keeping with the graphicness of represen- 
 tation of ciphers in the visual sphere. Mathematical prod- 
 igies are endowed with the capacity of enregistering 
 ciphers so vividly that they can see them as distinctly in
 
 64 The Faculty of Speech. 
 
 their " mind's eye" as if the characters were written on 
 paper before them, and they not infrequently explain their 
 methods by saying they read off the figures as they see 
 them in their mind. 
 
 It is not at all likely that there is a separate centre in 
 which such symbols are stored ; all the evidence bearing 
 on this point tends to show that, like letters, memories of 
 them are stored in the angular gyrus but that the registra- 
 tion is a simpler one. If this be so, it accounts for their 
 preservation after letters are lost and for the greater readi- 
 ness with which they are evoked. 
 
 Writing. 
 
 The faculty of writing is developed, like that of articu- 
 late speech, under stress of the impulse of imitation, the 
 co-ordination being one between the visual centre and that 
 part of the motor cortex from which impulses start to 
 move the member that holds the pen, whether it be the 
 hand or any other mobile part of the body which has ac- 
 quired or is acquiring facility by practice in making the 
 co-ordinated movements of writing. These movements of 
 writing are all accompanied by the reception of kinses- 
 thetic impulses that go to the somsesthetic area of the 
 brain, and the renewal of these memories makes writing 
 seem in those who have had long practice almost like an 
 automatic act, but in every instance, it matters not how 
 facile or apparently divorced from consciousness the act 
 of writing may be, the physiological procedure consists of 
 impulses passing through the same series of operations as 
 it did in the beginning. It must be remembered that the 
 motor tracts for writing and for speech are tracts for ex-
 
 The Genesis and Function of Speech. 65 
 
 pression and that they are influenced by any conditions 
 that influence the reacting organism. 
 
 The motor act of wielding a brush in painting or in 
 portraying visual sensory images, whether imaginary or 
 real, is done by a cortical area quite as specialized as that 
 for writing. When the child learns to write, it does so, 
 as has just been said, under the stress of imitation. It 
 is first made to copy or to trace letters or words that have 
 been put before it in orthodox script. Formerly the child 
 was taught to trace or copy individual letters. Even 
 now this method is by no means obsolete, which it richly 
 deserves to be. It is gratifying to hear that very few 
 of even the most "old-fashioned" schoolteachers require 
 their charges to "print" words, i.e., to copy them from 
 type, a procedure that was very common in bygone days. 
 Such inculcation was a striving for the antithesis of the 
 correct method. Most modern pedagogues teach their 
 young pupils to trace or copy syllables and words in the 
 same way as they teach them to learn syllables and words 
 instead of letters. Pedagogical experts are also maintain- 
 ing as a matter of sound principle that writing with a pen 
 should be taught relatively late in a child's educational 
 career and should always be preceded by writing upon the 
 blackboard with free arm movements from the shoulder, 
 because the former movements being the result of more 
 specialized centres, should be developed after and from 
 the latter. 
 
 In the beginning, tracing and copying words and letters 
 are a slow and tedious process, principally, however, on ac- 
 count of the awkwardness in holding and guiding the pen. 
 If the child is left-handed the awkwardness is more evi- 
 5
 
 66 The Faculty of Speech: 
 
 dent, because schoolteachers, almost without exception, 
 unless oriented to the contrary, insist upon having the 
 child write with the right hand, notwithstanding the fact 
 that the organism is left-handed. This the child soon 
 does with the same facility as though he had been allowed 
 to write with the left hand. 
 
 If the child copies or traces without understanding the 
 letter or the word, the neural process is a very simple one, 
 and all that is required is that the cortex of the brain shall 
 mirror the letters and then the transcription of these vis- 
 ual images by the arm-hand motor area. If, however, the 
 child is being taught to recognize the letters at the same 
 time, which is usually the case, there are stored up in its 
 higher visual centre memories which form part of the gen- 
 eral concept of the letter or the word. After the child 
 traces or copies letters for a time he acquires a visual 
 memory image of them ; he may and probably does at the 
 same time acquire their names and significance. After 
 this he no longer requires a copy before him to produce 
 the letters; he copies the letter in fact out of his visual 
 storehouse. In the beginning, before the images have 
 been firmly embedded, it requires strict attention to evo- 
 cate these imperfectly enregistered images, and the whole 
 process is done slowly and laboriously. In fact, often- 
 times some of the images cannot be evoked at all ; then 
 they are said to be forgotten. But any one who has stud- 
 ied a child who is learning to write knows that it has not 
 wholly lost the memory of the word, and by putting before 
 him a part of the recalcitrant letter he may succeed in 
 revivifying the letter or the word of which it forms a part. 
 For instance, a child who is asked to write the name
 
 The Genesis and Function of Speech. 67 
 
 " Frank" may say, " I don't know how it begins," mean- 
 ing that it cannot jut the first letter of the word with 
 sufficient vividness into the zone of language, and thus to 
 the concept centre. If, however, the perpendicular limb 
 of the letter and the middle short horizontal stroke is 
 made for it, the child may go on and complete the letter 
 /'"and the remainder of the word. In this case the visual 
 images are not thoroughly incorporated and need other 
 than volitional stimulation to invoke them. When writ- 
 ing becomes an habitual act, the letters and words which 
 one writes form an integral part of internal language, and all 
 the images of words are evoked simultaneously. In such 
 voluntary writing an impulse starting from C (Fig. 2) calls 
 up the images in V, and these proceed to an area in the 
 motor cortex at S, but in every instance there is reason to 
 believe that this pathway is through A and K. Color is 
 lent to this view by a study of writing in children and in 
 those who learn to write late in life. The fact that the 
 articulatory image of the word is called up is shown by 
 the experience that a word is always uttered either articu- 
 lately or to themselves immediately preceding its produc- 
 tion. As writing becomes more automatic, i.e., as one 
 becomes more adept in writing, this phenomenon ceases 
 entirely, particularly in those who have been instructed 
 " to keep what they are doing to themselves" (a common 
 admonition in schools, at least in New England country 
 schools) ; in others the phenomenon of articulating with- 
 out vocalizing the word is retained throughout life. 
 
 If one examines himself carefully and repeatedly while 
 writing, he is cognizant of a peculiar feeling or sensation 
 in the ears and throat. These correspond to the auditory
 
 68 Tke Faculty of Speech, 
 
 and articulatory evocation of the letters and words that he 
 is about to write down. It is, I believe, quite the same 
 in typewriters. I am sure this phenomenon occurs in my 
 own case when I operate the writing-machine, which I do 
 with rapidity and facility. If this is the case when one 
 externalizes his own thoughts by means of the writing- 
 machine, it is legitimate to inquire if the same process or 
 phenomenon is gone through when one writes from dicta- 
 tion. Numerous interrogations of my stenographer, a 
 very intelligent man, always bring the reply that in writ- 
 ing from dictation the words or the letters composing 
 them are uttered audibly immediately preceding the strik- 
 ing of the keys, or this is preceded by a feeling of move- 
 ment and tension in the ears and throat, which are the 
 congeners of such outward word production. I would not 
 be understood to say that this takes place in every in- 
 stance. Indeed, it is highly probable that long practice 
 does away with the necessity of conscious activity of the 
 articulatory centres before the externalization of the let- 
 ters and words by the tapping of the keys. 
 
 Thus we have a series of functions developing in suc- 
 cession : first, general expressive reactions; second, mimic 
 reactions; third, articulatory speech; fourth, writing. In 
 cases of disorder we should expect the last to be the least 
 stable and the first to be the most stable, and our experi- 
 ence as physicians teaches us that this is what really 
 occurs. 
 
 The following areas and centres have been considered : 
 (i) The visual area, and in close relation to it the vis- 
 ual word centre. (2) The auditory area, and in close re- 
 lation to it the auditory word centre. (3) The kinaesthetic
 
 The Genesis and Fimctton of Speech. 69 
 
 area, and in close relation to it the word-image centre, the 
 motor-articulatory centre. 
 
 The position of these centres and areas and the consti- 
 tution of the zone of language by the former, as well as 
 its environmental relationships to the different parts of 
 the brain, are pointed out in the chapter on " Conception 
 of Aphasia." The relation of the primary visual centre, 
 the visual centre for verbal images, the general auditory 
 centre, and the auditory centre for verbal memories, and of 
 the kinaesthetic art iculatory centre to the conception centre 
 are highly important. The centre in which are stored 
 visual images is adjacent to the primary visual area. The 
 centre in which are stored auditory word memories is in 
 the upper part of the general auditory area, while the im- 
 ages of articulation are allocated to the third frontal con- 
 volution, immediately adjacent to the somaesthetic area, 
 and to the motor speech area. 
 
 The destruction of any one of these centres or of the 
 connecting links is liable to produce the disorder of speech 
 known as aphasia. A consideration of the most frequent 
 types of aphasia with reference to this analytical scheme 
 of speech will show that some of the centres and their 
 pathways are frequently the seat of lesion and others less 
 frequently. It should be remembered (i) that the loca- 
 tion of a lesion that will cause aphasia is largely influ- 
 enced, as far as frequency of occurrence goes, by the blood 
 supply of that region ; and (2) that the amount of speech 
 disturbance that a lesion in the same locality in different 
 brains will produce will vary only slightly with the sen- 
 sory basis of the ideation of the individual to whom the 
 brain belongs.
 
 70 The Faculty of Speech. 
 
 To complete this analysis it will be necessary for us to 
 take up briefly the various elements in visual perception, 
 to consider (i) color sensations, (2) form, (3) dimen- 
 sions, (4) distance, (5) relation to the environment. It 
 will be necessary in the case of audition to distinguish 
 between the hearing of noises, musical tones, and the 
 hearing of articulated words; and to consider (i) 
 rhythm, (2) pitch, (3) tone quality, (4) intensity, (5) 
 sound sequence. On the motor side similar complica- 
 tions will be met with. In articulatory speech we can 
 distinguish (i) the lips, (2) the tongue, (3) the soft 
 palate, (4) the nose, (5) the larynx, (6) the lungs, (7) 
 the diaphragm. 
 
 Visual Sensation. 
 
 In attempting to analyze the various elements in visual 
 perception, I shall have to consider in the briefest possible 
 manner the typical physiological and psychological factors 
 of vision and the relation of physical and psychological 
 stimuli to psycho-physiological conditions. 
 
 I have previously spoken of the component parts of the 
 visual mechanism, and here I shall confine myself to an 
 enumeration of the elements of the peripheral visual appa- 
 ratus. They consist, i, (a) of a neuro-epithelial percipi- 
 ent apparatus, and (b) a ganglionic and nerve-fibre con- 
 ducting apparatus; 2, of a refractive apparatus;, and, 3, 
 of a muscular mechanism arranged to move the eyeballs 
 in any direction which may best contribute to the placing 
 of optical stimuli on the point of most acute perceptive 
 power. 
 
 Next in importance to the neuro-epithelial percipient
 
 TJie Genesis and Function of Speech. 71 
 
 apparatus is the muscular mechanism which not only 
 moves the eyeballs but also changes the shape of the re- 
 fractive media that project the rays of light on the retina. 
 These muscular actions, some of which are continually 
 being made during states of consciousness, and, to a lim- 
 ited extent during states of unconsciousness, produce 
 afferent stimuli, the memories of which are stored up 
 probably in the supramarginal gyrus, adjacent to or in the 
 somaesthetic area to which they are directly sent. The 
 evocation of kinaesthetic ocular memories plays a part in 
 the proper perception of visual impulses and contributes 
 to the interpretation of visual percepts. 
 
 The customary physical stimulant of vision is light, 
 which is a wave motion of the ether. These wave mo- 
 tions occur with a rapidity varying from 400,000,000,000 
 to 900,000,000,000 per second. Other forms of stimuli 
 than light may excite visual sensation. Such are me- 
 chanical and electrical stimuli. If one places the elec- 
 trode carrying a galvanic current on each temple, the 
 make and break of the current are accompanied by a flash 
 of light. 
 
 The physical stimulus, luminous vibration, or wave 
 motions of ether are said to act by decomposing the vis- 
 ual purple of the retina, which procedure indirectly sets 
 up a commotion in the optic-nerve filaments, which are 
 in connection with the cells over which the photo-chemical 
 substance is spread, and the filaments conduct the commo- 
 tion to the occipital cortex, where they are registered. 
 This, at least, is the theory of physiologists and psycholo- 
 gists. No real proof can be offered of the existence of 
 such a process. It may be said, indeed, that the part
 
 72 The Faculty of Speech. 
 
 played by the visual purple has been allotted too great im- 
 portance, as vision continues after it is exhausted and is 
 not lacking in animals devoid of it. Therefore I prefer 
 to say that luminous waves excite the elements of the 
 percipient apparatus, probably by photo-chemical means, 
 which excitation is carried by the conducting apparatus 
 along the optic nerves and their continuation to the oc- 
 cipital cortex. The registration in the cortex is not dis- 
 tributed in a haphazard manner. Certain parts receive 
 impulses coming from different parts of the retina, so that 
 visual impulses coming from one quadrant of the retina 
 are registered in a definite and correspondent portion of 
 the occipital visual area. 
 
 The three different substances assumed to be affected 
 in a photo-chemical way by luminous waves are supposed 
 to lie in different percipient elements, so that one of the 
 primary colors excites only those percipient elements 
 which contain the substance corresponding to that color. 
 Mixed colors excite two or three sets of percipient ele- 
 ments in different degree. 
 
 Psychologically, the different qualities of visual sensa- 
 tion are known as color. Different color sensations are 
 produced by the different colors of the spectrum, and 
 these color sensations differ according to wave lengths, 
 the longest waves being those at the red end of the spec- 
 trum and the shortest waves those at the blue. The lu- 
 minous intensity of a color varies with the amplitude of 
 vibration, but with an equal amplitude of vibration some 
 colors are inherently more luminous than others. As the 
 number of acoustic vibrations constitute the pitch, so the 
 wave length or number of vibrations to a second consti-
 
 The Genesis and Function of SpeecJi. 73 
 
 tutes the color. The relationship existing between the 
 intensity of color sensation and auditory phenomena is a 
 close one, and constitutes the basis of color audition. 
 Persons in whom this phenomenon takes place apparently 
 get auditory excitation through the perception of certain 
 colors. This is not a physiological interaction, however, 
 but a psychological one, and is often met with in psycho- 
 pathic states. 
 
 Each percipient element is not trained to vibrations of 
 certain wave lengths, and therefore not to the reception 
 of individual colors. The areas of the retina in which 
 the cones and ganglion cells are few are relatively less 
 sensitive to color perception, requiring for perception and 
 excitation greater intensity or a stimulus covering a great- 
 er area. 
 
 Before a child acquires perception of space and form, it 
 must acquire perception of color. It has been accepted 
 on the teachings of Preyer and others that in so doing 
 children follow such an unvariable formula that it may 
 be looked upon as a law. First they learn the recogni- 
 tion of yellow, then of red, later of green, and very much 
 later of blue ; in fact, Preyer contends that the color blue 
 may fail to be recognized until very late. Binet's and 
 Baldwin's studies seem to disprove this temporal acquisi- 
 tion of color perception. The latter' s experiments showed 
 that the order of acquiring color perception was blue, 
 white, red, green, brown. Much further experimentation 
 and observation are needed on this point before it can be 
 considered settled. The acquisition of color perception 
 is supposed to be proportionate with the maturation of the 
 photo-chemical substance, whatever that may be, in the per-
 
 74 Tke Faculty of SpcecJi. 
 
 cipient membrane. As a matter of fact, the acquisition of 
 visual perception of any kind is dependent upon the ripen- 
 ing of the optical neuron. The manner in which children 
 acquire perception of color can, however, legitimately be 
 explained by the fact that prismatic colors have different 
 luminosities, yellow being the brightest, green and red 
 next, and blue and. violet the dullest; and it is not at all 
 unlikely that children get perception of colors in the above 
 order on account of these different luminosities. 
 
 Visual memories for form are the result of muscular 
 co-ordinations made in the movements of the various com- 
 ponents of the eye which have been utilized in getting an 
 outline percept of the object, with the color sensations 
 coming from the object contrasted with the latter by the 
 conceptual sphere. The original motive of all ocular mo- 
 tions is the desire to perceive objects clearly, and to 
 accomplish this we must of necessity have the percep- 
 tion of light and color, a conception of form and space, 
 and the faculty of seeing things in the places where they 
 are, which may be called the projection of perception. 
 When a person is in possession of these three factors, he 
 may be said to be in possession of the means for fullest 
 visual orientation. It is this orientation visually of ob- 
 jects, animate or inanimate, symbolic or concrete, that 
 enters as an element of the mind and as a most important 
 factor in the evolution of thought communication. 
 
 Acoustic Sensations. 
 
 Acoustic sensations are produced by wave motions of 
 elastic substances. Although the rapidity of these wave 
 motions may vary within wide limits, a certain numb'er
 
 TJie Genesis and Function of Speech. 75 
 
 must take place within a second of time in order to pro-, 
 duce the sensation of sound. Ordinary sounds, or clangs, 
 are a series of component tones which, irrespective of their 
 intensity, can be distinguished from one another by their 
 tone quality. 
 
 The peripheral auditory apparatus consists essentially 
 of three parts: (i) of a neuro-epithelial percipient ap- 
 paratus, and a ganglionic and nerve-fibre and conducting 
 apparatus the organ of Corti, which has its origin in the 
 cochlea; (2) of the tympanum and ossicles; and (3) of 
 the meatus and the external ear. There is another part 
 of the auditory nerve than the cochlear one, which takes 
 its origin from the ampullae of the semicircular canal, and 
 which for this reason is called the vestibular nerve. It 
 does not go to the auditory area; it has nothing to do 
 with audition ; it goes to the cerebellum and in all proba- 
 bility it is of paramount importance in contributing to the 
 maintenance of equilibrium. 
 
 The meatus and the membrana tympani serve as pro- 
 tectors to the terminals of the cochlear nerve. They act 
 to prevent all stimuli, except those adequate and requisite 
 to contribute auditory information, from acting on these 
 terminals, and particularly from acting deleteriously on 
 them. The tympanum through its tensor muscle is ex- 
 cited reflexly to contraction to meet these sounds and to 
 prepare for them. The auditory nerves proper, that is, 
 the cochlear divisions, have their eventual distribution 
 in the superior temporal lobes on both sides of the brain 
 in what is called the general auditory area. It is highly 
 probable, although it cannot be absolutely so stated, that 
 these nerves undergo complete decussation, the left nerve
 
 76 The Faculty of Speech. 
 
 going to the right auditory area, and the right nerve to 
 the left auditory area. 
 
 The organ of Corti, a neurc-epithelial structure, lies on 
 an expanded membrane composed of fibres of different 
 lengths. This membrane may be compared to a harp, 
 each constituent of which is attuned to the various primi- 
 tive sounds. These different lengths are connected with 
 the elements of the organ of Corti, and it is probable that 
 more than one are connected with the same element of the 
 organ of Corti. 
 
 The periodic vibrations that the ear takes cognizance of 
 maybe considered grossly as of two kinds: (i) musical 
 sounds or tones, and (2) noises. Musical sounds are periodic 
 vibrations, while noises are irregular. The human voice, 
 which may produce both noises and musical tones, may 
 be taken as an example of these two forms. Musical 
 sounds or clangs are very complex in their constitution, 
 but they can be separated into simple acoustic elements 
 or tones. When musical sounds reach the human ear 
 they are analyzed into component tones by the membrane 
 covering the organ of Corti, and this communicates the 
 commotion to the individual organ of Corti, which is rep- 
 resented in the auditory area in the temporo-sphenoidal 
 lobes. 
 
 The characteristics of auditory perceptions that must 
 be considered are the intensity, the pitch, and the timbre. 
 The intensity of a sound depends upon the amplitude of 
 the vibration. The pitch or tone quality depends upon 
 the number of vibrations ; the timbre depends upon the 
 number and relative dominance of the constituent tones. 
 
 Individuals vary greatly in their discrimination of pitch,
 
 TJie Genesis and Function of Speech. 7 7 
 
 and on this discrimination depends the musical capacity 
 of the individual. When a person cannot distinguish tones 
 separated by an interval corresponding to a semitone he is 
 tone deaf. We shall see later on that this condition may 
 be caused by lesion of the auditory area, and probably as 
 well by lesion of the right temporo-sphenoidal lobe as by 
 lesion of the left. 
 
 Each nerve end of the cochlear nerve can be ex- 
 cited by only one pitch, or at least by a very limited num- 
 ber of pitches. The same stimulus of sound does not act 
 at the same time upon many nerve ends, but upon one or 
 a few neighboring terminations, and each nerve fibre of 
 the organ of Corti becomes accustomed and especially sen- 
 sitive to a certain pitch. This necessitates, for the fullest 
 effect of sounds, the condition known as sound sequence, 
 as there is no special sequence in the arrangement of sev- 
 eral tones heard simultaneously. This, in connection with 
 the fact that the sensations of sound are not projected into 
 space with any exactness or with any differentiation, al- 
 though some assume, without furnishing tangible proof, 
 that there exists an auditory field that can in a way be 
 compared to the visual field, necessitates a mechanism of 
 great selective or differentiating capacity. The only ac- 
 cessory means of determining the locality from which 
 sounds proceed is by turning the head, as the human ear 
 lacks a muscular apparatus especially contrived to put the 
 trumpet external ear in different positions to aid the local- 
 ization. Thus no kinaesthetic sensations of any import, 
 except those connected with the tensor tympani muscles, 
 enters into the auditory memories, nor are any sent to the 
 general somassthetic area.
 
 78 The Faculty rf Speech. 
 
 Articulation. 
 
 In the analysis of the mechanism of articulatory speech, 
 I must discuss, first, the part played by respiration, or, to 
 be more specific, by expiration ; the parts concerned in 
 phonation; and the parts concerned in articulation, using 
 the word in its limited sense. The expiratory cur- 
 rent is the absolute sine qjia non of phonation, and the 
 following characters of expiration have to be considered, 
 viz., the rapidity, the rhythm, and the force. Expira- 
 tion, as well as the entire respiratory act, is a reflex act 
 which is often described as an automatic act. It is not 
 automatic in the strict sense of the term. Its integrity is 
 vouched for by a centre consisting of two parts, an inspi- 
 ratory and an expiratory, situated in the oblongata, and the 
 functional activity of this centre stands in very close 
 relationship to the state of the blood. This is shown 
 by the overactivity of the centre in cases of anaemia 
 and by the cessation of activity in cases of superoxida- 
 tion. 
 
 The respiratory function is, nevertheless, under the di- 
 rect influence of the will, and can, within certain limits, 
 be subject to considerable change, and particularly it can 
 be influenced in its rapidity, rhythm, and force. Consid- 
 eration of this fact leads one to believe that there is a 
 distinct representation for the thoracic and laryngeal res- 
 piratory movements in the motor cortex, and that this area 
 can be stimulated to activity by impulses coming from the 
 higher intellectual area, either directly by force of the 
 will, or indirectly, as by fear and joyful emotions. There 
 is some experimental evidence to show the location of
 
 The Genesis and function of Speech. 79 
 
 this respiratory centre to be in the upper part of the 
 lower third of the ascending frontal convolution. That 
 is, it is adjacent to the centres for movement of the lips, 
 tongue, and larynx, in the lower part of the Rolandic re- 
 gion. 
 
 The expiratory current is necessary for all phonic phe- 
 nomena and for articulation, and in fact they are depen- 
 dent upon it. This can be easily demonstrated if one 
 attempts to articulate or phonate at the end of a full in- 
 spiration. Not a tone, not an articulate sound can be 
 produced until the lungs have taken some air in that can 
 go out in expiration. The degree of perfection of articu- 
 late speech depends upon the rapidity, rhythm, and force 
 of expiration, as witness the phonation and articulation of 
 a patient suffering with dyspnoea or with marked asthenia, 
 such as that accompanying Asiatic cholera. In the latter 
 the patient is as toneless and as inarticulate as if he had 
 a tracheotomy tube in the windpipe. Yet such patients 
 are in full possession of their mental faculties, including 
 that of internal language, if the statements of those who 
 recover can be relied upon. 
 
 The expiratory current is the motor power that sets the 
 vocal cords into vibration. The vocal cords may be con- 
 sidered simple bands of fibre-elastic tissue, having a mar- 
 vellously arranged muscular mechanism which is capable 
 of putting them in different states of tension and of relax- 
 ation. The expiratory current setting the cords in motion 
 originates all the different series of air waves of which the 
 voice is composed. After these series of air waves have 
 been started by the cords they are modified by the reso- 
 nance cavities. These resonance cavities are controlled by
 
 So 77/6' Faculty of Speech. 
 
 the muscles surrounding them, the principal ones of which 
 are those of the pharynx, mouth, and nose. They rein- 
 force the air waves set up by the vocal cords and thus give 
 character to the tone. The tone as it leaves the cords is . 
 a mere squawk, and would always remain \ i were it not 
 for the resonance cavities. Moreover, without resonance 
 cavities we could not articulate. 
 
 The vocal cords originate several different tones, prob- 
 ably eight or ten, all the time, and it is the blending of 
 these different tones that constitutes the " timbre" of the 
 voice. 
 
 The number and relative strength of these different 
 partial tones determine the quality of the tone, and here 
 it may be said that the different vowel sounds are simply 
 changes in quality of the tone. This is brought about by 
 changing the size and shape of the resonance cavities, so 
 that they reinforce some of the tones started by the cord 
 and suppress others. For example, the vowel a, as in 
 fatlicr, in a good voice may have ten partial tones, with 
 the lowest pitch strongest and the tones gradually dimin- 
 ishing in strength as they rise in pitch. There must be a 
 certain position of the tongue, lips, and soft palate to pro- 
 duce this result. These positions of the lips, tongue, and 
 palate in the same individual would always give the same 
 combination of partial tones, and this combination of par- 
 tial tones would always give the vowel a. To articulate 
 the vowel c there must be a change in position of these 
 parts. In the vowel a the tongue is in a low position in 
 the mouth, giving a large resonant space there. In the 
 vowel e the tongue is raised so that it fills the mouth cav- 
 ity, thus destroying it as a resonance chamber. The
 
 The Genesis and Function of Speech. 81 
 
 effect is to suppress all the tones except the first 
 four, and of these the second is strongly reinforced. 
 For the long a we have another position of the articulat- 
 ing muscles, and hence another combination of partial 
 tones, and so on through the whole list of vowels. The 
 consonants, on the other hand, are merely interruptions of 
 the vowel sounds produced by the use of the tongue and 
 the lips. Without the expiratory currents we could not 
 produce the sound, and without the resonance cavities we 
 could not articulate, as they are the only means by which 
 we change the character of the sound, and, after all, that 
 is what articulation is in reality. 
 
 The degree of perfection of articulate speech depends 
 largely on the use made of the resonance cavities; in 
 other words, the use of the muscles that change their size 
 and shape. The force of the expiratory current affects the 
 intensity of the tone, and the intensity of the tone is de- 
 termined by the height of the air waves of which the tone 
 is composed. The altitude of the air waves depends, first, 
 upon the extent of motion of the vocal cords. It is not 
 thought necessary here to enumerate the factors that affect 
 the pitch of the tone, or to describe the variations that 
 such causative factors may undergo by the contraction of 
 the muscles which control the activities of the cord. Suffi- 
 cient, it is believed, has been said to show that a number 
 of composite factors enter into the production of articulate 
 speech as a mode of externalizing thought. It will be 
 seen that the essential element in them all is one con- 
 ditioned by muscular action : expiration by action of the 
 diaphragm and other expiratory muscles, tension of the 
 vocal cords by the intrinsic musculature of the larynx r
 
 82 The Faculty of Speech. 
 
 change in the shape and size of the resonance cavities by 
 the muscles which enter largely into the constitution of 
 surrounding parts. It will be seen, moreover, that three 
 different sets or groups of muscles, or possibly four, par- 
 take of this composite act : the respiratory, the laryngeal, 
 the lingual, and the buccal. Each set or group of these 
 muscles has a definite representation in the Rolandic 
 area of the cortex, specifically in the inferior part of 
 the ascending frontal convolution, immediately adja- 
 cent to the third frontal convolution. From experimen- 
 tal and pathological evidence it is believed that the 
 representation for each of these muscles is very strictly 
 defined. 
 
 All the phenomena constituting articulation are under 
 the direct control of the will. When consciousness is ex- 
 ternalized in words of different phonic and articulatory 
 characteristics the words are framed in the zone of lan- 
 guage, and appropriate stimuli are sent to the cortical 
 motor area in which are represented the parts concerned 
 in phonation and articulation. The conscious impulse 
 that is responsible for their being starts also impulses 
 that modify them and give them the qualities that have 
 just been enumerated. ' There exists between the cortical 
 speech mechanism and the peripheral speech mechanism 
 an intervening mechanism whose function is to regulate 
 and co-ordinate the impulses coming from above. This 
 may be considered a subsidiary station, and it is situated 
 at the level where the peripheral axones of those neurons 
 of the cortico-motor tract whose function it is to carry 
 motor and articulatory impulses undergo end arboriza- 
 tion, i.e., in the pons-oblongata. Whether this subsidiary
 
 The Genesis and Function of Speech. 83 
 
 station has all to do in co-ordinating and regulating the 
 different elements of articulatory impulses cannot at the 
 present time be said. It is thought, however, that it is 
 very largely concerned in this function. 
 
 The child in learning articulate speech brings into play 
 a very composite motor mechanism. In the beginning, 
 before the impulses starting from the cortex are properly 
 co-ordinated, and before the child has learned how to use 
 its external speech apparatus, articulation may be defec- 
 tive in many ways. As soon, however, as the co-ordinat- 
 ing centre for these cortical impulses performs its func- 
 tion in the intended manner the externalization of speech 
 becomes perfect. 
 
 Although I have no intention of discussing in this 
 chapter the dissolution of speech, but propose to confine 
 myself entirely to the genesis of speech, it may be well 
 to call attention to the completeness with which externali- 
 zation of speech can be lost by a destruction of that part 
 of the cortex in which are located the motor centres for 
 the respiration, the larynx, and the resonance mechanism. 
 Such a destruction may constitute, as we shall see later, 
 the lesion of subcortical motor aphasia, a lesion that pro- 
 duces as complete aphemia, without in any way interfer- 
 ing with internal speech, as if the patient were devoid of 
 an external speech mechanism. It must also be seen, I 
 think, that a lesion that severs all the projection fibres 
 coming from these areas, it matters not at what level as 
 far, in fact, as the termination of the primary motor neu- 
 ron would produce exactly the same result. As a matter 
 of experience, we have learned that a subcortical lesion, to 
 cause complete aphasia, must be situated very close to the
 
 84 
 
 The Faculty of Speech. 
 
 cortex, and the reason for this is not far to seek. As far 
 as possible, nature attempts to make up for its apparent 
 shortcomings by substitution, and, as it is a necessity to 
 send all the motor projection tracts through an extremely 
 small space, the internal capsule at the base of the brain 
 (Fig. 4), it is probable that it does not send the projection 
 fibres coming from the various articulatory parts of the cor- 
 tex in which are situated 
 the representation of res- 
 piration, laryngeal, buc- 
 cal, and labial move- 
 ments in a direct way 
 from the centre to the 
 , subsidiary station through 
 
 * ' th e same part of the 
 
 capsule. Therefore a 
 lesion, unless it is suffi- 
 ciently great to cut across 
 the internal capsule, 
 
 FIG. 4. Position of Different Fibres Con- 
 stituting the Internal Capsule, after Van vVOUld not at the level 
 Gehuchten. i, Cortico-thalamic ; 2, mixed 
 
 motor fibres from the cortico-protuber- of the latter produce dpJlC- 
 antial fibres ; 3, sensory fibres ; CW, cau- 
 date nucleus ; T, thalamus ; LN, lenticu- fttta, but WOLlld, rather, 
 lar nucleus. 
 
 produce a dysarthric dis- 
 turbance of speech. As lesions so extensive as to cut 
 across the internal capsule are rarely consistent with life, 
 we do not meet with this form of subcortical aphasia. 
 
 A few sentences devoted to the word as a phonetic phe- 
 nomenon and we must take leave of this part of the anal- 
 ysis. A word varies phonetically according to the lan- 
 guage that it is a constituent of. In the languages of 
 civilized people it is an acoustic phenomenon, phoneti-
 
 The Genesis and Function of Speech. 85 
 
 cally differentiated, to which such peoples have given a 
 definite value as an expressive sign. In the language of 
 some uncivilized peoples, such as the Chinese, the value 
 of each sound or word varies with the intonation, and a 
 study of aphasia in a Chinese subject would be of great 
 service in illuminating the part played by expiration as a 
 psycho-motor act, for this conditions intonation.
 
 CHAPTER IV. 
 CONCEPTION OF APHASIA. 
 
 I. Remarks on the Anatomy of the Brain. 2. Zone of 
 Language. Site of Revival of Words in Silent 
 Thought. 3. Evidence in Favor of and against tJic 
 Existence of a Special Graphic Motor Centre. 
 
 BEFORE outlining the conception of aphasia which I ven- 
 ture to believe is the one most in accord with anatomical, 
 physiological, psychological, and pathological evidence, 
 and before discussing the theories or ideas of aphasia that 
 have held sway in the past, as well as those taught to-day, 
 I shall outline as briefly as possible the parts of the brain 
 concerned in the faculty of speech. To do this under- 
 stand! ngly it is necessary to take a survey of the architec- 
 ture and anatomy of the brain in general, and particularly 
 to describe explicitly the connections of the different parts 
 or centres that are known as speech centres. 
 
 No one will dispute that the cerebral hemispheres are 
 necessary for the maintenance of the faculty of speech. 
 No one will be likely to contend, having in mind the 
 studies of Goltz, that the cerebral hemispheres are neces- 
 sary for the maintenance of life in the higher animals. It 
 is well known that this investigator was able to keep a 
 dog alive for a considerable time after he had completely 
 extirpated both cerebral hemispheres. The dog was
 
 Conception of Aphasia. 87 
 
 devoid of memory and judgment, and incapable of find- 
 ing out for himself the things necessary for the sat- 
 isfaction of his needs; nevertheless, he could stand and 
 run, and he responded to direct stimuli, such as a blow, 
 light, noise, etc. When he was deprived of nutrition the 
 whole body was agitated, and when he had eaten abun- 
 dantly he became content and showed evident signs of 
 satisfaction. That absence of the cerebral cortex is con- 
 sistent with life is shown by many cases of anencephalic 
 monsters whose histories have been recorded. Moreover, 
 it has been shown by Flechsig that the infant at birth, 
 and for a short time after, is practically in the same con- 
 dition as a child without cerebral hemispheres. The child 
 is unable to make any conscious acts, all its movements 
 and responses are reflex, and not until the ripening of the 
 cortex begins by the development of myelin sheaths for 
 each nerve fibre has the cortex any functioning ability. 
 Flechsig has demonstrated beyond any question of doubt, 
 and many other scientists have corroborated the demon- 
 stration, that the nerve fibres of the hemispheres develop 
 their myelin sheaths at different periods of the infant's 
 life, that those destined to function first are the first to 
 develop myelin sheaths, while those destined to function 
 later develop them at a different time. By means of this 
 method of investigation the anatomist of Leipzig has 
 shown that the fibres serving different functions can be 
 followed with almost^ mathematical precision to the parts 
 of the cortex in which they terminate, or from the parts of 
 the cortex whence they go toward the periphery. This 
 method of investigation has put him in possession of facts 
 of such indisputability that it becomes necessary to re-
 
 88 The Faculty of Speech. 
 
 model, if not entirely to reconstruct, some previous teach- 
 ings of the anatomy of the brain, and particularly of theo- 
 ries built in consonance with such teachings. Of such 
 theories, that of aphasia is not one of the least important. 
 Flechsig's teachings of what may be called the physio- 
 logical structure of the brain do not, however, clash ma- 
 terially with the present topographical teachings, although 
 they point to the uselessness of dividing the cerebral hem- 
 ispheres into a number of lobes and lobules for any other 
 purpose than that of simple topographical orientation. 
 Bearing this in mind, it may be said that the cortex of 
 the brain is divided naturally by primary, principal, or 
 complete fissures (using the term complete fissures in the 
 sense of His) into the frontal, temporal, occipital, parie- 
 tal, and insular lobes.^The fissures by which such divi- 
 sion is made are the fissure of Sylvius, the central fissure, 
 and the parieto-occipital fissure. The fissure of Sylvius 
 is the one that particularly concerns us now, for about it 
 the so-called zone of language is builE/ The fissure of 
 Sylvius is one of the first markings to show itself in the 
 embryonic state. It appears at about the fourth week of 
 intra-uterine life as a large depression on the external sur- 
 face of the cerebral vesicle, or that part of it destined to 
 be the forebrain. The forebrain grows and expands tow- 
 ard the front and backward, in fact in every direction ex- 
 cept outward ; consequently there is left a depression at 
 the lateral surface which corresponds to the position of 
 the corpus callosum internally. This depression consti- 
 tutes the fossa of Sylvius (Fig. 5). As the brain con- 
 tinues to develop and to rotate on its axis, and the various 
 parts of the hemispheres approximate one another, this
 
 Conception oj Aphasia, 
 
 89 
 
 space becomes narrowed ; the portion of the cortex lying 
 at the bottom of it is covered over, and is known later as 
 the island of Reil, while the prolongations of the space 
 become very much narrowed and constitute the limbs of 
 the fissure of Sylvius. This elongation of the fossa of 
 Sylvius takes place at about the fourth month. On ac- 
 
 PIG. 5. Triangular Fossa Sylvii (foetal brain). 
 
 count of the disproportionate development of the occipi- 
 tal lobe, this elongation is directed obliquely upward and 
 backward. The various parts bordering the fossa of Syl- 
 vius, developing, extend into the fossa as well as in other 
 directions, and these interfossal projections form lids or 
 opercula, which are designated frontal, parietal, and tem- 
 poral, according to the lobe of which they are a part. Thus, 
 when the. fissure of Sylvius is completed, the parts of the
 
 go The Faculty of Speech. 
 
 cortex that extend into the fossa of Sylvius, which it is 
 to be remembered was originally a large triangular space, 
 are known as opercula the inferior operculum being 
 formed by the anterior part of the temporal lobe, the sup- 
 erior operculum formed in part by the frontal and in part 
 by the parietal, the anterior operculum, the shortest, con- 
 stituted by the frontal lobe. When the operculum alone 
 is mentioned, the superior operculum is always meant, for 
 it is in reality the important one. 
 
 The fissure of Sylvius in the fully developed brain is 
 a most striking feature. It starts from the fossa of Syl- 
 vius, which is just lateral to the anterior perforated space, 
 passes forward and upward to the lateral surface of the 
 brain, where it divides into a short anterior horizontal 
 branch, and a posterior ascending branch which continues 
 backward obliquely across the external surface of the cere- 
 brum and terminates in a bifurcation near the middle of 
 the lateral surface, this point being usually in the inferior 
 parietal lobule. The posterior limb gives off immediately 
 after the beginning of its oblique course a short anterior 
 vertical branch, which juts into the inferior frontal con- 
 volution and cuts off a portion of the convolution which is 
 known as the "foot." The Sylvian fissure separates the 
 frontal and the parietal lobes above from the temporal 
 lobe below. At its bottom is the most important annec- 
 tant convolution of the hemisphere, the island of Reil. 
 ^The frontal convolutions are named superior, middle, 
 and inferior, the latter alone being of interest to us now 
 on account of the physiological importance attributed to 
 it in the production of speech, or, to be more specific, I 
 should say, attributed to the left inferior frontal convolu-
 
 Conception of Aphasia. 91 
 
 tion when the organism is right-handed, and to the right 
 inferior frontal convolution when the organism is left- 
 handed. This convolution is usually known as the con- 
 volution of Broca. It borders the fissure of Sylvius be- 
 low, and posteriorly it is continuous with the ascending 
 frontal convolutioiy The anterior horizontal limb of the 
 fissure, and the much more insignificant branch of the fis- 
 sure of Sylvius, the anterior vertical branch, jut into the 
 convolution of Broca. 
 
 These branches of the Sylvian fissure divide the infe- 
 rior frontal convolution into three parts : 
 
 1. The opercular part, or foot of the convolution of 
 Broca, situated in front of the lower extremity of the an- 
 terior central convolution and comprised between the pre- 
 central fissure and the anterior vertical branch of the 
 fissure of Sylvius. 
 
 2. The triangular part, sometimes called the cap of 
 Broca's convolution, which is comprised between the an- 
 terior horizontal branch and the anterior vertical branch 
 of the fissure of Sylvius. 
 
 3. The orbital part, which is situated below the anterior 
 
 horizontal branch and which is continuous with the orbital 
 
 
 
 convolution on the inferior surface of the hemisphere. 
 
 Of these three portions, the first alone is considered 
 now to have any concern in the production of speech, and 
 when the unmodified term, Broca's convolution, is used, 
 this is the part that is referred to. It is the part of the 
 brain in which are stored the sensory memories (articula- 
 tory-kinaesthetic) of a motor act that of articulate speech. 
 
 The temporal convolutions, of which there are also 
 three superior, middle, and inferior constitute the lateral
 
 92 The Faculty of Speech, 
 
 part of the hemisphere below the posterior limb of the 
 fissure of Sylvius. The convolution immediately border- 
 ing the fissure of Sylvius, the superior temporal convolu- 
 tion, is the one to which is allocated the general auditory 
 area. The auditory area is not spread over the entire ex- 
 ternal surface of the superior or first temporal convolution ; 
 a large part of it is hidden in the wall of the fossa of 
 Sylvius, appearing on the external surface of the hemis- 
 phere only in the middle and posterior thirds of the con- 
 volution. There is some pathological evidence to indi- 
 cate that musical memories have separate allotment in 
 the left superior temporal convolution in the anterior 
 part of the auditory area. 1 
 
 The convolutions bordering on the fissure of Sylvius 
 above are, after the inferior frontal convolution, of which 
 we have already spoken, the central convolutions. These 
 have nothing to do with the genesis of speech, but a.11 to 
 do with its execution. As we shall see later, they consti- 
 tute almost exclusively the somaesthetic area and the cor- 
 tical motor area. Next beyond these, bordering the Syl- 
 vian fissure, comes the inferior parietal convolution. It 
 is believed that the higher visual centre is limited to the 
 posterior portion of the inferior parietal lobule, which is 
 known as the angular gyrus, and that the anterior portion, 
 or supramarginal gyrus, has little or no function of stor- 
 ing up visual images. These gyri, the inferior frontal, the 
 
 1 The only discordant testimony bearing on localization of the general 
 auditory area is that of Schafer and Sanger Brown, whose experiments on 
 monkeys did not lead them to substantiate Ferrier's statement that the 
 function was allotted to the superior temporal convolution. This negative 
 evidence of Schafer and Brown should not be given the slightest considera- 
 tion, however, in view of the incontrovertible pathological testimony at 
 our disposal, corroborative of this allocation.
 
 Conception of Aphasia. 93 
 
 superior temporal, and the inferior parietal, represent the 
 confines of the zone of language, and it only remains nec- 
 essary to speak of the relationship of the primary visual 
 areas in the cunei, the tip of the occipital lobe, and es- 
 pecially on its internal surface immediately around the 
 calcarine fissure. To this the radiations of the optic 
 nerve can be directly traced. In the chapter on " Anal- 
 ysis of speech," I have said that the optic nerve devel- 
 ops its medullary sheath in the tenth month; that 
 before this time it can be distinctly traced as a bundle 
 of non-medullated fibres, passing from the eyeballs by 
 means of the optic tract to the external geniculate body 
 and from there to the anterior quadrigeminal body, while 
 another bundle passes directly into the optic thalamus, 
 and fibres go from the external geniculate body to the 
 thalamus (see Fig. 6). The course of the optic nerve 
 from these ganglia backward is directly to the cortex of 
 the occipital lobes in the immediate vicinity of the cal- 
 carine fissure, the connection being effected by means of 
 the so-called radiations of Gratiolet. In their course to 
 the cuneus the optic radiations pass immediately sub- 
 jacent to the angular gyrus and a lesion in the latter loca- 
 tion, if it is not very superficial, is apt to interrupt some 
 of these fibres. The pathways leading from both cunei 
 to the left angular gyrus, the seat of visual memories, 
 cannot be traced with the same exactitude as the tract to 
 the primary visual areas can be. 
 
 The convolutions that have thus been described form 
 the anatomical basis of the zone of language (see Fig. 7), 
 and this definite part of the brain carries on the faculty of 
 speech ; or, expressed in another way, the centres neces-
 
 94 
 
 The Faculty of Speech. 
 
 sary for the reception and interpretation of impulses com- 
 ing to the brain bearing on speech, and for the emission 
 
 PIG. 6. Course of the Optic Fibres. EGB, External i?eniculate body ; AQH, 
 
 anterior quadrigemineal body ; P of T, pulvinar ; I'C, visual centre ; If I C\ 
 
 half-vision centre. 
 
 of impulses to the peripheral speech mechanism, are situ- 
 ated in a definite area of the brain cortex. To this area, 
 which is as much entitled to strict localization as the 
 motor area, the name zone of language is given. Every 
 one knows that the^fa'culty of speech is maintained by
 
 Conception of Aphasia. 95 
 
 the left hemisphere of the brain in those who are right- 
 handed, and by the right hemisphere in those who are left- 
 handed. And this for the same genetic reason that the 
 organism is right-handed in the majority of people and 
 left-handed in the few; when the organism is left-handed, 
 then the right hemisphere contains the zone of language. 
 It would seem that this is one of the facts of physiology 
 which is indisputable; nevertheless, every now and then 
 some one brings forward evidence purporting to deny it. 
 One of the most recent purveyors of such evidence is Molt- 
 schanow, ' of Moscow, who in relating a case says that his 
 observations were confirmed by Rossolimo. He cites the 
 following instance in support of the claim that the speech 
 area is not always on the left side of the brain when the 
 organism is right-handed : A man fifty-six years of age, 
 of alcoholic habits, had a stroke of apoplexy, followed 
 by disturbance of speech two years before his entrance to 
 the hospital, when the author discovered sharply defined 
 "amnesic aphasia" with word deafness and total left-side 
 hemiplegia. Recognizing that such an unusual combina- 
 tion as left-side hemiplegia and aphasia probably bespoke 
 a left-handed man, the author questioned the patient's 
 wife on many occasions to learn if the patient used the 
 left hand by preference, but she insisted that he was 
 right - handed. At the autopsy there were found t\vo 
 areas of softening in the right hemisphere, one in the 
 posterior segment of the first temporal gyrus, the second 
 in the posterior portion of the third frontal gyrus. Noth- 
 ing abnormal was found in the left hemisphere. The 
 
 1 Moltschanovv : " Zur Frage von der Localisation des Sprachcentrums." 
 Xeurologisches Centralblatt, 1893, p. 673.
 
 96 The Faculty of Speech. 
 
 writer says that this case speaks unequivocally against 
 what he is pleased to call Broca's dictum concerning the 
 location of the speech area. He says further that other 
 authors have probably had similar cases, for in looking 
 over the literature of aphasia he had noted that it is 
 oftentimes impossible to determine from the reported 
 cases whether the patient was right-handed or left. This 
 point the writer need have no difficulty, I believe, in de- 
 termining in the future. If the patient whose history he 
 reads has a left hemiplegia with aphasia, that patient is 
 a right-handed man, and vice versa. It is almost incredi- 
 ble that physicians will attempt to convince themselves 
 that evidence of this kind can have the slightest effect 
 in overthrowing such an invariable rule as the one relat- 
 ing to the location of the speech area, just cited. An 
 attempt to discredit a law so firmly established as this 
 by the citation of testimony of a woman concerning the 
 right-handedness or left-handedness of her husband is 
 like trying to trip up Atlas by putting a microbe to ob- 
 struct his path. How is any one to know that I as an 
 organism am left-handed ? I write with the right hand ; 
 with it I throw, I use a knife to whittle; I have used it 
 in the past to operate ; in fact, every ordinary and extra- 
 ordinary act calling for dexterity is performed sccnndnm 
 artem with the right hand. Yet I am left-handed in the 
 sense of the term that originally the organism was in- 
 tended to be served particularly by that hand, and were 
 it not for the care taken in the nursery the left hand 
 would be the dextrous member to-day. Therefore, it 
 seems to me that unless those who come in the most in- 
 timate contact with me are informed to the contrary, I
 
 Conception of Aphasia. 97 
 
 should be considered a right-handed individual. And 
 yet, no one, I think, would deny that, if such a person 
 were to have a lesion on the right side of his brain in- 
 volving the areas to which are allocated the functions of 
 speech, he would have with it aphasia. 
 
 The determining causes of right-handedness is a prob- 
 lem in biology that I can refer to only very briefly. It 
 is an extremely important one, because no one now doubts 
 that dextrality is conditioned by the same factors that de- 
 termine the unilaterality of executive-speech representa- 
 tion, and that the former is an evolutionary differentiation 
 of the latter. It has been considered to be dependent 
 upon tribal and social customs originally, and as an in- 
 herited characteristic. The most fanciful theories as well 
 as the most careful scientific experiments have been under- 
 taken to explain it. Of the former the one that crops up 
 most irrepressibly in popular and in scientific literature is 
 that right-handedness has to do with the way in which the 
 child is held in its waking hours and the side on which 
 it lies while it sleeps. This can be refuted so easily that 
 it is scarcely worth the doing. If a child becomes right- 
 handed because the nurse carries it so that the left arm is 
 hampered from free movement, then left-handed nurses 
 (who naturally carry their charges on the left arm and 
 therefore keep the child's right arm close to them) could 
 always be depended upon to bring up left-handed children ; 
 but as a matter of fact they cannot be. Among the seri- 
 ous theories that have been propounded for its explanation 
 a few deserve specific mention. Ogle suggested that it 
 was conditioned by peculiarities in the mode of origin and 
 distribution of the left internal carotid artery, and Bastian
 
 98 The Faculty of Speech. 
 
 pointed out that right-handedness, or the conditions that 
 determine it, has a definite relationship to the increased 
 specific weight of the cortical gray matter of the left 
 hemisphere and to greater convolutional complexity. Both 
 of these conditions may be the consequence and not the 
 cause of dextrality. Recently Baldwin has propounded a 
 theory, based on careful and intelligent observation of his 
 own child, that right-handedness is a manifestation of brain 
 variation utilized for expansion which develops further into 
 speech ; that it is due to differences in the two half-brains 
 reached at an early stage in life and that the promise of it 
 is inherited. 
 
 ^J,t has been proven beyond cavil that destruction of the 
 foot of the third frontal convolution causes inability to ar- 
 ticulate words ; that destruction of the superior temporal 
 gyrus causes inability to understand spoken words, and a 
 lesion in the inferior parietal gyrus causes inability to in- 
 terpret words which can be seen. These are the three 
 components that enter into the constitution of speech, and 
 they are the three factors that are absolutely essential to 
 the production of perfect speech. The convolutions of 
 the brain in which they are situated are immediately ad- 
 jacent to each other. They are intimately connected by 
 means of annectant convolutions, the most important of 
 which are the insular gyri, and by association tracts to 
 be named presently. These convolutions border on the 
 Sylvian fissure, and they are all supplied by branches of 
 one blood-vessel, the middle cerebral or Sylvian artery, the 
 direct continuation of the internal carotid artery. 
 
 The area thus mapped out is in shape somewhat like a 
 gondola; the bottom being formed by the superior tern-
 
 Conception of Aphasia. 
 
 99 
 
 poral gyrus, the upturned hind end by the angular and 
 supramarginal gyri, the front end, which does not rise 
 so high as the other end, by the frontal operculum, the in- 
 ferior end or foot of the third frontal convolution (Fig. 
 7). This area is not entirely occupied by the speech 
 centres, by which is meant portions of the cortex in which 
 are stored the visual, auditory, and kinaesthetic articula- 
 
 FlG. 7. Zone of Language ; Position of Centres. 
 
 tory memories. These centres, the storehouses of such 
 memories, are narrowly confined (though not sharply de- 
 limited, in all probability), and the remainder of the zone 
 of language, that is, the area between the centres, is con- 
 stituted by association tracts or pathways connecting these 
 centres. 
 
 The association or connecting pathways of the brain 
 must now be discussed. It is weil known that the nerve 
 fibres of the brain are divided into three groups : 
 
 i. Commissural fibres, which unite symmetrical points
 
 ioo The Faculty of Speech. 
 
 in the two cerebral hemispheres. These constitute the 
 corpus callosum and the anterior white commissure or 
 psalterium. They need not further concern us here. 
 
 2. The fibres of association ; long and short fibres which 
 unite different points in the same cerebral hemisphere. 
 
 3. Projection fibres ; fibres that unite the cortical gray 
 matter of a hemisphere with the gray substance of the 
 brain stem and cerebro-spinal axis. 
 
 The association fibres of the brain are divided into the 
 long and short fibres. The short fibres unite points in 
 the cerebral hemisphere that are more or less adjacent, 
 and they are found immediately beneath the cortical gray 
 matter. The long fibres, on the other hand, unite distant 
 parts of a hemisphere, and they are situated at some depth 
 from the cortex. They are described as the (a) superior 
 longitudinal fascicle, which unites the gray matter of the 
 frontal lobe with the gray matter of the occipital and the 
 temporal lobes ; (b} the inferior longitudinal fascicle, made 
 up of fibres that unite the occipital lobe and the tip of the 
 temporal lobe ; (c) the arciform fascicle or cingulum, which 
 is made up of fibres going in an antero-posterior direction 
 from the frontal to the temporal lobe (the fascicle gets 
 its name from the fact that it bends to conform to the 
 corpus callosum) ; (d} the uncinate fascicle, which connects 
 the inferior frontal convolution with the tip of the tem- 
 poral lobe immediately beneath the fissure of Sylvius. 
 These association fibres, which are formed by the axones 
 of the pyramidal cells in the cerebral cortex or their col- 
 lateral branches, are shown graphically by the following 
 diagram (Fig. 8), which, if contrasted with the diagram 
 showing the zone of language, will represent graphically
 
 Conception of Aphasia. 101 
 
 the avenues of connection between the three speech 
 centres. 
 
 All text-books on the anatomy of the brain, with the 
 one exception of Van Gehuchten's, describe under the name 
 of the cortico-protuberantial fascicle a bundle of nerve 
 fibres which unites the cerebral cortex of the frontal lobe 
 and of the occipital lobe with the gray masses constituting 
 the nuclei of the pons. But the recent researches of De- 
 jerine and of Flechsig have proven that the cortico-protu- 
 
 FlG. 8. Association Fibres. 
 
 berantial fibres, instead of arising from the cortical sub- 
 stance of the frontal and of the occipito-temporal lobes, 
 arise entirely from the gray masses which constitute- the 
 central convolutions, and the latter contends that no 
 fibres from other parts of the cortex than those of the 
 central lobe enter into the constitution of the pyramidal 
 tracts. The extremely important bearing of this on our 
 conception of aphasia will be seen later on. A second 
 fact of not much less importance than the first, but one 
 that is less generally accepted, is that heretofore it has 
 been held by many authors that every region of the cere-
 
 IO2 The Faculty of Speech. 
 
 bral cortex in man was in connection with the inferior 
 gray masses by fascicles of nerve fibres that were desig- 
 nated projection fibres. 
 
 Even so recent a writer on the subject of aphasia as 
 Mirallie has described the inferior pediculo-frontal fasci- 
 cle, which is considered by Pitres, by Raymond, by Bris- 
 saud, and by others to be of such paramount importance in 
 explaining the symptomatology of motor aphasia. But to- 
 day, in the light of the evidence furnished by Flechsig and 
 upheld by such a brilliant and trustworthy anatomist as 
 Van Gehuchten, the inferior pediculo-frontal fascicle must 
 go, and with it the idea that the projection tracts arise from 
 all or indefinite parts of the brain. It remained for Flech- 
 sig to prove, as he has done to the satisfaction of some 
 neuropathologists, although not to that of others (Deje- 
 rine), that the projection fibres exist only fora third of the 
 entire cerebral cortex, and that two-thirds of the cortex of 
 the human brain has no connection whatsoever with the 
 inferior nerve centres'. 
 
 Flechsig has shown in his study of the embryonal and 
 the postnatal cerebrum that the sensory paths are the 
 ones which first become medullated. And of these sen- 
 sory- paths the first to ripen is that concerned in the 
 sense of smell, and the last that which carries auditory 
 impulses. By^following these sensory paths to the cortex 
 he has shown that the latter may be divided into four areas 
 or spheres, to be enumerated presently. I shall make a 
 somewhat detailed review of the recent statements of 
 Flechsig regarding the localization of function in the 
 cortical area. This author has divided the cortex, first of 
 all, into two very distinct zones, the zone of the centres
 
 Conception of Aphasia. 
 
 10 
 
 of projection, or the sensory spheres, which take up about 
 one-third of the whole cortical area ; and the remainder of 
 the cortex, which is devoid of fibres of projection, but 
 which is united to the other sensory spheres by innu- 
 merable fibres of association, and to which are given the 
 names of zones or centres of association. 
 
 The zones or centres of projection comprise, according 
 to Flechsig, four sensorial spheres (Figs. 9 and 10) : 
 
 i. The tactile sphere, or somcestlietic area. It occupies 
 the entire region between the fossa Sylvii up to the corpus 
 callosum, and includes the central convolutions, the para- 
 central lobule and the posterior part of the three frontal 
 convolutions, and the midde third of the gyrus fornicatus.
 
 10.1 
 
 The Faculty of Spcecli. 
 
 This zone represents the cortical field in which terminate 
 on either side the fibres of the median fillet which do not 
 stop at the basal ganglia. These fibres carry into the 
 cortex the impulses that are concerned in sensations of 
 touch, pain, temperature, muscle and tendon sense, thirst, 
 sexual sensations, and in short, all the sensations that 
 
 FIG. io. Internal Surface of Brain, after Flechsig. A. Somzesthetic area; 
 /?, parietal association centre ; C, visual area ; D, occipito-temporal associa- 
 tion centre ; , gyrus hippocampus ; 7-", olfactory area ; G, frontal association 
 centre. 
 
 arise from within the body and inform us as to the condi- 
 tion of the body. Therefore the name, somaesthetic area. 
 This is the area in which are mirrored bodily sensations. 
 In addition to being a sensory field, this area is also the 
 great motor region from which nearly all the movements 
 serving for the voluntary satisfaction of the bodily feel- 
 ings and instincts seem to start. It is the area from 
 which the impulse starts when a person voluntarily
 
 Conception of Aphasia. 105 
 
 breathes, speaks, swallows, chews, or does any purpos- 
 ive movement. The cells of origin of the fibres conduct- 
 ing these impulses are analogous to the giant pyramidal 
 cells of the ventral horns of the spinal cord ; the axones 
 of these cells constitute the frontal cortico-protuberantial 
 fascicle of Flechsig. 
 
 2. The olfactory spJicrc. This sphere is limited t:> the 
 olfactory trigone and the adjacent part of the convolution 
 of the corpus callosum, the anterior perforated space, the 
 uncinate gyrus, which is in contact with the island of 
 Reil, and the adjacent parts of the hippocampus. 
 
 3. The visual sphere. This is situated on the internal 
 surface of each cerebral hemisphere, in the immediate 
 neighborhood of the calcarine fissure, and fibres run from 
 this tract into those adjacent areas of the occipital cortex 
 which show the macroscopic stripe of Vicq d'Azyr. The 
 centripetal fibres of the visual sphere come from the optic 
 thalamus, the external geniculate body, and the anterior 
 quadrigeminal body. Among these centripetal fibres, 
 those that come from the external geniculate body ter- 
 minate exclusively in the borders of the calcarine fis- 
 sure, while those coming from the optic thalamus and the 
 quadrigeminal tubercles terminate around this fissure. 
 This distinction, according to Flechsig, is important, be- 
 cause the external geniculate bodies receive exclusively 
 the fibres coming from the macula lutea. 
 
 4. The auditory sphere. The fibres communicating 
 auditory impulses to the cerebral cortex form the lateral 
 fillet in the pons and are connected largely with the me- 
 dian geniculate body. They terminate in the transverse 
 temporal gyri, especially in the anterior one. This sphere
 
 io6 The Faculty of Speech. 
 
 is united by centripetal fibres to the inferior quadrigemi- 
 nal body and to the internal geniculate body, and by 
 centrifugal fibres (the temporal cortico-protuberantial fas- 
 cicle) with the nucleus of the pons. Flechsig con- 
 siders these descending fibres as a motor pathway which 
 has for its function the transmission of impulses ar- 
 riving in the auditory sphere from the muscles that move 
 the ear. 
 
 In addition to these projection fibres uniting the sen- 
 sory spheres with the inferior gray masses of the brain 
 axis, there exists in each centre of projection a number 
 of fascicles, composed of centripetal and centrifugal fibres, 
 uniting the centre with the corresponding part of the 
 thalamus. 
 
 These centres of projection are in connection with all 
 the peripheral organs by a double set of nerve fibres, one 
 the ascending or centripetal fibres, which are sensory, the 
 other a descending centrifugal set of fibres, which are mo- 
 tor. These two sets of fibres end in the same cortical 
 region. According to this there is no exclusively motor 
 cortex, no exclusively sensory. The sensory spheres are 
 thus in reality the sensori-motor regions of the cerebral 
 cortex. All the impressions received by the terminals of 
 the peripheral nerves and their sensory fibres are con- 
 ducted to the tactile sphere of the cerebral cortex by 
 a series of centripetal neurons. These impressions are 
 transmitted to the cells of origin of the descending or 
 motor fibres of this same region, which then descend by 
 a series of centrifugal neurons as far as the peripheral 
 muscles. It is the same for the olfactory impressions, the 
 visual, and the acoustic. They are transmitted by the
 
 Conception of Aphasia. 107 
 
 centripetal pathways to the corresponding sensory spheres. 
 The centres of projection, considered by themselves, are 
 completely separated from the centres of association which 
 surround them, and constitute thus a sort of nervous 
 centre for reflexes of cortical origin. 
 
 When these centres have become ripe, that is, when 
 the fibres going to them and coming from them are 
 medullated, only about one-third of the whole area of the 
 cortex has been disposed of. Two-thirds of the cortex 
 appears to have nothing to do with the periphery, but is 
 reserved for other and apparently higher work. These 
 areas are the so-called association centres of Flechsig. 
 Before considering them it is well to draw attention to 
 two statements of Flechsig regarding the projection 
 areas. 
 
 The somaesthetic area is much more extensive than are all 
 the other areas combined. This disproportion should not 
 be a matter of surprise. In it are represented all the forms 
 of tactile excitation that acquaint us with the outer world, 
 and from it start all impulses by which are externalized 
 thought, feelings, desires. The olfactory sphere is very 
 little developed, because the sense of smell is so rudi- 
 mentary. The auditory sphere and the visual sphere re- 
 produce in the brain, the one the sensitive surface of the 
 organ of Corti of the internal ear, and the other the retina. 
 These last three spheres inform us of the external world 
 and are dependent for their activity on sensation coming 
 from without. The second point made by Flechsig is 
 that the sensory spheres are localized around the primary 
 fissures, the visual sphere around the calcarine fissure, the 
 tactile sphere around the central fissure, the olfactory
 
 io8 The Faculty of Speech. 
 
 sphere and the auditory sphere around the fissure of 
 Sylvius. 
 
 The zone of the association centres is formed of three 
 distinct centres : first, the posterior large association centre, 
 which comprises a part of the lingual convolution, the 
 fusiform convolution, all of the parietal convolutions, the 
 inferior temporal convolution, and the anterior part of 
 the external surface of the occipital lobe ; second, the 
 median association centre, which corresponds to the 
 island of Reil ; third, the anterior association centre, 
 which is constituted by a portion of the superior frontal 
 convolution and a large part of the median and third 
 frontal convolutions. Flechsig believes that these asso- 
 ciation centres represent arrangements which unite the 
 activities of the central internal sense organs and build 
 them up to higher limits. Sensory impressions of differ- 
 ent qualities, visual, auditory, tactile, olfactory, and gus- 
 tatory, are united, or, at any rate, the anatomical mecha- 
 nism is afforded for their union. These association centres 
 are completely independent of the inferior gray masses, 
 and are the portions of the cerebral cortex which above 
 all others are concerned in the higher intellectual mani- 
 festations, judgment, memory, etc. 
 
 The middle association centre is represented by the 
 cortex of the island of Reil. This is the centre which 
 unites all the convolutional areas bordering the fossa of 
 Sylvius, the integrity of which is indispensable for the 
 preservation of language. It belongs in part to the som- 
 jesthetic area (especially to the region for the speech 
 organs), partly to the auditory area, and partly to the ol- 
 factory area. The large posterior centre of association is
 
 Conception of Aphasia. 109 
 
 the part of the cortex which puts us en rapport with the 
 external world. It is that which unites the superior cen- 
 tres for all the sensations, tactile, visual, and acoustic, that 
 come to us from without. 
 
 Flechsig points out that the association areas, the con- 
 volutions which have no direct communication with the 
 crus, central ganglia, or the corpus callosum, are those 
 which are latest in the order of development, and on this 
 ground alone might be supposed to be concerned in more 
 strictly mental faculties, which are latest in their mani- 
 festations. These areas constitute a striking difference 
 between the human cerebrum and that of lower animals. 
 The centres of projection exist in the lower animals to 
 a very much more highly developed extent than in man. 
 But in man, on the other hand, the centres of associa- 
 tion are immeasurably greater, while as we descend the 
 scale of animal life the centres of association become 
 fewer and finally disappear. It has been noted that the 
 centres of association are often interpolated between the 
 centres of projection, so as to separate these last centres 
 completely one from another. It would seem to be in 
 accord with the general plan of construction of the 
 nervous system and with what we know of mental 
 operations, that these convolutions which are withdrawn, 
 so to speak, from direct relation with the outer world 
 should be the seat of the more purely intellectual 
 operations. 
 
 From a consideration of the morbid anatomy of some 
 cerebral diseases, especially general paresis, Flechsig has 
 come to the conclusion that the anterior association centre 
 is the part that conditions consciousness of personality
 
 1 10 The Faculty of Speech. 
 
 (Personlichkeitsbewusstsein). Lesion of this area causes, 
 in a word, loss of the faculty of abstraction. 
 
 This extensive reference to the view of- Flechsig has 
 seemed to me fitting not only because it is a most im- 
 portant advance in the interpretation of the physiology 
 of the brain, but also because it is of direct and signal 
 service in the conception of aphasia as here outlined, 
 although it is not in entire harmony with it. More- 
 over, it has a direct bearing on many problems in the 
 morbid physiology of the brain that confront the physi- 
 cian to-day. In a way, Flechsig's contentions are not at 
 all new. Views very similar- to them were expounded by 
 Broadbent nearly twenty-five years ago, when he pointed 
 out that the centres which Flechsig calls " association 
 centres" were parts of the cortex that were neither in 
 direct relation with peduncular fibres nor with those of 
 the corpus callosum. These association areas are also 
 in reality what Bastian has described as " annexes of the 
 perceptive centres." 
 
 Some of Flechsig's views, it seems to me, will be very 
 slowly accepted, particularly those referable to the projec- 
 tion systems of fibres. Already Monakow and Kolliker 
 have taken serious exception to a number of his conten- 
 tions and very recently Dejerine contests them. 
 
 e of Language Site of the Revival of Words in 
 Silent Thought. 
 
 The zone of language is a part of the brain in which 
 are carried on the processes essential to the facultas syna- 
 trix. It is that part of the brain whose function is the
 
 Conception of Aphasia. \ \ \ 
 
 necessary material substrate of conception and of com 
 prehension and expression. 
 
 By way of introduction, it may be said that when the 
 expression "zone of language" is used I do not mean 
 an area which can be mapped out on the surface of the 
 brain by unvarying mathematical lines. Rather than have 
 such interpretation put upon the use of the term, I should 
 prefer to be understood to use it merely as an expression 
 of convenience. 
 
 This speech area or zone of language is not, in all prob- 
 ability, strictly delimited. It varies in individual cases, 
 and at different periods of life in the same individual, i.e., 
 it is subject to phylogenetic variation and to ontogenetic 
 variation as well ; the latter depending somewhat on the 
 speech acquisition of the individual, arid on the range and 
 number of avenues by which he receives or has schooled 
 himself to receive information of objects. This area is 
 a receptive and an emissive centre for all forms of stimuli 
 or excitations that reach it, and which its individual de- 
 velopmental metamorphosis has accustomed it to accept, to 
 give tenancy to, and to elaborate into new forms of stim- 
 ulation. It is receptive chiefly to auditory and visual 
 stimuli, which it emits to other centres, and also to kinaes- 
 thetic, olfactory, and gustatory stimuli. It is emissive 
 to the frontal lobes and to the cortex of the Rolandic 
 region, from which start the motor projection tracts and 
 by which all thought externalization is mediated. 
 
 The speech area or zone of language is an area made 
 up of neurons, some of which send their axones into the 
 Rolandic region and into the frontal regions of the brain, 
 while others confine their distribution to the speech area
 
 i 1 2 The Faculty of Speech. 
 
 itself, and, as they do not pass outside of this area, they 
 may be looked upon as intercentral neurons. 
 
 The zone of language has no projection fibres going 
 directly into the motor projection tract ; it sends no im- 
 pulses directly to the projection tract which carries down 
 neural impulses to be externalized as speech. On the 
 contrary, the zone of language sends impulses composed, 
 in the illiterate, of auditory and articulatory memories of 
 the word, and, in the educated, of auditory, visual, and ar- 
 ticulatory memories, to the Rolandic cortex and to partic- 
 ular areas of this region, depending on the manner in 
 which the idea is to be externalized; that is, whether by 
 spoken or written word or symbol, or by some form of 
 mimetic or purposive action, which the judgment of the 
 individual decides to be most serviceable in conveying 
 the thought. If the idea is to be expressed by articulate 
 speech, the impulses are sent to that area of the Rolandic 
 region in which there is separate allocation for the move- 
 ments of respiration, vocalization, lingual and labial ac- 
 tion. This area is in the foot of the ascending central 
 convolution, adjacent to the area in which are stored sen- 
 sory memories of articulatory movements, Broca's area. 
 From here the real motor impulses start. They go down 
 through the motor projection tract, the axones of which 
 en masse form the pyramidal tract, and the central motor 
 projections of the cranial nerves, to the various muscles 
 whose contraction produces articulate speech. There is 
 reason to believe that these outgoing impulses are co- 
 ordinated, given rhythm, force, and association, not 
 in the cortex of the brain, but in stations situated in 
 the brain ganglia, the cerebellum, and the pons-ob-
 
 Conception of Aphasia, 113 
 
 longata, the centres composing these stations acting 
 automatically. 
 
 When the idea is externalized in writing, in complex 
 movements such as mimetic movements, or by a simple 
 nod of negation or affirmation, a simple movement of 
 beckoning, the genesis of the symbol or the pantomime 
 is exactly analogous to that of articulate speech. They 
 are all the result of internal language, and the person 
 who writes an impassioned editorial on some subject that 
 fires his patriotic spirit is as cognizant of the words 
 ringing within him as the orator who enunciates them 
 from the platform. The preparation of the language 
 and the words is in both cases the same. They both re- 
 quire the absolute integrity of the zone of language, the 
 only difference being that in the second instance the fin- 
 ished product is sent to the cortical area which is the cen- 
 tre of the articulo-vocal musculature, and in the other to 
 the Rolandic allocation of a much less complex motor 
 mechanism, namely, to the cortical centre of the member 
 that holds the pen, whether that member be the hand or 
 other mobile part of the body. In the case of the speaker, 
 the primary revival is in the auditory centre, and this in- 
 fluences to activity both of the other speech centres the 
 articulatory-kinaesthetic centre strongly, the visual centre 
 slightly and the perfected word is externalized by the 
 articulatory area/ o ihe Rolandic cortex. 1 In the case of 
 a writer, it is probable that the visual centre is the seat 
 of primary revival of the word, but it may be quite as le- 
 
 1 Some students of language believe that the primary revival of word 
 images in the case of the speaker is in the kinresthetic articulatory centre, 
 but I hold to the view as stated above.
 
 ii4 The Faculty of Speech. 
 
 gitimately explained by considering that this takes place 
 in the auditory area. The visual centre being then thrown 
 into a state of vigorous activity, the articulatory-kinaes- 
 thetic influenced very mildly, the finished product is sent 
 to and executed by the arm area of the Rolanclic cortex. 
 The direct association that may take place between the 
 primary revival of auditory word images and the produc- 
 tion of written symbols is seen in those rare cases of chil- 
 dren born blind, who afterwards learn to write. As 
 a rule, the visual centre conditions writing, both in its 
 development and in its production. 
 
 The action may be compared to that of a corporation 
 which is accustomed to send simple commissions to one 
 broker for execution, while other more complicated com- 
 missions, requiring the concerted action of a number of 
 people, are sent to a firm having facilities for the execution 
 of such orders, who have accustomed themselves to such 
 responsibilities. The first broker may execute offer- 
 ings in a way very similar to the second, but his transac- 
 tion is done in a different place and requires little or no 
 concerted action, while the transaction of the latter is so 
 complex that it requires the associate action of a number of 
 individuals in different locations, perhaps in different cities. 
 
 It is the same way in pantomime. Every one has felt 
 the intensity with which some simple command, such as 
 " Come back !" " Get out !" and the like, has been formed 
 in internal speech on occasions when necessity or circum- 
 stance compelled communication by signs. In such an 
 instance the words are fully formed in the zone of lan- 
 guage; we are cognizant of internal language, but our 
 judgment informs us that it is wiser to attempt to sum-
 
 Conception of Aphasia. 115 
 
 mon to us a person who is beyond the reach of the voice 
 by motioning of the hands or arms than by shouting. In 
 such a case internal speech, though fully formed by the 
 activity of centres in the zone of language, is externalized 
 by a wave of the hand, the motor impulse of which starts 
 from that portion of the cortex known as the arm-hand 
 centre, and which is externalized by simple muscular 
 movements. 
 
 All thought or ideas are revealed through words, acts, 
 and deeds, all of which are the immediate result of mus- 
 cular action. This action is conditioned by influences 
 operative on the Roland ic cortical area, for it is there and 
 there alone that movements having differentiated func- 
 tions have representation. It should be said here that 
 this is in apparent contradiction to the claims of some 
 experimentalists who teach that by excitation of the su- 
 perior temporal convolution there results contraction of 
 the musculature of the. ear, and by excitation of the oc- 
 cipital cortex there follows movement of the eyeballs. It 
 is by no means so on closer examination, and the theory 
 here suggested explains more logically than does any other 
 the slight muscular activity that results from such excita- 
 tion. All the special senses are provided with a highly 
 developed muscular mechanism whose function is to fa- 
 cilitate the action of the special sense and to contribute to 
 its perfection. The most typical example of this is the 
 complex musculature of the eyeball, which is of inesti- 
 mable importance in contributing to all of the welfare 
 and pleasure that result to one through vision. The de- 
 gree of complexity and the amount of musculature devoted 
 to any one sense are conditioned by its needs, which always
 
 1 1 6 The Faculty of Speech. 
 
 stand in definite relations to the evolutionary stage or pe- 
 riod of its possessor. In the human, the most advanced 
 product of evolution, the musculature of the external ear is 
 rudimentary, though not yet vestigial, because in man the 
 sense of hearing has reached such a rare degree of perfec- 
 tion, such an advanced .stage of development (it conditions 
 speech), that he no longer requires a trumpet-like apparatus 
 to turn reflexly in the direction from which sounds ema- 
 nate, as do lower animals. It is the same with the other 
 special senses, smell, taste, and touch. The sniffing move- 
 ments of smelling, the smacking movements of tasting, 
 the delicate movements that facilitate the tactile sense 
 and which reach such a degree of acuteness in the blind, 
 are all in evidence to show how important a part move- 
 ment plays in contributing to the exquisite function of a 
 special sense. 
 
 Every time that the eyeballs move to look at an object, 
 every time the ears are moved to contribute to the readi- 
 ness and completeness with which the auditory excitation 
 is obtained in the lower animals, there is stored up a 
 memory not alone of the object seen or the sound heard, 
 in their respective situations in the inferior parietal and 
 superior temporal lobules, but a memory register is made 
 of these movements, kinsesthetic memories, and it is 
 highly probable that where the one is registered the other 
 is registered also. It will then follow that excitation of 
 such an area might produce movements similar to those 
 the memories of which are there enregistered. Such 
 movements would result on excitation of these areas by 
 sending the impulses of excitation to the Rolandic area 
 of the cortex ; thus the movement would be in reality an
 
 Conception of Aphasia. 117 
 
 indirect one along the route exactly analogous to that 
 travelled by impulses from the zone of language to the 
 Rolandic cortical area that result in articulate speech. 
 
 I have said that all thought is externalized by words, 
 by acts, or by previous acts called deeds. Articulate 
 speech is the customary manifestation of thought, but the 
 word speech is often used generically to include other 
 forms of thought externalization, such as writing, paint- 
 ing, instrumentation, pantomime, etc., which are specifi- 
 cally called acts ; and I use it in such generic sense here. 
 
 What is said for aphasia might as truthfully be said for 
 amusia and for agraphia if it were wise to consider music 
 and writing independent forms of expression, but it is not. 
 Writing and other forms of symbolic notation are but 
 media to which mankind attach a certain conventional 
 significance in order to expedite and harmonize inter- 
 course. The possession and utilization of such notation 
 requires the integrity of the zone of language the zone 
 of symbols and the production of internal speech. In 
 order to use them, the memory images, visual, auditory, 
 and articulatory, must be revived by stimuli coming from 
 without, or spontaneously by the intelligence. In either 
 case they are jutted into consciousness or not, as the case 
 may be, after the completion of internal language, and 
 they are externalized by motion in some form. I have 
 used the phrase, "they are jutted into consciousness or 
 not, as the case may be," advisedly, for articulated and 
 written language may be produced without imperfection 
 during unconsciousness. Normal sleep is the typification 
 of unconsciousness. The time occupied by it is taken 
 out of the cognizant existence of the individual as com-
 
 1 1 8 7^ he Faculty of SpeecJi . 
 
 pletely as if he were dead ; consciousness of the slightest 
 degree is antipodal to normal sleep. Yet it is within the 
 experience of every physician to have witnessed examples 
 of pavor nocturnus, somnambulism, etc., in which articu- 
 late speech, even to a considerable extent, was produced. 
 In such cases the speech centres act harmoniously to an un- 
 known excitant. The auditory images of the word are in 
 some way revivified, and they in turn invoke the articu- 
 latory images which send their impulses to the foot of 
 the ascending frontal convolution, from which they pro- 
 ceed to cause the movements of vocalization and of articu- 
 lation. It seems very probable that, when speech im- 
 pulses from the zone of language are deposited in the 
 cortical motor area of articulation, the latter has no discre- 
 tion or decision about what it shall do with them ; it must 
 execute them at once. In the normal conscious state, 
 however, the faculty of inhibition plays the part of moni- 
 tor to this motor area of articulation and decides whether 
 or not impulses sent there from the zone of language shall 
 be externalized. If the judgment decides that it is wiser, 
 more politic, more humanizing, not to externalize the mes- 
 sages sent up from the speech area, it will annul them, 
 but they are none the less vivid in internal language. It 
 is not necessary, it appears to me, to dwell on this, for 
 every reader must be in possession of numberless experi- 
 ences conveying the truth of it. It is at trie basis of so 
 many social amenities, the retort polite, the true psychologi- 
 cal explanation of turning one cheek when the other has 
 been smitten instead of making the reply that instantly 
 arises in the zone of language, that I need dwell no fur- 
 ther on this conscious inhibition of execution of all in-
 
 Conception of Aphasia. 1 1 9 
 
 ternal language. I wish only to emphasize that in states 
 of unconsciousness the zone of language may be incited 
 to activity and send its finished product to the Rolandic 
 area cortex, which executes it, and executes it as it is sent 
 there, without inhibition, addition, or deviation by the 
 mandates of consciousness. In similar manner may be 
 explained the aphorism " In vino veritas. " Alcoholic intoxi- 
 cation brings about various degrees of intellectual abnega- 
 tion, extending up to profoundest unconsciousness. There 
 is a degree of this unconsciousness characterized by a ces- 
 sation of the inhibitory influences of consciousness over 
 the amount of internal speech that shall be externalized, 
 and when this stage is reached the veritas vini is evident. 
 The motion that externalizes ideas may be of the fingers 
 in executing a musical fantasy; it may be of any complex 
 action which " speaks louder than words." The more in- 
 tricately co-ordinate the action by which ideas are exter- 
 nalized, the more specialized is its representation in the 
 Rolandic area, and the more liable is the localized lesion 
 to cause disturbance of it. Articulate speech requires the 
 co-ordinate action of a number of highly specialized peri- 
 pheral parts. And it has been shown beyond parley that 
 the larynx, tongue, palate, and lips have special Rolandic 
 representation, while those for the execution of movements 
 of writing have no other specialization in the Rolandic 
 cortex than, that of the mobile part which holds the pen. 
 Persistent repetition of the act of writing may bring about 
 such great facility that the act is performed almost auto- 
 matically ; but practice, though contributory to perfection, 
 is not contributory to the development of a special centre; 
 and the scrivener does not possess a special centre in
 
 120 The Facility of Speech. 
 
 which arc located the graphic motor memories any more 
 than does the telegrapher a telegraphic centre, or the 
 typewriter a typewriting-centre, or the pianist a special 
 centre in which are represented the complex movements 
 of the fingers. There is a special and very definite corti- 
 cal allocation for movements of the hand and for move- 
 ments of the fingers, probably for each individual finger; 
 at least it would seem to be definitely proven that there 
 is such representation for the index finger. The acquisi- 
 tion of great dexterity from long practice in writing fa- 
 cilitates the readiness with which such specialized motor 
 centres functionate, the same as practice facilitates the 
 execution of all acts, voluntary and involuntary. And 
 this facilitation may become so great that the muscular 
 movements required are made quite unconsciously, ap- 
 parently automatically, as witness the movements of the 
 telegrapher's fingers when they touch the keyboard, or of 
 the violinist as he fingers the strings. Nevertheless, not- 
 withstanding this facilitation, which may be dependent 
 anatomically upon new association tracts, the essential 
 constitution of the act is the same as it was in the begin- 
 ning, and no short cuts have been formed nor has a new 
 centre been developed. 
 
 I shall return to the discussion of a special writing-cen- 
 tre later on, but before doing so it seems to me desirable 
 to cite some of the evidence that may be offered in sup- 
 port of separate localization in the Rolandic regions for 
 the movements of the larynx, palate, tongue, lips, and 
 respiratory movements before taking up a discussion of 
 the constitution of the speech area and the closer relation 
 of the centres there situate to other parts of the brain.
 
 Conception of ApJiasia. 1 2 1 
 
 Because of the importance that I attribute to clinico-path- 
 ological observation in comparison with the experiment- 
 al, although fully cognizant of the great value of the 
 latter, I shall cite first, as briefly as possible, a few cases 
 that have been studied clinically and anatomically which 
 seem to give unequivocal support to such localization. 
 And before doing this, I shall call the reader's attention 
 to the necessity of bearing in mind that in this mono- 
 graph the term Broca's convolution is not used in the 
 sense which many writers of the last generation would 
 give to it to include the foot of the third frontal convo- 
 lution, the lower part of the ascending frontal convolution, 
 and the lower part of the ascending parietal convolution, 
 and thus not only the entire frontal operculum but a part 
 of the parietal as well. In this treatise the term Broca's 
 convolution is used synonymously with " foot of the third 
 frontal convolution," and its physiological synonym may 
 be said to be " centre for articulatory kinaesthetic images." 
 A case reported by Elder 1 is one of much importance. 
 The essentials of this case are as follows : A man sixty 
 years old, who had previously been healthy, suddenly 
 developed difficulty in speaking. Speech became in- 
 distinct and blurred, and saliva trickled from the mouth. 
 On the following day he was so weak that he demanded 
 admission to the hospital, and it was then found that 
 there was paresis of the right side of the face, more 
 marked in the lower part and at the angle of the mouth 
 and not involving the orbicularis palpebrarum. The pa- 
 tient was perfectly conscious, understood everything that 
 was said to him, had no hemiplegia, and his only trouble 
 
 1 Elder : Edinburgh Hospital Reports, vol. :ii., 1895.
 
 122 TJie Faculty of Speech. 
 
 apparently was incapacity to enunciate words, due to diffi- 
 culty in moving the tongue, lips, and other muscles of artic- 
 ulation as readily as was necessary. There was no aphasia. 
 The voice was unimpaired. He could protrude the tongue, 
 although it came out rather slowly, and there was diffi- 
 culty in swallowing liquids. The patient grew weak very 
 rapidly and died five days after the occurrence of the dys- 
 arthria, the immediate cause of death being hypostatic 
 pneumonia, coma, but no hemiplegia having preceded 
 death. On examination of the brain, there was found in 
 the lower part of the ascending frontal convolution, about 
 half an inch from the Sylvian fissure, a blood clot which 
 had pushed its way through the cortex and which could 
 be seen before cutting into the hemisphere, so completely 
 had it destroyed the cortical substance. On slitting the 
 brain horizontally, the blood clot was found to contain 
 about two drachms of blood, situated at the level of the 
 lower part of the ascending frontal and the ascending 
 parietal convolutions. It had destroyed almost entirely 
 the cortical substance of the lower end of these convolu- 
 tions. It did not involve quite the whole of the lower 
 end of the ascending frontal, as there remained intact a 
 strip of cortex adjoining the foot of the third frontal. 
 The foot of the third frontal was quite intact. The ac- 
 companying diagram shows the extent of the lesion, both 
 as it appeared from a view of the uncut hemisphere and 
 on horizontal section (Fig. n, A). Internally, the hem- 
 orrhage extended inward and forward immediately about 
 the level of the lenticular nucleus in a very thin layer for 
 about two-thirds of the distance between the cortical sur- 
 face and the internal surface of the hemisphere. Its far-
 
 Conception of Aphasia, 
 
 123 
 
 thest point internally was close to the anterior limb of the 
 internal capsule and quite in front of the motor tract. 
 The situation and extent of the lesion is shown in pip;, 
 n, B. 
 
 This observation is almost equal to a mathematical 
 demonstration, so convincing is it that a localized lesion 
 of parts of the cortex which 
 are strictly motor, namely, 
 the Rolandic-area cortex, 
 
 ./i 
 
 may when diseased be at- 
 tended by inability to make 
 the peripheral associations 
 or movements necessary for 
 speech. It is not the only 
 one of its kind on record, 
 but it is the most con- 
 vincing one on account of 
 the fact that there were no 
 complicating lesion and, of 
 course, no other symptoms. 
 Then the strictness with 
 which the lesion was con- 
 fined to the lower part of 
 the Rolandic cortex, i t s 
 sharp delimitation from the 
 third frontal convolution, 
 and the rapidity with which 
 death followed the occur- 
 rence of the lesion, all tend to make it an ideal case in 
 proof of the claim of separate localization for the peri- 
 pheral speech mechanism. 
 
 Fig. ii. A y Subdivision of Broca's 
 convolution, according to Elder, a, 
 Centre of psycho-motor speech im- 
 ages ; b, centre for adduction of vo- 
 cal cords ; c and </, articulo-motor 
 centre ; e / g; centre for lower and 
 upper face, respiratory movements of 
 larynx, respectively ; dotted circle in- 
 dicates seat of lesion. .#, Lesion on 
 cross-section.
 
 124 Th e Faculty of Speech. 
 
 Cases in which there has been subcortical lesion of the 
 motor tracts that come from somewhat indefinite parts of 
 the Rolandic area are recorded to a considerable number; 
 but, no matter how carefully they have been observed or 
 the pathological lesion has been described or depicted, 
 they never can be offered as absolute proof, because 
 the fibres which are interrupted by such a subcortical focus 
 of disease can never be said positively to come from a 
 definite localized part of the cortex. Moreover, it is ex- 
 tremely rare for a subcortical lesion to be so limited that 
 it will sever the fibres going from one small area of the 
 cortex and leave intact all the others, for it will be remem- 
 bjrcd that the projection fibres continually approximate 
 one another from the time they leave the cortical cells 
 until they are brought into the internal capsule, where they 
 are crowded together in a space that is little more than 
 visible to the naked eye. 
 
 Dejerine 1 has described two cases of subcortical lesion 
 in which a small area of softening existed just internal to 
 the anterior nart of the foot of the ascending frontal con- 
 volution. These patients had the symptom complex of sub- 
 cortical motor aphasia and were not hemiplegic, which 
 shows that the lesion was not of sufficient extent to involve 
 any of the projection fibres coming from the arm or the leg 
 areas. The only discordant symptom in these cases of 
 Dejerine was that in both cases there existed a degree of 
 paralysis of the right vocal cord; in one case the paralysis 
 was complete, and in the other partial. This is in contra- 
 diction to the findings of experimentalists, who believe that 
 
 1 Dejerine : " Aphasie motrice sous-corticale et localisation cerebrale des 
 centres larynges." Societe Biologic, 1891, p. 97.
 
 Conception of Aphasia. 125 
 
 the vocal cords have a bilateral and double representation; 
 that is, stimulation of the vocal-cord centre on one side 
 of the brain will cause adduction of both vocal cords, and 
 therefore lesion of one side should not cause complete 
 paralysis of either vocal cord. This apparent contradic- 
 tion, however, should not stand in the way of utilizing 
 the cases to prove that a lesion subcortically situated in 
 the brain, that cuts off the projection fibres coming from 
 the lower end of the ascending frontal convolution, will be 
 followed by a degree of dysarthria which may be so com- 
 plete that the patient is devoid of articulate speech, and 
 therefore of proving that the movements necessary for ar- 
 ticulate speech have a cortical representation all in one 
 definite area of the Rolandic zone. 
 
 Bernheim 1 has recorded a case which indicates with a 
 good deal of directness the cortical localization of lingual 
 movements. Clinically, there was pronounced deviation 
 of the tongue to the right ; no other paralysis, and no 
 aphasia. After death there was found a sarcomatous blood 
 cyst, five to six millimetres long, located near the inferior 
 border of the left ascending frontal convolution, about six 
 millimetres behind the sulcus which separates it from the 
 third frontal. 
 
 An observation of Garel * is strikingly corroborative of 
 Dejerine's contention that the cortical laryngeal centre is 
 situated in the lower end of the ascending frontal convolu- 
 tion. In this case, the principal symptom was paralysis 
 of the vocal cords. The autopsy showed a localized me- 
 
 1 Bernheim : "Contribution a 1'etude des aphasies." Rev. Med., pp. 
 372-388, 1891. "Des aphasies." Congres Francais de Med. Interne, 
 Lyon, 1894. 
 
 *darel : Ann. des Mai. de 1'Oreille, du Larynx, etc., April, 1890.
 
 126 The Facility of Speech. 
 
 ningo-encephalitis at the lower end of the right ascending 
 frontal convolution. 
 
 The cortical representation of the laryngeal muscles .has 
 been carefully studied by Krause, by Masini, Beevor, and 
 by Horsley and Semon. Their conclusions regarding the 
 centre for the laryngeal movements are very much in ac- 
 cord. They show that in the ape the centre for the larynx 
 is situated in the anterior part of the foot of the ascending 
 frontal convolution, that the representation is bilateral, but 
 that the preponderant representation for the vocal cords of 
 one side is in the opposite hemisphere, and that each hem- 
 isphere governs the movements of both vocal cords. Wal- 
 lenberg has published a case in which there was laryngeal 
 paralysis of the left side, and the projection fibres from the 
 portion of the cortex in which the laryngeal centre is situ- 
 ated were entirely destroyed. The experimental physiolo- 
 gists furthermore have proven that in the anthropoid the 
 centres for the movements of the lip and the tongue are 
 situated in the lower part of the ascending frontal and 
 the ascending parietal convolutions, and that these move- 
 ments are not represented in any way in the third frontal 
 convolution. They have shown, furthermore, that the 
 centres for the movements of the- muscles of the tongue, 
 throat, and mouth are situated adjacent to one another in 
 the central convolutions on either side of the fissure of 
 Rolando, and that the centres for the angle of the mouth 
 and the upper part of the face are placed higher up, tow- 
 ard what is generally known as the face area. 
 
 The part of the cortex to which the centre for respiratory 
 movements is allocated is yet unknown. Respiration is 
 essential to speech, and, although we may produce sep-
 
 Conception of Aphasia. 127 
 
 arately the three distinct mechanisms of respiration, vocal- 
 ization, and articulation, it is by the simultaneous activity 
 and co-ordination of these three that perfect speech is pro- 
 duced. As respiration, then, seems to be one of this im- 
 portant triad, and, as it is positively proven that the other 
 two have a cortical representation in the Rolandic region, 
 it seems reasonable to assume that there is a cortical centre 
 or area for respiration. This representation is a diffi- 
 cult one to prove, because respiration is more completely 
 under the control of the reflex centre situated in the 
 oblongata than is any other function. The only experi- 
 mental evidence that can be utilized in favor of the 
 localization of the movements of respiration is that 
 of Horsley and Semon, who found that stimulation of 
 the frontal convolution immediately adjacent to the face 
 area in the ascending frontal caused an increase in the 
 rate and in the force of respiratory movements. In the 
 dog and in the cat, Franck has shown that by stimu- 
 lation of the motor areas of the cortex decided accelera- 
 tion or slowing, according to the duration and the intensity 
 of the stimulation, v/as prodrced. 
 
 After this brief account of the separate localization 
 of parts concerned in the externalization of articulate 
 speech, I may, before discussing the relation of speech to 
 consciousness, intelligence, or, in general, to the frontal 
 lobes, revert for a moment to the relative positions of the 
 centres of speech in the area of language. As I have pre- 
 viously said, these centres are three in number : the centre 
 for auditory memories, the centre for visual memories, and 
 the centre for articulatory kinaesthetic memories. The lat- 
 ter, unfortunately, is often called the centre for motor memo-
 
 128 The Faculty of Speech. 
 
 ries. These three centres have a very definite localization, 
 and their position is of great ontogenetic importance. The 
 centre in which are stored the images of articulation is 
 situated in the third frontal convolution immediately adja- 
 cent to that portion of the Rolandic cortex the cells of which 
 give origin to the projection fibres going to the tongue, 
 the lips, and the larynx ; that is, to the parts which supply 
 the peripheral mechanism of articulate speech. Where 
 else should such a centre be, if its fullest integrity were 
 desired, than immediately adjacent to the part whose com- 
 missions it executes? The centre in which are stored the 
 visual images is situated in a definite part of the inferior 
 parietal lobule, in that portion of the lobule known as the 
 angular gyrus, and if we have in mind the central projec- 
 tions of the optic tract after it leaves the external genicu- 
 late body, the anterior quadrigeminal body, and the pulvinar 
 of the thalamus, until they reach the lingual and fusiform 
 lobules bordering the calcarine fissure, we shall appreciate 
 that the angular gyrus is the most direct, the most adja- 
 cent, and the most elective place in which the visual images 
 could be stored. In fact, its relationship to the primary 
 visual centre and to the fibres that convey visual im- 
 pulses, the radiations of Gratiolet, is analogous to the en- 
 vironmental relationship between the centre for art i dilatory 
 memories and the Rolandic cortex that externalizes speech, 
 but there must always be a revivification of the articu- 
 latory kinaesthetic memories before speech can be pro- 
 duced. The third centre, the auditory centre, the most 
 important of all speech centres, the one by whose func- 
 tioning speech is developed, the one that conditions speech 
 more than do both the others combined, the one in which
 
 Conception of Aphasia. \ 29 
 
 words are primarily revived in the vast majority of peoples, 
 the one that is least tolerant of disorder without mani- 
 festing itself by imperfections of speech, is situated be- 
 tween these two centres in the zone of language, and oc- 
 cupies the first temporal convolution and particularly that 
 portion of the cortex which surrounds the temporo-parietal 
 sulcus. It occupies such a position in relation to the dis- 
 tribution of the auditory nerves and the mechanism of 
 hearing that experimentalists as well as clinicians have 
 been led to posit it as a general auditory area. The 
 centre for the storage of auditory memories is not placed 
 anywhere in the general auditory area : it is placed in 
 the posterior part of the first temporal immediately ad- 
 jacent to the gyrus in which are stored visual memories. 
 Thus it will be seen that the auditory and visual mem- 
 ories which are contributory to the development of speech 
 and education in general are not widely separated. They 
 are not so far removed from each other that a great dis- 
 tance must be travelled before the products of one can be 
 compared with those of another ; they are, on the contrary, 
 immediately adjacent. On the other hand, they are not 
 adjacent to the centre in which are stored the memories of 
 articulation, and to which the products of the activity of 
 the former two are sent before they go to the Rolandic- 
 area cortex to be executed. Furthermore, the location of 
 the visual and auditory centres on the one hand, and of the 
 centre for articulatory memories on the other, would seem 
 to me to have a very definite suggestiveness in relation to 
 the frontal lobes, which physiologists, psychologists, and 
 pathologists believe to be the most essential parts of the 
 brain for the production of the higher mental processes 
 9
 
 130 The Faculty of Speecli. 
 
 judgment, will, inhibition, and emotions and whose 
 integrity must be maintained if the individual is to de- 
 velop or persist in habits of attention, concentration of 
 thought, balance of feeling, sound judgment, and moral 
 conduct. In a previous portion of this chapter we have 
 referred to the important part played by consciousness 
 or intelligence in the faculty of speech. The relation 
 which the zone of language bears to the frontal con- 
 volution, topographically and morphologically, is not 
 without its significance. A glance at Fig. 7 which repre- 
 sents the zone of language will show that it is on the 
 lateral surface of the brain; that behind, it is contigu- 
 ous with the visual area ; below, with the auditory area ; 
 above, with the motor executive area, and in front with 
 the intellectual area. This speech zone, this zone of lan- 
 guage, receives information ; it is apperceptive of impulses 
 coming into it, mainly from below and behind; it sub- 
 mits them to the area in front, and they are externalized 
 by the Rolandic area. It is, then, one great association 
 sphere of the brain, in which are located for reasons of 
 expediency certain centres for the reception of impulses. 
 But the reception of impulses alone could not give rise to 
 intelligent speech. Even granting them a certain auton- 
 omy, they could give rise only to an echo of the impulse, 
 and this is often beautifully illustrated in certain forms 
 of sensory aphasia in which one of the centres is destroyed 
 and the circuit for internal speech broken ; the patient, 
 though still capable of receiving in his zone of language 
 some speech impulses, has not the means to co-ordinate 
 them and submit them to the intelligence, and he can only 
 echo sounds heard, a condition called echolalia.
 
 Conception of Aphasia. 1 3 1 
 
 Pathological observation and clinical experience are in 
 fullest accord with this conception of language, and if 
 clinical experience has proven one fact more conclusively 
 than another to the satisfaction of trustworthy observers, 
 it is that no centre of this zone of language can become 
 disorganized without there appearing a perversion of func- 
 tion, not alone of the centre that is destroyed, but of 
 all the others ; in short, that in every form of genuine 
 aphasia, whether it be so-called motor, auditory, or visual, 
 there is some perversion of idea externalization and of 
 language. It is to Dejerine and his pupils, Mirallie, 
 Thomas and Roux, that we owe the proof of this state- 
 ment more than to any others, and to them we cheerfully 
 accord deserved praise for maintaining their contention in 
 the face of very nearly universal opposition. 
 
 Perversion of internal language is manifest most dis- 
 cernibly by disorder of internal reading. During the 
 past few years I have examined all my cases of aphasia, 
 whether motor or sensory, with the object in view of de- 
 termining whether or not there was defect of internal or 
 mental reading, and thus of corroborating the statement 
 of Dejerine. I have found that in every case, without 
 exception, examined with sufficient care and patience and 
 in the right way, there was detectable loss of the ability 
 to read mentally. Naturally, it is in the cases of cor- 
 tical motor aphasia that the results are of great im- 
 portance, for in genuine sensory aphasia, visual and 
 auditory, there necessarily exists disturbance of mental 
 reading. As I shall say in the chapter on articulatory 
 or true motor aphasia, disturbance of reading has been 
 noted by nearly every observer from the time of Trous-
 
 132 The Faculty of Speech. 
 
 seau, and various explanations have been put upon its 
 occurrence, the usual one being that it was the result of 
 either a slight dementia or a mixed aphasia. According 
 to the conception of aphasia which I have attempted to 
 outline, defect of mental reading is just as likely to oc- 
 cur in a patient with cortical motor aphasia, although not 
 so profoundly, as in a patient with auditory aphasia. 
 
 The degree of dyslexia that occurs when the convolu- 
 tion of Broca is diseased is discussed in another chapter 
 (Chapter V.), but it needs to be mentioned here that one 
 reason for its less common recognition, and therefore for 
 the unwillingness on the part of certain writers to admit 
 its occurrence, is the fact that after it has existed for a 
 certain length of time it is only slight and very often 
 latent. These patients essay to read and often busy them- 
 selves for hours with books and papers, from which they 
 apparently get the customary enjoyment and diversion. 
 On the other hand, after the alexia has lasted for a time, 
 the patient may learn anew to read, and the fact that he 
 learns anew in a manner which is entirely the reverse of 
 that which he employed when a child has been used by 
 modern pedagogues as an argument in favor of the word- 
 and-syllable method of learning to read. The patient with 
 cortical motor aphasia who must re- learn to read does so 
 by first getting the perspective of the word, the outline, 
 then the syllables that constitute the word, and, last of all, 
 the letters and their association that enter into the forma- 
 tion of the word. Thus they learn to read in a way simi- 
 lar to that at present advanced by many educationalists, 
 and the reverse of the way in which most of us learned to 
 read.
 
 Conception of Aphasia. 133 
 
 It will be seen at a glance how materially this concep- 
 tion of aphasia differs from that which is taught by a ma- 
 jority of writers on the subject of aphasia to-day. Even 
 the most recent writers on the subject, those who essay 
 to contribute to our knowledge of aphasia, of whom we 
 may mention Wyllie, Elder, and others, as well as those 
 who have no such object, who merely restate in their own 
 way that which passes as current knowledge, describe dif- 
 ferent forms of aphasia and the different centres diseased 
 to produce these forms, as if the faculty of language were 
 made up of a different set of entities and each of these 
 entities were localized to a different part of the brain. 
 The conception of aphasia that passes muster to-day with 
 the majority of writers is one suggested by Marce, in 
 1856, and which was adopted by Charcot ; and the wide 
 dissemination and acceptance that have been given to it 
 are largely due to the assiduous and lucid teachings of the 
 latter. I shall now concern myself particularly in showing 
 that these views are no longer tenable. At the very outset, 
 I wish to say that it is not the logic of the arguments of 
 Charcot and his followers with which I am concerned, 
 but it is with the original contention, which is, I believe, 
 entirely unwarranted. 
 
 Charcot and his school, as well as many other writers on 
 aphasia who are entirely opposed to Charcot' s concep- 
 tion of it, such as Bastian, believe that there are four 
 speech centres. I have already stated that the Charcot 
 school teaches the autonomous action of these centres, 
 although admitting that they have a certain functional 
 interrelationship. These centres on the emissive side of 
 language are the articulatory motor and the graphic motor,
 
 134 The Faculty of Speech. 
 
 and on the receptive side the centres for auditory images 
 and for visual images. These centres have a definite au- 
 togenetic individuality, which is augmented decidedly by 
 education. Depending upon this congenital or inherited 
 tendency for the predominance of one centre over an- 
 other, and contributed to by education, the individual 
 acquires a knowledge of things, their properties, their 
 names, their usage, principally by the employment of one 
 of these centres. In speech, words are revived predomi- 
 nantly by the activity of one of these centres, and in 
 speaking he orients himself through the activity of this 
 individual centre. Depending upon the centre that plays 
 such an important part in the primary revival of words, the 
 individual is said to be a visuel, a moteur, an audit if, a 
 gmpJiic moteur, or an indifferent, both in the acquisition 
 of knowledge by language and in the use of knowledge by 
 language. Leaving aside for the time being the fact that 
 psychology, physiology, and pathology are in accord in 
 denying the autonomous existence of any one of these 
 centres, this theory of Charcot and of his followers must 
 stand or fall with the existence of the four centres, and I 
 venture to believe that we are in possession of sufficient 
 evidence to deny the existence of a graphic motor centre. 
 I have striven to show that the zone of language con- 
 tains three centres, each of them the seat of memory 
 images of a sensory nature and none of them of absolute 
 autonomous activity. That they are relatively inter- 
 dependent, and that one cannot be deranged without 
 causing some disturbance in the totality of function 
 of these three centres, has already been shown. Indeed, 
 in the early history of aphasia, before Broca made his
 
 Conception of Aphasia. 135 
 
 memorable observations, Naugere taught that disturbance 
 in the production of one component of speech manifested 
 itself by disorder of all the others. These teachings 
 were followed by Gairdner and by the Nestor of English 
 neurologists, Hughlings Jackson. According to the the- 
 ory of Charcot, the emissive centres of speech, the articu- 
 latory motor centre and the graphic motor centres, are 
 loci in which are stored the motor memories of articulation 
 and the motor memories that guide the hand in writing. 
 Indeed, it is not entirely apparent that this savant was 
 not of the opinion that these centres are the places in 
 which originate the motorial impulses that are external- 
 ized as speech and as writing. The localization of these 
 two autonomous centres Charcot believed to be absolute, 
 and he fixed the one for graphic motor images in the foot 
 of the second frontal convolution, and that for articulatory 
 motor images in the foot of the third frontal. The fre- 
 quent association of motor agraphia and motor aphasia he 
 explained by the juxtaposition of the centres, and he 
 averred, apparently in the face of conclusive contradictory 
 evidence, that a lesion that destroys the third frontal does 
 not entail agraphia. The coexistence of motor agraphia 
 with motor aphasia he claimed was not necessary, and it 
 might be said that since then his pupils, Pitres, Grasset, 
 Marie, Brissaud, and others have claimed the same and 
 contend that there are cases of pure motor agraphia with- 
 out aphasia, but the cases they cite to substantiate their 
 position do not stand the test of analytic scrutiny 
 
 It will readily be seen how opposed to our conception 
 of speech and of the function of the zone of language 
 is this conception of Charcot. In one word, according
 
 136 The Faculty of Speech. 
 
 to his teaching, the centre is all- important ; according to 
 ours, the centres are important, but only as one indi- 
 vidual in a community. I have no intention of dwelling 
 further on this distinction, except to show the untenability 
 of the position of the school of Charcot by discussing the 
 existence of a graphic motor centre. 
 
 Is there a GrapJdc Motor Centre for Registration and 
 Regulation of Writing- Movements f 
 
 The most important evidence that the claimants for the 
 existence of a graphic motor centre, in which are stored 
 the motor images of writing (which by this school are 
 looked upon as a constituent part of the idea of the word), 
 can offer is that which was furnished by Exner, 1 of Vi- 
 enna, in 1 88 1. It is not hazarding the truth to say that 
 the evidence offered by Exner in support of the exist- 
 ence of such a centre would not be admitted as proof in 
 any other department of science than medicine. Never- 
 theless, it has been admitted to the latter and it must, 
 therefore, be discussed. It was the necessity for the 
 existence of such a centre apparently that led Exner to 
 seek it, and Charcot," seeing in it a contribution to his 
 
 1 Exner: " Untersuchungen liber die Localisation der Functionen in 
 der Grosshirnrinde des Menschen." 
 
 * It is astonishing how universally accepted is the existence of a particu- 
 lar or undivided graphic motor centre. Writer after writer accepts the 
 findings of Exner in a way that leaves the impression that no doubt can 
 possibly exist concerning the reality of the centre. Even Bastian, who is 
 not a believer in the complete topographical distinctness of the several 
 sensory centres in the cerebral hemispheres, and who has been one of the 
 most unswerving opponents to the conception of aphasia taught by the 
 school of Charcot, says, in the Lumleian Lectures, the first of which ap- 
 peared after this monograph was practically finished, that " the grapho-motor 
 centre can be localized with nearly as much confidence as the articulatory
 
 Conception of Apkasia. 137 
 
 theoretical exposition of the faculty of language, ac- 
 cepted it. 
 
 Exner made an artificial division of the external, internal, 
 and inferior surfaces of the cerebral cortex. There was no 
 method in his division, no rule, no preconception. So far 
 as possible the principal fissures were the lines of separation 
 of these artificially outlined areas, but this was merely for 
 the sake of convenience and ease of orientation. The areas 
 had different shapes and sizes, so that when the division 
 was made the result might be compared to a territorial 
 map of the United States. If one will look at such a 
 map, he will see that oftentimes natural divisions, rivers 
 and mountains, separate the States. These are the prin- 
 cipal fissures of Exner, but in most cases the division is 
 arbitrary. He then searched the literature of local brain 
 disease and made notes of three hundred and sixty-seven 
 cases, to find how many times any one area was the seat 
 of lesion in the cases observed and how often each area 
 was affected when individual symptoms had been observed 
 in relation to the disease. 
 
 I do not deem it necessary to give the details of his 
 analysis but may say that the majority of his conclu- 
 sions do not correspond with the present teachings as to 
 cerebral localization. The correspondences that do exist 
 might laudably be explained by chance. The fact that 
 
 kinaesthetic centre." There is such a dubiousness about his further state- 
 ment of its localization that I shall quote his exact words. " The tendency 
 for some years has been to follow Exner, who believes the graphic motor 
 centre to be situated in the posterior part of the second frontal gyrus, 
 though we shall see later the evidence in favor of this localization is at 
 present extremely scanty. All that can be said on this point, therefore, is 
 that we know approximately where to look for it." This, it would seem to 
 me, scarcely warrants the language of the first quotation.
 
 138 The Faculty of Speech. 
 
 every brain varies in fissuration, in convolutional area, and 
 in formation, and the fact that no one surface marking can 
 be taken to fit another brain, make it difficult to see how 
 any definite inferences could be drawn from such a method 
 of investigation. This method would seem to me to be 
 paralleled if a sociologist who had become convinced of a 
 definite locus for homicides should set to work to substan- 
 tiate his contention by getting statistics of the number of 
 men slain in the United States, let us say in ten years, 
 and then statistics to show how many homicides were to be 
 found living in any State, and how many times the victims 
 were found in any given State. The State that had the 
 greatest number of homicides and the greatest number of 
 victims would be a homicidal centre. It would depend 
 upon the sociologist whether or not that State would be 
 considered the only homicidal centre. In seventy-three 
 of Exner's cases there were lesions that gave rise to paral- 
 ysis of the face, and of these about one-half were grouped 
 in the median part of the ascending central convolution, 
 while four of them showed lesion of the third frontal ; 
 fourteen, lesion of the second frontal ; eleven, lesion of 
 the angular gyrus ; eight, lesion of the first temporal, etc. 
 It must be granted that such contributions as these are 
 not of much service in helping to give brain localization 
 scientific exactitude. Let us take, for instance, another 
 example. The lesion in one hundred and thirty-one cases 
 was one that caused paralysis of the upper extremity, and 
 in eight of these cases the third frontal was the seat of 
 lesion, in thirteen the second frontal, in eleven the first 
 frontal, in twenty-three the ascending frontal, in eighteen 
 the ascending parietal, in fourteen the superior parietal,
 
 Conception of Aphasia. 139 
 
 in thirty-three the angular gyrus, and so on. In other 
 words, the area of the cortex for the representation of the 
 arm is distributed all throughout the brain cortex. Let 
 us contrast this for a moment with the facts as they really 
 exist. All clinicians and anatomists are in accord in allo- 
 cating to the cortex of the central lobes, particularly the 
 ascending central, the representation for the upper ex- 
 tremities. 
 
 Exner's analysis of the cases taken from the literature, 
 and studied by the men who had reported the cases, 
 showed only four instances in which agraphia had been 
 present. In all of these, with the exception of a case 
 reported by Bar 1 in 1878, there were multiple lesions in 
 the brain. In Bar's case, the symptoms had been motor 
 aphasia, agraphia, and facial hemiplegia, and the lesion 
 was localized in the foot of the second frontal convolution ; 
 therefore Exner posits this convolution as a graphic centre, 
 and by dint of repetition by writers on aphasia since Ex- 
 ner's claim was first made this fallacy has taken an almost 
 undislodgable place in medical teachings. It seems to 
 have been forgotten that the patient had motor aphasia 
 and only partial agraphia. He could not express his 
 thoughts in writing, no more could he in speech. If 
 the lesion was of the graphic motor centre and strictly 
 confined to it, as we are told that it was, why was the 
 agraphia not total and why did the patient have aphasia? 
 The fact that he had aphasia is evidence enough that 
 there was lesion of the zone of language (a subcortical 
 lesion being excluded), and the fact that he had motor 
 
 1 Bar : " Aphasie et hemiplegie faciale passagere." La France Medicale, 
 1876, p. 609.
 
 140 The Faculty of Speech. 
 
 aphasia is sufficient explanation of the partial agraphia. 
 The former entailed the latter. This case, therefore, instead 
 of lending itself to Exner's claim, to Charcot's theory, or 
 to Ziehen's argument (not to mention the scores of other 
 writers on aphasia who have quoted it with the reverence 
 accorded to Scripture), is unequivocally opposed to them. 
 
 The ideal case to prove the existence of a centre 
 whose function is to store graphic images, and whose de- 
 struction would cause agraphia, would be one in which 
 there was inability to write sponanteously and from dic- 
 tation, and in which no disturbance of motility, partic- 
 ularly no disturbance of the right upper extremity, no 
 aphemia, no alexia (that is, no inability to read aloud), no 
 verbal deafness, and no verbal blindness existed. It is 
 remarkable, considering the zeal of physicians in ob- 
 serving and reporting cases of aphasia during a period 
 which now covers nearly a half of a century, that no such 
 case has been recorded. It is also remarkable that no 
 instance has been reported in which there was strict limi- 
 tation of the lesion to the second frontal convolution, with 
 the exception of Bar's case, which has been already 
 mentioned. 
 
 Although clinical cases should not be allowed to bear 
 absolute testimony in favor of the existence of a separate 
 centre for graphic motor images, when such are unaccom- 
 panied by autopsy, nevertheless, a number of clinical cases 
 have been reported in which the evidence, on superficial 
 examination, seems to point with great certainty to the ex- 
 istence of such a centre. Although all of these cases can- 
 not be considered here, I shall cite a few of them to show 
 that a different and satisfactory interpretation can be put
 
 Conception of Aphasia. 141 
 
 upon them, one that does not require the existence of 
 a graphic motor centre. A case of this kind that has 
 often been cited to prove the existence of such a centre, 
 but which has been interpreted by Dejerine and others 
 in an entirely different manner, is one reported by Pitres. 1 
 In this case, Pitres says, there was no disturbance of in- 
 telligence, nor was there paralysis of the right side. There 
 was no trace of word deafness or of word blindness. 
 Nevertheless, the patient was incapable of expressing a sin- 
 gle thought by writing, and he was quite as incapable of 
 writing from dictation. Examination of the patient nearly 
 ten years after the history was first published showed that 
 the conditions were practically unchanged ; that is, that 
 still the unique symptom was agraphia. It therefore 
 seemed probable to Pitres that this one symptom, per- 
 sisting unchanged for such a long time, was the result of 
 lesion of a region of the brain which, does not serve men- 
 tal vision, nor yet phonetic articulation, but which pre- 
 sides uniquely over the motor excitation of writing. It 
 does not seem to me that such inference is at all warrant- 
 able. In Pitres' last reference to this case he has neg- 
 lected to mention one or two very prominent symptoms, 
 whose importance is, I believe, vital. In the first place, 
 the patient had hemianopsia, and, in the second place, he 
 was able to write with the left hand. These two facts 
 alone would seem to me to stamp the case as one of sen- 
 sory agraphia dependent upon a unilateral subcortical le- 
 sion that had interrupted the connection of the area in 
 which is stored the visual memory of words, the angular 
 gyrus, with the motor zone of the left hemisphere, leaving 
 
 1 Pitres : " Agraphie motrice pure." Rev. Med., 1884, p. 855.
 
 142 TJie Faculty of Speech. 
 
 the connections with the right hemisphere intact. In 
 such event, the patient would be unable to project the 
 visual images of letters and words which were properly 
 conserved to the Rolandic-area cortex of the left zone, 
 but there would be no impediment to the passage of such 
 images to the right Rolandic area. Therefore the in- 
 ability to write with the right hand would follow as a 
 natural consequence, likewise the ability to write with 
 the left hand after the latter had been trained to writing- 
 movements. Pitres states that the patient, on being asked 
 to write the word Bordeaux, said that he could call up in 
 the mind, that is, visualize, most distinctly the word Bor- 
 deaux, but he could not write it, and the author offers this 
 in evidence that the inability to write was not due to loss 
 of visualization of words, but was due to destruction of a 
 centre in which are stored graphic motor images. To 
 quote the patient's own language,"! know very well, " 
 said he, " how to write the word Bordeaux, but when I 
 wish to write it with the right hand I cannot make any- 
 thing." This appears to me to be the keynote to the 
 interpretation of the case. The centre of visual images 
 was intact, but the pathway by which images travel to the 
 hand centre in che Rolandic-area cortex, to be externalized, 
 was interrupted. Therefore he could not write anything 
 with the right hand. Pitres very correctly says that this 
 is quite different from sensory agraphia, and so it is from 
 sensory agraphia due to destruction of the angular gyrus, 
 but it is not different from the cases of agraphia due to 
 a subcortical lesion. If there be a centre in which are 
 stored graphic images of words, it would seem to me that 
 destruction of this centre must entail complete agraphia,
 
 Conception of Aphasia. 143 
 
 not only for one hand, but for the other, and for any other 
 part of the body which may be trained to hold the pen. 
 If this is not so, then persons who are capable of writing 
 as well with the left hand as with the right, as I am, must 
 have a separate graphic motor centre on each side of the 
 brain. This does not seem to be at all in accord with 
 what we know definitely of the cortical localization of 
 speech functions. 
 
 A second case that has taken an important place in 
 literature to prove the existence of cortical motor agraphia 
 is one cited by Charcot. 1 The patient, a Russian general, 
 who was able to speak with facility in addition to his 
 mother language both German and French, suddenly lost 
 the ability to speak in either one of these languages, al- 
 though he was still able to understand them. After a 
 time the capacity to speak French was regained, but he 
 was never again able to use the German tongue. At no 
 time was there any paralysis, nor was there any difficulty 
 in understanding any of these languages in print or in 
 writing. The interpretation put upon this case by Mirallie 
 seems to me lucid and satisfactory. The patient was prob- 
 ably a motor aphasic for two of the three languages which 
 he had spoken fluently, that is, there was loss of the. arti- 
 culatory images of the languages which he had last ac- 
 quired, and apparently, they were lost, relatively to their 
 temporal acquisition. The articulatory images of the 
 mother tongue, which every one concedes are more in- 
 delibly fixed than the images of languages acquired later 
 in life, were not concerned. The motor aphasia was, 
 therefore, very slight, and a considerable degree of re- 
 
 1 Charcot : " Lemons sur 1'aphasie." Progres Medical, 1883.
 
 144 The Faculty of Speech. 
 
 covery followed. Careful examination of the report of 
 the case shows that the patient was not totally agraphic, 
 but that he could write a few letters. When he was 
 asked his address he said, " I reside at the H6tel de Bad, 
 Boulevard des Italiens," but when he was asked to put 
 his answer in writing he was able to write voluntarily 
 
 only " I re " and then wrote the remainder of the word 
 
 from dictation. It is interesting to note that the agraphia 
 was most complete for the German language, less so for 
 the French, and least so for Russian, for he was able to 
 write Charcot's name in the latter language without much 
 difficulty. If one admits that there was here a slight form 
 of cortical motor aphasia that had undergone .considerable 
 amelioration, that is, loss of the articulatory images to a 
 slight degree for the Russian, and to a very much greater 
 degree for the French and German, he must admit that 
 such loss of images would cause a disturbance of internal 
 speech, and that this disturbance would be manifested by 
 agraphia. 
 
 A very similar interpretation must be put upon the case 
 recently reported by Prevost, ' who cites a case of Jack- 
 sonian epilepsy accompanied by motor aphasia without 
 agraphia to prove that the former may exist without 
 the latter. The patient was a man sixty years old who 
 had been neurasthenic for a number of years. A few 
 days before he consulted Prevost he had remarked a con- 
 siderable difficulty of speech, particularly in finding ap- 
 propriate words. After this the nervousness increased ; 
 he complained of headache and of a disagreeable sensa- 
 
 1 Prevost: " Aphasie motrice sans agraphie." Revue Medicale de la 
 Suisse Romande, June 2Oth, 1895.
 
 Conception of Aphasia. \ 45 
 
 tion in the right arm. Shortly after this there occurred 
 epileptiform attacks with partial loss of consciousness. 
 During these attacks he made efforts to speak, and suc- 
 ceeded in uttering some unarticulated sounds while he 
 grasped the chin with the left hand and the head was 
 turned convulsively to the right by a series of clonic 
 convulsions extending into the right facial region and 
 associated with conjugate deviation of the eyes toward 
 the same side. Immediately after the attack, there was 
 very pronounced difficulty in speaking. During the next 
 few days the patient had a number of attacks in which 
 the convulsions extended to the right arm, but spared the 
 right leg. On the eighth day after the beginning of 
 the epileptiform symptoms he became, immediately after 
 an attack, completely unable to speak, although it is 
 stated that he understood perfectly spoken and written 
 words, and that writing was in no way disturbed. Con- 
 sidering the fact that the patient was not tested for abil- 
 ity to write from dictation and from copy, it cannot be 
 said positively that writing was not disturbed. Under 
 vigorous antisyphilitic treatment, the fits ceased abruptly 
 and the ability to speak returned. Eight months later 
 the patient developed a right-sided hemiplegia. It is 
 probable that in this case the lesion was a syphilitic one, 
 as there was an inconclusive history of luetic infection 
 and the symptoms yielded to antisyphilitic treatment, and 
 that the first manifestations of the lesion were in the lower 
 part of the Rolandic-area cortex ; that the patient had a 
 subcortical motor aphasia, and that the twitching in the 
 right side of the face and later of the right arm indicated 
 an accession of the lesion irritating the fibres conducting 
 
 10
 
 146 The Faculty of Speech. 
 
 motorial impulses from the cortex to these regions ; that 
 the syphilitic vascular lesion was not an extensive one and 
 did not destroy the area in which it was seated. This 
 explanation would readily account for the temporary loss 
 of speech following the convulsive attack, and for the 
 preservation of ability to write. The fact that the patient 
 developed complete hemiplegia a few months later is of 
 considerable weight in substantiating this interpretation 
 as being one of slight cortical motor aphasia in the begin- 
 ning, the lesion being one that interrupted the passage 
 of motor articulatory images to that part of the Rolandic 
 region that starts the impulses to externalize them. 
 
 Finally, a number of cases must be considered, to show 
 that there are no real examples of cortical motor aphasia 
 without agraphia. Several examples have been cited to 
 prove the existence of such a condition, and of these 
 the one by Banti ' is the best-known. His case was that 
 of a man thirty-six years old, sufficiently well educated 
 to read and write correctly, right-handed, who was sud- 
 denly stricken in the street with apoplexy, followed by 
 temporary loss of consciousness. During the following 
 night the right-sided hemiplegia from which he suffered 
 almost entirely disappeared, but the inability to speak 
 which had come on simultaneously with the loss of con- 
 sciousness still persisted. He was examined by Banti 
 on the following day, who noted that there was scarcely 
 any trace of paralysis. On being asked his name and 
 other simple questions, the patient made futile efforts to 
 speak, but was unable to articulate a syllable or a sound. 
 
 1 Banti : " L'aphasie et ses formes." Lo Sperimentale, 1886, vol. Ivii., 
 p. 261.
 
 Conception of Aphasia. 147 
 
 He chafed under this inability and essayed to convey his 
 thoughts by pantomime. On being given a pencil, he 
 wrote his name and the answers to other questions, with 
 great readiness. Moreover, on being requested to give 
 an account of his illness, he wrote a very detailed descrip- 
 tion. Writing from dictation and from copy was also pos- 
 sible, and the patient assured Banti that he was able to 
 understand everything that he wrote, everything that he 
 saw written, and everything that was said to him. That 
 is, there were no traces of word blindness or of word 
 deafness ; but the inability to articulate was complete, al- 
 though Banti states that he wrote a number of simple 
 words and endeavored to incite the patient to read them in a 
 loud voice and to say them after him. Although the patient 
 observed with great attention the movements of the phy- 
 sician's lips and made strenuous efforts to obey, he was 
 never able to pronounce a single word. Three years later 
 the patient had entirely recovered, the amelioration of the 
 aphasia having been a gradual one. After the recovery 
 was complete, it was still noticeable that occasionally 
 he slightly mispronounced words. The patient died five 
 years later of an aneurism of the aorta. In the brain 
 there was found a patch of yellow softening situated in 
 the posterior portion of the left third frontal convolution, 
 comprising part of the cortex situated between the pre-Ro- 
 landic fissure and the anterior branch of the fissure of 
 Sylvius. The author explicitly states that it did not in- 
 volve the white substance. This case, which apparently 
 on first sight proves the possibility of the occurrence of 
 motor aphasia without concomitant agraphia, does not 
 really do so. The fact that the patient recovered the
 
 148 The Faculty of Speech. 
 
 ability to speak shows that all the cells of Broca's convo- 
 lution could not have, been destroyed. Moreover, the fact 
 that there were no word blindness and no auditory aphasia 
 shows that the lesion of the zone of language must have 
 been slight. If particular information had been given of 
 the time and way in which the patient recovered the 
 ability to speak, the case would have been very much more 
 instructive, for it might be made to bear testimony in be- 
 half of the assumption of speech function by the unedu- 
 cated centre of the opposite side. Yet I am inclined to 
 think that we must admit that neighboring cells are ca- 
 pable of taking up the functions of destroyed cells, 
 not only of symmetrically located ones but of adjacent 
 ones. Such information was not vouchsafed, and there- 
 fore the case must be looked upon as an inconclusive 
 one. 
 
 Kostenitsch ' has published an observation of a man 
 fifty-six years old who had a right-side hemiplegia with 
 complete motor aphasia of seventeen years' duration, but 
 who wrote with great ease with the left hand. He avowed 
 that he could understand everything that was said to him, 
 he could sing melodies without the words, and he could 
 read what he had written. At the autopsy very extensive 
 lesions were found, particularly in the central ganglia, and 
 the whole left hemisphere, more particularly the frontal 
 lobes, was very much atrophied. The atrophy of Broca's 
 convolution was especially well pronounced. This may 
 be considered an illustrative example of the cases that 
 have been cited to prove the existence of so-called motor 
 
 1 Kostenitsch : " Ueber einen Fall von motorischer Aphasie," etc. 
 Deutsche Zeitschrift fur Xervenheilkunde, 1893, vol. iv.
 
 Conception of Aphasia. , 149 
 
 aphasia without agraphia. It is an exact counterpart of 
 the case cited on page 201 of this monograph, and it is 
 susceptible of very similar interpretation. The case 
 is, in reality, quite a typical one of subcortical motor 
 aphasia, and the report of the autopsy is the most 
 conclusive proof of this contention. That the original 
 lesion was subcortical was shown by the complete destruc- 
 tion in the central masses, and to these the atrophy of the 
 cortical substance, a pure inactivity atrophy, was due. The 
 microscopical examination of the cortex, which showed 
 stunted cells and cells lacking in axones, is decidedly 
 in favor of this view. 
 
 In this country a case observed by Osier 1 has often 
 been cited in support of a centre for graphic motor im- 
 ages. A rfsnmt of this case is briefly as follows : An old 
 man suddenly developed, without paralysis, inability to 
 read the newspaper, right lateral homonymous hemianop- 
 sia, paraphasia, and complete word blindness. On being 
 asked his name, he was able to pronounce it, but the al- 
 teration of spontaneous speech was very manifest when he 
 attempted to tell his occupation, which was that of book- 
 keeper. As Osier noted it, the response to this question 
 was, " Keep, keep, keep oh, you say it for me." In refer- 
 ring to a wetting he said, " Deliberate attack of wet dress." 
 It was difficult to get him to write and it was impossible 
 for him to write from dictation. He was able to write his 
 own name quite as well with the eyes closed as with them 
 open. He wrote the word " Record" when told to do so, 
 
 'Osier: "A Case of Sensory Aphasia Word Blindness with Hemi- 
 anopsia." American Journal of the Medical Sciences, Philadelphia, pp. 
 219-224, 1891.
 
 i 50 The Faculty of Speech. 
 
 but he spelled it " Freedom." These symptoms persisted 
 two months, during which time there was gradual loss of 
 muscular strength and mental power, and finally, thirty-six 
 hours before death, there was paralysis of the right arm 
 and leg. The autopsy showed necrotic softening in the 
 left hemisphere, especially of the posterior part of the 
 first and second temporal convolutions and of the two 
 annectant convolutions uniting the first temporal to the 
 parietal lobe. There was complete transverse softening 
 of the white matter between these convolutions externally 
 and the lateral ventricle. Tlie gray and white matters of 
 the occipital lobe were uninvohed. The softening in the 
 supramarginal gyrus was more superficial than in any 
 other portion, and it seemed to involve only the gray mat- 
 ter. The gray matter of the angular gyrus looked wholly 
 normal. 
 
 The concluding sentence, taken in connection with the 
 clinical history, makes it evident that this was a case of 
 subcortical sensory aphasia, the softening proceeding from 
 the deeper parts toward the periphery. The lesion was 
 a progressive one probably, but the patient died before 
 the cortex of the angular gyrus became destroyed. This 
 accounts for the writing-capacities of the patient, as stated 
 by Osier. 
 
 Charcot and Dutil ' put upon record the case of a wo- 
 man, sixty-four years old, who had suffered during the 
 last twenty years of her life four distinct attacks of apo- 
 plexy, after the first of which she was unable to write, al- 
 though there was no speech disturbance. Following on 
 
 'Charcot and Dutil: " Agraphie motrice suivie d'autopsie." Mem. 
 Societe Biologic, 1893, p. 120.
 
 Conception of Aphasia. 151 
 
 a second attack, there were added difficulty of speech, left- 
 sided hemiplegia, and eventually trouble in swallowing, all 
 of which indicated a pseudo-bulbar palsy. Although the 
 authors say that the agraphia had all the clinical charac- 
 ters of motor agraphia, it is to be noted that all forms 
 of writing were interfered with. She copied defectively, 
 she wrote from dictation very badly, and was incapable of 
 writing spontaneously. At the autopsy there were found 
 in the right hemisphere numerous small foci of. softening 
 and in the left hemisphere two such foci, one of which 
 occupied the second frontal convolution and the other 
 the inferior parietal convolution. In reality, this case was 
 one in which the visual images were disordered, and the 
 patient was not able to evocate them sufficiently in her 
 internal language to give the complete idea of the word. 
 Instead of its being a case of motor agraphia, the case 
 was in reality one of sensory agraphia, as all the modalities 
 of writing, spontaneous writing, writing from dictation, 
 and writing from copy, were defective. 
 
 After taking all the evidence into consideration, of what- 
 ever nature, that can be cited in favor of the existence of 
 a specialized graphic motor centre, and carefully weighing 
 it, the conclusion is forced upon us that, so far, the advo- 
 cates of the existence of such a centre have furnished us 
 with no absolute proof. It seems to me entirely contrary 
 to all that we know of speech, from a study of its genesis 
 and its dissociation, to look for the existence of such a 
 centre. 
 
 If claimants for the existence of a graphic centre are 
 willing to admit that this centre coincides with the allo- 
 cation for the hand and arm in the Rolandic area of the
 
 152 The Faculty of Speech. 
 
 cortex, and that writing is a hand motor function inner- 
 vated from either hemisphere, as the case may be, I, for 
 one, am inclined to agree with them. The product that 
 writing externalizes, however, is the result of activity in a 
 sensory area, the zone of language.
 
 CHAPTER V. 
 MOTOR APHASIA. 
 
 I. Motor Apliasia ; General Considerations. 2. Cortical 
 Motor ApJiasia ; Articulatory Kincesthetic Aphasia. 
 J. Subcortical Motor Aphasia. 
 
 THERE seems to be a unanimity of opinion among writers 
 on speech disorders in using the term aphasia generically 
 to designate the disturbances of speech that result from le- 
 sion of the zone of language, or of the pathways leading 
 to and from the zone of language, whether these relate to 
 its reception, its interpretation, or its emission; although, 
 strictly speaking, aphasia occurs only when there is per- 
 version of function of the zone of language. Aphasia may 
 be classified, as I have pointed out in another connection, 
 in a variety of ways. Disturbance of speech is manifested 
 predominantly in its reception and emission, and as the 
 reception of speech is dependent essentially on sensation, 
 and only in a contributory way on motion (movements of 
 eyes, ears, extremities kinaesthetic sensation), the defect 
 in speech that results from interference in the reception 
 and interpretation of speech is called sensory aphasia. 
 On the other hand, communication of thought by speech, 
 and, in fact, communication of thought in any form, is 
 mediated through movement. For the spoken word it is 
 by the co-ordination of the respiratory movements, the 
 movements of the vocal cords, the palate, tongue, and
 
 154 The Faculty of Speech. 
 
 lips ; in writing, by the movements of the mobile part of 
 the body holding the pen and acting under the conscious 
 or subconscious direction of the visual centre ; in the case 
 of pantomime, by movement of the muscles of the face 
 and of the extremities. A lesion that disables or mili- 
 tates against externalization of speech is termed, in a 
 general way, and principally for convenience' sake, .motor 
 aphasia. 
 
 For a number of years after the universal recognition of 
 aphasia which followed on Broca's description of his first 
 cases it was supposed that the unique lesion of aphasia 
 was in one very definite part of the brain. In the chap- 
 ter on history we have seen how the labors of Wernicke 
 and of others disproved this when they separated sensory 
 aphasia. Then for a time, although it was fully recog- 
 nized that aphasia was both motor and sensory, it was 
 taught that motor aphasia occurred only when the gray 
 substance forming the foot of the third frontal convolu- 
 tion, the seat of the articulatory kinsesthetic memories of 
 words, was destroyed. Since that time, however, a new 
 conception of aphasia has become dominant, and motor 
 aphasia has lent itself to subdivision with a readiness 
 equal to that of sensory aphasia. And to-day, thanks to 
 the labors of Pitres, Dejerine, and other masters in the 
 field of language, it is possible to differentiate cases of 
 motor aphasia according to the seat of the lesion, whether 
 it be in the articulatory kinaesthetic centre, in which are 
 preserved the phonetic images, or whether it be at any 
 level of the pyramidal projections extending from the 
 Rolandic area, where the movements of respiration, phona- 
 tion, and articulation are separately allocated, down to the
 
 Motor Aphasia. 155 
 
 pons-oblongata, where the peripheral neurons of these 
 pyramidal tracts begin. 1 Cortical and subcortical motor 
 aphasia are dependent upon anatomical lesions which may 
 be widely separated. Clinically, if they are studied with 
 great care, they can be differentiated, although it must 
 be said that the features which allow us to distinguish the 
 one from the other are not quite so absolute and convinc- 
 ing as one might be led to infer from reading the au- 
 thors who have contended for this differentiation in the 
 past. Lichtheim 2 averred that subcortical motor aphasia 
 was characterized by the loss of voluntary speech, by ina- 
 bility to repeat what was heard, by inability to read aloud, 
 by the preservation of the comprehension of spoken and 
 written language, and by the faculty of writing in all its 
 forms that is, voluntarily, from dictation, and from copy. 
 Lichtheim suggested an apparently original test for sub- 
 cortical motor aphasia to prove that patients preserve the 
 memorial notion of the word ; that is, that they have in 
 their minds the name of the object which they are inca- 
 pable of emitting. This test is not infrequently men- 
 tioned in literature as the Lichtheim test, but Pitres has 
 pointed out that it was first suggested and utilized by 
 Proust in 1872." Nevertheless, Lichtheim's employment 
 and advocacy of it caused its general utilization and 
 acceptation. As the test is of great importance in dif- 
 ferentiating cortical from subcortical motor aphasia, it 
 
 1 1 desire to repeat, even at the risk of tiresome repetition, that in the 
 true sense of the term subcortical motor aphasia is in reality not aphasia 
 at all. 
 
 9 Lichtheim : " Ueber Aphasie." Deutsches Archiv fiir klinische Med., 
 1885, vol. xxxvi., p. 204. 
 
 3 Proust : " De 1'aphasie." Arch. Ge'ne'rales de Me'decine, 1872.
 
 156 TJic Faculty of Speech. 
 
 is necessary to be explicit concerning it. The patient 
 with cortical motor aphasia is devoid of articulatory 
 kinaesthetic memory images. When he is shown the 
 flower chrysanthemum, or when the word chrysanthemum 
 is said to him, he sees the flower and he hears the spoken 
 word ; but when the impulses going frcm the visual centre 
 and the auditory centre attempt to invoke the word chrysan- 
 themum in its application to the flower seen or to the word 
 heard it cannot evoke them in his internal language, be- 
 cause the area of the cortex in which articulatory kinres- 
 thetic memories are stored is destroyed. This perversion 
 of internal language is the distinguishing feature between 
 cortical and subcortical motor aphasia. Internal language 
 being disordered in cortical motor aphasia, there is always 
 some imperfection in every modality of internal language, 
 for it is a law that admits of no exception that when one 
 of the physiological factors constituting or subserving 
 speech is impaired all manifestations of speech will be 
 disordered, just the same as when one portion of an intri- 
 cate mechanical device is disarranged it interferes with 
 the proper and harmonious working of the whole appa- 
 ratus. This will be the case despite the fact that special 
 conditions may determine the relatively greater promi- 
 nence in any given consciousness of one element of in- 
 ternal speech over others. What these conditions may 
 be it would be impracticable, were it not impossible, for 
 us to say. Psycho-physiologists have given no clear ac- 
 count of the causes that determine the excitation of cor- 
 tical nerve elements above the threshold of consciousness. 
 To call the phenomenon a selective direction of attention 
 to one of several possible mental elements, as does Bald-
 
 Motor Aphasia. 15; 
 
 win, 1 is only restating the problem in terms somewhat 
 less direct and to me more difficult of comprehension. 
 
 To test this deficiency of internal language, Proust and 
 Lichtheim showed that it sufficed to ask th patient who 
 had heard some polysyllabic word, such as chrysanthe- 
 mum, or had seen and recognized the object indicated by 
 that word, to press the interlocutor's hand as many times 
 as the word has syllables ; for instance, in the case of the 
 word chrysanthemum, to press it four times, and, if not 
 by pressure of the hand, to indicate by some movement 
 the number of syllables; then to indicate by similar 
 pressings the number of letters in the word and the num- 
 ber of letters in the syllables. It will be readily seen 
 that this test is merely the embodiment of the experience 
 that every child has in learning to talk. When a child 
 who is learning to talk and to read finds itself in the 
 presence of a new word it splits it up into syllables and 
 pronounces the syllables, if the child is moderately ad- 
 vanced in the acquisition of printed or written language ; 
 if it is not, it splits the word up into letters and pro- 
 nounces each letter separately and aloud. If the articu- 
 lation of these words aloud (or even not aloud under 
 breath, as it is called) calls up in the mind by the evo- 
 cation of auditory memories similar words or objects or 
 qualities of objects for which the word stands, the child 
 comprehends. If it does not, the child has no compre- 
 hension of the word until after it has educated the articu- 
 latory kinaesthetic centre to associate the production of 
 the word with that which the word stands for. The artic- 
 ulatory centre becomes cognizant of that word by learn- 
 
 1 " Mental Development," The Macmillan Company, 1896.
 
 158 The Faculty of Speech, 
 
 ing the sounds of the letters and syllables of which it is 
 composed, and when this area is destroyed this knowledge 
 is lost; so that, when the patient is asked to indicate by 
 sign or movement the number of letters or syllables in a 
 word, he is quite unable to do so. 
 
 Subcortical motor aphasia spares the centre in which 
 are seated the memories of articulation. The lesion in- 
 terrupts the fibres that carry the speech impulses from 
 the cortex, to which they have gone from Broca's centre, 
 passing from the area for the movements of the lips, the 
 tongue, the palate, the larynx, and the respiratory mus- 
 cles, at some level of their course before they reach the 
 crura. It has been contended by some writers, by Pitres, 1 
 by Brissaud, 2 by Juhel-Renoy, and Revilliod, that such 
 lesions are not situated at some indefinite point, but that 
 they are invariably situated at the level of the internal 
 capsule, and that they are never in the so-called infero- 
 pediculo-frontal fascicle, adjacent to the cortical gray sub- 
 stance ; that a lesion of the latter location causes aphasia 
 which does not differ from pure cortical aphasia. With 
 this last statement I can in nowise agree. I have already 
 pointed out in the chapter dealing with the genesis of 
 speech why this symptom complex is usually associated 
 with lesion very closely subjacent to the cortex. A lesion 
 that cuts across the axones of the motor neurons consti- 
 tuting the pathway from the lip-tongue-laryngeal-respira- 
 tory cortex, no matter where this lesion may be, will pro- 
 duce the clinical picture of subcortical motor aphasia, even 
 though it be of the very cell bodies of these neurons. On 
 the other hand, unless the lesion be of the cells constitut- 
 
 1 Loc. cit, * Article " Aphasie." " Traite de Medecine," vol. vi.
 
 Motor Aphasia. 
 
 ing the articulatory kimesthetic centre and their axones, 
 which I believe to be entirely association tracts and not 
 at all projection tracts, the features of the aphasia will 
 not be those of cortical motor aphasia. Nevertheless, I 
 frankly admit that it is very much more difficult to make 
 a diagnosis of subcortical motor aphasia when the lesion 
 is situated contiguous to Broca's centre than when it is 
 situated at some distance. It must be kept in mind, how- 
 ever, that it is not easy in any instance to make during 
 life a diagnosis differentiating between cortical and sub- 
 cortical motor aphasia. The truth is that the Proust- 
 Lichtheim test is not very readily applied, because many 
 of the patients with whom we have to deal are quite inca- 
 pable of comprehending what we are striving for when we 
 endeavor to utilize it and what we wish them to do ; but 
 when it can be applied it is a test of great value. 
 
 The most striking picture of cortical motor aphasia is 
 the loss of speech, articulate or non-articulate, which is 
 manifest on attempting to make voluntary communica- 
 tions, on attempting to repeat what is heard, and on at- 
 tempting to read aloud. If the lesion is closely restricted 
 to Broca's convolution, these are the leading features of 
 the aphasia. The patient understands all that is said to 
 him ; he gets the proper apperception of visual objects 
 which leads to the formation of concepts; he receives 
 trustworthy information from other sources on which he 
 has been accustomed to rely for information, at first hand 
 or for corroboration, and they in turn endeavor to invoke 
 the images of articulate speech, which images normal man 
 utilizes in intercourse with his fellows and which many 
 persons, particularly the illiterate, use in thought. The
 
 160 The Faculty of SpeecJi. 
 
 area of the cortex in which such images of articulative 
 speech are stored is destroyed, and as the result of its 
 destruction its function is abolished. The lesion that 
 causes motor aphasia is in the great majority of the cases 
 a vascular one, and as the same blood-vessel, the left mid- 
 dle cerebral, is the principal medium of arterial supply for 
 the remainder of the speech area, it is only in exceptional 
 instances that destruction of Broca's convolution is not 
 accompanied by some anatomical perversion of other parts 
 of the zone of language, although these are usually transi- 
 tory. There is invariably some perversion of function of 
 the other speech centres, because perfect speech demands 
 the harmonious co-operation of all the speech centres, and 
 one cannot be disordered without entailing derangement 
 of all. 
 
 Cortical Motor Aphasia. Articulatory Kincesthetic 
 Aphasia. 
 
 By cortical motor aphasia I mean a disturbance of 
 speech due to loss of the sensory images of articulation 
 associated with loss of the sensory memories of co-ordi- 
 nate movements entering into vocal expression ; the latter 
 is not essential, but it is an accompaniment in nearly every 
 instance. Cortical motor aphasia is characterized partic- 
 ularly by a loss of spontaneous and repeated speech and 
 by the preservation of the capacity to comprehend spoken 
 speech. The peripheral speech mechanism the tongue, 
 lips, palate, and vocal cords is in condition to function- 
 ate. The only justification for the use of the word motor 
 in this, form of aphasia is that the images of articulation 
 are called into being by movement and are externalized by
 
 Motor Aphasia. 161 
 
 movement^ Therefore in true cortical motor aphasia there 
 exists the same inability to call into being the sensory mem- 
 ories of articulation, and thus to make them a part of in- 
 ternal speech, as there is to externalize them in the shape 
 of articulate words. Many of the cases of aphasia in the 
 literature which are considered to belong in this category 
 are not of this variety at all, but are examples of pure 
 motor aphasia (of Dejerine), or subcortical motor aphasia; 
 that is, disturbance of speech dependent upon interruption 
 of the projection tracts which convey the articulatory im- 
 pulses from the cortical area of the peripheral speech mech- 
 anism to the peripheral speech apparatus. In fact, not 
 much more than one-half the reported cases have been 
 studied with sufficient care to warrant including them in 
 this category. And this is so for many reasons. In the 
 first place, the centres of the speech area in which are 
 stored definite memories are rarely involved alone. In 
 the great majority of instances the lesion is of vascular 
 origin, and the nutritive supply of one centre or the struc- 
 ture of the centre itself is not perverted without a ma- 
 terial disturbance of function in some of the other centres. 
 And in the second place, it is only within recent times 
 that the possibility of, and the necessity for, differentiating 
 this form of motor aphasia from the subcortical form has 
 been generally understood. The motor area of the brain 
 should be, as I have said before, limited to that part of the 
 brain from which the motor projection system of fibres 
 passes, and there is no unassailable evidence to show that 
 the inferior frontal fascicle, which has been allotted as the 
 system of projection fibres extending from Broca's convo- 
 lution, has anything to do with this purpose. Until within
 
 1 62 The Faculty of Speech. 
 
 a very recent time, motor aphasia, which was described by 
 Broca as true aphasia or aphemia, by Wernicke as motor 
 aphasia, and by Kussmaul as ataxic aphasia, was supposed 
 to be fully understood and most thoroughly established 
 on an anatomical foundation. But the writings of De- 
 jerine and his pupils, of Wyllie, of Elder, of Onuf, and 
 of others, and the labors of the physiologists, particularly 
 Horsley, Krause, Masini, and Semon, have shown the 
 necessity of rewriting the chapter on motor aphasia and 
 emancipating it from the dicta of the older writers. 
 
 As a case of cortical motor aphasia in which the symp- 
 toms indicated that the lesion was very closely limited to 
 Broca's convolution, the seat of articulatory-kinaesthetic 
 images, I may cite the following : 
 
 A young man, thirty-two years of age, was admitted to 
 my wards in the City Hospital, suffering from an incom- 
 plete right-side hemiplegia. His history antecedent to 
 the attack, which had occurred five months previously, is of 
 no interest, except that he had had two attacks of inflamma- 
 tory rheumatism. After the apoplectic stroke, which came 
 suddenly in the night and which was followed by loss of 
 consciousness, he was unable to talk, and this condition 
 obtained when he entered the hospital. The apoplectic 
 stroke was considered to be of embolic origin, as exami- 
 nation of the heart showed well-marked incompetence of 
 the aortic valves. Investigation of the speech defect 
 showed that he was unable to communicate his thoughts 
 by spoken words, that he was unable to repeat from dicta- 
 tion ; that he was unable to write, save his name, and that 
 very slowly and laboriously with the left hand ; and that 
 he was unable to indicate the number of syllables in a 
 word previously seen or heard, by pressing his interlocu-
 
 Motor Aphasia. 163 
 
 tor's hand as many times as there were syllables. He in- 
 terpreted quickly and easily everything that was said to 
 him, but he could not write from dictation. There was no 
 trace of word blindness or of letter blindness, and he cop- 
 ied letters and words correctly. On account of the paral- 
 ysis of his right arm, he was not able to copy quickly, but 
 if he was given sufficient time he showed that he was 
 quite capable of doing this. When he was given a para- 
 graph in a newspaper and asked to copy it, he copied it 
 in writing. The patient was able to read and apparently 
 to comprehend what he read, but he never took any inter- 
 est in the newspapers, nor was he seen to read anything 
 spontaneously during his stay in the hospital. That he 
 comprehended written and printed requests, however, was 
 shown by the readiness with which he obeyed requests 
 when they were communicated to him in this way. The 
 patient remained in the hospital but a short time, and 
 only one opportunity was had to test his ability to write 
 by means of individual letters. On this occasion a num- 
 ber of each of the letters of the alphabet were put before 
 him on the table and he was requested to construct the 
 sentence, "The President of the United States is inaugu- 
 rated on the 4th day of March." This sentence was com- 
 pleted after the expenditure of a considerable time, and, 
 save for two or three mistakes in spelling, it was correctly 
 done. 
 
 This brief rehearsal of the symptoms in this case shows 
 that the speech defect was, strikingly, loss of the sensory 
 images of articulation. The patient, though in full pos- 
 session of the avenues by which one receives stimuli, au- 
 ditory, visual, and kinaesthetic, necessary to speech pro- 
 duction, was unable to speak any words except " Yes" and 
 " No," the former of which was enunciated most indis-
 
 164 The Faculty of Speech. 
 
 tinctly. That this loss of power of articulation was de- 
 pendent upon lesion in the zone of language and not upon 
 the projection tract of pyramidal fibres is shown conclu- 
 sively by the fact that the patient could not call up the 
 articulatory kinaesthetic memories of words. For in every 
 instance when he was tested in this way he failed to indi- 
 cate by pressing the hand or by holding up the fingers the 
 number of syllables in the word desired. 
 
 From this it will be seen that the essential accompani- 
 ment of cortical motor aphasia is : loss of spontaneous 
 speech, due to a destruction of the sensory images of artic- 
 ulation stored up in the foot of the third frontal convolu- 
 tion. Associated with this loss of spontaneous speech 
 there is a loss of all forms of speech utterance for which 
 an evocation of articulatory kinaesthetic memories is re- 
 quired. Therefore there are inability to repeat words and 
 inability to read aloud, but the patient comprehends spoken 
 words, oftentimes somewhat imperfectly. There is inabil- 
 ity to express thoughts in writing, because in writing the 
 motor word representations are always revived by the im- 
 pulse which travels from the percipient centre (which is 
 either in the visual area of the brain in spontaneous writ- 
 ing, or in the auditory speech area in writing from dicta- 
 tion) through the articulatory kinaesthetic centre to that 
 part of the Rolandic region which guides the mobile part 
 of the body holding the pen. On account of the onto- 
 genetic intimacy existing between the receptive speech 
 centres and the emissive, disturbance of the emissive 
 speech centre almost invariably produces some disturb- 
 ance which is manifest through the former. This is 
 shown in cortical motor aphasia by difficulty in calling
 
 Motor Aphasia. 165 
 
 up promptly and with readiness auditory word images to 
 which articulatory kinaesthetic images are subservient, and 
 in some degree by a disturbance of internal reading. In 
 the great majority of people it is probable that reading 
 to one's self is accomplished by evoking the images of 
 articulation, and that as a matter of education, of expedi- 
 ency, a short cut is established between the area in which 
 visual images are stored and the association tracts con- 
 stituting the anatomical basis of comprehension. 
 
 In cortical motor aphasia there is sometimes very com- 
 plete amimia. This is to be explained by the fact that 
 studied pantomime is associated normally with arousal of 
 the images of articulation. 
 
 If destruction of Broca's area is total, or nearly so, 
 the capacity for articulate speech will be correspondingly 
 complete ; while if the convolution of Broca be only 
 partially destroyed, and particularly if the lesion be a 
 vascular one, such as plugging of the branch of the middle 
 cerebral artery that suplies Broca's convolution, with sub- 
 sequent exudation, a reparative process may set in. Then 
 the degree of the completeness of the aphasia bears some 
 relation, though just how much cannot be said, to the 
 amount of repossession of articulated images. It seems 
 to me that this offers quite as satisfactory explanation of 
 the possession of certain words or the acquisition of a few 
 words by patients who have a lesion of Broca's centre as 
 does the view that attributes such partial recovery of speech 
 to the vicarious assumption of function by the so-called 
 uneducated centre of the opposite side, of which so much 
 has been made by many writers in accounting for recov- 
 eries and for the utility of certain modes of treatment. I
 
 1 66 The Faculty of Speech. 
 
 hasten to say that I do not deny that the corresponding 
 centre of the other side, although not ontogenetically 
 intended for speech, may and does take up in a crude com- 
 pensatory way the function of the speech area. This sub- 
 ject will be referred to again, in the chapter on "Treat- 
 ment." Nevertheless, I believe that it never does so except 
 by process of education ; it does not seem to me that there 
 is any spontaneous assumption of function. Naturally, I 
 cannot offer any tangible or incontrovertible evidence in 
 support of this belief, but here my position is not very dif- 
 ferent from that of those who hold to spontaneous assump- 
 tion of speech function by the uneducated side. They cite 
 in support of their contention cases which I believe to be 
 typical examples of subcortical motor aphasia. Such a 
 case has been reported by Wyllie :' 
 
 A young man developed a right-sided hemiplegia, prob- 
 ably of thrombotic origin. The attack came on gradu- 
 ally and in successive stages. At first he was completely 
 speechless, but soon regained ability to say " Yes" and 
 " No" and to answer questions in writing. " He states that 
 he never from the first had any difficulty in calling up in 
 Jiis mind the words that he wished to write" (italics mine). 
 This, it seems to me, stamps the case as one of aphasia due 
 to lesion outside the zone of language. If there was no 
 other evidence than this, it would be sufficient to convince 
 me that he had likewise no difficulty in calling up the words 
 that he wished to utter, for people of his education usually 
 spell words articulately when writing them. But witness 
 testimony to this effect from the patient : " With regard to 
 my forming words in my mind, i could always form them in 
 
 1 Wyllie : " The Disorders of Speech," Edinburgh, 1894, p 323.
 
 Motor Aphasia. 167 
 
 my mind but trc ible was in getting them out. i could not 
 get them out at all and after making all the signs i could 
 think of to my friends if they could not understand me i 
 would have to take paper and pencil and write it down for 
 them." 
 
 This, I venture to believe, is conclusive evidence that 
 the patient had no defect of internal language, such as 
 invariably accompanies destruction of the articulatory 
 kinaesthetic images in Broca's area. The patient recov- 
 ered the use of the paralyzed side, and consequently it ex- 
 cites no astonishment in me that he recovered the power 
 to externalize speech commensurably with this ; nor can I 
 for a moment consider it an example which goes to show 
 how " the previously uneducated centre educates itself." 
 Moreover, it does not seem to me that the case is remark- 
 able, " inasmuch as it is one of that comparatively rare 
 variety in which the patient, utterly aphasic as to spoken 
 speech, is yet capable of expressing himself in writing." 
 I shall hope to show in this chapter that subcortical 
 aphasia is not rare, and that it is characterized by the re- 
 tention of the capacity on the part of the patient to express 
 himself in writing. 
 
 There are on record a number of cases which illustrate 
 a partial destruction of Broca's area with preservation of 
 the ability to write and repossession of the ability to speak. 
 Of such cases the most remarkable is one recorded by 
 Banti. 1 
 
 This patient, a man thirty-six years of age, right-handed, 
 capable of reading and writing, was stricken suddenly 
 with an attack of apoplexy, while walking the street, fol- 
 
 1 Banti : Sperimentale, Firenze, 1886.
 
 1 68 The Faculty of Speech. 
 
 lowed by loss of consciousness. Consciousness returned 
 after a few minutes, but he was paralyzed in the right 
 arm and right leg and was wholly unable to speak. The 
 hemiplegia disappeared almost completely during the fol- 
 lowing night, but the inability to speak still continued. 
 On the following day he was admitted to the hospital and 
 there examined by Banti, who noted that the motility of 
 the extremities was normal and that there was no trace 
 of paralysis of the face or of the tongue. The patient 
 made futile efforts to speak, but he was incapable of artic- 
 ulating a word or a syllable. He chafed exceedingly 
 under this mutism and sought to convey his meaning by 
 gestures. On being asked if he could write, he made a 
 gesture of affirmation, and on being given a pencil imme- 
 diately wrote his name. To numerous other questions he 
 responded with accuracy in writing, and without hesitation 
 wrote a detailed account of his disease when he was re- 
 quested to do so. He wrote also the names of objects 
 that were shown to him, and of objects whose qualities 
 he heard. He answered questions that were asked in 
 writing with perfect precision. He comprehended script 
 and print equally well, seized the sense of a question very 
 quickly, and wrote rapidly and without the slightest hesi- 
 tation. But he was unable to pronounce or articulate a 
 word. The aphasia ameliorated gradually, so that in less 
 than three years he was able to express himself freely. 
 Nevertheless, attentive examination showed slight defects 
 of articulate speech. Five years later the patient died 
 of an aneurism of the aorta ; and on autopsy there was 
 found a patch of yellow softening situated in the posterior 
 portion of the third left frontal convolution, and separated
 
 Motor Aphasia. 169 
 
 from the white substance by a portion of tissue only a few 
 millimetres in thickness. In this case it does not seem to 
 me that there can be much doubt that a part of the area in 
 which are stored the images of articulation was undestroyed. 
 In no other way can be satisfactorily explained the re- 
 markable degree of preservation of writing-capacity and 
 the rapidity with which he regained speech possession. 
 
 It is more than likely that our attention has been cen- 
 tred too exclusively on the unilateral representation of the 
 speech faculty. It is possible that the right side of the 
 brain contains appercipient speech centres which are in 
 direct anatomical and physiological association by means 
 of the fibres of the corpus callosum. The apperceptive 
 centres of the right side of the brain do not, however, 
 constitute an autonomy, nor do they seem to have any 
 effect in determining the execution of speech functions. 
 Therefore when the right hemisphere is the seat of lesion 
 in right-handed persons, there is no trouble in the execu- 
 tion of speech. The influence that has most to do with 
 determining the superiority of the left hemisphere as the 
 speech side of the brain, after ontogenetic influences, is 
 education. Just what the antecedent factors are in this 
 determination it is impossible to say. The general speech 
 education, so to say, that the opposite hemisphere receives 
 has much to do with the possibility of educating it to 
 compensate in part for destroyed centres of the zone of 
 language. 
 
 The capacity for articulate expression which a few, com- 
 pared with the entire number of motor aphasics, retain is 
 for a few words whose utterance partakes more of the na- 
 ture of a reflex act or of an' emotional possession than it
 
 i 70 The Faculty of Speech. 
 
 does of a process of intellection. They consist of " Yes" 
 or " No," the patient's name or address ; possessions which 
 from long usage signify one definite purpose or thing and 
 are uttered nearly reflexly. In like manner, they some- 
 times retain the capacity to use conventional expressions, 
 such as "Good morning," "How are you?" "Very fine," 
 etc., and these they employ for every occasion, pertinent 
 and non-pertinent alike. Oftentimes these expressions are 
 used by the patient in a way that reminds one of an echo. 
 Whether such reflex or echo-like words cannot be pro- 
 duced by the action of sensory impulses directly on the 
 central executive motor speech mechanism, I have often 
 debated. The answers that such patients give are com- 
 parable to the speech of a parrot, and no one believes 
 that a parrot has an ontogenetic speech centre for memory 
 images of articulation. Sensory excitations call forth uni- 
 form responses in the parrot with tiresome monotony, and 
 it is the same way in the patients ; they may respond " Tan, 
 tan," or " Yi, yi," or " Yes" to everything. Echoing or 
 echolalia in cortical motor aphasia is a phenomenon that 
 is occasionally present, oftenest when the patient is recov- 
 ering. The occurrence of echolalia has been thought to 
 indicate the assumption of function by the uneducated 
 side. The patient repeats a word which he has heard, or 
 a sound, in the same senseless fashion and with the same 
 tireless persistency that a child does who is learning to 
 talk. It may possibly be an indication of the functioning 
 of a centre on the right side of the brain which is not yet 
 fully under control, inhibitory or exciting, of the sensory 
 apperceptive centres. On the other hand, it may be the 
 manifestation of a certain retention of function by the dis-
 
 Motor Aphasia. \ 7 1 
 
 eased area. The disorganization of Broca's convolution 
 being sufficient to rob it of all purposive activity, it retains 
 a semblance of function pointing to what it once was. 
 
 Another very striking variety of articulate speech which 
 patients with motor aphasia show is that to which the 
 term lalling or lallation is applied. The significance of 
 the term, " baby talk," is indicated by its derivation. It, 
 like its congeners, stammering and dysarthria, is a symp- 
 tom of subcortical motor aphasia, and rarely of the cortical 
 variety. 
 
 The degree of completeness of the loss of articulate 
 speech is, as has been said, a variable quantity. Al- 
 though in cortical motor aphasia the power to make vol- 
 untary expression is usually entirely gone, the loss may 
 be partial, nearly all words or only a certain class of words 
 having perished. When partial, the power of expression 
 is limited, as a rule, to one or more monosyllabic words, 
 which the patient may use intelligently but which are not 
 infrequently used in answer to every question for in- 
 stance, the word " No" to express negation and assent 
 alike. In other cases, the ability to articulate certain 
 vowel sounds, such as a, o, 11, or some of the consonants, 
 may be preserved. Occasionally, patients who are afflicted 
 with complete motor aphasia are able to utter some words 
 of the nature of an oath, which seem to escape from them 
 in a rapid, uncontrollable way, or to ejaculate words ex- 
 pressive of the feelings. Such expresions are not the 
 product of cognition, but of the emotions, and partake of 
 the nature of reflex action. Other patients repeat con- 
 tinually some expressive -or meaningless word or words. 
 These repeated words or sentences, though often of no
 
 1 72 The Faculty of Speech. 
 
 pertinency, seem occasionally to have a definite meaning, 
 in so much as they are connected with the onset of the 
 patient's disease. Thus, a patient who had complete 
 motor aphasia, observed by Hughlings Jackson, kept re- 
 peating, " I want protection. " The man had received a 
 serious injury of the head during a quarrel, and it has 
 been suggested that in such a case (there are many of 
 them on record) the frequently repeated word or phrase 
 was the last one uttered by the patient before he became 
 aphasic, and that these words, the last enregistered in the 
 centre of articulatory memories, are the ones most promptly 
 evoked when sensory impressions reach it. 
 
 Such recurring utterances are distinctive features of 
 cortical motor aphasia, and not of the subcortical variety, 
 for the latter really is a shortcoming of articulation, and 
 if articulation is not wholly impossible the defect is man- 
 ifest by some variation in the perfectness with which the 
 word is produced. 
 
 In the ordinary case of motor aphasia, although the 
 emotional faculties are often disturbed, the patient is 
 capable of giving spontaneous expression to his feelings 
 when such expression does not require the use of words. 
 The patient's intellectual faculties do not on casual exam- 
 ination seem to be materially impaired, although there is 
 usually an indisposition or lack of readiness on the part 
 of the patient to indulge in anything requiring mental 
 application. On that score cortical motor aphasia differs 
 most materially from subcortical forms. Patients with 
 the latter are as ready and willing and capacious to at- 
 tack mental problems as normal man, and not infrequently 
 transact business calling for great mental integrity and
 
 Motor Aphasia. 173 
 
 indulge in games requiring profound abstraction, such as 
 chess. Patients with cortical motor aphasia often show 
 great amnesia and lack of comprehensive grasp of facts 
 that have been communicated to them since their illness. 
 This is easy of interpretation if it be borne in mind that 
 lesion of Broca's area entails perversion of the function of 
 internal language. He has lost the ability to repeat in- 
 wardly what is said to him, what he hears ; and as most 
 people obtain knowledge for storing up in this way, the 
 person with true motor aphasia is deprived of the power 
 of thus laying up knowledge. This, combined with the 
 dyslexia or alexia which unfits him for obtaining knowl- 
 edge by reading, is abundant explanation of the amnesia. 
 Cortical motor aphasia is sometimes manifest merely 
 by a loss of substantives ; amnesia of the names of the 
 things or objects of which the patient tries to speak. 
 For instance, a patient who wishes to request some- 
 thing may be able to produce every word except the one 
 which is the embodiment of his request. A patient 
 
 of Trousseau would say, " Give me my u u sacrt 
 
 matin." "Your umbrella?" "Yes, my umbrella." It 
 seems to me very questionable, however, that this is a 
 genuine example of amnesia of the articulatory memories 
 for substantives, and the fact that he was able to say the 
 first letter of the word in the name of the desired object 
 is rather in favor of its being a case of subcortical motor 
 aphasia, the stumbling and stammering being apparent 
 when he attempted to utter particular names. A much more 
 convincing example of the loss of the articulatory memory 
 of substantives is furnished by a patient who, knowing 
 just what he wants, instead of saying, "Give me my
 
 i 74 The Faculty of Speech. 
 
 watch," says, " Give me what I tell the time with," or 
 who calls a knife " something to cut with," and so on. 
 In these cases the amnesia for substantives may be the 
 only aphasic symptom. Very much less common is artic- 
 ulative amnesia of verbs, the ability to use substantives 
 being preserved. When it is recalled how very much 
 more complex the formation of a mental percept of a 
 name is than that of an object, and how much easier it is 
 to recall the qualities, capabilities, and possessions of ob- 
 jects than the name of such an object, it will be under- 
 stood that articulatory amnesia of substantives is much 
 more common than articulatory amnesia of verbs. 
 
 The retention of speech capacity that patients with artic- 
 ulatory kinaesthetic aphasia sometimes have is very sur- 
 prising. In addition to the form of which I have just 
 spoken, in which the speech defect is confined to loss of 
 substantives, others are occasionally observed in which 
 the patient is unable to repeat any words except to count 
 or to say the multiplication table. Such an instance has 
 been recorded by Volland. 1 The patient was completely 
 speechless, except that he could count up to one hundred 
 and say, " Once one is one," etc. A much more interest- 
 ing retention is that sometimes met in polyglots, i.e., in 
 patients who before their illness could speak with fluency 
 other languages than their mother tongue. The loss of 
 speech in such an individual may be complete for one or 
 all of the foreign languages, while for the mother tongue 
 it may be only partial. As a rule, however, in these cases 
 the ability to speak is entirely lost in the beginning of the 
 
 1 Volland : " Aphasie apres une blessure de la tete ; conservation de la 
 faculte de compter. " Milnch. med. Wochen., iSSG, No. 4.
 
 Motor Aphasia. 175 
 
 disease, but after a time the patient may gradually regain 
 the capacity to speak his mother tongue, but not the foreign 
 languages, the languages that he acquired at a later period 
 in life than the mother tongue. Such cases have been 
 reported by Charcot and by others, and the subject has 
 recently been studied very carefully by Pitres. 1 The ex- 
 planation given by this writer is one that must meet with 
 universal acceptance. The phenomenon does not in any 
 way posit the existence of separate word-image centres 
 for different languages. On the contrary, it is explained 
 by the fact that the word images in one's mother tongue 
 are more indissolubly imprinted or enregistered in the 
 area for the storage of word images, and consequently they 
 are the least readily dislodged or destroyed with lesions of 
 this area that are not of sufficient intensity to destroy it 
 completely. 
 
 Inability to recall substantives or verbs is the condition 
 to which the name amnesia verbalis is given. This con- 
 dition is to be distinguished from that to which the term 
 ataxia verbalis is sometimes applied to indicate the disa- 
 bility of producing and co-ordinating the movements that 
 subserve articulation, and which is such a prominent fea- 
 ture in subcortical motor aphasia that the term ataxic 
 aphasia has been applied to it. Wyllie deprecates the 
 fact that the term asynergia verbalis, suggested originally 
 by Lordat to denote the disablement of speech in motor 
 aphasia, has not been retained, as it means the want of 
 power of working together, as this is really what exists 
 in subcortical motor aphasia, and not that which is sug- 
 
 1 Pitres : " L'aphasie chez les polyglottes." Rev. Me'd.. November,
 
 I 76 The Faculty of Speech. 
 
 gested by ataxia, which means want of order. But I can- 
 not agree with the distinguished Scotchman in this, for 
 the term asynergia verbalis, although extremely pertinent, 
 does not encompass the defect entirely ; there is ataxia as 
 well. 
 
 According to the conception of speech promulgated by 
 Charcot, the amount of amnesia verbalis in motor aphasia 
 should depend very largely on the category to which the 
 patient belongs. If he were a moteur, that is, if he de- 
 pended largely on the evocation of articulatory memories 
 to jut thought or memories into consciousness, then de- 
 struction of the cortical area in which are stored such 
 memories would reduce the vocabulary of the patient 
 much more materially than if he were an auditif or 
 a visncl. If the patient were an anditif and called up 
 words and names habitually by a revivication of audi- 
 tory images, articulate verbal amnesia would be, compared 
 with the previous condition, very slight. The logic of 
 this is unassailable, but unhappily for the advocates of 
 the view the premises are false, and the conclusions are 
 not in accord with clinical experience. Probably no one 
 speaks from a primary evocation of the images of articula- 
 tion, and the loss of evocation of names and words in par- 
 tial motor aphasia is due to the fact that there is always 
 a disability in the arousal of auditory images spontaneously 
 in this condition. 
 
 A patient with cortical motor aphasia is unable to express 
 his thoughts in writing. His capacity to write is propor- 
 tionate to the amount of derangement of internal lan- 
 guage, and it bears a definite relation to the amount of 
 latent or actual visual amnesia of words which every patient
 
 Motor Aphasia. \-j 
 
 with cortical motor aphasia has. In most cases the ca- 
 pacity to write is limited to writing the name and a few 
 other words, such as the age, the address, and the name 
 of the wife or the parents, that have been done so habit- 
 ually, automatically, and frequently that they form a part 
 of the patient's habitual acts, and are done almost re- 
 flexly. Motor aphasia is almost invariably associated, at 
 least in the beginning, with right-side hemiplegia due to 
 extension of the lesion on which the aphasia is dependent 
 to the psycho-motor zone, and this hemiplegia prevents 
 the patient from writing with the right hand. Although 
 most educated people can write with the left hand, of 
 course more clumsily, less gracefully, and with greater 
 effort, than with the right hand, they can accomplish it ; 
 and if for any reason the right hand becomes disabled 
 they acquire within a few weeks the ability to write 
 with the left hand with ease and facility. But a patient 
 with cortical motor aphasia is completely agraphic, never 
 learns to write with his left hand, no matter how long 
 he may live after the aphasia has developed. However, 
 every modality of writing is not interfered with ; though 
 writing voluntarily and writing from dictation are prac- 
 tically impossible, yet the patient is able to write from 
 copy. 
 
 This preservation of the capacity to write from copy is 
 entirely in harmony with the explanation that suffices for 
 loss of the ability to write that occurs in cortical motor 
 aphasia. The inability of patients who have cortical 
 motor aphasia to write spontaneously and from dictation 
 has been recognized almost from the beginning of the 
 history of the disease. Trousseau gave much space to a
 
 i 78 The Faculty of Speech. 
 
 discussion of it in his lectures on aphasia and cited many 
 examples. " In the English language the subject was fully 
 discussed by Ogle and by Gairdner, particularly by the 
 latter, who said very tersely and truthfully that the motor 
 aphasic could write as well as he could speak, and if 
 unable to speak he was also unable to write. There 
 would seem to be entire unanimity of opinion of the oc- 
 currence of agraphia with cortical motor aphasia, but dif- 
 ferent observers put widely different interpretation on 
 the manner of its occurrence. Those who follow the 
 teachings of Charcot, Exner, Strieker, ' et al., and believe 
 that there exists a special centre for the deposition and 
 storage of graphic motor images, have no difficulty in ex- 
 plaining it by saying that as the graphic motor centre is 
 adjacent and contiguous to the centre for images of artic- 
 ulation the one is almost always affected with the other. 
 They experience a very serious difficulty, however, when 
 they attempt to prove the existence of such a hypothetical 
 centre, as well as when they seek to defend the autonomy 
 of any one centre in its relation to finished speech or to 
 its predominancy in furnishing us with the idea of a word. 
 Of all the cases of aphasia accompanied by autopsical 
 details on record there is not one that can be used suc- 
 cessfully to prove the separate existence of a graphic 
 motor centre. As pointed out in another chapter, the 
 existence of such a centre is opposed to the conception 
 of speech which it has been our endeavor to set forth 
 in these pages. 
 
 At the time of Trousseau and Gairdner, when sensory 
 
 1 " Zur Lehre von der Aphasie." Wiener med. Blatt., 1881, vol. iv., 
 pp. 1,477, 1,509, 1,565-
 
 Motor Aphasia. 179 
 
 aphasia was as yet scarcely differentiated, the explanation 
 that was given to account for the occurrence of agraphia 
 was more nearly in accord with the explanation that I 
 believe to be the correct one than that which many 
 writers give to-day. It was believed that in these cases 
 the lesion extended posteriorly to include other areas 
 than that of Broca's convolution. And as a matter of 
 fact that is just what sometimes occurs. In every case 
 of cortical motor aphasia there is some dyslexia, which 
 shows that the visual centre in which are stored the im- 
 ages of the seen word (the angular gyrus) is functionally 
 impaired. This impairment may be slight, and if the 
 examination to reveal it is made some time after the 
 occurrence of the aphasia it may be difficult to bring it 
 out. It has been shown conclusively by Thomas and 
 Roiix 1 and by others that, nevertheless, it exists, though 
 possibly in a latent form in every case. As a rule, the 
 verbal blindness is slight and undergoes restitution even 
 before any signs of improvement are manifest in the 
 aphemia. Agraphia occurs, then, in motor aphasia because 
 the idea of the word that the patient wishes to write vol- 
 untarily or from dictation is lost. In writing voluntarily 
 it is necessary in every instance to visualize, that is, to 
 call up the visual memory or image of the letter and the 
 word, and these in turn, acting upon the images of artic- 
 ulation, evocate them, and the latter guide the motor 
 area in making the movements that transcribe the letters 
 to form words. In educated people and people habituated 
 to writing, it may be necessary to arouse the articulatory 
 images ; a short circuit may be established between the 
 
 1 Hull. Societe Biologic, February 22d, 1896.
 
 180 The Faculty of Speech. 
 
 visual images of the word to be written and the motor 
 area from which originate the movements of the part that 
 grasps the pen, but it is extremely improbable that this 
 takes place. It is much more likely that the sensory 
 images of articulation are evoked in every instance. If 
 one watches a person unaccustomed to writing, or a be- 
 ginner, indite a line or a page, he will find almost invari- 
 ably that either the lips and the tongue move visibly with 
 the tracing of each letter and word, or the words are dis- 
 tinctly articulated. Moreover, if one asks typewriters 
 who are accustomed to take dictation directly on the ma- 
 chine how they transcribe what they hear said to them, 
 it is probable that the majority will say that they do so 
 by spelling to themselves (but still most audibly to them- 
 selves) the words that they hear, before striking the cor- 
 responding keys. This shows that there is with the visual 
 image of the word a corresponding evocation of the articu- 
 latory images. When the area in which are stored the 
 articulatory images is destroyed, then a link in the circuit 
 by whose integrity we are in possession of the proper idea 
 of the word, and so capable of utilizing it in any form of 
 exteriorization, is gone, and the result is failure to write 
 it and failure to speak it. 
 
 This loss of the idea of the word is one of the distin- 
 guishing features of every form of cortical aphasia and 
 the absence of it is the most pathognomonic accompani- 
 ment of subcortical aphasia, it matters not what the degree 
 of the aphasia is. In subcortical motor aphasia there is 
 no dyslexia, because there is no word amnesia of any 
 kind, visual, auditory, or aphemic, and the patient can 
 write with the left hand, or with the right if not para-
 
 Motor Aphasia. 181 
 
 lyzed, with as much ease as he could before the illness. 
 This ability to write is dependent upon the possession of 
 the conception of the word, and particularly upon the 
 ability to evocate the visual image of the word. When 
 such evocation is possible, voluntary writing and copying 
 from dictation are done without hesitation by any mobile 
 part of the body accustomed to hold the pen. The right 
 arm being almost invariably paralyzed in subcortical motor 
 aphasia, this prevents writing with the right hand. 
 
 Writing from copy is possible in motor aphasia and in 
 subcortical motor aphasia, as has already been said. Writ- 
 ing from copy cannot be looked upon as an act necessitat- 
 ing realization of the idea or concept of the word, and it 
 therefore may be retained when such idea or conception 
 is lost. It is probable that copying involves no intellec- 
 tion except that entering into seeing the word as a de- 
 sign, and then the copying of the design, conditioned by 
 a psycho-motor act. The notion of the word may not 
 enter into the internal language at all, and unless the 
 patient reads what he is copying, and therefore revivifies 
 the visual memory images in the angular gyrus, he may 
 copy writing as he would copy a figure with which he is 
 not familiar. The fact that these patients copy print in 
 script and not in print, however, shows that they do not 
 copy mechanically and servilely, and this is explained by 
 the fa:t that in no case of motor aphasia is there absolute 
 inability to revivify visual memories ; there is only par- 
 tial disability, sufficient being left to orient the patient 
 in copying. The other reason is that man is habituated 
 from childhood to write in script and not in print, and 
 he does this unconsciously from such habituation. Dys-
 
 1 82 The Facility of Speech. 
 
 lexia, difficulty in reading (reading to one's self), is a 
 common accompaniment of cortical motor aphasia, al- 
 though it may be wholly recovered from and often exists 
 only in a latent state. In some instances the difficulty 
 in reading is so pronounced as to constitute real alexia. 
 As an instance of well-marked dyslexia, even in a case of 
 motor aphasia that has nearly recovered, I may cite the 
 following instance, which may at the same time serve as 
 an example of typical motor aphasia : 
 
 Philip Masterson, thirty-one years of age, a right-handed, 
 hard-working, temperate man, the father of three healthy 
 children, was stricken suddenly while at the dinner table 
 with a complete right-side hemiplegia. There was no 
 coma, or at least it was not sufficient completely to ob- 
 literate consciousness, although he was in a dazed state 
 for several days. Loss of speech existed from the first. 
 A few days later he could apparently understand what was 
 said to him, and made some efforts to answer, yet no articu- 
 late words came to him ; but after endeavoring to answer 
 for some time he suddenly blurted out the word " Lizzie" 
 (his wife's name), and thereafter he repeated this word 
 almost incessantly when he was spoken to and when he 
 was not, and when he wished something or when he de- 
 sired to be let alone. It partook of the nature of a recur- 
 ring utterance. After a number of weeks he was able by 
 pointing to indicate what he desired or what he meant 
 to convey. The first word that he spoke besides the word 
 " Lizzie" was after he had received a visit from a man 
 with whom he had worked for many years. When the visit- 
 or had gone he very quietly articulated the word " Lynch," 
 although there had been no conversation about the visitor 
 after he had left. He was completely agraphic, unable 
 to form the most crudely printed letter with the left hand.
 
 Motor Aphasia. 183 
 
 He understood when spoken to, would obey quickly and 
 intelligently simple requests when they were of such a 
 nature that a partially hemiplegic man could obey, and 
 he apparently put proper interpretation on impressions 
 received through the optic nerves. When any one spoke 
 to him he watched the movements of the lips very atten- 
 tively, and sometimes tried to articulate, but never with 
 
 J 
 
 any success. Six weeks after the stroke he was able to 
 articulate the words " Yes" and " No," but in response 
 to the invitation that he should tell something about his 
 illness, he was quite mute. Gradually he began to use 
 verbs and afterward to apply names to persons and things. 
 For instance, in calling the children, he would apply the 
 name of some person with whom he had worked, or of some 
 unknown person, or even the name of some object in the 
 shop where he had worked. Instead of saying, " Give me 
 my stockings," he said, " Give me those kittens." When 
 he asked for his vest he said, " Hand me that clock." 
 One day he wished to have a sponge, and endeavored to 
 convey his meaning by saying, " Where are the chickens ?" 
 Immediately after making such errors, which were often- 
 times very ludicrous, he would recognize the impropriety, 
 and particularly if he noticed some one smiling, and would 
 immediately assume a facial expression as if searching for 
 the right word, and wind up by saying, "That's damn 
 funny." If he were asked the name of his neighbor, he 
 would at once and without the slightest hesitation say, 
 " Robinson," but would recognize his error, and on being 
 asked if it were not O'Connor he would say, " Of course 
 it is; I guess I ought to know." At this time he ex- 
 hibited well-marked paraphasia. If the sentence con 
 tained no proper names, he would use the requisite ; 
 proper words to convey his idea, but they did not come 
 from his mouth with the right sequence. This was some-
 
 184 The Fac^{,lty of Speech, 
 
 what more marked when he endeavored to repeat sentences 
 and when he tried to read aloud. It was also present 
 when he essayed to speak sentences that he had formerly 
 learned by heart, such as the Lord's Prayer, or simple 
 verses of poetry. 
 
 He was very loath to try to write with the left hand, 
 and it was only with the greatest difficulty that he could 
 be induced to write his name and address, but after 
 some persuasion, fortified by assurance, he did so. He 
 was able to copy, and copied script in script, and print in 
 print, but he was quite unable to write anything from 
 dictation. 
 
 On being given a number of detached letters, and re- 
 quested to make words out of them, and then a sentence 
 informing me when he had last been to the hospital, 
 he framed with great difficulty the words, " Last Thurs- 
 day." 
 
 On testing him for powers of association and applying 
 proper names to certain things and objects, I said to him, 
 " If on your way home, you see great black clouds coming 
 up in the sky, and it begins to get dark, what do you think 
 is going to happen?" He answered very promptly, "A 
 storm." A number of other questions of similar import 
 were answered correctly. One of his answers is so thor- 
 oughly in accord with the teachings that one's thoughts 
 are largely reactionary to his environment that it deserves 
 to be quoted. I said to him : " Suppose you were on 
 your way here, Sunday morning, about ten o'clock ; you 
 hear the bells ringing, and see a great number of people 
 going into a large stone or brick building, some going in 
 singly, others in couples, some in groups; what would 
 you call the place where they were going?" He hesitated 
 a moment and then said : " A saloon, I suppose," and the 
 absurdity of it was not apparent to him.
 
 Motor Apkasia. 185 
 
 The following is a stenographic report of an interview 
 with him : . 
 
 Patient (reading from newspaper). Lead pipe his 
 mande hen of powerful presses. This medi in operation 
 before he invented the lead pipe places press the lead 
 pipe no they was about every s-sway lead was cuts 
 in pieces of the length of foot or two, which were the 
 roller which want, then rolled between grow and rollers 
 into lengths of to of about ten feets. Length being the 
 sahder, the solder, the solder together make a marse, and 
 some longer by another meadows, meadow ma-madow 
 shaped lead was cut off, the lengths rolled up, an so and 
 sa and sader (cannot say that now) and another sader 
 lead pipe was drawn in thump in something the same man- 
 ner that wire was drawn ma-a now wait- that the metis 
 required. (Lost place entirely; cannot go on.) The lead 
 pipe presses in on the new. No, it is not there. The 
 lead pipe press is not new. 
 
 Q. Do you remember what you have been reading? 
 
 A. Yes, sir. 
 
 Q. You do remember what you have been reading? 
 Now tejl me slowly what you have been reading. 
 
 A. Oh, about the lead pipe and how long them are cut- 
 ting it, and how big it was getting. I don't know of any 
 more. 
 
 O. Can't you remember anything else? 
 
 A. No, not as I know of, unless - (hesitates). 
 
 Q. How is lead pipe made ? 
 
 A. It is dumped into the boiler, isn't it? 
 
 Q. Is not lead pipe made by means of powerful presses ? 
 
 A. Yes, I guess they are. 
 
 O. Before the presses were invented how was lead pipe 
 made? 
 
 A. Oh, I don't know how that would be.
 
 1 86 The Faculty of Speech. 
 
 Q Why don't you know ? 
 
 A. I don't know; but I don't remember. 
 
 Q. Have you not just read here how it was made before 
 the presses were invented ? 
 
 A. Yes, in that paper? Yes. 
 
 Q. Then why don't you tell me ? 
 
 A. I don't know. 
 
 Q. Did you understand what you read here ? 
 
 A. No, not at all. 
 
 Q. Why did you not understand it? 
 
 A. I don't know. 
 
 Q. Before you were sick you could read English and 
 understand it, could you not ? 
 
 A. Why, of course; I wouldn't look for anything. I 
 would look around the front of the paper, of course, and 
 would not read it all. 
 
 Q. The manufacture of lead pipe ought to interest 
 you. 
 
 A. No, sir ; it did not arrest us no, we did not make 
 anything out of it. 
 
 Q. But you are interested in learning how such a 
 common thing as lead pipe was made ? 
 
 A. No, sir; we were not exactly that; we were but 
 lead, but copper, and rocks. 
 
 Q. Do you see the words when you attempt to read ? 
 
 A. Yes, sir. 
 
 Q. You can see the words, following on one after 
 another ? 
 
 A. No, sir ; I sometimes skip over a line. 
 
 Q. Why is that ? 
 
 A. I don't know. 
 
 Q. Even when you read a verse, do you understand 
 what you have read ? 
 
 A. No.
 
 Motor Aphasia. 187 
 
 This alexia which is now so manifest in attempting to 
 read is probably explained by the fact that the patient 
 always in reading evocated the articulatory word images. 
 That is, the impressions received through the visual 
 images were transformed into articulatory word images 
 before they were carried into the consciousness, and now, 
 when the articulatory word images are partly destroyed, 
 visual impressions, although properly received, do not 
 fully enter into consciousness. 
 
 Q. Now, I want you to repeat after me, the Pilgrim 
 Fathers landed on Plymouth Rock on the 22d of De- 
 cember. 
 
 A. The plim on the plim the plim no, the plimbic 
 rock. 
 
 Q. Repetition of sentence. 
 
 A. The pil the pirn the rock. The can't get that 
 out. The pirn (mutters). , 
 
 Q. Now we will try another sentence. The Declara- 
 tion of Independence was framed by Benjamin Franklin. 
 
 A. The bee the bee the bet of independence- 
 no (hesitates). 
 
 Q. Now I am going to ask you to repeat something 
 very much easier. Before the foreigner can become an 
 American citizen he must live here five years. 
 
 A. Before a for'ner who had lived here had (mutters) 
 had to go back. Is that it? 
 
 Q. (Repeating the question.) You know that is the 
 fact, do you not ? 
 
 A. Yes, sir. (Tries to repeat.) Before a commoner, 
 comner, before a commoner who had lived here- 
 couldn't go no further. 
 
 O. Now, I shall give you another question. The Papal 
 Dekgate is the head of the Catholic Church in America.
 
 1 88 The Faculty of Speech. 
 
 A. The papal dedicate was a was the was the 
 papal the pap cake oh, I couldn't. 
 
 Q. Shall I repeat it for you ? (To wife.) You repeat 
 it. (She cannot remember it all, whereupon the patient 
 says very quickly : He is a head of the U. S. of America.) 
 
 Q. Repetition of sentence. 
 
 A. The Papal Delicate is the head of the United States 
 of America. 
 
 O. Now I am going to give you a very easy one. To 
 go to the theatre is a pleasure. 
 
 A. To go to the theatre is a pleasure. 
 
 Q. To go to the theatre after a hard day's work is a 
 restful pleasure. 
 
 A. To go to the theatre is a hard day's work I don't 
 know more you run away too quick. 
 
 O. (Repeats.) 
 
 A. To go to the theatre is a hard day's work is after a 
 rest of pleasure. 
 
 Q. Does that seem reasonable? 
 
 A. Well, I don't know what word got out that time. 
 
 Q. You are not foolish, are you? 
 
 A. (Quickly.) No, not a bit, as I know of. 
 
 O. Now I will take one more sentence. In the spring- 
 time sparrows chirp. 
 
 A. In the springtime the schu eh-h-h float I think 
 ah no. 
 
 Q. Now, Mr. Masterson, I want you to tell me slowly 
 and distinctly how this sickness of yours came on. 
 
 A. I don't know how it came on. 
 
 Q. Describe it. 
 
 A. Only remember coming up the stairs ; went to the 
 hydrant, and came over and laid on a chair chucked on 
 a chair that's all I know. 
 
 Q. That is all you know of your sickness ?
 
 Motor Aphasia. 189 
 
 A. That is all I know that time well, I can't move 
 my arm, 
 
 Q. Well, tell me why you got put on a chair. 
 
 A. I don't know. 
 
 Q. What happened? 
 
 A. I could not eat any more. 
 
 Q. Now answer me this one question. Tell me what 
 has happened to you since the time when you were first 
 taken sick. 
 
 A. Eh-a I couldn't tell you that. I don't know what 
 to ask em is going around I can't tell him. 
 
 Q. Why can't you tell ? 
 
 A. Well, I can't very well. I do not remember it so 
 well. I remember the day I got sick, that is all. 
 
 Q. Well, tell me everything that happened that day. 
 
 A. Well, I worked pretty hard that morning coming 
 down stairs sometimes jumped down. Then went home, 
 of course and had that that e-e-a-e (drawling). Did 
 not eat dinner at all. I fell out of my hand, and I went 
 over to the hydrant. 
 
 Q. What is the next thing that you remember? 
 
 A. That is all now, I think. 
 
 Q. Can you remember anything else ? 
 
 A. Well, I was on the sofa, and I was lying there, and 
 I could speak to them. Ever since I have been just as 
 good as ever. I ain't done any more. 
 
 Q. Is that all you can tell ? 
 
 A. Yes; I don't know. 
 
 Q. What occurred on the 4th of March in this country ? 
 
 A. The President and Vice- President went in. They 
 took the grand opera house. 
 
 Q. What do you mean by that ? 
 
 A. Why, the name of the washing-house. 
 
 Q. You mean they entered the White House?
 
 i go The Faculty of Speech. 
 
 A. Yes, sir. 
 
 Q. What else occurred in the White House ? 
 
 A. A ball was there all big women high-toned 
 women. 
 
 Q. Yes ; but who went out ? 
 
 A. Cleveland. 
 
 Q. Where did he go ? 
 
 A. Oh, I don't know where he went. 
 
 Q. Did you not hear ? 
 
 A. No. 
 
 To test his memory and associative faculties a few 
 questions such as the following were asked : 
 
 Q. Name me all the four-footed animals you can 
 think of. 
 
 A. Why (hesitates) do you want the lion ? Buffalo 
 eh the lion (mutters) did I say buffalo already ? 
 
 Q. Name all the two-legged animals that you can. 
 
 A. Bird, chicken, and what is it ? (mutters) I think 
 of 'em (hesitates, mutters). 
 
 Q. Now name all the different birds that you can. 
 
 A. Chicken, eagle the-e stuck now. 
 
 Q. Have you been in the country ? 
 
 A. Yes. 
 
 Q. Now, sitting here, if you should suddenly hear some 
 music, hear a tune the tune, " On the Bowery" where, 
 in all probability, would it come from ? 
 
 A. Why, I don't know. Somebody had an accordeon, 
 somebody had a fiddle. 
 
 Q. Does it not occur to you that it might be a hand- 
 organ in the street, or it might be a piano upstairs ? 
 
 A. Yes, sir, come to think of it. 
 
 Q. Can you whistle? 
 
 A. No, sir. 
 
 Q. Why not ?
 
 Motor Apkasia. 191 
 
 A. Can't whistle ever since. 
 
 Q. You know tunes, don't you? 
 
 A. Well, I have not much of a fancy for music. 
 
 Q. Tell me what tune this is as I whistle it. (Whistles 
 " Home, Sweet Home.") 
 
 A. Home, sweet mother. 
 
 Q. (Whistles another tune.) 
 
 A. Don't know that tune. 
 
 Q. (Whistles " On the Bowery.") 
 
 A. Yes, I know it, but I can't say it. It can't come 
 into my head. 
 
 Q. It is " On the Bowery," is it not? 
 
 A. Yes, sir. 
 
 O. (Whistles "Yankee Doodle.") What is that? 
 
 A. I don't know what the deuce it is. I don't know 
 that one. 
 
 The essential features of this case are the total loss of 
 articulate speech for a number of weeks following the 
 attack of apoplexy, then the gradual possession of a few 
 words to signify assent and negation, and later the names 
 of his wife and of one or two of the men with whom he 
 had long worked and lived. After a number of months 
 his vocabulary began to increase gradually, particularly in 
 words that signified action or quality. In the use of these 
 words there were well-marked paraphasia and amnesia ver- 
 balis of the articulatory memory of the word. In addition 
 to this the patient had agraphia and dyslexia, although 
 there was no sensory aphasia, word blindness or word 
 deafness, optic aphasia, or hemianopsia. 
 
 The most interesting feature of his present state is the 
 agraphia and the dyslexia. He has been tested a number 
 of times with the block alphabet, and although he can
 
 192 The Faculty of Speech. 
 
 frame simple words it requires a very long time, and he 
 stops after he has made a few simple words, some of which 
 are misspelled, and he insists that he is not able to go on. 
 The dyslexia is strikingly shown by the transcript of an 
 attempt to read a newspaper paragraph telling how lead 
 pipe is made, a subject in which he should be interested, 
 as he handles that article in his occupation. I have al- 
 ready spoken of disturbances of reading and of writing in 
 cortical motor aphasia and have explained how they de- 
 pend upon the disablement of internal language which 
 accompanies every case of cortical aphasia. 
 
 Subcortical Motor ApJiasia. 
 
 The term subcortical motor aphasia is used to indicate 
 a partial or complete inability to externalize speech which 
 has been properly formed in the speech centres constitut- 
 ing the zone of language. The lesion is one that causes 
 a break in those speech-carrying neurons extending from 
 the portion of the Rolandic cortex to which is allocated 
 the representation of the different parts of the peripheral 
 speech mechanism to the cells constituting the peripheral 
 neurons of the same mechanism. Some recent writers, 
 such as Ziehen, 1 use the term fascicular anarthria to indi- 
 cate the same condition. The earliest important contri- 
 bution to the differentiation of subcortical motor aphasia 
 was made by Pitres, 2 in 1877, when he essayed to study 
 the symptomatology of lesions of the centrum ovale. At 
 
 ' Ziehen : Article " Aphasie." Eulenburg's " Real Encyclopedic, " sup- 
 plementary volume. 
 
 2 Pitres : " Recherches sur les lesions du centre ovale." These de 
 Paris, 1877.
 
 Motor Aphasia. 193 
 
 that time Pitres believed that there was no difference 
 clinically between aphasia caused by lesion of Broca's area 
 and that caused by lesion of subjacent white fibres. This 
 was a legitimate supposition, in full accord with the an- 
 atomical and physiological teachings of the times. It 
 was at that time supposed that Broca's convolution was 
 the unique area of language and that in functioning it 
 transmitted its influence by means of bundles of white 
 fibres, the inferior pediculo-frontal fascicle, to the bulbo- 
 medullary centres which conditioned the execution of 
 speech. Therefore it was logical to suppose that inter- 
 ruption of the fibres constituting this pathway would 
 cause the clinical equivalent of destruction of the cor- 
 tical area of which it was said to be the projection. The 
 conclusion would have been unassailable if the premises 
 were correct. At the present day no one believes Broca's 
 area to be the unique organ of aphasia, and modern inves- 
 tigation has shown conclusively that, even if it were, it 
 sends no fibres into the great motor projection system 
 that passes through the internal capsule on the way to 
 the motor cranial-nerve nuclei and the pyramidal tracts. 
 The completest destruction of Broca's area entails no 
 paralysis of the lips, the tongue, the palate, or the larynx. 
 Anatomists have shown that the speech centres in the 
 zone of language are association centres, intimately inter- 
 connected by commissural fibres and devoid of projection 
 fibres. The lower end of the ascending frontal convo- 
 lution immediately adjacent to the portion of the area of 
 language in which are stored articulatory kinaesthetic im- 
 ages (Broca's area) is the executive area of the zone of 
 language. When this executive area is destroyed, or when 
 '3
 
 194 The Faculty of Speeck. 
 
 all the projection fibres going out from it to the motor 
 cells constituting the beginning of the peripheral neurons 
 which go to the speech apparatus are destroyed, there may 
 be inability to articulate, which is just as complete and 
 total as if Broca's area was destroyed, but the zone of lan- 
 guage is intact and therefore internal speech is unim- 
 paired. 
 
 The symptoms of subcortical motor aphasia are practi- 
 cally the same as those attending destruction of Broca's 
 area, with two striking and all-important exceptions. The 
 first of these is that the patient retains the capacity to 
 write, which it will be remembered is lost in cortical 
 motor aphasia proportionately to the completeness of the 
 aphasia, and, secondly, the patient responds to the Proust- 
 Lichtheim test; that is, he can indicate by movement 
 in some form, by squeezing the physician's hand, by mak- 
 ing expiratory efforts, by winking, etc., the number of 
 syllables that constitute a given word or the number of 
 letters. In other words, he can prove to the satisfaction 
 of his examiners that he retains the ability to call up 
 spontaneously the .sound of the word, the visual image 
 of the word, and the articulatory memory of the word. 
 
 One of the most interesting and instructive examples 
 of subcortical motor aphasia in general literature, and 
 there are many such, is that of the illustrious Samuel 
 Johnson. He, after suffering for a number of hours with 
 a curious sensation in the head, found that he had lost 
 the power of articulate speech, though he could write 
 with customary facility. This filled him with a porten- 
 tous dread, although it is probable that his concern was 
 in nowise comparable to that of Boswell, who foresaw in
 
 Motor Aphasia. 195 
 
 this catastrophe the perishment of all that life held dear 
 to him ; the transmission to paper of Johnson's Solonic 
 utterances. Johnson, desiring to convince himself that 
 his intelligence was not impaired, essayed to write Latin 
 verse, which he did with customary ease. He also in- 
 dited a letter in the same language to his physician. This, 
 in addition to being complimentary to the intelligence of 
 the latter and to the profession of his day, showed clearly 
 that the memory of the word in all of its forms, audi- 
 tory, visual, and articulate, was intact, and that there 
 was no disturbance of internal language. Even the oc- 
 currences attending the final attack were typical of sub- 
 cortical motor aphasia. After consciousness, which had 
 been submerged during an apoplectic attack, was re- 
 gained Johnson essayed to speak in the English language. 
 Finding that he could not do so, he tried to talk Latin, 
 but found this impossible. He then uttered a few words 
 in Greek with greatest difficulty. Notwithstanding this 
 difficulty in communicating his thoughts by articulate 
 speech in any of the languages that had been familiar to 
 him, he wrote a Latin hymn addressed to the Creator, the 
 prayer of which was that so long as the Almighty should 
 be pleased, graciously, to permit him to live, he should 
 be allowed to have the enjoyment of his understanding, 
 that his intellectual and bodily powers should expire to- 
 gether. This shows satisfactorily that, although he could 
 not manifest thoughts in external speech, internal speech 
 was intact and that it could be externalized by writing. 
 
 In discussing the clinical manifestations of subcortical 
 motor aphasia, I shall record a few cases, beginning with 
 the simplest, in which the phenomena are closely restricted
 
 The Faculty of Speech. 
 
 to inability to execute the movements of articulation. I 
 shall then take up the more complex forms of subcortical 
 motor aphasia. The following case, which occurred in 
 the practice of Dr. J. C. Kendall, and to whom I am 
 indebted for the notes, may be cited as one of the most 
 restricted examples of subcortical motor aphasia that I 
 have seen. The history of the case is much abridged. 
 
 A seventeen-year-old schoolboy felt quite well on the 
 1 9th of May. On the following day he noticed that his 
 right arm was clumsy and awkward, and while in school 
 he was not able to use the pencil dexterously. On the 
 following day there was much impairment of strength of 
 the right side of the body, and he dressed himself with a 
 great deal of difficulty and got down stairs. On attempt- 
 ing to cross the floor, he fell. Examination of the patient 
 soon afterward showed a right-side hemiplegia, the arm 
 being most affected, the face less so, and the leg still 
 possessed of sufficient motility to be flexed and extended. 
 There was slight twitching of the right angle of the 
 mouth. The tongue protruded naturally, and the pupils 
 were of equal size and responsive. At this time it was 
 distinctly noticed that there was no impairment of speech. 
 On the following day the right leg became paralyzed, and 
 his vocabulary was limited to the use of the words " Yes" 
 and " No." He understood everything that was said to 
 him, and was keenly appreciative of his surroundings and 
 environment. During his illness he diverted himself with 
 pictures, and often read, which he seemed able to do un- 
 derstandingly. Impressions coming through the visual 
 apparatus and auditory apparatus were heard and inter- 
 preted. On the following day he could not articulate a 
 word. He understood words readily ; he could indicate 
 the number of syllables in a word by pressing the physi-
 
 Motor Aphasia. 197 
 
 clan's hand the same number of times as there were syl- 
 lables in a spoken or written word. The hemiplegia re- 
 mained the same. Five days later he was able to make 
 slight movements with the toe of his right foot. The 
 next day, that is, one week after speech disturbances first 
 manifested themselves, he articulated the word " Paper," 
 pointing to a newspaper that was lying on a distant table, 
 and which he wished to get. The next day he said 
 " Yes," in response to a question. From this time on 
 he regained the ability to speak and at the end of a week 
 he was able to answer and talk voluntarily in a stammer- 
 ing, hesitating manner. He never misplaced words, nor 
 did he use words incorrectly. The hemiplegia disap- 
 peared rapidly, and a month from the time when he was 
 stricken he could walk and run, and use his right upper 
 extremity, even to perform such complex movements as 
 writing, although this was very awkwardly done. Six 
 months after the attack there were no trace of hemiplegia, 
 except a slight exaggeration of the knee jerks on the right 
 side, and no trace of speech disturbance. 
 
 The clinical history of this case, particularly its mode 
 of development, course, and termination, indicates that the 
 pathological lesion was of the nature of a thrombosis, 
 while a study of the speech defects shows that the pa- 
 tient was in possession of the faculty of language in all 
 its components, including articulatory kinaesthetic images, 
 but that he was not able to give expression to his properly 
 formed thoughts and words on account of some interrup- 
 tion of continuity between the area where such articula- 
 tory kinaesthetic images are stored and the peripheral 
 executive apparatus of speech. In short, the case is one 
 of subcortical motor aphasia, or pure motor aphasia of 
 Dejerine. Although this is fully apparent from a study
 
 198 The Faculty of Speech. 
 
 of the speech defect alone, a consideration of the manner 
 of his recovery makes the truth of this much more ap- 
 parent. If the cortical area in which are stored the sen- 
 sory articulatory images had been destroyed, the mode of 
 recovery would have been quite different. In such case 
 learning to talk would have been a slow and tedious 
 process. 
 
 It may possibly be urged that the thrombotic lesion 
 interfered with the vascular supply of Broca's convolu- 
 tion, and so temporarily that is, during the period when 
 the vessel was thrombosed prevented this convolution 
 from functioning ; but the fact that the patient recognized 
 the number of syllables in a word, thus showing the pos- 
 session of articulatory images, is opposed to this view. 
 The case, then, is one of strictly motor aphasia in the 
 same sense as the paralysis of the right arm was motor, 
 and it is explained in exactly the same way. The motor 
 projection fibres that convey the speech impulses were 
 temporarily interrupted just as the projection fibres that 
 convey simple motor impulses were interrupted. 
 
 Writers are by no means in accord as to the location of 
 the lesion that causes subcortical motor aphasia. Pitres, 
 in a very recent contribution to the subject, contends that 
 destructive lesions of the white substance adjacent to the 
 foot of the third frontal convolution on the left side 
 cause aphasia which cannot be differentiated from true 
 cortical aphasia, and that the symptoms of subcortical 
 aphasia are dependent upon lesions situated in the central 
 part of the cerebral hemispheres and contiguous to the 
 internal capsule. Very few writers are willing to concede 
 this. It is undoubtedly true that it is oftentimes ex-
 
 Motor Aphasia. 199 
 
 tremely difficult to differentiate between aphasia due to 
 lesion of Broca's area and subcortical lesions subjacent 
 to it ; but it is my belief that in every instance it can be 
 differentiated if the patient be studied with sufficient care 
 and persistence, particularly with reference to his internal 
 language, the ability to read, to write with the detached 
 alphabet, etc., not to speak of the Proust- Lichtheim test 
 and the information to be derived from objective study of 
 the patient. It is not denied that lesion of the projection 
 tracts at the level of the capsule sometimes produces a 
 symptom complex very similar to that attending lesion of 
 the white substance immediately subjacent to the lower 
 end of the area of Broca and the ascending frontal convo- 
 lution. Cases in proof of this have been recorded by 
 Banti, by Dejerine, and other most trustworthy writers 
 on this subject. 
 
 The case of Banti is a very typical one. A man, sixty- 
 two years old, who had never learned to read, was stricken 
 with apoplexy, followed by right-side hemiplegia and in- 
 ability to speak. He understood everything that was said 
 to him, and he endeavored to respond, but the only result of 
 such efforts was a sound comparable to " tititititi." When 
 words of one syllable or individual letters were spoken 
 before him and he was requested to try to say them, he 
 could articulate some of them so that they could be under- 
 stood, if he did it very slowly and with great deliberation. 
 He died five years after the apoplectic attack, there being 
 in the mean time very little change in the state of his ex- 
 pressive faculties. On autopsy, there was found an apo- 
 plectic cicatrix, of a brownish-yellow color, at the level of 
 the internal capsule, between the lenticular nucleus and
 
 2oo The Faculty of Speech. 
 
 the thalamus that is, in the anterior part of the posterior 
 segment of the capsule. 
 
 Another case related by Dejerine is even more instruc- 
 tive, for the patient was a man of some education and the 
 Proust- Lichtheim test was applied. The patient, sixty- 
 seven years old, had right-side hemiplegia and aphasia 
 of many years' standing. There was absolute impossibil- 
 ity to speak aloud, but he could whisper words that were 
 intelligible. He was able also to indicate very well the 
 number of syllables in words that he was entirely unable 
 to pronounce. There was no agraphia or paragraph i a. 
 The autopsy, made eleven years after the first apoplectic 
 stroke, showed three small foci of softening situated in 
 the anterior of the hemisphere, one in the middle of the 
 internal capsule, one in the caudate nucleus, the third in 
 the fibres of the white substance subjacent to the foot of 
 the third frontal convolution. 
 
 The recitation of one case or of a hundred cases of sub- 
 cortical motor aphasia in which the autopsy showed the 
 symptom to be dependent upon a lesion of the projection 
 tracts at the level of the capsule in nowise militates against 
 the statement that lesion at other levels higher than this, 
 even up to the cortex of the Rolandic area, from which 
 starts the projection tract, may produce the symptom com- 
 plex of subcortical motor aphasia, and therefore I venture 
 to think that Pitres takes an entirely unjustifiable and un- 
 tenable position in saying that " it occurs only when the 
 lesions are situated at the level of the internal capsule or 
 at the origin of the capsular irradiation," unless the capsular 
 irradiation begins at the motor cortex. It would seem to 
 me that if the following case, recorded by Dejerine, were
 
 Motor ApJiasia. 201 
 
 the only one at our disposal it would disprove Pitres' con- 
 tention. The patient had incomplete hemiplegia of the 
 right side; no sign of verbal blindness or verbal deafness. 
 The patient understood everything that was said to him. 
 He was unable to pronounce a single word, to read in a 
 loud voice, or to repeat aloud. The motor word images 
 were meanwhile intact, because when he essayed to speak 
 he made as many efforts of expiration (Dejerine's applica- 
 tion of the Proust- Lichtheim suggestion) as there were 
 syllables in the word. He wrote easily with the left 
 hand. At the autopsy, an incision, passing horizontally 
 to the foot of the third frontal convolution and not im- 
 plicating the caudate nucleus, showed an oval spot of soft- 
 ening three centimetres long and two wide beneath the 
 foot of the third frontal, reaching into the subjacent white 
 substance as far as the lower extremity of the ascend- 
 ing frontal and parietal convolutions. I believe, more- 
 over, that in many instances cases of subcortical motor 
 aphasia due to lesion at the level of the capsule can be 
 differentiated from those due to lesion closely subjacent 
 to the cortex, and from a consideration of the objective 
 symptoms alone. 
 
 Before taking up an analysis of these differentiating symp- 
 toms, I shall cite two cases of subcortical motor aphasia, 
 the first an example of a subcortical lesion situated near to 
 the cortex, the second due to a lesion at the level of the cap- 
 sule. Opportunity was given to study the following case 
 through the courtesy of my friend, Dr. Joseph Fraenkel : 
 
 M. W , thirty-three years old, married ; the father of 
 
 healthy children ; a native of Polish Russia ; by occupa- 
 tion a tailor; and of good family and personal history.
 
 202 The Faculty of Speech. 
 
 Four years ago he was carrying a sewing-machine in the 
 street, and fell, on account of weakness. He went home, 
 complained of severe headache, was not able to be about, 
 and the next day sent for a physician, who, after attend- 
 ance upon him for a day or two, diagnosticated typhoid 
 fever. Five days after he had taken to his bed, he be- 
 came unconscious, and so remained for about sixty hours. 
 When he regained consciousness, he was paralyzed on the 
 right side and unable to speak. After six weeks his gen- 
 eral condition began to improve, and in a short time he 
 was able to be taken out of bed. Paralysis of the right 
 side of the body persisted. 
 
 Examination shows a well-nourished, intelligent-looking 
 man, of good disposition, who is apparently able to look 
 after himself. He goes all over the ward and out of doors 
 in a wheel chair, which he manages with great readiness. 
 Aside from the spastic hemiplegia of the right side, which, 
 however, does not involve the face, and the speech defects, 
 his physical and mental conditions are very satisfactory. 
 He has been examined repeatedly, and the results of these 
 examinations are monotonously uniform. 
 
 What is your name ? A. (Shakes his head and smiles 
 sadly.) 
 
 How old are you? A. (Holds up three fingers twice, 
 then puts his hand to his lips ; then quickly reaches for 
 the pencil with which I am writing; takes the pencil 
 and writes " 33.") 
 
 Are you thirty-three years old? A. (Nods affirma- 
 tively and nonchalantly.) 
 
 Are you married ? (Affirmative nod of the head ; then, 
 when he notes that I am still waiting, he writes " Yes." 
 Then, without being asked, he holds up in succession five 
 fingers and four fingers, to indicate that he has been 
 married nine years.)
 
 7i/r ^ 
 Motor .>,*^ ' 203 
 
 -v^~ ^/ O 
 
 Have you children ? A. (Holds up one finger.) Is it 
 a boy or a girl? A. (Smiles and makes a nod of nega- 
 tion.) 
 
 I want you to tell me if your child is a boy or a girl ? 
 " B' B' ba" (that is, he endeavors to say " boy," which is 
 the correct answer, but he is unable to articulate it.) 
 
 How old is he? (Holds up five fingers and then three 
 fingers to indicate that he is eight years old.) 
 
 What is your wife's name? A. (Reaches for pencil, 
 and writes in distinct Hebrew characters the word 
 " Rachel.") 
 
 It should be said here that the patient is fairly well 
 educated in the use of his own language. He has 
 learned to write with the left hand. He spends his time 
 in writing letters to his family and friends, and in put- 
 ting on paper his memories, thoughts, and hopes. The 
 Hebrew language readily lends itself to construction 
 by the left hand, its continuity being from right to left, 
 and this patient writes with great distinctness and ac- 
 curacy. It would seem on testing him a great many 
 times that he writes spontaneously with more ease, 
 accuracy, and correctness than from dictation. When, how- 
 ever, dictation is slow and he is not hurried, he repro- 
 duces most commendably. Many of his written produc- 
 tions he carries with him, and when they are read it is 
 seen that not only the thoughts but the diction are very 
 creditable. In response to simple questions or sugges- 
 tions, such as, " How would you ask the nurse to get 
 you a glass of water?" he fixes the nurse in his gaze, 
 nods to him expressively, points first to a glass, then in 
 the direction of the hydrant, and then to himself. After- 
 ward he makes a movement of carrying the glass to his 
 lips. When asked to put out his tongue, to close the 
 eyes, to squeeze my hand the same number of times as
 
 V 
 
 204 J & of Speech. 
 
 there are syllables in the word " Constantinople," he does 
 so very intelligently and correctly. The nurses and order- 
 lies in the hospital say that he never makes use of articu- 
 late words. 
 
 The sensory side of his speech mechanism is apparently 
 intact. On being asked if he understands everything that 
 he reads, he nods his head in the affirmative, and writes 
 "Yes." On being asked to read a paragraph from a 
 Hebrew newspaper, and then to write its significance or 
 meaning he does so consistently, but uses nearly the same 
 words that he has read. Numerous attempts were made 
 with this patient to determine whether or not internal 
 speech was intact. On every occasion he was able to in- 
 dicate the number of syllables in a spoken word, the num- 
 ber of letters in a word, to write quickly the names of 
 objects. In response to the question if he hears in his 
 ears the sounds of the words that he reads, he writes 
 "Yes." As to his hearing them with the same distinct- 
 ness as when they are spoken, he answers " No," but that 
 he hears them within himself. It may be said that he 
 hears whispers with the same ease as loud-spoken words 
 and sentences. He readily interprets familiar sounds, and 
 when his eyes are bandaged and a watch, a bell, or the 
 like impinges its sound upon his ear, he smiles and then 
 quickly writes the name. In the same way he interprets 
 the names and uses of familiar things that make impres- 
 sion upon his visual, tactual, and olfactory apparatus. 
 When shown a handful of coins and requested to pick 
 out all the five-cent pieces, or twenty-five-cent pieces, 
 or cent pieces, he does so with accuracy. He likewise 
 matches pennies, according to the heads or tails, dates, 
 etc. When a twenty-dollar bill is taken in one hand 
 and a number of bills amounting to eighteen dollars in 
 the other, and the patient asked which he would rather
 
 Motor Aphasia. 205 
 
 have, there is no hesitation in his decision. Quality goes 
 before quantity with him every time. On being given a 
 number of bills and coins, and asked to tell how much 
 they aggregate, he writes down the correct answer. Sim- 
 ple columns of figures are summed up with accuracy but 
 slowly, and other problems in mental arithmetic are per- 
 formed in such a way as to indicate the workings of the 
 associative faculties. He can hum the national anthem, 
 can whistle in unison with another, and plays dominoes, 
 cards, and penochle with a great deal of skill. On being 
 asked if he would like to be able to speak again, he looks 
 suspiciously at his interlocutor and smiles in a most dis- 
 couraged sort of a way ; but after a moment he reaches for 
 the pencil and writes "Yes." On being told that it is 
 very probable that he could learn to speak some words, 
 he quickly joins in the physician's effort to repeat after 
 him simple sounds, such as " o, a, n," and when he is 
 shown how to place the tongue and when the lips are 
 fixed in the proper position for him he makes intelligent 
 efforts to produce the sounds into words, but persistent 
 effort to teach him to speak has not been rewarded by 
 material progress. 
 
 This is a case of subcortical motor aphasia. It is the 
 purest and most uncomplicated that I have ever seen. It 
 is not associated with agraphia or with amimia, and the 
 sensory side of speech production seems to be absolutely 
 intact. Whether or not it was formerly, before he came 
 to the hospital, I am unable to say, for critical examina- 
 tions of his speech defects had never been made. His 
 case illustrates with great force the fact that in subcor- 
 tical motor aphasia loss of articulate speech may be the 
 only expression of inability to project outwardly states of 
 mental content. He writes with accuracy, both sponta-
 
 206 The Faculty of Speech. 
 
 neously and from dictation. He expresses mental feel- 
 ing by means of mimicry which is very easy to compre- 
 hend, but with the one exception of the word " Yes" and 
 a sound resembling " No" he makes no use of articula- 
 tion. His writing shows no evidence of repetition, of 
 transliteration, or of agraphia. It shows, however, an un- 
 commonly accurate portrayal of cognitions and feelings, 
 for one of his class. 
 
 To summarize the clinical conditions in this patient, 
 they are : Loss of volitional speech ; the images of articu- 
 lation are preserved and he responds to the Proust- Licht- 
 heim test. On account of inability to speak, he cannot 
 repeat from dictation. He can hum the air of a song, but 
 not the words. He is unable to read aloud. On the other 
 hand, there is no alexia or dyslexia, there is no agraphia; 
 he can write voluntarily, from dictation, and from copy. 
 He comprehends spoken speech, written speech, and ges- 
 ture language. The word memory is not disturbed, the 
 intrinsic speech mechanism is intact ; none of the word 
 memories, visual, auditory, articulatory, are in any way 
 destroyed. 
 
 The left motor area or the projection fibres going out 
 from it are destroyed, and this is indicated by the spastic 
 hemiplegia which the patient has of the right side of the 
 body. The fact that there are complete inability to articu- 
 late a sound and pronounced inability to co-ordinate lin- 
 guo-buccal movements, as in whistling, without facial 
 paralysis, leads me to the belief that the lesion is of the 
 cortical Rolandic area to which are allocated the repre- 
 sentation for the vocal cords, tongue, lips, etc., and not 
 lower down in the projection tracts. For if the lesion
 
 Motor Aphasia. 207 
 
 were of the latter it is probable that there would not be 
 such complete aphemia as there is, but that there would 
 be pronounced dysarthria or stammering. In this case, 
 it would seem that the word impulse representing the 
 idea left the zone of language properly and completely 
 formed, but, on being handed over to the cortical execu- 
 tive mechanism, it could not be started down the emissive 
 pathways, the projection tract, on account of destruction 
 of that part of the cortex. 
 
 The next case, in which I believe from analysis of 
 speech the lesion is lower down, is as follows : 
 
 Mrs. S , a Polish Russian, thirty-eight years old. 
 
 There is nothing of interest or of import in her family 
 or previous personal history, with the exception of the 
 event with which her present illness is associated. From 
 members of her family it is learned that she was in per- 
 fect health until immediately after the birth of her last 
 child, five years ago, when she was stricken with an at- 
 tack of apoplexy, followed by right hemiplegia and inabil- 
 ity to communicate thought by means of spoken language. 
 Examination shows, as will be seen hereafter, that she is 
 in possession of the most complete understanding of every- 
 thing that is said to her, and that she has the faculty of 
 making manifest such understanding and her wishes by 
 means of the most expressive gestures. Her whole vocab- 
 ulary is contained in two or three words, which she uses 
 for every occasion. 
 
 What is your name? A. Frieda, Frieda, Frieda- 
 Perl. (With a look of discouragement) Ich kann nicht. 
 
 How old are you? A. (In a sing-song tone.) Five, 
 and five, and five, and five, and five, and five, and five 
 (and then she holds up three fingers, at the same time 
 smiling very knowingly).
 
 2o8 The Faculty of Speech. 
 
 How old did you say you were? A. (Starts to repeat 
 it.) 
 
 Are you thirty-nine? A. No. 
 
 Are you thirty-eight? (Quick as a flash.) Yes (this 
 being the number of years indicated by the use of the 
 seven fives plus three, reckoned on the fingers). 
 
 Are you married? (In a sing-song way.) Oh, yes, 
 yes, yes. Then she begins repeating, " Five, and five, 
 and five, and five" in a sing-song way, and then holds up 
 one finger, all of which indicates that she wishes to say 
 that she has been married twenty-one years. On being 
 asked if she has been married twenty-one years, she 
 responds very quickly and accurately, " Yes." 
 
 How many children have you had ? (She holds up one 
 finger.) One? A. Yes. 
 
 What is your child's name? A. I can't say. 
 
 Is it a girl or a boy? (Points to herself to indicate 
 that the child is one of her own sex. ) 
 
 How old is she ? A. Five, and five, and five ; then she 
 holds up three fingers, which, of course, means that her 
 daughter is eighteen years old. 
 
 Is she married ? A. Yes. 
 
 What is her husband's name? A. I can't say (ich kann 
 nicht). 
 
 Has she children ? In response to this question, the 
 patient makes the most exquisitely intelligent and ex- 
 pressive gestures that I have ever seen ; her face is 
 wreathed in smiles, she places her. left hand over her 
 heart, and her right hand a short distance from the floor, 
 as if to lift up the baby, and then she carries the imagi- 
 nary baby to her breast, caresses and kisses it ; then she 
 puts it down and kisses her hand to it; and then she 
 waves kisses in the direction of her previous home in the 
 lower part of the city. After doing this, tears are seen
 
 Motor Aphasia. 209 
 
 welling up in her eyes, but this condition is not the 
 lachrymose uncontrollable attacks of depressed emotion, 
 such as are sometimes seen in hemiplegia. 
 
 Interpreted, these gestures mean, in the most inimitable 
 way, that she has recently become a grandmother; that 
 the little child is just beginning to creep; that she would 
 like to press it to her bosom ; that it is the embodiment 
 of her maternal affection ; and her tears come because she 
 is separated from it. If it is suggested to her that this 
 is the proper interpretation of her gestures she gives the 
 most appreciative and grateful assent. If some other 
 interpretation is suggested to her, she laughs scornfully. 
 
 Tell me about your sickness. Oh, yi, yi, yi, yi, yi, yi, 
 yi, vergessen (forgotten), kann nicht (I cannot) friiher 
 (before), weiss es nicht (I do not know), spater (later), in, 
 vergessen (forgotten), Frieda Perl (her first name, to which 
 she attaches the word " Perl," for what reason I have not 
 yet been able to fathom), finger. All this is said in a 
 singing tone. After she repeats these words over for 
 a time, she ceases to speak, as if discouraged with her 
 own efforts. She then makes most suggestive gestures 
 of combing her hair and then of toppling over, which 
 means that her attack of hemiplegia came on without 
 warning in the morning five years ago, while she was 
 combing her hair, that she toppled over, and that she was 
 unconscious for quite a long time. 
 
 On examination of the patient's physical condition, it is 
 seen that she is a well-nourished woman, that she has 
 the gait and station of one with partial right-side hemi- 
 plegia, and that the remains of the paralysis are more 
 marked in the right upper extremity than in any other 
 part of the body. The patient is able to perform all the 
 general movements of the tongue and lips, and there is 
 no difficulty of swallowing, no dribbling of saliva, and
 
 2io The Faculty of Speech. 
 
 she goes about and takes care of herself as does any 
 patient whose, mental integrity is undisturbed. As has 
 been said, the language of her emotions is not at all im- 
 paired, and she smiles, frowns, laughs, and cries, when- 
 ever there is cause for any of these outward expressions, 
 but she does not manifest them without cause. She under- 
 stands all that is said to her, and detects with the great- 
 est readiness unreasonable or ridiculous statements or 
 speeches. The sensory side of her speech faculty is ap- 
 parently intact. The patient has never been able to read 
 or write, but she recognizes the letters of the Hebrew 
 alphabet and words which form parts of familiar prayers, 
 and she recognizes and puts the proper interpretation 
 upon pictures. For instance, shown the picture of a girl, 
 she smiles, and points to some young female patient in 
 the ward, or goes through the gestures mentioned above 
 to indicate that one of the kind in the shape of her little 
 granddaughter is in her own family. When shown the 
 picture of a cow she tries to pronounce the word, but when 
 she cannot she reaches for a glass and by carrying it to 
 her lips aims to indicate that the cow gives milk ; and so 
 on, with all the objects or subjects with which she is vis- 
 ually familiar. 
 
 Sounds and words apparently make natural and proper 
 impression upon her auditory peripheral and central ap- 
 paratus, and the tick of a watch, the sound of a bell, the 
 paring of an apple, the note of a pianoforte, are all heard 
 and properly interpreted. As I have said, she is wholly 
 uneducated from a scholastic standpoint, and unable to 
 write. Naturally, therefore, it is impossible to say whether 
 or not there is agraphia or paragraphia. We may infer, 
 however, that had she been able to write there would have 
 been no defect in the graphic representation of thought 
 except that due to the immobility of the right hand. It
 
 Motor Aphasia. 2 1 1 
 
 is perhaps unnecessary to state, after what has been said, 
 that the patient responds with alacrity to the ordinary 
 commands, such as " Put out your tongue," " Close your 
 eyes," " Bring me a piece of paper," and the like, and con- 
 ducts herself in every way like a person in the fullest pos- 
 session of her mental faculties. 
 
 Repeated examination of this patient, week after week, 
 shows no material change in the responses to various tests. 
 
 The age of the patient, a consideration of her previous 
 history, the physiological effort immediately antecedent to 
 the attack, the mode of onset, duration, symptoms, and 
 termination of the attack, and the degree of physical and 
 mental recovery which followed it, all point unerringly to 
 an embolus of one of the lenticulo-striate arteries as the 
 cause of her apoplexy. It is not my purpose to pursue 
 further a discussion of this question here, first, because 
 it is not patent to the symptom complex of subcortical 
 aphasia, which now interests us, and second, because the 
 onset and course of the hemiplegia were typical of cere- 
 bral embolism. 
 
 A retrospect of her history shows that in the beginning 
 there was complete aphemia, and that now, some five 
 years later, the aphemia is still present, but is not ab- 
 solutely complete. She can articulate a certain number 
 of words; she can use properly the words "Yes" and 
 "No;" and almost always the sentence, "I can't say." 
 The few words of her vocabulary are used with conven- 
 tional significance; but they are produced in a sing-song 
 fashion, that is, the sounds are intonated and the words are 
 repeated, and the rhythm of their emission is irregular. 
 
 Really, the most striking and interesting side of her
 
 2 1 i The Faculty of Speech. 
 
 possessions in the way of projecting mental contents is her 
 ability to use pantomime so expressively and intelligently. 
 It is not necessary, in this connection, to say again that 
 thought is expressed by movements. Movements are 
 particularized in three ways, namely, by speech, by writ- 
 ing, and by pantomime, and inability to express thought 
 by any one of these three ways is known respectively as 
 aphemia, agraphia, and amimia. In some cases of apha- 
 sia, all of these defects are present, in others one may 
 be complete, and the others only partial ; while in sub- 
 cortical motor aphasia, of which this case is an example, 
 one of these faculties, oftentimes two, are entirely spared, 
 while the third is completely destroyed. In this patient 
 it would seem that the projection areas of the cortico- 
 nuclear neurons which serve motor speech production were 
 interrupted by the vascular lesion that occurred five years 
 ago, but that the cortico-nuclear neurons which conduct 
 impulses that are manifest by pantomime have remained 
 intact. Sufficient has been said in speaking of the exam- 
 ination of the patient to show that the associative faculties 
 which are the basis of intellectual activity have not been 
 seriously impaired in this woman, nor has the internal 
 language. Her mode of answering questions into which 
 the element of time is interjected shows that she is capa- 
 ble of reckoning. I might say in this connection that if 
 she were asked to compute simple problems in mental 
 arithmetic she would indicate the correct answer by hold- 
 ing up successively the fingers of the hand, or by intonat- 
 ing, " Five and five and five," and so on, until she ap- 
 proached as nearly as possible to the correct figure by 
 using the multiple ; then she would complete the answer
 
 Motor Aphasia. 213 
 
 by holding up one, two, three, or four fingers as the case 
 required. 
 
 The distinguishing features in these two cases are that 
 in the first there is no agraphia and the patient responds 
 to the Proust- Lichtheim test, and in the second there is 
 no disturbance of internal language. If it be a fact that 
 a lesion of any of the speech centres entails some perver- 
 sion of internal language in every instance, these cases do 
 not belong to the category of cortical or true aphasia. 
 They differ one from the other by the fact that the first 
 patient is absolutely speechless, and the second can say a 
 few words but only in a sing-song manner. When she 
 says, " Fiinf und fiinf und fiinf und funf," etc., she does 
 not speak it, she sings it. The other words that she uses 
 are pronounced very imperfectly and indistinctly. It is 
 impossible to indicate this on paper, for she speaks the 
 Yiddish jargon and it has to be translated into English 
 that it may mean anything on paper; but as a matter of 
 truth the words that she uses are very imperfectly articu- 
 lated. It is this imperfectness of articulation of words 
 that she can say and the sing-song way of making replies 
 that lead me to believe that the lesion in her case is at a 
 lower level than in the case first enumerated. That is, I 
 believe that in the second case the words may get started 
 down the projection tracts on their way to be externalized, 
 but they meet with an interruption in the shape of the 
 lesion at some lower level. Those fibres that are not en- 
 tirely severed allow the transmission of the impulses that 
 are externalized by the patient's few words. 
 
 When the lesion causing subcortical motor aphasia is 
 situated at a level as low as the internal capsule, then a
 
 214 The Faculty of Speech. 
 
 diagnosis can often be positively made, not alone from the 
 employment of the Proust- Lichtheim test, but from study 
 of the trouble of articulation. Such a patient has all the 
 components of internal language absolutely intact, inclu- 
 sive of the articulatory kinaesthetic images of words. He 
 hears, sees, writes, mimics, and in other ways gives evi- 
 dence of intellectual integrity. He is incapable only of 
 causing the co-ordinate movements which subserve articu- 
 late speech. He may not be totally devoid of power of 
 articulation ; his incapacity may vary from simple slur- 
 ring and elision of certain syllables and words, through 
 dysarthria, dysrhythmia up to complete anarthria and 
 arhythmia, and thus complete speechlessness. This partial 
 loss of the capacity for articulate speech is well illustrated 
 by the first case of Dejerine cited above. 
 
 In the conventional use of the term, this condition is 
 aphasia; but it is not true aphasia, for true aphasia occurs 
 only with lesion of the area of language. Yet it simulates 
 true aphasia so closely that a differential diagnosis can 
 be made only after very careful study. The nearer the 
 lesions to the cortex, the more difficult will this differ- 
 entiation be for such cases. All the projection fibres 
 coming from the executive articulatpry area are more 
 likely to be involved, and with it there may be some func- 
 tional perversion (possibly transitory) of the zone of lan- 
 guage. 
 
 The differentiation of cortical and subcortical aphasia 
 sometimes becomes of inestimable importance from a 
 medico-legal point of view. For instance, a patient who 
 has the symptom complex of motor aphasia due to a sub- 
 cortical lesion may be just as competent to make a will
 
 Motor Aphasia. 215 
 
 and dispose of his possessions as a man who has hemi- 
 anaesthesia due to a central lesion ; but a man who has 
 cortical motor aphasia, and thus a derangement of his in- 
 ternal language, entailing some deviation from normal in 
 every component of speech, be it in hearing, in seeing, or 
 in expressing himself (including writing), may be quite 
 incapacitated from such disposition, according to the 
 interpretation of the law. 
 
 Cortical motor and subcortical motor aphasia are both 
 almost invariably associated with right hemiplegia, and 
 are dependent upon the same lesion. 1 In the cortical 
 form the hemiplegia is apt to be less complete, and the 
 spasticity of the paralyzed parts great. Moreover, it usu- 
 ally follows immediately after the stroke, although it may 
 occur with epilepsy, tumors, abscess, foci of inflammation, 
 or other conditions which slowly destroy Broca's area. 
 
 1 In Appendix II. a case of cortical motor aphasia is cited in which there 
 was no hemiplegia. It may be of interest, or instructive perhaps, to read it 
 in connection with this chapter.
 
 CHAPTER VI. 
 
 SENSORY APHASIA. 
 
 I. General Considerations. 2. Sensory Aphasia: Word 
 Deafness or Audit ony Aphasia, and Word Blindness 
 or Visual Aphasia. J. Subcortical Sensory Aphasia. 
 
 As motor aphasia is used to designate those disturb- 
 ances of speech expression in which the chief diffi- 
 culty is in making speech, sensory aphasia, as a term, is 
 applied to those cases in which imperfections of language, 
 disability or inability to speak, are due to interference 
 with the reception of speech forms ; that is, to lesion of 
 the perceptive areas of the brain and the immediate in- 
 coming and commissural pathways of such areas. The 
 perceptive centres by whose functioning speech is onto- 
 genetically developed are the auditory and the visual, and 
 sensory aphasia is thus practically auditory and visual 
 aphasia, and it is as such that I shall describe it, after a 
 brief introduction to the subject. 
 
 Sensory aphasia may be defined as loss of the under- 
 standing of words, due to interference with the formation 
 of associations necessary for complete perception. An- 
 atomically speaking, cortical sensory aphasia might be de- 
 fined as aphasia due to lesion of the posterior part of the 
 area of language, and cortical motor aphasia as due to 
 lesion of the anterior end of this zone. The subcortical
 
 Sensory Aphasia. 217 
 
 forms of each variety occur when there is lesion of the 
 pathways which carry impressions into and away from the 
 zone of language. 
 
 When Wernicke first described sensory aphasia it was 
 as a symptom complex characterized chiefly by loss of 
 comprehension of words, heard and read, often associated 
 with paraphasia and agraphia. Clinically speaking, this is 
 what is understood by the designation, and although sensory 
 aphasia is subdivided into auditory and visual, it is only 
 that the subject may be easier of comprehension and more 
 in accordance with the symptoms that our cases present. 
 The separation of sensory aphasia into auditory aphasia 
 and visual aphasia is quite natural, in view of the fact that 
 physiology and pathology are in the fullest accord in 
 granting separate allocation to the two functions, seeing 
 and hearing, whose integrity is so essential to the de- 
 velopment and maintenance of speech. As the cortical 
 representation of these two functions is independent, it 
 follows that one may be diseased without the other. In 
 such case the resulting symptoms are predominantly of 
 the centre diseased, but nevertheless there are always 
 some symptoms referable to the centre not the seat of 
 lesion, for none of the speech centres are autonomous and 
 lesion in one entails perversion of the function of all the 
 others. In other words, in order that speech may be per- 
 fect, whether it be internal speech or external speech, it is 
 necessary that the entire speech mechanism be intact. For 
 the occurrence of a physiological reflex it is necessary that 
 the afferent tract, the centre, the efferent tract, and the 
 part in which the reflex act is manifest be intact ; and if 
 any one of them be disorganized the reflex act will be cor-
 
 2 1 8 The Faculty of Speech. 
 
 respondingly abnormal. Each element entering into the 
 constitution of the reflex arc is an entity, if one chooses 
 to call it so, and each one of its parts may continue to 
 discharge certain functions after another part is diseased, 
 but it can no longer contribute its share to the perform- 
 ance of a compound or a conjoint act after such disease. 
 In the same way speech becomes disordered when one of 
 the components entering into the speech mechanism is 
 diseased. Nevertheless, when the auditory area is alone 
 the seat of destructive process, there is no reason why the 
 visual and articulatory kinaesthetic memories should not 
 remain intact, and so they do ; but when memorial recalls 
 from these centres are intercalated into the speech circle, 
 the auditory link is missing, and the circuit cannot be 
 completed ; the result is disturbance of speech, referable 
 particularly to the hearing, because that is the element 
 that is wanting. Moreover, as the primary revival of words 
 takes place in the vast majority of peoples by the initia- 
 tive of the auditory centre, when this is diseased internal 
 speech is very defective. 
 
 The blood-vessel supplying the zone of language is the 
 left middle cerebral artery, the so-called Sylvian artery. 
 Lesion of different parts of its course entails different re- 
 sults. Disease of the anterior part and branches is apt to 
 cause motor aphasia ; of the posterior part and branches, 
 sensory aphasia. In the beginning the sensory aphasia 
 may appear to be equally of both the auditory and the vis- 
 ual centres, but, as time goes on and nature strives to over- 
 come the lesion, the affection of one of these centres of lan- 
 guage may be less serious than that of the other, and there- 
 fore the symptoms referable to it will be soon cleared up.
 
 Sensory Aphasia. 219 
 
 The symptoms referable to the other sensory centre may be 
 caused by lesion of a branch of the vessel going directly 
 to that centre, and therefore these symptoms are continu- 
 ous and persistent. Thus it is readily seen that a degree 
 of auditory aphasia and visual aphasia, or word deafness 
 and word blindness, as they are unfortunately called, are 
 frequently coexisting phenomena. The predominance of 
 the one, or the apparent individual occurrence of the other, 
 depends upon the seat and the intensity of the lesion. 
 Many cases of sensory aphasia, especially those due to 
 vascular lesion, have in the beginning symptoms pointing 
 to implication of both the auditory and the visual centres; 
 yet after the condition has existed for a time the symptoms 
 referable to one of these centres may be reduced or even 
 become latent, while those referable to the other centre per- 
 sist and dominate the clinical picture. Thus auditory 
 aphasia or word deafness and visual aphasia or word blind- 
 ness are differentiated remains of one and the same sensory 
 aphasia. 
 
 Sensory aphasia possesses certain very definite general 
 features, which I propose to enumerate briefly before 
 taking up the separate discussion of auditory aphasia and 
 visual aphasia. These general features are in many ways 
 materially different from the general features of motor 
 aphasia, and they are explained by the location and rela- 
 tionships of the different centres. Motor aphasia is al- 
 most invariably associated with hemiplegia, while sensory 
 aphasia is rarely accompanied by hemiplegia unless the 
 lesion is a most extensive and severe one. In the case of 
 motor aphasia this is easily explained by the proximity of 
 the convolution of Broca to the motor centres in the
 
 220 The Faculty of Speech. 
 
 Rolandic region and to the motor projection tract. On 
 the other hand, if the lesion be confined to the posterior 
 part of the zone of language, the cortical motor area and 
 the projection tract constituted by its central axones may 
 be entirely spared. Compared with motor aphasia, sen- 
 sory aphasia is relatively more often associated with 
 lesions that are not primarily vascular in origin. In 
 other words, it is more likely to occur with encephalitis, 
 with tumors, with injury, and with certain degenerative 
 diseases of the brain ; and thus its evolution is often very 
 different from that of motor aphasia. Whereas the former 
 is almost always abrupt, and consequent on an apoplectic 
 stroke which usually entails more or less prolonged loss 
 of consciousness, sensory aphasia not infrequently unfolds 
 itself slowly, and even when due to a vascular lesion it 
 oftener comes on progressively or in repeated accessions 
 than does motor aphasia. 
 
 Another very striking feature of sensory aphasia is that 
 in the beginning it is the aphasia of comparative speech- 
 fulness, while motor aphasia in the beginning is usually 
 absolute speechlessness. Sensory aphasia is characterized 
 by logorrhoea, motor aphasia by alogia. Then the career 
 of sensory aphasia is most instructive. The unfortunate 
 patient starts in with his senseless loquacity, and week 
 after week, sometimes day by day, one notes the shrink- 
 age of his useless vocabulary, through the stages of bab- 
 bling, of lalling, and of echoing, down to absolute mutism 
 as complete as that produced by total destruction of the 
 articulatory kinaesthetic area. The course of a sensory 
 aphasic may be compared to that of a runaway engine. 
 Some accident opens the throttle during the absence of
 
 Sensory Aphasia. 221 
 
 the driver, and away it flies without regard to destination, 
 to danger, to results. Gradually, as its steam becomes ex- 
 hausted, its pace becomes slower, it becomes less boister- 
 ous, it is more easily overtaken, until finally the last atom 
 of steam is exhausted and it comes to a dead halt. There 
 is nothing to stir it up and start it on. It stands ready, 
 however, at any moment to be made a useful agency ; it 
 requires but coals and water. If it remain unused 
 for a long time, rust and other accompaniments of time 
 so incapacitate it that, even if these elements be given 
 to it, it is no longer a useful agent, and it stands a useless 
 wreck of its former self, a wreck induced by loss of the 
 agencies necessary to drive it, all dating back to the acci- 
 dent that opened the throttle. 
 
 It is the same with the patient who has had a lesion 
 of his auditory speech centre which is sufficient to derange 
 it without completely destroying it. From the beginning 
 of the person's ability to speak this centre has exercised 
 the influence of a director-general over the articulatory 
 speech centre, inhibitory and excitatory. Now this in- 
 fluence is taken away. The result is that all the inhibi- 
 tory influence is destroyed by one blow, and the work 
 of years of experience on the part of the articulatory 
 centre in the endeavor to become a centre of the primary 
 reviver of words begins to dissipate like a corundum wheel 
 when breaking, and the result is logorrhoea. After this 
 automatic storehouse (which is always small, even in the 
 most expert linguist and most highly educated man) is ex- 
 hausted, the vocabulary begins to shrink, and, as the centre 
 which has always acted as the stimulator in the memorial 
 recall of words is destroyed, the patient gradually approxi-
 
 222 The Faculty of Speech. 
 
 mates mutism, although the articulatory kinaesthetic centre 
 is itself intact, ready to do its work on the reception of the 
 proper incentive. But if this incentive has been long with- 
 held, like the engine that becomes incapacitated by rust 
 and other ravages of time, it will be incapable of doing it, 
 even though such incentive should be given to it long 
 after. This is but another bit of evidence in favor of the 
 interactivity of the different speech centres and against 
 the autonomy of any one of them. 
 
 Patients with sensory aphasia are very rarely reduced to 
 a condition of mutism by such lesion alone, because de- 
 struction of the auditory centre is rarely complete. When 
 the lesion of the auditory centre is slight, the most strik- 
 ing abnormality in voluntary speech is the inability to use 
 words with their proper signification, although the words 
 that are used are articulated with as much clearness and 
 distinctness as in the normal state. The patient may 
 utter words that are entirely the opposite of those which 
 he intended to use. No more striking example of this can 
 be given than a reference to the history of a lady cited 
 by Trousseau, ' who, arising to greet a visitor, would with 
 courteous bow and apparent welcome say in the most 
 matter-of-fact way, " Pig, brute, stupid fool," which when 
 interpreted by one of her family meant, " Madame begs 
 you to be seated." Happily the misuse of words does not 
 often take this decidedly frappant form. It may be ap- 
 parent only by a change of position of words in a sentence, 
 or by the use of one word for another that has a somewhat 
 similar sound or beginning. The condition is one that 
 admits of ready explanation : the sensory centres being de- 
 
 1 Trousseau : "Clinical Medicine," fourth edition, vol. ii., p. 674.
 
 Sensory Aphasia. 223 
 
 stroyed, their images can no longer be evoked to act as a 
 check or control on the articulatory centre, the images in 
 which are always evoked before the thought that is to be 
 externalized can be expressed. 
 
 The defect of speech known as " jargonaphasia" occurs 
 oftentimes with sensory aphasia. This may be considered 
 a degree of paraphasia, although the latter is properly 
 applied to a condition in which words are used in an incor- 
 rect sense. Jargonaphasia consists of the production of a 
 jumble of words all forged into one, the syllables of which 
 may be articulated, but the words have no similarity to 
 words as usually spoken. Indeed, so wholly dissimilar are 
 they that some cases of jargonaphasia have been con- 
 sidered evidence of a supernatural influence manifesting 
 itself in the sudden acquisition of a language undecipher- 
 able by the most profoundly versed in strange tongues. 
 
 Reports of these cases not infrequently find their way 
 into newspapers, and excite great attention and are much 
 marvelled at by the laity. They are oftentimes investigated 
 by committees made up of men imbued with praiseworthy 
 scientific zeal, but oftener by persons who have exhausted 
 their interest in things that conform to the established 
 laws or courses of nature and who find inclination only in 
 the supernatural. Jargon speech is occasionally an accom- 
 paniment of disordered cerebration dependent upon altered 
 states of consciousness attending acute sthenic and asthenic 
 states. 
 
 It is not alone in spontaneous speech that these perver- 
 sions are manifest ; they are as evident when the patient 
 attempts to repeat what he hears (indeed oftentimes very 
 much more so, particularly if the patient is partially word
 
 224 The Faculty of Speech. 
 
 deaf). In singing also the condition of paraphasia and 
 even of jargonaphasia is sometimes very striking. The 
 patient remembers and is able to hum the air of a familiar 
 tune, but the words that he attempts to fit to it have no 
 sense, no propriety, no reason. The occurrence of para- 
 phasia and of jargonaphasia on reading aloud is also very 
 striking, but as this subject will be considered in more 
 detail under the subdivisions of sensory aphasia auditory 
 and visual aphasia I shall merely make mention of it here. 
 Not secondary in importance to the information that 
 may be obtained from a study of articulate speech is that 
 which is to be had from an examination of the spontaneous, 
 dictated, and copied writing. Patients with pronounced 
 sensory aphasia are not usually hemiplegic, so that tests for 
 defects of writing can be undertaken without trouble if the 
 patient be made to comprehend what is wanted. Defects in 
 writing are most striking when visual aphasia is the prom- 
 inent feature of the sensory aphasia, although they occur 
 in every case of sensory aphasia. The degree to which 
 spontaneous writing may be preserved, or lost, in sensory 
 aphasia varies with the patient, the seat, and the intensity 
 of the lesion. Oftentimes there is preserved, even in cases 
 of genuine visual aphasia, the ability to write a few words 
 spontaneously, such as the patient's name, address, the 
 name of some member of his family, and possibly a few 
 other words ; but even in the production of these the patient 
 gets the surname following on the family name, and in 
 other ways shows the condition known as paragraphia. If 
 the patient has destruction of the angul'ar gyrus, there will 
 be practically total agraphia, because he cannot revive the 
 visual memories that are necessary to be evoked in order
 
 Sensory Aphasia. 
 
 22=; 
 
 that the mobile part of the body carrying the pen may be 
 directed by the thought to inscribe them. If the lesion 
 is principally a destruction of the auditory area, there will 
 be absolute inability to write from dictation; and even 
 though writing spontaneously may be preserved to a very 
 limited extent, the words or sentences produced will be 
 markedly disordered in their arrangement. 
 
 Writing after copy is preserved in every case of genuine 
 sensory aphasia, but the patient copies in a way that at 
 once puts the stamp of his infirmity upon his work. He 
 copies letters the way a beginner does a drawing, line for 
 line, curve for curve, angle for angle, and makes an exact 
 reproduction of what is before him in the same manner 
 as does an engraver or a forger of a man's signature. 
 These variations in writing will be discussed particularly 
 under visual aphasia, in which variety of sensory aphasia 
 they are most pronounced. 
 
 I shall cite the following case as a typical example of 
 sensory aphasia, even though the symptoms were predomi- 
 nantly referable to that subdivision of sensory aphasia 
 known as visual aphasia. It appears to me much more 
 instructive to give accurate reports of interviews with 
 such a patient than merely to state the results of such ex- 
 aminations. These reports demonstrate more conclusively 
 than can any description, the shortcomings of speech as 
 they really exist. This case has been of great interest to 
 me as one offering difficulties of interpretation, and I have 
 many stenographic reports of interviews with the patient, 
 two or three of which I shall now present. 
 
 L. B , female, thirty-nine years old. Said to be 
 
 married. Admitted to my wards in the City Hospital, 
 15
 
 226 The Faculty of Speech. 
 
 July 8th, 1896. History: One year ago on awaking in 
 the morning she could not move the right side. The lower 
 extremity was not so helpless as the upper. Since that 
 time she has not been able to talk understandingly. About 
 eight or nine months later she had an epileptic attack, and 
 since then she has an attack about once a month. Practi- 
 cally nothing is known of this patient's history. The 
 facts just mentioned were obtained from the registrar of 
 the hospital, to which she had been taken immediately after 
 the beginning of her illness. These facts were given by 
 the individual who brought her to the hospital. Since she 
 has been in the City Hospital we have not been able to 
 find out anything about her from herself, nor has any one 
 been to visit her from whom such information could be 
 obtained. In discussing the case I shall limit myself, 
 therefore, to the results of examination. 
 
 A general survey of the patient shows that she is able 
 to walk without the aid of a stick ; she swings and drags the 
 right leg and foot, not in a characteristic hemiplegic way, 
 yet with a considerable paresis and spasticity. The right 
 upper extremity is in a state of contracture and very 
 nearly completely paralyzed. There is no involvement of 
 the face or cranial nerves. To convey a proper idea of 
 her speech disturbance, I shall give a stenographic report 
 of a few examinations. 
 
 Examination, September ^.th. 
 
 What is your name? m'm'm'y name, m'name's Samp- 
 son, my name's's I don't know. I can't tell that. 
 
 You heard the doctor read the name ? No, that I know. 
 Is your name Lucy Brown ? Yes. 
 Is your name Lizzie Brown ? No. 
 What is your name ? Lucy. 
 Lucy what? I can't say.
 
 Sensory Aphasia. 227 
 
 Is it Lucy Black ? No. 
 
 Is it Lucy Brown ? Yes. 
 
 How old are you? I can't tell you, mu mother, my 
 mother, my g'mother go. 
 
 Are you twenty ? I wouldn't say. 
 
 Are you more than twenty or less than twenty? Oh, 
 yes; twenty-one, twenty-two; I had children you know. 
 
 Are you forty ? Oh, no. 
 
 You are seventy-five ? Yes, ma'm. 
 
 Is your mother living? Yes. 
 
 When did you see her last ? She comes on the first 
 m'm'mth. 
 
 Was she here the first of this month ? No, the last of 
 the month. 
 
 Are you older than your mother? I can't tell that 
 much. 
 
 Is your mother twenty ? (Putting hand to throat) I can't 
 tell that much. 
 
 Is she fifty ? Of course I can't boys got 
 
 Are you married? Yes, I'm married about o'o'o' can't 
 call it now. 
 
 How long have you been married? This boy twenty- 
 one boy. 
 
 How long have you been married? I told you, I 
 couldn't tell you I couldn't tell; sometimes my 
 speech 
 
 Why can't you tell me? What? (in surprised tone). 
 
 Why can't you tell me? Married I tell you, please 
 (pointing toward city) mother-care. 
 
 Here she began to talk of her paralyzed side "My 
 hand s'clame [lame] sometimes s'clame, sometimes 
 strong." 
 
 I do not know yet whether you had one child or twenty ? 
 I have had two.
 
 228 The Faculty of Speech. 
 
 Do you understand all I say to you ? Oh, me. Why 
 yes, ma'm ; I was sleeping, that's all. 
 
 Where are your children ? Boy and a girl, boys, boys, 
 girls. 
 
 How big are they ? One boy is dead. 
 
 How big is the other? Twenty-one. 
 
 That is right, is it not ? Yes, sir, right. 
 
 How long have you been in the hospital? Well, I 
 think it is two months, I can't tell, Miss Buckley (the 
 nurse) knows. 
 
 Have you been here a year? Oh^ no, sir; no, sir. 
 
 Where did you live before you came here? Its, its, 
 its, in though its, its I can't tell it (in despair). 
 
 Where do you live ? I can't tell you, but I can tell 
 you tame. 
 
 Do you remember how the house looked? Oh, yes, sir; 
 yes, sir. 
 
 Would you know it again if you saw it ? Yes, sir ; yes, 
 sir. 
 
 Can you remember the house next door? I don't 
 know, I think so. 
 
 Can you remember how your mother looked? Yes, 
 ma'am ; my m'm'm'oth other was lighter woman. 
 
 Can you remember the sound of her voice? Mercy, 
 yes ; oh, yes. 
 
 What was it like ? White woman. 
 
 What was it like ? What do you mean ? My mother 
 was a white, my mother was a white, light woman. 
 
 Can you remember the scund of a bell ? Oh, I guess so. 
 
 Can you imagine that you hear a bell now ? No. 
 
 What is a voice ? Voice, voice. 
 
 Yes; is my voice like the voice of that gentleman? 
 (Smiles.) Voice, voice. 
 
 Have you ever heard that word before ? No answer.
 
 Sensory Aphasia, 229 
 
 I then spell v-o-i-c-e and ask her to repeat it, but she 
 cannot. 
 
 When she tries she says p-u-c-c-b. 
 
 You can say that pretty well ? Yes I can't once in a 
 while, I have to suffer. 
 
 Do you know the letters of the alphabet ? I can say 
 them. 
 
 Say them ! C, c, c, no, no, is that right ? C, u, t, v, 
 u, c, o, n, u, p, e, u, t, m, n, o, t, c, t, o. 
 
 Does the alphabet not begin, a, b, c, etc. ? Yes, that's it. 
 
 Now let me hear you repeat the letters of the alphabet 
 after me. A? u. B? c. C? u. D? w. E? w. F? 
 i. G? c. H? h. I? i. J? j. K? k. L? o. M? 
 i. N ? u. - O ? o. P ? u. O ? yaw. R ? r. S ? t. T ? 
 a. U? t. V? u. W? w. X? x. Y? a. Z? c. 
 
 You recognize that the alphabet starts off a, b, c. 
 Yes., sir, I recognize but I can't say them, that's all. 
 
 It is noticed that she watches very closely the lips of 
 her questioner. 
 
 Test for Recognition of Objects and Naming Objects. 
 
 Holding up a watch. Clock. 
 
 Chain? Clock, it's a clock. 
 
 Key? It's a clock (said very hesitatingly and starts to 
 correct herself after the word is partly out, but at last lets 
 it go). 
 
 Holding up another and more typical key? It's a key. 
 
 Pencil? 'S'key, it's what's its name, can't tell it now. 
 It's a clock, can't tell it now. 
 
 Knife ? Knife. 
 
 A roll of bills ? It's a dollar. 
 
 A two-dollar bill ? I can't tell, a dollar. 
 
 A twenty-dollar bill? A dollar. Tain't, can't do it 
 now; I know it but I can't do it now.
 
 230 The Faculty of Speech. 
 
 Count on your fingers how many dollars this is (showing 
 five-dollar bill). Doesn't understand and cannot be made 
 to, and even after I show her how to do it and illustrate 
 what I mean she cannot do it. Once she recognized and 
 named a five-dollar note. Although she seemed to know 
 the value of different denominations, she could not pick 
 out the money when bills were called by face notation. 
 
 Match box ? Match box. 
 
 Cigar? P-p-five, pipe. 
 
 Is it a pipe ? (With emphasis) No, sir. 
 
 It is a cigarette ? Oh, no. 
 
 It's a cigar? Yes, it's a cigar. 
 
 What am I doing now (lighting a match) ? Match, 
 turning it up, lighting. 
 
 How old do you think I am? I don't know. 
 
 Eighty- six? (Scornfully) Oh, no. 
 
 How many eyes have I ? Two. 
 
 What is the color of my beard ? No answer. 
 
 Black? No. Yellow? No. Green? W'w'ee, I 
 can call it, but I can't say the name. 
 
 Is it red? Y-e-s (doubtfully). 
 
 What day of the week is it ? Wesday (it is Sunday). 
 
 What day? W-e-s , yes, sir, Sunday. 
 
 What do you do on Sunday? Sleep. 
 
 Are you tired ? Oh, no, no, sir ; oh, no. 
 
 Can you move your right hand ? That one (pointing). 
 
 Apparently she cannot tell right from left with ac- 
 curacy. 
 
 (Shown a picture of a man.) What's that ? (Hesitates.) 
 Is it a cow ? Oh, no. 
 
 Is it a woman ? It's a man. 
 
 (Shown a picture of a woman.) Sat's boy. 
 
 Why, that is a woman. Yes, I say it's a boy. 
 
 (Shown some letters, words, a book.) Points at them
 
 Sensory Aphasia. 231 
 
 all indiscriminately, yet still she seems to recognize some 
 difference between them. 
 
 (Testing letters.) A? u. N? o. H? c. E? t. 
 R? r. S? r. E? t. M? c. I? _. N? 
 E? r. W? n. 
 
 What did you have for breakfast ? (No answer, seems 
 to be thinking.) 
 
 Stewed kidney (most improbable) ? Oh, no. 
 
 At what hour do you dine, as a rule, Lucy? (Greeted 
 with laughter.) 
 
 What do you like to eat? I'm not pertickler. 
 
 Test for hearing. A tuning-fork held to the ear seems 
 to annoy her, as if there was great hyperaesthesia of hearing. 
 She can detect a bell and the jingle of coins in one ear 
 as well as in another, but she cannot say what they are. 
 She hears the lowest whisper and apparently comprehends, 
 and if one says she does not she assures him that she 
 does. Calls a watch a clock when put to ear. She could 
 not tell the time, but seemed to recognize the error if one 
 said it was a different hour than indicated by watch. 
 
 (A cat walks across the floor). (Suddenly) Lucy, what 
 is that? (Flabbergasted.) Is it a dog? Oh, no, no, sir. 
 Is it a cat? Yes, sir. What kind of a cat? (Smiles.) 
 
 Lucy, do you take in washing here ? No, sir, not here. 
 
 Do you drink beer? Once in a while. Whiskey? 
 No, sir. 
 
 What is your husband's name? Lucy Brown. 
 
 There is no tone deafness and she can hum tunes in 
 unison when some one whistles ; can detect tunes but can- 
 not say what they are. 
 
 A knife, a pencil, a tuning-fork, a spool of thread, a 
 book, a pair of scissors, a small bell and a penholder were 
 put in a row in front of her, and she was asked to pick 
 them up as their names were called. She did this with
 
 232 The Faculty of Speech. 
 
 considerable accuracy, particularly after she had done it 
 once or twice. In the beginning there was some hesita- 
 tion, a searching look directed toward me, as if to ask, 
 "Is it right?" and a clumsiness in picking them up, but 
 she soon selected them without mistake or appreciable 
 uncertainty. 
 
 Examination, September i^tli. 
 
 What is your name? Well, tell him, m'u mame can't 
 you (last addressed to nurse). 
 
 What is your name? I can't, can't, can't tell it now. 
 
 Why not ? I can't, I can't, my name is oh, o-, o-, o-, 
 o-, I can' . 
 
 How old are you? Ma' mother's name, my mawth' 
 name is ma'name. 
 
 How old are you ? My mother got it down. 
 
 Can't you tell me? No, ma'am. 
 
 Have you a father and mother? My father is dead, 
 my mother is dead. 
 
 What was your father's name ? Reilly. 
 
 His first name? Can't tell that. 
 
 Your mother's name? M'a mother, Margaret Reilly 
 (bit off). 
 
 Are you Irish? I don't know, but that is my name 
 though. 
 
 What is your name? M'm'ma name is I can't tell 
 you. I can't call it. I know what it is though. 
 
 Is it Lucy Brown? Yes, sir (slowly). 
 
 Did you ever go to school ? N'o, not much ; I used to 
 t'k washing. 
 
 Could you read? Yes, ma'm (with a glib, cock-sure 
 manner). 
 
 Could you read ? Little bit. 
 
 Could you read? Write, oh, no, sir; no, sir, no.
 
 Sensory Aphasia. 233 
 
 Are you married ? No, I told you yes. 
 
 Were you married? Yes, sir; two children. 
 
 What was your husband's name ? Sampson. 
 
 His first name ? I can't call that name, but I can say it. 
 
 Is he living? Yes, ma'am, but I don't know where he 
 is tho'. 
 
 How long were you married? Two children, I can't 
 catch that. 
 
 What were your children? Two boys. 
 
 You told me the other day they were a boy and a girl. 
 No, sir, I didn't. 
 
 I beg your pardon, you did. I did not (beginning to 
 cry). 
 
 What was your first boy called ? Sampson, after his 
 mother. 
 
 The second boy ? Little boy was dead, was dead any- 
 how. 
 
 What do you mean by that ? I can't tell. 
 
 Was he born dead ? Yes, sir. 
 
 How long is it since you had a child? I can't say, I 
 can't call ; fo', fo' years, I can't call it but anyhow my 
 boy, ah, u, oh, ah (sort of a re very). 
 
 Will you count for me? 12345 67? 9 
 1 1 i j_ _I can't. 
 
 What is that figure (large 4) ? No answer. 
 
 Same for other figures. 
 
 (Showing coins) What is that? Money. 
 
 How much is that? Five cents (right). That? 
 Twenty-five cents (right). 
 
 Please pick out a dime ? Selects a penny. 
 
 Pick out a ten-cent piece ? Does it correctly. 
 
 Pick out a five-cent piece? (Picks out a ten.) 
 
 (Showing two-dollar bill) How much? I can't tell, I 
 can't call it.
 
 234 The Faculty of Speech. 
 
 Is it money? Yes, but I can't call it. 
 
 Is it a five-dollar bill ? Yes, I know it now, it's a one- 
 dollar bill; no, it's a five-dollar bill, yes. 
 
 (Holding up key) What's that? Key. 
 
 (Penknife.) (After some hesitation) Knife. 
 
 (Pencil.) Key isn't it ; no, was do you do with it ? 
 
 Interlocutor recites first line of Longfellow's " Bridge," 
 also Lord's Prayer, and asks her to repeat the first line, 
 then half a line at a time. It is absolutely impossible, she 
 makes the mouth go and occasionally makes an audible 
 sound, but in no way repeats. 
 
 Say birds ? Words. 
 
 Rat? Cat. Mother? Mother. Steamer? Simmer. 
 
 Kettle? (In amazement, and does not repeat.) 
 
 Says wasin for basin, richer for pitcher, and in other 
 ways simulates the sounds of words. 
 
 A number of familiar things are spread out before her, 
 and she is requested to pick them up as their names are 
 called. Pick up the key? Picks up scissors. Spoon? 
 Correct. Glass? Correct. Hair pin? Correct. Look- 
 ing-glass? Pincushion. Pencil? Correct. Key? Knife. 
 Lock? Bell. Thimble? Correct. Looking-glass? Fum- 
 bles pin cushion, then picks up mirror. (This is in 
 marked contrast to the successful efforts of the last ex- 
 amination.) 
 
 I then said to the house physician that she had mistaken" 
 the pincushion for the mirror before, and then she began 
 to say something very inco-ordinate, like " I said, you, well, 
 some, befo'," etc., all of which might be construed as an 
 explanation of her failure to pick things up properly. 
 There was marked confusion of names of things. After 
 she had picked them up once, she seemed to be able to do 
 it more accurately the second time, but after picking them 
 up a number of times she got more confused.
 
 Sensory ApJiasia. 235 
 
 She seemed to have the faculty of tracing simple figures 
 such as squares, circles, and crosses, but she could not copy 
 simple printed letters, although she could trace them fairly 
 well. When asked to make a square or a circle after she 
 had been shown a drawing of one, or to make such figures 
 from memory she failed in the attempt. 
 
 To-day she seems to be able to match pennies with 
 considerable accuracy. If I put down three pennies and 
 ask her to put down an equal number, she does so. She 
 also matches heads and tails very well. She cannot call 
 the notation of money. 
 
 She does not appear to be so well to-day as heretofore. 
 She is emotional and several times is about to cry, and 
 when starting to cry she says something about children. 
 
 Examination, November ^.th, 1896. 
 
 What is your name ? Lucy. 
 
 Is that all of your name ? Lucy Reilly. 
 
 Is it not Lucy Black? No, ma'am. 
 
 Is it not Lucy Brown? Lucy Brown. 
 
 What is your name ? Lucy Reilly, I told you (indig- 
 nantly). 
 
 You said it was Lucy Brown ? Me (in tone of aston- 
 ishment) ? No, sir. 
 
 Well, is it not Lucy Brown ? Yes, I told you it was. 
 
 How can you have two names, Lucy Brown and Lucy 
 Reilly? m'm'w son. 
 
 What about your son ? He's dead, he is. 
 
 Well, what about him ? Nothing at all. 
 
 Then what did you mention him for? Oh, I don't 
 know. 
 
 Did you ever go to school ? Not much ; no, sir. 
 
 Why not ? Don't want ; the doctor told me, washing 
 all the time, my mother.
 
 236 The Faculty of Speech. 
 
 Can you read ? No, sir. Why not ? Cause I could. 
 
 How old are you? Ma answere, mo amte got my 
 age. 
 
 How old do you think you are ? I can't tell. 
 
 Are you a hundred ? Oh, no. 
 
 Are you more than one hundred ? Yes, sir. 
 
 Less than one hundred ? I don't know. (This is rather 
 characteristic.) She apparently appreciated the ridiculous- 
 ness of asking her if she were upward of one hundred, still 
 in the very next breath she said that she was. Then she 
 denied it, and if her questioner looked astonished or in- 
 credulous she became embarrassed or indignant. One is 
 almost sure that she does not understand the question, but 
 she assures him that she does. Then the next moment 
 she answers a question not only properly but very quickly ; 
 for instance : 
 
 How do you feel to-day? First rate, only I want to go 
 home, that's all. 
 
 Where do you live? I, I'v, I told, I can't tell you, I 
 can't tell you now, but I know the name of the street all 
 the same. 
 
 Tell me how your sickness came on. 
 
 She hesitates, and after a time, during which she seems 
 to be getting ready to talk, she begins : " One day I had 
 the morning I was on street swashing one day I 
 was my mouth come she said I was so tizzy I, I, I, 
 morning I forget the rest." 
 
 All this is told in a long drawn-out way, as if she were 
 telling a story that she had memorized. 
 
 Test for Recognition of Money. 
 
 (Handful of change, eighty-one cents.) How much? 
 Fifty cents. (This after she picks the coins up in suc- 
 cession, looks at them, and feels them with great de-
 
 Sensory Aphasia. 237 
 
 liberation). Then I ask again, How much? She hesi- 
 tates. 
 
 (Holding up twenty-five-cent piece) How much? 
 Three, I told you. 
 
 One cent ? Three cents. 
 
 Ten? Three cents, f, f, f, f ( as if endeavoring to 
 say fifty or five). 
 
 Fifty? M'o, five, no. 
 
 Is it fifteen ? No. 
 
 Is it ten ? Yes (correct). 
 
 Examination, November 2$th. 
 
 How many fingers are held up? One, two, three, four, 
 five, six, seven, seven, five, seven, five, five fingers (lat- 
 ter correct). 
 
 (Holding up seven fingers) How many? Nine. (It 
 seems that she cannot tell without reckoning on her own 
 fingers, and then not correctly.) 
 
 I hold up five fingers, and she counts them slowly and 
 correctly. 
 
 I hold up ten fingers, and she responds "nine." 
 
 Ten, wasn't it ? Yes, sis. 
 
 She is now given a roll of money and asked to count it. 
 She turns it over, separates the individual bills, then pays 
 no attention to it until told to go on with it again. There 
 are fourteen dollars in the roll. She counts the four one- 
 dollar bills, but hesitates when she comes to the ten-dollar 
 bill, and then says : Dollars, dollars, you know what I 
 mean. 
 
 Show me with your fingers how many dollars that bill 
 stands for? She makes no reply. She is either unable 
 to respond or she does not comprehend the question, and 
 emotionally there is no evidence that she does understand. 
 
 It is a twenty-dollar bill, isn't it? Yes, yes, sir.
 
 238 The Faculty of Speech. 
 
 It is a twenty-dollar bill ? No, sir. 
 
 Well, you said it was a twenty-dollar bill ? (Exclama- 
 tion of indignation and surprise.) I did? No, sor; no, 
 sir; (mumbling) yes, sir; no, sir. 
 
 Did you ever go to school ? Once in a while. 
 Couldn't ; working all the time. Well, when I was a girl, 
 playing all the time. Yes, sir, working. 
 
 A cat walks into the room, and I ask her to tell me 
 what it is. She replies quickly and promptly, That is a 
 book. 
 
 It is a little book? Oh, no, sir. Or, no. No. 
 
 Well, you said it was a book. (Indignation) I ? Oh, 
 no, sir. 
 
 Well, what is it? (Hesitatingly) a child. A little girl. 
 
 What color is it ? I can't call it. 
 
 I kept urging her to name it, and finally she burst out, 
 "It's a little cat." 
 
 Is it the same color as that (holding up brown paper) ? 
 A. No, sir. As you ? Yes, sir. 
 
 She not infrequently uses " Yes, sir," for " No, sir," and 
 vice versa, and sometimes there is a repetition of words 
 " intoxication" by a word. 
 
 What's that (pointing to bird in cage) ? Bird. 
 
 What kind of bird ? I know but can't tell. 
 
 It's a robin, isn't it? Yes, sir. 
 
 It's a canary bird ? Yes, sir. I knew it was. A 
 robin. What is it ? 
 
 A robin? No, I tell you it's a canary. Yes, sir; I 
 said it was a robin (indignant tone of voice). 
 
 (Pointing to a pair of shoes.) What are those ? Ladies' 
 shoes. 
 
 (Pointing to an artificial orange.) Ladies' shoes. 
 
 (Pointing to a mirror?) Ladies (hesitates). 
 
 (Pointing to a purse.) Can't call it.
 
 Sensory Aphasia. 239 
 
 (Pointing to a book.) Bo', bo', bo', I can't call it, I 
 can't. (Stops abruptly.) 
 
 Lucy, tell me again about your sickness? One day 
 wa' was washing, and all I tell you that, I don't know I 
 tell you, but was, s s washing, com par my daughter, 
 the girl me, and I should I can't, I can't, and then 
 the girl, washing, oh, o-h, the boy other, some stuff, and 
 I look, that's all, got me I said it, see? Well, tant, I 
 can't tan o-h, I can't tell that. 
 
 Tell me what you did yesterday. Warden, on I 
 sway all looking warden names fighting, fighting, 
 fighting, I'll go home anyhow. Se doctor names (it is 
 thought that the patient is endeavoring to say that some 
 of the other patients in the ward taunt and tantalize her, 
 call her nigger, etc. , and when she is asked if this is so 
 she responds promptly that it is.) 
 
 I ask her to repeat the following sentence, " I am de- 
 lighted to make your acquaintance." Way, m', me, me, 
 m, once, me (continued to get more monotonous and 
 lower). 
 
 Lucy, what day of the week will to-morrow be? Pure, 
 fure, not Friday, I can't call it. 
 
 Friday? No, sir. 
 
 Saturday? Yes, sir. (After a little bit, when her 
 interlocutor makes no reply, she promptly says, " No, sir.) 
 Thus she is absolutely unable to repeat. She is also 
 completely unable to read words and letters, and I be- 
 lieve unable to read figures, although I have never been 
 able to convince myself of the latter. Sometimes she 
 apparently recognizes the figures on a banknote. Cer- 
 tain it is that she cannot read figures on a test card. She 
 is unable to write a letter spontaneously or from dictation, 
 and she is unable to copy, except the simplest lines. She 
 is, however, able to trace.
 
 240 The Faculty of Speech. 
 
 It is now for the first time made quite certain that 
 she has typical right-side homonymous hemianopsia. This 
 was thought to be the case after the first examination, 
 but the paraphasic answers on the part of the patient 
 and the difficulty in making her comprehend what was de- 
 sired of her when objects were brought into the visual 
 field, made the test very uncertain. To-day objects thrust 
 toward the right sides of both eyes, as if they were going 
 directly into the eye, do not cause the slightest blink- 
 ing. A candle brought toward on the right side is not 
 perceived until it gets beyond the mid line. 
 
 When a summary is made of the results of repeated ex- 
 aminations of the speech defects of this patient, we find 
 that the most striking defects of spontaneous speech are 
 amnesia of words, particularly of nouns, and paraphasia. 
 The patient can usually tell her name, but she cannot tell 
 the names of members of her family or her residence. 
 In fact, even to-day we do not know where she lived or 
 the names of any of her friends. The articulatory images 
 seem to be preserved. If she can call up what she wishes 
 to say, there is no difficulty in saying it. It is impossible 
 for her to repeat the simplest sentence after me. This is 
 well illustrated by her effort to repeat the conventional 
 phrase, " I am glad to make your acquaintance." All that 
 she produces is an unintelligible mixture of sounds consti- 
 tuting gibberish. There is relative preservation of the 
 melody of some songs with inability to use the proper 
 words. She can sing the airs of hymns and popular tunes, 
 but she cannot get the words in properly. There is in- 
 ability to read aloud or to herself. She cannot write spon- 
 taneously or from dictation, and there is very great diffi-
 
 Sensory Aphasia. 241 
 
 culty in copying. In copying simple geometric figures, if 
 the copy is removed for a moment she cannot go on with 
 the delineation. There is word blindness, a loss of the 
 comprehension of written and printed words. She is still 
 capable of distinguishing one object from another, one 
 color from another ; and she can match pennies with some 
 certainty. Figures on a banknote are recognized but not 
 mentioned. During one test she seemed to have little or 
 no notion of the difference between a letter and a word, 
 and in looking at a printed page she could not point out 
 single letters as different units from the individual groups 
 of letters constituting single words. There is right 
 lateral homonymous hemianopsia. There is a slight 
 degree of word deafness, which becomes more apparent 
 the longer the case is studied. This word deafness does 
 not seem to me to be due so much to a destruction as to 
 a functional degradation of the auditory word centre. This 
 functional degradation is the most patent cause of her am- 
 nesia. The amnesia verbalis which she has, i.e., of per- 
 sons, places, and things, is the usual kind of amnesia as- 
 sociated with slight disorder of the auditory area. The 
 symptoms which she presents are characteristic of sensory 
 aphasia, and I believe it to be a case of sensory aphasia 
 in which lesion of the visual centre and the subadja- 
 cent white substance is responsible for the leading speech 
 disturbances. Her capacity to speak and her vocabulary 
 vary from day to day, and vary considerably with her dis- 
 position and general tone. She has shown herself able to 
 articulate with distinctness at times words presented to 
 her consciousness by voluntary recall of past impressions, 
 by auditory impressions, and by association ; i.e., those sug- 
 16
 
 242 The Faculty of Speech. 
 
 gested to her mind by an appropriate question. She fre- 
 quently says, " I can't tell," and oftentimes in such situa- 
 tions she manifests the state that is best termed amnesia 
 verbalis. This amnesia is most marked for proper names 
 and nouns, and very slight for verbs, adjectives, and pro- 
 nouns. It is not easy to decide whether this be due to 
 conceptual, to kinaesthetic, or to auditory amnesia, and no 
 tests so far have positively settled which one of these 
 important elements is most disturbed, but it is very prob- 
 able that the amnesia is predominantly auditory. On the 
 other hand she at times indicates that the word is just on 
 the tip of her tongue. It appears as though the word were 
 mentally formed. She gives every indication of know- 
 ing what she wants to say and of having the feeling of 
 making the proper innervations ; but the wrong word comes 
 out. In other words there is paraphasia. This wrong 
 word frequently presents interesting relationships with the 
 correct word ; if she is asked to say B, she may say C in- 
 stead. On one occasion when asked to say X, she called 
 out I. Here there was a double relationship, first to the 
 contiguous letter Y, and then to the similarly sounding let- 
 ter I. Many contrast relationships manifest themselves, 
 such as saying "yes" when she means "no;" "mam" 
 instead of "sir." The wrong word was also frequently 
 associated by similarity of sounds with the proper one. 
 The influence of words just heard, or just thought of, 
 also manifests itself occasionally, simulating an enforced 
 echolalia. There are many instances, moreover, which 
 suggest that the right word is just about to be spoken 
 after a number of struggles, without any result; "wed" has 
 been enunciated for " red," and through a series of approxi-
 
 Sensory Aphasia. 243 
 
 mations of this sort, the patient has frequently been able 
 to arrive at the proper word or words. 
 
 She seems to have hypersesthesia to tone vibrations, 
 and they appear to produce a disagreeable tickling sensa- 
 tion in the ears. This is mentioned because it has been 
 associated by Freund and others with verbal perceptual 
 deafness, without general acoustic deafness. The pa- 
 tient, despite this intelligent hesitation in responding 
 to questions, shows at times a faulty perception of the 
 significance of the words of others. I say to her, 
 " You said yesterday that you had three children," and 
 she will say, " Yes, three. " I say, " What were they, 
 "two boys and a girl?" She will say, "No, two boys." 
 I then say, " You have three children, both of whom are 
 boys?" She will say, "Yes," even repeating the state- 
 ment after me. If I then say, '" You do not mean three 
 children, you mean two," she will say, "Yes, two." In 
 repeating words and letters her greatest difficulty seems 
 to be on the articulatr/y side. Nevertheless, I feel cer- 
 tain that there is some perceptual word deafness, but it is 
 the slightest of her deficiencies. She seems to call up 
 with a great degree of certainty the use and significance 
 of objects, and even their names. At times, however, 
 she shows marked deficiencies amounting almost to com- 
 plete perceptual blindness. I have seen her overlook an 
 object that was held in the hand, which I named with dis- 
 tinctness and with which she had shown herself quite 
 familiar. She tried to strike a match on the inside of a 
 box, although she had just shown that she understood the 
 significance of a match and understood what striking it 
 meant, and it was not until I had told her that she should
 
 244 '-The Faculty of Speech. 
 
 strike it on the outside and move the box about a little 
 that she seemed to perceive the side of the box, felt of 
 it, and then ignited the match. 
 
 The mental power that seems most persistently deficient 
 is the ability to grasp ideas of number. If I say, " Match 
 that penny," she will put the penny down, correctly match- 
 ing it. If I say, " Put down as many pennies as I do," 
 she is utterly at sea. She seems to have no notion of 
 number. This is manifest also in regard to relative ages. 
 She seemed only to be sure that her mother was older than 
 herself. A fairly simple task she performs with ease ; but 
 even a small complication throws her off the track. She 
 matches one penny at a time with ease. Put down three 
 pennies and ask her to match them with an equal number, 
 even though the pennies are widely separated, she will put 
 down all the coins in her hand, at the same time making 
 no attempt to match them ; or, if she does, failing signally 
 to do so. The case seems to present some symptoms of 
 restriction of consciousness and of detachment of con- 
 sciousness, such as are met with in cases of hysteria. 
 Then again she shows, but only very occasionally, a blank 
 stupidity, absent-mindedness, or mental vacuity and conse- 
 quent confusion. 
 
 Auditory ApJiasia. Verbal Deafness. Word Deafness. 
 
 In discussing the localization of the various sensory and 
 motor elements involved in the faculty of speech, we dis- 
 tinguish three distinct speech centres : the articulatory, 
 the auditory, and the visual centres. Strictly speaking, 
 the latter centres, in so far as their functions concern the 
 faculty of speech, are not sensory areas but areas of per-
 
 Sensory Aphasia. 245 
 
 ception, or, better still, of apperception. The so-called 
 sensory aphasias do not present disorders of sensation, nor 
 yet of simple perception, but disorders of the interpreta- 
 tion or understanding of certain classes of perception. 
 Destruction of these centres produces conditions in which 
 memory significance of spoken or written speech is lost. 
 Though the sound of the words and the images of the 
 words may be clearly perceived, there is a loss of co-ordi- 
 nation which prevents these simple receptive centres from 
 arousing other elements in adjacent centres, whose activity 
 is necessary in order to awake the memory impressions 
 stored there as the result of past experience with the 
 spoken and written symbols of speech. 
 
 In this form of aphasia, first differentiated by Wernicke 
 and given the name word deafness by Kussmaul, there is 
 inability to understand spoken words. This is dependent 
 apparently upon the total loss of auditory verbal memory 
 images. It is one of the uncommonest forms of aphasia, 
 and it rarely occurs individually, being frequently asso- 
 ciated with some degree of visual aphasia or motor apha- 
 sia. Strictly speaking, the defect is not word deafness at 
 all, for not only do such patients hear spoken words, but 
 frequently they show no diminution in the intelligent ap- 
 preciation of the significance of simple, co-ordinate, or 
 purposive sounds. 
 
 Such patients, although word deaf, may be as alert as 
 ever to the significance of a shrill blast of the whistle 
 from an approaching engine. They detect sounds, even 
 the slightest, as quickly as does the person whose auditory 
 mechanism is intact, and they seek the origin and the sig- 
 nificance of such sounds. In fact, because they are un-
 
 246 The Faculty of Speech. 
 
 able to interpret spoken words they are often apparently 
 more keenly alive to sounds. It is true that an aphasic 
 patient may also lose the significance of differentiated or 
 purposive sounds but such an occurrence would needs be 
 in a more pronounced case of aphasia than that which is 
 typified by the term auditory aphasia. Such sounds are 
 not usually complex and highly differentiated, therefore loss 
 of the capacity to interpret their significance is rare. 
 
 There are as many kinds of auditory aphasia as there 
 are varieties of interpretation put upon symbolic sounds 
 by our consciousness. The seat of lesion which causes 
 auditory aphasia has already been pointed out to be the 
 cortex of the middle and posterior portions of the first 
 temporal convolution, extending over into the second tem- 
 poral and upward into the supramarginal convolution, 
 where it impinges upon the cortical area for visual verbal 
 images. Lichtheim 1 has reported a case of so-called subcor- 
 tical auditory aphasia in which there was word deafness 
 with no disorder of speech. The lesion was thought to be 
 of the auditory projection system, in the white substance 
 within the left cerebral hemisphere. Wernicke and his 
 pupil Freund * report cases of extracortical peripheral le- 
 sion, located by them in the labyrinth, which manifested 
 symptoms of word deafness, very similar to those reported 
 by Lichtheim and others, as due to subcortical and trans- 
 cortical aphasia. It would appear that pseudo-aphasia 
 symptoms, which must be very carefully distinguished 
 from those of true aphasia, may be due to actual lesion or 
 to functional defect in the sense organ or in part of the 
 subcortical receptive tract. 
 
 1 Loc. fit. 9 Loc. fit.
 
 Sensory Aphasia. 247 
 
 The symptoms of auditory aphasia are subjective and 
 objective. If the aphasia is limited to simple word deaf- 
 ness, the patient hears the voice in which words are spoken, 
 but the words convey no idea to him and he has no 
 more comprehension *what they mean than if they were 
 spoken in a tongue which he never before had heard. 
 He, however, recognizes the significance of other sounds, 
 unless it be that the memory pictures for such sounds are 
 also lost. Naturally there are different degrees of word 
 deafness, depending upon the extent of the lesion or the 
 destruction of the auditory area. In some cases the ex- 
 tent is so great that the sound of the voice which speaks 
 them is simply perceived as a sound, and such patients do 
 not recognize the sound of their own name. In other in- 
 stances they recognize the sounds of their own names and 
 possibly the names of other members of their family, their 
 places of residence, business, etc., words that have for them 
 a much wider significance, and are more deeply imprinted 
 in their memories than is the ordinary concrete word. In 
 other cases the limitation of the lesion in the auditory area 
 allows the patient to comprehend that he is being spoken 
 to, and possibly to understand a word here and there. It 
 is often very difficult when the patient gathers the sig- 
 nificance of a single word to say just how complete the 
 auditory deafness is, unless the physician be very careful 
 in controlling suggestive gestures and facial expressions, 
 for some patients quickly interpret in part the significance 
 of what is spoken and guess the rest. If this form of 
 aphasia exists for a long time, the patient may acquire con- 
 siderable skill in lip reading. 
 
 In the milder forms of word deafness it is often neces-
 
 248 The Faculty of Speech. 
 
 sary, in order to estimate correctly the degree of word 
 deafness, to test trje patient carefully and repeatedly. 
 For instance, if the patient is asked to protrude the tongue 
 and he does so ; to extend the right hand and he obeys, it 
 might lead one far astray if he were" to make a note, " The 
 patient has not lost the comprehension of spoken words, 
 for he obeys requests." Patients with word deafness are 
 often keenly alive to their infirmity, in fact morbidly so, 
 and they strive to conceal it by adopting any ruse that 
 occurs to them. As protruding the tongue, extending the 
 hand, etc., are customary accompaniments of a doctor's 
 visit, they guess the meaning of questions which convey 
 no ideas to them, and sometimes the responses are perti- 
 nent, either by accident or clever gesture reading. In 
 those cases in which the word deafness is slight, the pa- 
 tient understands one or two words of a question, and 
 pieces it out in his own mind accordingly. The simula- 
 tion can be easily exposed by changing the sense of the 
 question, while employing practically the same words or a 
 number of the same words. It is then apparent that the 
 patient does not recognize the different questions, for he 
 answers as before. 
 
 The concomitant accompaniments of word deafness, in- 
 ability to write from dictation, defective comprehension 
 of what is read, imperfect writing, paragraphia, etc., may 
 be disposed of very quickly. Inability to write from dic- 
 tation, which a patient with auditory aphasia presents, 
 needs no explanation. If the sound of the words do not 
 revive the memorial significance of these words in the 
 auditory centre, no impulses inciting the visual centre to 
 visualize the word proceed from the auditory centre.
 
 Sensory Aphasia. 249 
 
 Internal reading is disordered, because the primarily 
 excited visual word centre, in transmitting the impulses 
 to the auditory area, finds the latter disordered, and there' 
 is in consequence defective revival of corresponding word 
 memories and lack of comprehension of what is read. 
 The paragraphia is an expression of the disorder of inter- 
 nal language, which is always present in true auditory 
 aphasia. 
 
 A patient with word deafness, having a lesion that cuts 
 him off from the significance of all that is said to him is 
 practically rendered deaf. And as the catastrophe comes 
 suddenly, after he has for years been accustomed to the 
 delights of auditory sensations, he is naturally very much 
 changed in manner, in appearance, and in demeanor. He 
 is quiet and observant ; his glance betrays suspicion or 
 fear, and his demeanor is often one of trouble and unrest. 
 This change in demeanor and manner, combined with the 
 paraphasia which is often strikingly manifest, the inability 
 to repeat from dictation, and the profound diminution, 
 even to complete absence, of spontaneous speech, have 
 often led physicians and laymen alike to look upon these 
 unfortunate patients as insane. It need scarcely be said 
 that such an implication is unjust. 
 
 As has already been said, word deafness rarely, if ever, 
 exists alone. It is often associated with cortical mo- 
 tor aphasia, and frequently, on account of the proximity 
 of the auditory area to the visual area, with some degree of 
 word blindness. Wernicke and Lichtheim claim to have 
 seen cases in which there were absolutely no defects of 
 articulate speech. If the first of these two conditions ex- 
 ists, the patient is unable to communicate thoughts in
 
 250 The Faculty of Speech. 
 
 writing and is dyslexic, while if the last be present he 
 is word blind as well. 
 
 Examination of patients with word deafness reveals dif- 
 ferent objective conditions dependent upon the degree and 
 completeness of the word deafness. Even though the 
 patient does not grasp the question that is addressed to 
 him, he will endeavor to give answer, but the answer has 
 no pertinency to the interrogation ; in the first place be- 
 cause the patient does not understand the question, and in 
 the second place because emissive speech is dependent 
 upon the integrity of the auditory centre, that is, upon the 
 revival of auditory memories and their transmission to the 
 articulatory kinaesthetic centre. On account of the fact 
 that the centre for articulatory memories is guided and 
 correlated in action by the auditory centre, disease of 
 the latter causes not only amnesia of words, but misuse of 
 words, a condition to which the name paraphasia is given. 
 I have said before that a patient in whom the primary re- 
 vival of words has been through the auditory centre will 
 be more incapacitated by a lesion that interferes with his 
 auditory centre than will one who relies in part or largely 
 on the revival of visual memories of words, or for the re- 
 inforcement of the memory of words by visual images. 
 Such individuals are rare compared with those who revive 
 words through auditory memories, but nevertheless they ex- 
 ist. An illiterate man who gets word deafness becomes al- 
 most speechless, because the illiterate man is then deprived 
 of his only mode of recalling words to mind. According 
 to Hughlings Jackson, Ballet, Strieker, and others, words 
 may be revived as motor processes, i.e., by stimulation of 
 the centre of articulation (which they consider motor). It
 
 Sensory Aphasia. 251 
 
 is perhaps unnecessary to say here that the writer does not 
 admit this, for it is one of the fundamental ideas in the 
 conception of aphasia that he has put forth that Broca's 
 area is not motor but sensory, as has been contended by 
 Bastian for more than a quarter of a century. Moreover, 
 in another place it has been pointed out that, developmen- 
 tally, in the child the articulatory power is conditioned by 
 audition. If the centre in which are stored the articulo- 
 kinaesthetic memories of words that is, Broca's centre 
 is not affected, articulation of words revived in thought by 
 visual impressions may be but little impaired. This is 
 especially noticeable in response to questions the signifi- 
 cance of which the patient gets through the visual areas ; 
 that is, questions addressed to him by writing and by pan- 
 tomime. But in such replies the words may be transposed, 
 because the patient is not in possession of the faculty to 
 know whether or not they have the proper sequence, for 
 he can hear his own words no better than he can those of 
 others, and, the auditory centre being destroyed, the artic- 
 ulatory centre is deprived of the directing control which 
 the former exercises over the latter. It is very necessary 
 that this statement should be as lucid as possible. If 
 when one is speaking aloud a word is misplaced or a word 
 is not used in its proper sense, if there be made what is 
 called a lapsus lingua, the auditory area, which is keenly 
 alive to the slightest misuse of words, quickly detects the 
 error and communicates it to the intelligence or carries it 
 into consciousness. This in turn calls up the articulatory 
 image of the proper term, which is then articulated. The 
 sound of every articulated word acts as a stimulus to the 
 auditory centre for the next. If the auditory centre has
 
 252 The Faculty of SpeecJi. 
 
 been destroyed there is no such leader in the memorial 
 order of words, and the frequent occurrence of lapsus lin- 
 guae constitutes paraphasia. The patient is usually not 
 cognizant of the mistakes that he makes in speaking, 
 though sometimes when he is he treats them lightly and 
 essays not to notice them, or he is loath to express him- 
 self in words at all, providing he be in no way demented. 
 Usually, however, the patient with partial auditory apha- 
 sia is loquacious, the logorrhoea being devoid of sense or 
 pertinency. Occasionally one encounters a patient with 
 word deafness who prefers to answer questions in writing, 
 because the intactness of the visual memories of words 
 enables him to control his output. In a similar way the 
 auditory centre guides the action of the articulatory centre 
 in the employment of internal language. In other words, 
 I do not believe that the motor centre of speech ever be- 
 comes independent of the sensory centre which presided 
 over its education, as is claimed by Bernard in his exten- 
 sion of Charcot's teaching. 
 
 If the visual area is coincidently diseased and the pa- 
 tient has right-side hemiplegia as well, such a patient will 
 be, objectively, as one without a mind. The important re- 
 ceptive avenues of speech are closed to him and the emis- 
 sive, likewise. He may be able to make known some of 
 his thoughts or wants by means of pantomime, but just 
 how much it is very difficult to say, except by the study of 
 each individual case. As an instance of a case of this kind 
 I may cite the following, which I saw with Dr. H. P. 
 Hirsch : 
 
 A. M , German, fifty-nine years old, married; by 
 
 occupation a merchant. His wife has had four miscar-
 
 Sensory Apkasia. 253 
 
 riages and has borne one full-term child, which has since 
 died. The patient, who had been a temperate, well-pre- 
 served man, of a kind and lovable disposition, was in ex- 
 cellent health until about three years before the onset of his 
 present illness, when he had an attack of rheumatic sciatica. 
 Since then he has had recurring attacks of " rheumatics" 
 in the arms and legs. About two years after the attack of 
 sciatica he had a mild attack of endocarditis. During the 
 year preceding the present illness his entire disposition 
 and temperament underwent a change. He became iras- 
 cible, irritable, worried over trifles, and got fatigued more 
 easily than formerly. He never complained of headache, 
 nor were there symptoms that led to an examination of 
 the urine. Attacks of the blues came oftener and stayed 
 longer. 
 
 On the afternoon of the 2 1 st of November the patient 
 came home from business, apparently in his usual health. 
 He sat in an easy chair and read a paper. Suddenly with- 
 out warning his wife noticed his arms drop, his eyes roll 
 up, his respirations become dyspnoeic. She applied re- 
 storatives and in about five minutes, he recovered con- 
 sciousness, asked his wife what she was troubled about, 
 did not seem to recognize that anything had befallen him, 
 averred that he was all right, and did not want a phy- 
 sician. If he appreciated that he had had an attack of 
 unconsciousness he did not say anything about it, and 
 when dinner time came he went to the table as usual and 
 partook of the meal. It was noticed by the members of 
 the family that he did not use the right hand so much as 
 usual, and he said that it felt somewhat stiff and heavy. 
 Before retiring he took a hot bath, and on getting out of 
 the tub he had another syncopal attack of very short dura- 
 tion. He passed a restless night, and in the morning on 
 arising he found that his right hand was very stiff, un-
 
 254 Th e Faculty of Speech. 
 
 wieldy, and lame. He seemed to be in other respects 
 quite well. There were no noticeable change of facial ex- 
 pression, no hesitation of speech, and no difficulty of getting 
 about. On the afternoon of the 22d, Dr. Hirsch, a friend 
 but not heretofore his physician, was sent for. He noted 
 that the pulse was rapid and hard, the face flushed and 
 anxious, and the patient evidently in a very anxious state. 
 Examination showed a paralysis of the right arm which, 
 although not complete, prevented the patient from using 
 the arm except slightly. There was no involvement of 
 the face or of the right leg. There were no sensory dis- 
 turbances. The patient seemed to be in fullest possession 
 of his faculties, talked distinctly, and explained rationally 
 to the physician why he had been selected as the medical 
 adviser ; told of his symptoms, showed that he was able to 
 read understandingly, and in other ways demonstrated that 
 he used words at their proper worth. 
 
 The physician was sent for again about seven o'clock 
 that evening. The patient had become unconscious while 
 in the bathroom. He remained profoundly unconscious 
 for upward of seventy-two hours, during which time his 
 temperature was subnormal. He then recovered conscious- 
 ness gradually. He was completely paralyzed on the right 
 side, unable to speak, and apparently unable to understand 
 anything that was said to him. For the next six weeks he 
 was completely speechless ; then he began to say the words . 
 " Yes" and " No" and some other monosyllabic words,. but 
 he did not use them correctly. He has not been able to 
 understand spoken or written words since the attack. Oc- 
 casionally, if commands are repeated a number of times, 
 such as "Put out your tongue," etc., he will obey, but 
 almost always it is necessary to show him pantomimically 
 what is meant. After the second month his newly ac- 
 quired, limited, monosyllabic vocabulary began to shrink,
 
 Sensory ApJiasia. 255 
 
 and then he began to " babble" and to echo words that he 
 heard. The babbling became almost continuous for a time 
 and it was thought that the patient was insane. After a 
 while it became less frequent and was produced only in 
 response to or after a question. 
 
 One day, about six weeks after the attack, he suddenly 
 began to sing a German song, which he had often sung, 
 " O Tannenbaum, O Tannenbaum, bau, bao, ba, ba, ba, bo, " 
 ending in a laugh ; and on a number of occasions he es- 
 sayed to sing when the piano was played, but he never got 
 beyond a few words. 
 
 Status, March i6th, 1897, nearly four months after the 
 beginning of the present disease. There is hemiplegia of 
 the right side of the body, the right side of the face being 
 involved only to a very slight degree. The paralysis of 
 the extremities is not pronouncedly spastic, but the ten- 
 don jerks are very much exaggerated. The heart impulse 
 is weak, about ninety times a minute ; there is a harsh 
 systolic murmur, heard with greatest intensity over the 
 aortic valve and the second sound is accentuated. The 
 pulse is small and feeble. 
 
 On being asked his name he begins to whine and intone 
 sounds which may be expressed by the following words : 
 " Nein, nein, na, no, no, nein, bettau, betta, tau, tau, nein, 
 nein," etc., beginning in a moderate tone and then get- 
 ting higher pitched, and ending in a babble. All the time 
 the musculature of the face is in such a state that on 
 looking at the patient one would suppose that he is 
 crying, but in reality there are no tears. 
 
 " How old are you ?" No response, but after a few mo- 
 ments he begins the above senseless, articulated babble. 
 
 " Are you ninety years old ?" Does not recognize that 
 he is being spoken to. 
 
 In fact, test as long and as completely as we may, it
 
 256 The Faculty of Speech. 
 
 is absolutely impossible to convey any meaning to him 
 by spoken word. He is alive to the slightest noise, and 
 turns his head when a person comes in the room or on the 
 occasion of a slight noise the origin of which he does not 
 understand. 
 
 It is possible that there is right homonymous hemi- 
 anopsia. It was difficult to get positive proof of this, as 
 it is in all cases in which the patient cannot understand a 
 word that is spoken to him and does not comprehend writ- 
 ing. The wife, however, suggested its presence by insist- 
 ing that when she approached anything to his mouth from 
 the right side, such as in giving him a spoonful of medi- 
 cine, or to wash his eye, he did not see her until after 
 she had got it immediately in front of him. On bringing 
 the finger or fist quickly toward the right side of the eye, 
 the patient does not blink or make any movement to indi- 
 cate that he recognizes the approaching object which is 
 seemingly going directly into his eye. When the same 
 test is tried on the other side, the eye blinks at once, and 
 he even indicates that he sees objects, such as the light of 
 a candle brought into the visual field from the left, but in 
 no way gives heed to it when brought into the visual field 
 from the right. 
 
 There is complete alexia. A letter from his family, 
 who are in Europe, is given to him, but although he takes 
 it in the hand he does not recognize a word. It is the 
 same with print. There is total agraphia; he cannot 
 make a stroke with the pencil put in the left hand. When 
 the hand is made to grasp it and the physician's hand 
 guides it to shape a word, he takes no interest in the matter, 
 apparently not having the slightest idea of what is being 
 done, and begins to say, " Nein, nein, na, na, bateau," etc. 
 
 There is in addition to this some mind blindness, but 
 this does not seem to be so pronounced now as it was a
 
 . 
 
 Sensory Aphasia. 257 
 
 few weeks before, when he many times endeavored to drink 
 out of the urinal, and in other ways showed that he did not 
 recognize the uses of objects. Nevertheless the apraxia is 
 not complete, for when given his eyeglasses he places them 
 astride his nose, in a particularly dexterous and intelligent 
 way. This, however, may be an automatic act. 
 
 Voluntary speech is entirely lost, except the words that 
 we have given, which he uses on all occasions. Repeti- 
 tion of speech is also lost, but sometimes he surprises the 
 examiner and the family by echoing what is said, particu- 
 larly if it be said a number of times and in a loud voice. 
 
 For instance, if one says " Good by" or " Good morning" 
 a number of times, he may respond like a parrot, " Good by, 
 ba, ba, ba, ba," and he will take up the old refrain, " Na, 
 nein, nein, betteau," etc. 
 
 In this way he occasionally says, " Pfui" (first used by 
 his wife, on one occasion when he was about to drink from 
 the urinal) ; " Lieb, " after the question, " Liebst du mich ? 
 Hast du mich lieb?" Without in the slightest manner 
 understanding the question he may articulate with con- 
 siderable clearness, " Lieb, lieb." 
 
 He apparently has some recognition of music, for when 
 his daughter plays a familiar air on the piano he is atten- 
 tive and seemingly follows it. 
 
 Examination of this patient eight months later reveals 
 practically the same condition as above stated, save that 
 the word deafness is, if changed at all, more complete. 
 The hemianopsia is very difficult to demonstrate, and, if 
 it exists, it is very slight. The only change of any im- 
 port is a marked echolalia that he has developed. If one 
 says, " How old are you ?" he repeats over and over, " You, 
 you," with a rising inflection on the last letter. " How is 
 papa?" "Papa, papa," repeated and repeated. Usually 
 he takes the last word of the sentence that he hears and
 
 258 The Faculty of Speech. 
 
 echoes it, occasionally the last two words. Such as " Will 
 you have an orange?" "An orange, an orange," he re- 
 peats--the "an" with great vigor and clearness of enunci- 
 ation and with a rising inflection on the last syllable of 
 orange. Complex words he occasionally attempts to echo, 
 but he does not succeed in so doing. There is still a de- 
 gree of that condition known as mind-blindness, but it is 
 not so conspicuous as when he was first seen. 
 
 No general description of auditory aphasia can be given 
 to cover every case, so great is the variation in individual 
 instances. In some cases there is only inability to inter- 
 pret a certain language, or a certain dialect, or a certain 
 number of words. For instance, there are a number of 
 cases on record in which persons seemingly as familiar 
 with several languages as with one, have had word-deaf- 
 ness for all of them except one, and that one the mother 
 tongue, the one acquired first. Some years ago I had a 
 patient who was employed as an official interpreter at the 
 Immigration office. He developed a very slight right-side 
 hemiplegia, which soon ameliorated so much that it was 
 scarcely to be noticed unless examined for, but he had a 
 marked degree of word deafness for all languages except 
 Swedish his mother tongue a language which he had in 
 later years rarely used, and never except when occasion 
 or necessity compelled him. He was partially word deaf 
 for Swedish. This language having been first acquired, 
 it is logical to infer that it was most indelibly imprinted 
 in his speech area and least easily destroyed. 
 
 I have said before that there must necessarily be as 
 many forms of auditory aphasia as there are distinctive 
 symbolic sounds. Spoken speech is the most highly sym-
 
 Sensory Aphasia. 259 
 
 bolic ; the next most differentiated is music. To the form 
 of aphasia in which there is deafness for musical notes, the 
 designation tone deafness (musical deafness) is given. 
 Amusia as an accompaniment or as an integral part of 
 aphasia has been studied carefully by Edgren in recent 
 years. In his article a number of cases are cited in which 
 the auditory form of amusia has been subjected to criti- 
 cal examination, and some of them were studied in the 
 light of post-mortem examination. 
 
 Musical deafness is almost always associated with word 
 deafness, but there have been a few cases recorded in 
 which it occurred apart from the latter. Such is an in- 
 stance cited by Brazier, ' in which a famous tenor of the 
 Opera Comique was suddenly seized during a performance 
 of an opera with complete amnesia of words and music ; 
 neither the orchestra nor his fellow-singers, who tried to 
 prompt him, succeeded in reviving his memory. Another 
 instance in which the tone deafness was not associated 
 with word deafness was that of a man who suffered from 
 attacks of ophthalmic megrim, during which there were 
 passing attacks of motor aphasia, lasting from four to five 
 hours. On one occasion there was no aphasia but he could 
 not distinguish musical airs. The " Marseillaise," on being 
 played by a military band, was not recognized ; although 
 he could hear quite well, he did not know the tune. He 
 knew only that it was a noise of brass. 
 
 The clinical forms of amusia are strikingly analogous 
 to the clinical forms of aphasia, and they generally accom- 
 pany the latter, although the different varieties of amusia 
 
 1 Brazier: " Amusie dans 1'aphasie." Rev. Philos., October, 1892, p. 
 337, t. xxxiv. '
 
 260 The Faculty of Speech. 
 
 have some clinical independence. The cases of word 
 deafness and tone deafness reported by Serieux 1 and by 
 Dejerine ? may be taken as classical examples. In the case 
 reported by the first mentioned there was total loss of the 
 conception of spoken words. The patient remarked that 
 she could hear the words very well, but that she did not 
 understand them. The most familiar tunes when played 
 on any instrument were not recognized. " Au Claire de 
 la Lune" was said to be a "dead march." Cafe chantant 
 music was designated church music, etc. 
 
 Lichtheim 3 has reported a very instructive example of 
 amusia. His patient was a teacher and journalist, who 
 became completely word deaf after a second attack of apo- 
 plexy. Communication with the patient could be made 
 only in writing. He heard when one sang or whistled, 
 but he did not recognize the melodies. Concert singing 
 by his children was most annoying because it was " so 
 noisy." The most familiar melodies, such as " Rufst du 
 mein Vaterland," were not recognized. 
 
 This case is worthy of remark, in so much as the pa- 
 tient wrote facilely and correctly, and understood every- 
 thing that he read. These features, I venture to think, 
 stamp the case as one of subcortical sensory aphasia. 
 
 A still more striking example of subcortical sensory 
 aphasia with notal amusia is that reported by Pick, 4 in 
 which there was loss of musical recognition with preserva- 
 
 1 Serieux : " Sur un cas de surdite verbale pure." Revue de Medecine, 
 tfyi, P- 733- 
 
 4 Dejerine : " Ce'cite verbale." Memoires de la Societe de Biologic, 
 February 27th, 1892. 
 
 3 Lichtheim : " Ueber Aphasie." Deutsches Archiv f. klin. Med., 
 vol. xxxvi., 1885, p. 238. 
 
 4 Pick : Archiv f. Psychiatric, 1892, p. 910.
 
 Sensory Aphasia. 261 
 
 tion of musical expression associated with word deafness. 
 All other disturbances of speech and writing could be ex- 
 cluded. When the brain was examined it was found that 
 it had its usual normal configuration, save that the convolu- 
 tions were rather small. The patient had had a left-side 
 hemiplegia, and changes were found in the right hemi- 
 sphere to explain its existence. In the left hemisphere 
 there was a subcortical softening of the posterior half of 
 the first temporal convolution and of the medullary sub- 
 stance of the adjacent supramarginal convolution, which 
 accounted for the preservation of internal speech associ- 
 ated with word deafness and loss of musical recognition. 
 
 Much evidence might be cited to show that there is a 
 definite representation of musical memories, viz., auditory 
 perception of notes, accords, and melodies, in the first and 
 second temporal lobes of the left hemisphere. Edgren' 
 believes, after careful weighing of the facts bearing on 
 this allocation, that it is immediately in front of the area 
 for word memories. The indications are that it is a part 
 functionally and anatomically of the auditory centre. 
 
 Visual Aphasia Verbal Blindness Word Blindness. 
 
 This is a form of aphasia in which there is loss of the 
 significance of written or printed words, although the words 
 themselves can be seen with the usual distinctness. The 
 designation "word blindness" or "verbal blindness" to in- 
 dicate the inability to recognize words and letters, and in- 
 terpret what they stand for, is a very unhappy one, because 
 the term blindness has here a very different significance 
 
 1 Edgren : "Amusie." Deutsche Zeitschrift f. Nervenheilkunde, vol. vi., 
 1895, p. i.
 
 262 The Faculty of Speech. 
 
 than that given it in every-day use. In the form of apha- 
 sia which is described under the caption of verbal blind- 
 ness the patient can see the word perfectly, but he gathers 
 no meaning from it. The peripheral visual apparatus is 
 intact. A printed page of a language previously entirely 
 familiar to the patient suffering from this form of aphasia 
 conveys no more meaning to him than does a page of 
 Greek or Hebrew to the illiterate, or a page of Chinese 
 symbols to him who reads only English, although he sees 
 with the customary distinctness the letters printed or writ- 
 ten, and he may even be able to tell the handwriting of 
 one person from that of another. As in word deafness, 
 in the literal interpretation of the term, the defect is not 
 word blindness but loss of the significance of words. 
 Words seen do not arouse a corresponding content of 
 consciousness. 
 
 Word blindness may be classified according to the de- 
 gree of its completeness and according to the kind of con- 
 crete written or printed symbols which we associate with 
 ideas, such as algebraic symbols, musical notes, geometri- 
 cal figures, hieroglyphics, etc., that the patient is unable 
 to recognize. When the unmodified term word blindness 
 is used, it is understood that other forms of printed and 
 written symbols than letters and words are seen and in- 
 terpreted, and that they call forth corresponding ideas. 
 Many cases are on record in which a patient absolutely 
 word blind was able to have roused in his consciousness 
 certain ideas or thoughts leading to efforts of judgment by 
 such printed or written, verbal or numeral notation. De- 
 jerine has described a man with complete word blindness 
 who was able to interpret the markings on goods in his
 
 Sensory Aphasia. 263 
 
 shop, and to tell customers the price. In other words, 
 written letters having an entirely different significance 
 than that ordinarily attached to them quickly called up a 
 content of consciousness which he was able to associate 
 with previously acquired knowledge. 
 
 I have already mentioned that blindness for words may 
 be met with as an isolated condition. Broadbent in 1872 
 was the first to note such occurrence, but it was not until 
 Kussmaul's discussion of it that it began to be carefully 
 studied. The visual area is in the posterior lobe of the 
 brain. It is made up of two more or less distinct centres : 
 a visual perceptive centre and a centre in which are stored 
 the visual memory of words and other symbols. The for- 
 mer is situated on the mesial surface 9!' the occipital lobes 
 in the enviromental area of the calcarine fissure ; the latter 
 (usually known as the visual centre) is in the posterior 
 portion of the inferior parietal lobule, the angular gyms, 
 and the adjacent margin of the supramarginal convolution 
 which curves over the posterior extremity of the fissure of 
 Sylvius. Destruction of this centre produces a form of 
 sensory aphasia in which there are inability to put interpre- 
 tation on words seen and consequent inability to read the 
 condition known as word blindness, alexia, but it causes no 
 loss of visual acuteness. It will be seen later on that the 
 primary visual area and the higher visual centre are fre- 
 quently diseased simultaneously, but the symptoms pro- 
 duced by each can be differentiated. In these cases it is 
 to be understood that no lesion exists in the peripheral 
 visual apparatus, although the condition known as homony- 
 mous hemianopsia, which will be referred to hereafter in 
 some detail, oftentimes exists.
 
 264 The Facility of Speech. 
 
 If cases of uncomplicated word blindness existed, the 
 study and interpretation of their symptomatology would 
 be a very simple matter ; but such cases do not exist. 
 There is almost always some association of motor aphasia, 
 agraphia, and word deafness, and these coincident occur- 
 rences make the interpretation more difficult. In addition 
 to the fact that word blindness is thus complicated with 
 other conditions, it is to be remembered that word blind- 
 ness due to lesion of the zone of language is some- 
 times associated with right homonymous hemianopsia or 
 concentric limitation of the visual fields, on account of the 
 juxtaposition of the optic radiations of Gratiolet to the an- 
 gular gyrus on their way to the cortex around the calcarine 
 fissure. Or, to express this anatomically, there is fre- 
 quently some destruction of the optic projection fibres con- 
 stituting the radiations of Gratiolet and those connecting 
 the area in which visual memories are stored, the angular 
 gyrus, with the primary visual centre in the left occipital 
 lobe, which mirrors objects in the right visual fields of 
 both eyes. Recent and trustworthy observations prove 
 beyond cavil that destruction of the higher visual centre 
 in the angular gyrus and supramarginal convolution does 
 not cause hemianopsia, nor does it cause concentric con- 
 traction of the visual fields. In every case, therefore, in 
 which hemianopsia and concentric limitation are present, 
 the lesion must involve either the primary visual centre 
 in the cunei or that band of white fibres which is the back- 
 ward prolongation of the optic tract connecting the exter- 
 nal geniculate body, the anterior quadrigeminal bo/ly, 
 and the thalamus with the primary visual centre, and 
 known as the radiations of Gratiolet. I am at a loss to
 
 Sensory Aphasia. 265 
 
 understand why Brissaud, 1 while admitting that there are 
 cases of cerebral hemianopsia without verbal blindness, 
 denies that cases of verbal blindness, and by that I mean 
 
 literal verbal blindness, may occur without hemianopsia 
 
 facts laid down by Prevost and substantiated by the work 
 of Dejerine and Serieux. These observers have put on 
 record a number of cases which lead them to conclude that 
 lesion of the visual centre, the angular gyrus, causes word 
 blindness and agraphia, but does not cause hemianopsia if 
 the lesion is limited to the gray matter, and that a lesion 
 of the primary visual centre in the left occipital lobe alone 
 causes right homonymous hemianopsia, but if limited to 
 that the higher visual centre remains intact and the pa- 
 tient is not word blind so long as the latter is in connec- 
 tion with the primary visual centre in the other occipital 
 lobe ; but if a lesion should cut across the connection be- 
 tween both primary visual centres and the centre in the 
 left angular gyrus, the patient is word blind but not 
 agraphic. 
 
 Before proceeding to a discussion of visual aphasia I 
 wish to record the following case of true sensory aphasia 
 in which visual aphasia was the leading feature. I am 
 under obligations to Dr. Joseph Fraenkel for opportunity 
 to study the patient. 
 
 R. M , a right-handed woman ; native of Russia ; 
 
 forty-five years old. She is married and has borne several 
 children. There is no history of miscarriages or of 
 syphilis. She has now what seems to be an atypical form 
 of Basedow's disease, the only attributable cause of which 
 is emotional shock. She complains of fever and pain 
 
 1 Brissaud : " Traitc de Mcdecine," vol. vi.
 
 266 The Faculty of Speech. 
 
 around the heart. Objectively tachycardia, exophthalmos, 
 and enlargement of the thyroid gland, more pronounced on 
 one side, are very evident. A year or more ago she was quite 
 melancholy ; then she got very much better, and remained 
 fairly well for a few months. The symptoms from which 
 she now suffers came on very abruptly, about eight months 
 before she came to the hospital, and followed an attack of 
 pneumonia. Shortly before she came to the hospital she 
 had a transitory attack of right-side hemiplegia ; the right 
 side of the face and the right arm were particularly in- 
 volved, and the right leg very slightly. Admitted to the 
 hospital, June i6th, 1896; died, October 24th, 1896. The 
 notes of the house physician previous to my first examina- 
 tion are as follows : 
 
 " Futile attempts to get a history, patient being aphasic, 
 this condition having come on, it is said, on the way down 
 from the ward to the office. She appears to understand 
 when spoken to, but her answers show paraphasia and mo- 
 tor aphasia. She cannot read ; does not understand written 
 words ; laughs frequently ; is very active ; soils the bed ; 
 has dyspnoea. 
 
 " Examination : Weight, seventy-five and three-quarter 
 pounds; pulse 148, arhythmical and irregular ; respiration, 
 42; temperature, 99.5 F. ; skin hot and dry. Patient 
 fidgety ; slight bed sores ; thyroid gland enlarged ; has 
 Basedow's disease. When asked to do simple things, 
 such as 'Put out the tongue/ 'Give me your hand,' etc., 
 she seems to understand, and does it quickly and hastily. 
 Favors the left hand ; the right arm hangs down from the 
 body. 
 
 " July 2Oth, 1896 (one day later). Aphasia exists ; con- 
 siderable psychical bewilderment ; her vocabulary, com- 
 pared with that of yesterday, is diminished. There is well- 
 marked motor paralysis of the right upper extremity, and
 
 Sensory Aphasia. 267 
 
 the forearm is kept in a semiflexed position. The knee- 
 jerks are nearly equal on both sides, and they show the 
 peculiarity of being increased with a flaccid condition of 
 the lower extremities. There is distinct hemianaesthesia 
 on the right side, but it is difficult to ascertain of what 
 nature this is, on account of the jabbering character of 
 the responses. Examination of the urine reveals the 
 presence of albumin, the specific gravity being 1.028." 
 
 Since she has been in the hospital she has had one or 
 two recurrences of the hemiplegia, but like the other at- 
 tacks they were transitory. The most striking feature of 
 the case in looking at her is her intense restlessness and 
 the rapidity with which every movement is performed. 
 She is either continually moving and agitated, or talking 
 strings of words that are wholly unintelligible. She gives 
 the impression of a person who is on the verge of bursting 
 into an attack of acute mania, but who still has some coh- 
 trol of herself. On my first examination, I found the 
 patient to be an emaciated, excited-looking woman, who, 
 on account of the bulging of the eyes, the never-ceasing 
 physical activity, and the verboseness, presented a strik- 
 ing picture. At this time there was no trace of the pre- 
 vious hemiplegic attacks, the last of which occurred only 
 a few weeks before the examination. The patient was 
 sitting up in bed ; she held continually a folded handker- 
 chief or a towel against the face and mouth with the right 
 hand, for what purpose I could not learn, but there was no 
 drooling. Her speech possession is best indicated by the 
 following stenographic report : 
 
 What is your name? Tanes tanes tanes. (Then 
 she smiles, looks distressed, turns abruptly and reaches 
 for the card which hangs over her bed and on which her 
 name, age, period of admission, etc., are written. This 
 she holds out to her interlocutor and laughs.)
 
 268 The Faculty oj Speech. 
 
 How old are you? Sex sex vier vier fiinf fiinf 
 (then, with the same rapidity as before, points to the 
 card). 
 
 Are you married ? Sure sure. 
 
 Are you one hundred years old? Sure, sure. (It must 
 be marked here that the lower class of Polish Jews give 
 wider significance and usage to the word sure than does 
 any other race, and it is necessary to bear this in mind in 
 this patient, with whom the word " sure" seemed to be a 
 recurring utterance.) 
 
 How many children have you? Four. Sure, sure, 
 sure. (All this with the greatest facial and bodily activ- 
 ity and emotional display smiling and laughing.) 
 
 What is the name of the first ? Sexel. 
 
 What is the name of the second? Vier. 
 
 What is the name of the third ? Fickel. (These are 
 possible Hebrew words, but they have no appropriate- 
 ness.) 
 
 What is your husband's name ? Fickel. 
 
 What is your mother's name? Finckel. 
 
 Now, Mrs. M , quiet yourself (it should be said here 
 
 that the patient is very verbose, continually emitting a 
 string of words which have no sense or meaning), and tell 
 me slowly all about your sickness. My husband my 
 husband. He will say, explain. I can't. Sure, sure. 
 Yesterday morning early (then she repeats a string of 
 words of which it is impossible to make a report, which 
 here and there can be recognized as elements of Hebrew 
 jargon, but the larger number of them are not a constitu- 
 ent of any language, nor have they any connection. Their 
 production is accompanied by great motor activity, rest- 
 lessness, gesticulation, and occasionally the word "sure.") 
 
 (Holding up a spoon) What is that ? A book. 
 
 Is it a spoon ? Yes. (Says it with pleasure.)
 
 Sensory Aphasia. 269 
 
 (Holding up a cup.) A cup. (It is probable that she 
 heard the word cup.) 
 
 (Holding up a watch.) A thing to look for the hour. 
 
 (Holding up a match.) To rub. I understand all. 
 
 (Holding up a pencil.) To write. 
 
 (Pointing to some bread.) To eat. (After hearing the 
 word " bread" uttered, she says it very quickly and with 
 avidity.) 
 
 (Holding up a key.) Pickle (German, Schliissel). 
 (Then replies) What one opens with. 
 
 (Holding up a knife.) (Making a motion as if to open 
 it) To eat. 
 
 Is it a knife? Sure (repeats jargon). 
 
 She is given a handful of coins and asked to select all 
 the five-cent pieces, but she is entirely unable to do so. 
 She starts in as if she fully understood what she was 
 requested to do, but she is unable to do what is asked. 
 
 How much is there there? Twelve, six, four (and 
 then she begins to laugh). 
 
 (Shown a two-dollar bill) How much is that? Six, six, 
 six, six. 
 
 \Yill you please count for me? Six, six, seven, eight, 
 one (then gets rather emotional). 
 
 On being asked to repeat the line, " Aus tiefem Schlaf 
 bin ich erwacht," she was unable to do so. She started 
 with " aus" and then poured forth a jargon interspersed 
 with " sure," all the time smiling, grimacing, gesticu- 
 lating. 
 
 Can you read ? Yes. (She is given the text of a very 
 familiar Hebrew prayer, and asked to read it, but she 
 cannot repeat a word correctly. She is unable to de- 
 cipher either words or letters.) 
 
 When an interpreter who is very familiar with her jar- 
 gon asks her her name, she repeats, " Weitl, sceitl, heitl,
 
 270 The Faculty of Speech. 
 
 weitl." (It is thought that she is endeavoring to say 
 " Rachel." All this time she is talking rapidly and ges- 
 ticulating.) 
 
 How old are you ? Six and four, and two, and sure, and 
 sure. 
 
 Are you married ? Sure, sure. 
 
 How long? Sixty-four, sixty-five. I can't remember. 
 
 Now try and count again for me ? four, six, seven, six, 
 seven, five, six, eight, seven, seven, eight, eight, sixteen, 
 forty-six, six and four and five and six. 
 
 Can you repeat the letters of the alphabet ? She begins 
 to say the same figures as above. 
 
 Her people say that she was formerly able to read and 
 write. She is now given the printed page of text that 
 she should be familiar with if she had been able to read a 
 word. She cons it very studiously and then begins, " Six 
 and four and four and six," and so on in the most mixed-up 
 fashion. She then takes an individual line and points the 
 words out with the finger, and as she points to a word and 
 makes some articulate sound she looks up at the physician 
 inquiringly as if for corroboration. It is impossible to say 
 from examination of the vision whether or not there is 
 hemianopsia. It is oftentimes very difficult to say just how 
 much she recognizes through the visual sense. I ask her 
 to look at my watch and tell me what hour it is. She 
 looks carefully and says it is nearly five (correct time, 
 4 130). Is it ten minutes after five? Yes. 
 
 And sometimes on being given a number of coins and 
 requested to match them she does it very accurately. It 
 is absolutely impossible for her to repeat a sentence or a 
 few connected words. 
 
 On being handed a pen and asked to write she makes 
 a show as if she were about to write (that is, she seems to 
 recognize fully the use of the pen or pencil), but nothing
 
 Sensory Aphasia. 271 
 
 in the shape of writing results. There is complete 
 agraphia. Of course it must be kept in mind that she 
 has a very severe tremor; but this is not sufficient to 
 prevent the formation of letters. She can copy, but in the 
 most laborious and servile way. 
 
 The efforts at copying figures and numbers are somewhat 
 more successful, but she cannot call the numerals that she 
 is trying to write. A tuning-fork, a watch, etc., held to 
 the ear she heard, but she apparently did not associate 
 them with any distinct source or sound. It is impossible 
 to test her for possession of associative faculties, for 
 aside from the fact that she does not indulge in foolish 
 actions, there are no means of judging. 
 
 In order to show the slight variation in her symptoms 
 I append a protocol of an examination made some weeks 
 later on the 24th of September : 
 
 What is your name? Heitem, weitel, sure. Can't say 
 it. (All the time she is talking some sort of jargon of 
 which neither I nor any of the attendants can make out a 
 syllable, and she gesticulates at the same time.) 
 
 How old are you? (Apparently does not understand 
 the question.) Question repeated, and she looks inquir- 
 ingly at the nurse and at me, and then says, " Six and four 
 and four and four," and then all at once as if she suddenly 
 interpreted the question she points to her card. 
 
 Are you married? Sure. 
 
 How long? Six and four and four and six. I can't 
 tell, I can't remember; sure. (Always after an apparent 
 reply she goes on with considerable jargon, then smiles, 
 laughs, looks around. She keeps the corner of her shawl, 
 or a napkin, or whatever she may have in hand, up to the 
 right side of the mouth.) 
 
 How long have you been married ? Six and four, sixty- 
 five, I can't say it.
 
 272 The Faculty of Speech, 
 
 She does not comprehend questions that are addressed 
 to her in writing, and although she essays to read such 
 questions the answers are not at all a propos. Interro- 
 gated in this fashion she looks at the writing eagerly, 
 quickly, and knowingly, but when she starts to answer it 
 is always the same, " Six and four, weitel," etc., etc. If 
 one smiles incredulously, he is pretty apt to hear " Sure," 
 etc. 
 
 Tests to make her repeat after her interlocutor resulted 
 the same as determined previously. Sense of smell seems 
 acute, but whether she detects the individual substance 
 held to her nostril is not clear, for she cannot name it 
 properly. 
 
 She seems to know the use of things. 
 
 Autopsy (Dr. Fraenkel) : Asymmetry of the skull, shown 
 by bulging of the right parietal boss. Dura and sinuses 
 normal. Pia of the convexity normal. The Sylvian vessels 
 as well as their branches are normal. Along the sulcus 
 of the right insula there are three yellowish-white papules 
 on the surface of the cortex, each about three millimetres 
 in diameter. These lie either in the pia or upon the ex- 
 treme surface of the brain, or in both places. In the left 
 hemisphere there is seen at the posterior portion of the 
 inferior parietal lobule a soft pultaceous yellowish mass, 
 which is slightly depressed beneath the surface of the 
 brain cortex. This measured four centimetres in diame- 
 ter. Where this softened region joins the surrounding 
 brain cortex it is less yellow and more firm. The pulta- 
 ceousness is most pronounced at the centre. It occupies 
 the angular and supramarginal gyri, not completely effac- 
 ing both, and has slight impingement on the superior 
 temporal in its posterior portion (Fig. 12). The depth 
 of this softened region is so great that it extends through 
 and involves the outer portion of the posterior arm of the
 
 Sensory Aphasia. 
 
 2/3 
 
 internal capsule just as these fibres enter the basal ganglia. 
 The occipital lobe is slightly encroached upon. The right 
 hemisphere shows a recent softening of the posterior por- 
 tion of the third frontal convolution. This grayish mass 
 is about two centimetres in diameter. 
 
 The areas of softening in the right side of the brain 
 were of very recent date apparently, and they, like the 
 
 FIG. i2.-Shaded Area Indicates Spot of Softening. 
 
 one on the left side, can probably have their origin traced 
 to emboli coming from the hypertrophic and thrombotic 
 auricular appendix, and the chronic endocarditis, 
 probable, moreover, that the lesion on the right side of 
 the brain had nothing to do with determining either 1 
 aphasia or the paralysis, and the case is one of true sensory 
 aphasia, the word blindness being the most pronnn 
 feature. The comparatively slight degree of word dea. 
 ness that the patient presented was dependent upon t 
 impingement of the area of softening in the inferior pai 
 tal lobule upon the posterior end of the superior temporal. 
 1 8
 
 274 The Faculty of Speech. 
 
 The total agraphia and alexia are of course "significant of 
 destruction of the angular gyrus, and the paraphasia and 
 jargonaphasia are likewise most interpretable in the light 
 of the autopsical findings. 
 
 Word blindness in its simplest form entails alexia, in- 
 ability to read, or inability to get any information from 
 written or printed symbols. Naturally there are various 
 degrees of intensity of word blindness. The patient may 
 be unable to read words, and yet retain the faculty of rec- 
 ognizing letters; or, on the other hand, this may also be 
 lost, constituting literal as well as verbal blindness ; or 
 he may be able to recognize letters and unable to join 
 them in syllables (asyllabia). For instance, Mierze- 
 jewski ' has described a case as a form of caecitas sylla- 
 baris et verbalis sed non literalis, and Badal, 2 in his mono- 
 graph, mentions another case which was carefully studied 
 by the author. The patient studied by Badal could read 
 individual letters, but he could not combine them or keep 
 them long enough in memory to form a word. This, it 
 will be readily seen, is merely a difference in degree and 
 not a difference in species. It has been noted in excep- 
 tional instances that a patient who has verbal but not lit- 
 eral blindness is able, if his auditory centre is intact, to 
 have the meaning of the word made evident to him by 
 spelling it out. For instance, though he cannot read the 
 word " cat" he can read c-a-t and comprehend what the 
 letters stand for. This conservation of the ability to read 
 
 1 Mierzejewski : " Ein Fall von Wortblindheit. " Neurologisches Cen- 
 tralblatt, p. 750, 1890. 
 
 2 Badal : " Contribution a 1'etude des cecites psychiques ; alexie, 
 agraphie, hemianopsie inferieure, trouble du sens de 1'espace." Arch. 
 d'Ophthal., p. 97, 1888.
 
 Sensory Aphasia. 275 
 
 individual letters when the sight of words calls up in 
 mind no corresponding ideas is not difficult of explana- 
 tion. It is dependent upon the mode of education of the 
 individual. Most children, and indeed all until recent 
 years, learned to read, that is, learned to attach certain 
 significance to printed and written words, by first learning 
 to recognize the individual letters of the alphabet and to 
 differentiate them one from another. They are not sup- 
 posed to associate any significance with such acquisition. 
 Recognition of the letters of the alphabet is attained as 
 the result of prolonged and tedious effort. Later, the 
 child joins a number 'of letters together to form words, 
 which he may or may not have previously heard, but 
 which have a visual and auditory individuality and which 
 give rise to a distinct content of consciousness, and the 
 visual and auditory memory of them leaves its impress upon 
 the cortex of the angular gyrus and the first temporal con- 
 volution of the left hemisphere in right-handed persons; 
 of the right hemisphere in left-handed persons. The 
 early acquisition of letters, and the primitiveness of their 
 registration, explains the greater tenaciousness of their 
 possession and the greater difficulty of their disintegration. 
 At the present day, one of advanced pedagogic en- 
 lightenment, children are no longer required to learn let- 
 ters before syllables and words. It is probable that in a 
 person thus educated there would be letter blindness co- 
 incident with word blindness. A condition somewhat 
 analogous to that of variation in intensity of word blind- 
 ness is that in which a patient becomes unable to read 
 the letters and words of one or more languages that he 
 had previously been able to read and speak perfectly,
 
 276 The Faculty of Speech. 
 
 while still retaining the capacity to read other languages. 
 Cases of this kind are by no means common, but a num - 
 ber of them have been reported, particularly by Charcot 
 and Pitres. It is not often that suc*h a condition is the 
 only disability, object blindness and some degree of 
 mind blindness are generally associated with it. In 
 the case cited by Charcot, for example, there was loss of 
 visual memory for form and for color, for objects and for 
 places. The monuments, houses, landmarks, streets, etc., 
 of the town in which the patient had lived for many years, 
 and with which he had been very familiar, all seemed new 
 to him. Moreover, he did not recognize the members of 
 his own family ; they seemed to him like strangers. Some 
 writers make the very grave error of confounding these 
 cases of object blindness and mind blindness with cases 
 of word blindness. 
 
 In many cases of visual aphasia, or word blindness, the 
 patient, although absolutely unable to recognize anything 
 else, still tells his own name when he sees it written. 
 But unless he has been accustomed to see it in print, he 
 will not recognize it. The only explanation for this fact 
 that can be offered is that the individual's name, because 
 of his long experience in seeing it, in writing it, in hear- 
 ing it, is more deeply printed on the specialized sensory 
 area of the brain to which it has been carried by the 
 hearing and seeing apparatuses. In such cases it is under- 
 stood that the angular gyrus is not completely destroyed. 
 Oftentimes the patient will preserve a recognition of a 
 number of other words, particularly of names with which 
 he has been for a long time familiar, such as those of the 
 members of his family, his business, his place of resi-
 
 Sensory Aphasia. 277 
 
 dence, the church of which he is a member, etc., and 
 for precisely the same reason that he recognizes his 
 name. 
 
 Occasionally cases are met with in which the verbal 
 blindness is so very slight that it requires careful and 
 persistent examination to reveal it. This is particu- 
 larly true of cases in which the symptom of word 
 blindness unfolds itself slowly, and of cases in which 
 there has been a considerable degree of recovery. In 
 such cases the patients may be able to recognize one or 
 two words of a sentence, especially the substantives, and 
 from them they gather the sense of the phrase. If the pa- 
 tient is not an educated person, the examiner may be misled 
 at first by the readiness with which the patient essays to 
 read, but there is that about his actions and demeanor that 
 will suggest to the experienced physician that the patient 
 is guessing. He very rarely reads right along unhesitat- 
 ingly, as one usually does. He watches the expression 
 of the person for whom he is reading, and at the end of 
 every sentence or line he looks up and asks, " Is that 
 right?" heaves a sigh of relief if it is, and turns to 
 again. 
 
 It is a well-known fact that the acquisition of, and the 
 memory for, figures and numerals are a different process 
 than that for letters, and it is also known that the memory 
 for the latter may be preserved and the former lost. In- 
 deed, it is not so very rare for a patient to be word and 
 letter blind but not figure blind. A very instructive case 
 is one recently reported by Hinshelwood, in which a man 
 although absolutely letter blind could read figures quickly 
 and with the greatest readiness.
 
 278 The Faculty of Speech. 
 
 The term dyslexia is one that was first used by Berlin, 1 
 of Stuttgart, in 1886, to indicate a form of word blindness 
 which differed materially from the ordinary forms. The 
 first patient described by Berlin was a man sixty-six years 
 old, who had been forced to abandon his occupation be- 
 cause the reading of printed and written characters had 
 become quite impossible. He was not word blind in the 
 usual sense of the term. He could pick up a paper and 
 read five or six words quite correctly and get full appreci- 
 ation of their meaning, and then he would have to stop, as 
 the words had no longer any meaning for him. After he 
 had rested for a short time he could go on and read a few 
 words more. There was precisely the same difficulty 
 with letters of every size. On being asked why he could 
 not read he gave no satisfactory explanation. The letters 
 did not become dim or confused, he simply could not read 
 them. Efforts to read were most obnoxious to him, so 
 keenly alive was he to his infirmity. Later, the patient 
 developed other, cerebral symptoms and eventually died 
 from apoplexy. Berlin' looks upon the symptom as a 
 special form of word blindness due to interruption in the 
 conductivity of the connecting fibres of the visual centre, 
 the angular gyms. It does not seem to me necessary to 
 look upon the symptom as an exclusive " aphasia of con- 
 duction," and I see no reason for not believing that it may 
 be due to a partial impairment of the molecular function 
 of the centre for visual memory, a condition that may re- 
 sult from injurious agencies that pervert the function of 
 
 1 Berlin : " Weitere Beobachtungen tiber Dyslexic mit Sectionsbefund." 
 Berliner klinische Wochenschrift, p. 522, 1886. 
 
 4 Berlin : Archiv f. Psychiatric, pp. 289-292, 1887.
 
 Sensory Aphasia. 279 
 
 this area without causing anatomical destruction of it. In 
 such a condition the centre is capable of being aroused 
 for the memorial recall of letters and words for a short 
 time, then it becomes exhausted. After it has time 
 to rest, a brief period of excitability follows. I am in- 
 clined to this view of it particularly from the fact that the 
 symptom is not accompanied by symptoms pointing to 
 impaired functioning of the auditory centre, which would 
 be the case if the disturbance was in the internuncial 
 fibres connecting these two centres. This view would 
 seem to receive further corroboration from the fact that 
 the symptom has been observed a number of times in 
 alcoholic patients, and it has disappeared when the use of 
 the toxic agency was abandoned. This view is in har- 
 mony with the genesis of alcoholic visual hallucinations 
 which are so often of an extraordinarily vivid character, 
 and with the occurrence of alcoholic retrograde amnesia. 
 
 Hinshelwood ' has published a very instructive example 
 of dyslexia due to alcohol. His patient was a tailor, 
 forty- nine years old, who before his present trouble was a 
 very capable workman. Latterly, on starting a piece of 
 work, he forgot how to proceed, and every step had to 
 be -pointed out to him as though he were a beginner. 
 Even then he would make the absurdest mistakes, and 
 after he had sewed parts together they had to be ripped. 
 The greater part of his time in the shop was spent in 
 looking for things that he would put out of his hand, such 
 as the thimble, needle, glasses, etc., so that finally he had 
 to be dismissed. A rather remarkable feature of the case 
 was that he frequently lost his way in the most familiar 
 
 1 Hinshelwood : Lancet, December 2ist, 1895.
 
 280 The Faculty of Speech. 
 
 parts of the city, and he could find his way home only 
 with the greatest difficulty, even over a route that he had 
 travelled for years. The difficulty of reading was very 
 similar to that described by Berlin. The patient could 
 read a few words and then he would completely lose the 
 capacity to proceed. The letters, though seen with dis- 
 tinctness on first endeavors to read, would lose all mean- 
 ing when he continued in his attempts to read. There 
 was no blurring or running together of the letters. There 
 was no disturbance of speech or deterioration of mental 
 power, while memory for past events was not at all im- 
 paired. The patient recovered under tonics. 
 
 This case is one that admits of interpretation along the 
 lines already suggested. The effects of the alcohol would 
 seem to have been first and particularly upon the centre 
 for the memorial recall of printed and written words, which 
 were followed later by affection of those parts in which are 
 stored the visual memory of objects, and finally, and to a 
 comparably slight degree, upon the primary visual area 
 which reflects the images of things. Hinshelwood con- 
 tends that memories for form, color, etc., are stored up in 
 both occipital convolutions, and the symptoms of his case 
 would lend credence to this view. It would seem warrant- 
 able to suppose, in this case at least, that the seat of the 
 disturbance was the entire visual area, the primary cen- 
 tres, and the centre for the visual memories of words. 
 The integrity of speech and the fact that there was no loss 
 of memory for past events show that the auditory word 
 memories could be revived with their customary vividness 
 and transmitted to the articuiatory kinaesthetic centre. It 
 is to be regretted that careful tests were not made to de-
 
 Sensory Aphasia. 281 
 
 termine the patient's capacity to write, for the auditory 
 centre, acting with its customary force, should send im- 
 pulses, which have a marked influence in arousing the 
 memory of graphic images, to the visual centre. 
 
 If the angular gyrus is completely destroyed, the fac- 
 ulty of writing is lost with it, or, perhaps I should say, if 
 the power of visual memorial recall is lost, then writing is 
 no longer possible. In those cases in which voluntary 
 writing is preserved, the lesion, involves the primary visual 
 centre, and, as this lesion is so often associated with right 
 homonymous hemianopsia, the patient begins to write at 
 the extreme left side of the sheet and stops in the middle 
 of the page, unless he takes the trouble to inform himself 
 by mediation of the tactual sense that there is still room 
 on the line and pushes the sheet toward the left in order 
 that it may be brought into the visual field. These pa- 
 tients, being unable to read what they have written, are 
 totally unconscious of any errors, of spelling or phrase- 
 ology that they may make, although they may put the 
 words on paper in as orderly a fashion as they were able 
 to do before the development of the aphasia. 
 
 If the auditory centre is uninjured, the patient is able 
 to comprehend what is read to him, and if his own hand- 
 writing is read he may be able to detect errors of se- 
 quence, of diction, and of spelling, but he is unable to 
 take a pen and correct them, because he does not recognize 
 and appreciate the value of a word or a letter. Patients 
 who have word blindness will occasionally take a paper, 
 a book or written matter and essay to read aloud, but 
 naturally what they produce has no connection with the 
 subject matter before them. Why they do this is difficult
 
 282 The Faculty of Speech. 
 
 of explanation. In many instances it has been the reason 
 for considering the person to be demented. 
 
 Patients with word blindness are sometimes able to read 
 written or printed words and sentences by tracing the 
 word (which, it is to be remembered, they see with cus- 
 tomary acuteness) with the end of the index finger or with 
 a pencil. This is a most instructive phenomenon, and, 
 although it is not often elicitable, it is by no means very 
 rare and it should be studied carefully in every case. 
 Such patients by utilizing kinaesthetic stimuli excite pre- 
 vious kinaesthetic memories, which in turn react upon or 
 act conjointly with auditory and articulatory memories to 
 revive the mental concept of the word, the idea that it 
 represents. In other words, the kinaesthetic apperceptive 
 area acts vicariously for the visual, and if it acts more 
 slowly and with less certainty it is because it is neither 
 ontogenetically nor phylogenetically intended for that pur- 
 pose, while the visual area is. This should not be con- 
 strued, I think, as a revivification by "motor processes," 
 as taught by Strieker and others. The idea of the word 
 is revived by kinaesthetic stimuli which consist of sensory 
 impressions coming from the muscles, joints, and skin of 
 the hand and upper extremity. Patients who practice 
 perseveringly this method of conveying to their minds the 
 meaning of written symbols, often acquire great facility 
 with this mode of interpretation. The principle involved 
 does not differ materially from that by which the con- 
 genitally or accidentally blind acquire ideas of form, of 
 space, of size, of quality, and even of color, in which 
 association becomes established between the auditory 
 centre and various parts of the somaesthetic area.
 
 Sensory Aphasia. 283 
 
 The fact that such patients interpret by tracing written 
 characters more readily than by tracing printed, indicates 
 that muscular sense and the centre of graphic motor co-or- 
 dination are the elements that mediate the connection of 
 the word and the concept, for in every person the training 
 of the hand has been to trace written and not printed sym- 
 bols. These patients read the movements of which the 
 letters are the tracing, the usual pathway between the word 
 and the concept in the revivification of visual images being 
 destroyed. In some cases there is complete inability to 
 read printed or written characters, while the recognition 
 of musical notes, of figures, and of various other expres- 
 sive symbols is preserved. In other words, there is a dif- 
 ferentiation of graphic symbols, just as we have seen a 
 differentiation of auditory symbols, and the more highly 
 differentiated these symbols are the more completely and 
 easily are they lost. The denomination of money and its 
 representative value may be quickly and thoroughly 
 grasped; the patient may retain any skill which he may 
 have possessed in playing cards and in giving perception 
 to symbolic formula other than those represented by let- 
 ters, all of which tends to show that the storage of written 
 symbols is not the same as it is for other forms of nota- 
 tion. 
 
 It should not, however, be understood that the patient 
 may not be blind to all forms of notation, graphic and 
 symbolic representation. Thus, there may be sensory 
 amusia, sensory asymbolia, sensory amimia, etc. The oc- 
 currence of these will vary with the composition and char- 
 acter of the patient's intellectual possessions. A musician 
 who has been accustomed to carrying simple or most in-
 
 284 The Faculty of Speech. 
 
 tricate themes by means of musical notation may gaze on 
 scales without their having any other signification for him 
 than they have for a person who has never seen a page of 
 music. He may also watch the movements of a leader's 
 baton while they give no more orientation for the execu- 
 tion of a piece of music which he may be able to play by 
 revivification of auditory memories than would a person 
 who had never heard of tempo. 
 
 Musicians, by virtue of the acquisition of a unique 
 method of eye externalization, are in possession of special- 
 ized sensory images, visual and auditory, entirely divorced 
 from the memory of letters, of words, and of figures, which 
 probably posit for their possession different cells or asso- 
 ciation tracts, and the one may fail to be revivified when 
 the eye falls on it, as it appears on paper, while others are 
 called up by gazing on their like. 
 
 It is my desire to make as clear as possible that the 
 patient with visual aphasia, word-blindness, sees with per- 
 fect distinctness the letters in his visual field. This is 
 done by virtue of the primary visual area in the occipital 
 lobe, but the reflection of letters by the primary visual area 
 does not convey anything to the intelligence, it does not 
 call up any memory pictures, for the area in which they 
 have been stored is destroyed. The primary visual area 
 reflects letters and words as a mirror does an object held 
 up before it, except that there is no reversal, and as reflec- 
 tions by a mirror make no impression which remains after 
 the object reflected is taken away, neither do words make 
 any impression because of the impingement of their 
 images on the primary visual area. Destruction of the 
 primary visual area produces blindness in the literal sense
 
 Sensory Aphasia. 
 
 285 
 
 of the word; there is loss of perception of luminous ob- 
 jects, virtually the same kind of blindness as when the 
 retime are destroyed. When the primary visual area of 
 
 FlG. 13. Course of the Optic Fibres. EGB, External Reniculate body; AQB, 
 
 anterior qiuulrigeminal body ; P of 7\ pulvinar ; J'C, visual centre ; 11','C, 
 half-vision centre. 
 
 one side is destroyed, the blindness that follows is of half 
 of each retinal field, and on account of the partial decussa- 
 tion in the chiasm this blindness is homonymous, that is, 
 of the same half. This visual defect is shown graphically
 
 286 The Faculty of Speech. 
 
 by the adjoining figure, which is based upon recent knowl- 
 edge- of the course of the primary optic neuron. 
 
 There are two or three subdivisions of visual aphasia, to 
 which I shall refer. The first is a form in which there is 
 loss of the perception of the word, not only of the visual 
 impressions corresponding to the word, but a loss of the 
 value of the symbol in arousing the idea of which it is the 
 written representation. This form of sensory visual 
 aphasia is entitled to the name loss of word visualization, 
 verbal amnesia, or psychic blindness of words. Unlike 
 word blindness, the patient interprets letters as letters and 
 words as words. They are not simply marks on paper, 
 and he can read them and copy them, but they convey no 
 meaning to him after he has read them. When they are 
 pronounced before him he hears and interprets them very 
 readily ; but he has no idea that they are the same words 
 that he has been reading or copying unless he is so in- 
 formed. It has been suggested that psychic blindness of 
 words is a phenomenon exactly analogous to that which 
 occurs on reading a book when our attention is absorbed 
 with something entirely apart from the subject matter be- 
 fore us ; we read on, line after line, we reach the bottom 
 of the page, and not until the necessity for turning the 
 page arouses us do we find that although the page has 
 been faithfully read not a word has entered into con- 
 sciousness, nor can we cite a single fact that the writer 
 attempted to convey. 
 
 It is unnecessary to dwell upon the difference between 
 this and letter blindness and word blindness. It is read- 
 ily seen that the lesion which produces such a condition 
 must be one that interferes with the pathway that conveys
 
 Sensory Aphasia. 287 
 
 the sensation from the printed word or object to the idea, 
 or to where the idea is formed ; and we are warranted in 
 saying that such interference is nearer the seat of con- 
 sciousness, wherever that may be, than it is to the seat of 
 memory images of words. 
 
 A second subdivision is that in which the patient on 
 looking at an object, which he has previously seen and 
 used is unable to call up its name, although he is in 
 condition to utter the name if he could call it up. This 
 is the condition to which the name optic aphasia has been 
 given by Freund. The striking symptom is the inability 
 to name things. This inability is not difficult of interpre- 
 tation. It depends upon an interruption of the pathways 
 that unite the seat of cortical visual representation and the 
 seat of cortical auditory memories. It is necessary in order 
 to enunciate a name to influence articulatory images through 
 the auditory centre ; in other words, the impulse that starts 
 the externalization of a name travels along the intercentral 
 (or internuncial) auditory-articulatory pathway, and if 
 auditory images are properly revived, and there be no dis- 
 turbance of the articulatory kinaesthetic area, the name 
 will be uttered. If, however, something prevents the im- 
 pulse from passing through the visual apparatus by which 
 one gets a visual concept of the object and thus from 
 reacting on the seat of auditory speech images, then 
 calling objects by their names, when such are presented 
 to the peripheral organ of the visual apparatus, will be 
 entirely impossible. On the other hand, if the object 
 is of such a nature that it can appeal directly to the audi- 
 tory apparatus, the auditory mechanism being intact, the 
 name may still be produced. One or two simple examples
 
 288 The Faculty of Speech. 
 
 will suffice to show this clearly. If a photograph be held 
 before an individual and he is asked to designate it by 
 name, an impulse travels from the percipient ocular ap- 
 paratus to the primary visual centres and to the higher 
 visual centre, and the impression thus produced will excite 
 the auditory centre, to which the articulatory kinaesthetic 
 area is subservient, and the result will be the enuncia- 
 tion of the word "photograph." On the other hand, if 
 the visual mechanism is destroyed, and the photograph is 
 held to the ear, the patient will not be able to name it, 
 although the auditory mechanism is intact. The photo- 
 graph has no qualities that appeal to the ear. If, how- 
 ever, the object used be an apple, a patient with loss of 
 visual memories, but with auditory memories intact, may 
 still be able to name the word '' apple" if the object be pared 
 and sliced within his hearing. The occurrence of this 
 condition, with its sharply denned symptomatology, has 
 led certain writers to allocate special portions of the speech 
 area as a "concept centre" and a "naming centre." 
 Broadbent was the first to advance this view, in a paper 
 published in 1872.' In his own language: "There is a 
 primary or rudimentary perceptive act in which the exter- 
 nal cause of a given set of sensations is recognized as 
 such, and in which the simple attributes, as of form, color, 
 hardness, etc., are perceived. And there is a higher de- 
 gree of elaboration in which, by the combination or fusion 
 of perceptions derived from the various organs of sense, 
 a conception or an idea of an object as a whole is obtained. 
 This is a new and distinct process, and is usually accom- 
 panied by the affixing of a name to the object. The higher 
 
 1 Loc. cit.
 
 Sensory Aphasia. 289 
 
 elaborations and the fusion of various perceptions together, 
 and the evolution of an idea out of them, will be accom- 
 panied not by radiation from one perceptive centre to all 
 the others, but by convergence of impressions from the 
 various perceptive centres upon a common intermediate 
 cell area, in which a process analogous to the translation 
 of an impression into a sensation and of a sensation into 
 a primary perception will form a part of the supreme 
 centre, and will be situated in the superadded convolutions 
 which receive no radiating fibres." In the further elabo- 
 ration of this theory, Broadbent postulated a " proposition- 
 izing" centre, in which words other than substantives were 
 registered and in which words were arranged orderly pre- 
 paratory to being uttered. 
 
 It seems to me unnecessary to point out how completely 
 at variance this is with the conception of speech that I 
 have attempted to portray in another chapter, and how 
 contrary it is to the idea that the various speech centres 
 have an integral part in the conception of words, the sym- 
 bols of thought. The existence of such a centre is, I be- 
 lieve, contrary to the conception of the psychogenesis of 
 speech. The reasoning on which its existence is posited 
 is fallacious, and the cases that have been cited to estab- 
 lish its autonomy are made to .support it only by putting 
 unwarrantable interpretation upon accompanying symp- 
 toms. If such a centre existed, it is reasonable to suppose 
 that cases of aphasia would have been described before 
 this in which the symptoms pointed to the destruction of 
 this area, especially considering the autonomic activity that 
 its sponsors give it. I have been unable to find any such 
 cases ; that is, no case in which the speech disturbance
 
 290 The Faculty of Speech. 
 
 could not be explained by a lesion of one of the speech 
 centres or of its afferent and efferent pathways. The case 
 cited by Mills 1 in support of this contention is reported in 
 such an incomplete and fragmentary fashion that I am 
 astonished that one of his clinical astuteness and erudi- 
 tion should consent to offer it in evidence. The follow- 
 ing is a n'sum^ of his case : 
 
 A woman, forty-five years old, complained of numbness 
 in the back of the head and neck, vertigo, and vomiting. 
 Soon after this it was noticed that she did things differently 
 from her usual custom. She hung upside down a certifi- 
 cate of membership in a society without realizing her mis- 
 take. She had to forego her occupation, that of dress- 
 making, because she no longer got the parts together 
 properly, etc. In othenwords, she developed optic apJiasia. 
 (If she had been tested there would have been found, in 
 all probability, dyslexia or alexia, but no information is 
 given concerning the reception, interpretation, or emis- 
 sion of speech.) About three years after these symptoms 
 were first noticed, she had an epileptic fit, and after this 
 forgetfulness of words became very evident. Examina- 
 tion showed left lateral homonymous hemianopsia, word 
 blindness, but not letter blindness, inability to name ob- 
 jects, it mattered not through what receptive avenue she 
 got information concerning them, although she knew their 
 uses. I infer there was Considerable agraphia, although 
 nothing 'is said about it, for a fac-simile of the patient's 
 signature shows the last name unfinished. There was 
 slight paraphasia in spontaneous and repeated speech, but 
 the former soon became limited to the use of " Yes" and 
 " No, " which she used properly. About ten weeks before 
 death there developed slowly a right-side hemiplegia. On 
 
 1 Mills : Journal of Nervous and Mental Disease, p. i, 1895, 

 
 Sensory Aphasia. 291 
 
 autopsy, which is most meagrely reported, there was found, 
 on cutting into the temporal lobe, a hard tumor, yellowish- 
 brown in color. Its hardest and apparently oldest part 
 was in the middle of the third temporal gyrus, but a firm, 
 nodulated, more or less hemorrhagic condition extended 
 backward as far as the white matter of the occipital lobe 
 and forward toward the anterior ends of the second and 
 third temporal convolutions. It was thought that the dis- 
 ease started in the third temporal convolution, at a point 
 in line with the posterior extremity of the horizontal 
 branch of the fissure of Sylvius. 
 
 I find it difficult to convince myself that the gradually 
 developing optic aphasia and word blindness in this case 
 were due to anything else than a gradually progressive 
 lesion which encroached upon the projection tracts of the 
 visual fibres, the optic radiations, which lesion was mani- 
 fest by such infallible evidence as homonymous hemianop- 
 sia, and which later severed the connections between the 
 area of visual and auditory speech memories, the invoca- 
 tion of which by the former is necessary before concrete 
 words can be used. (Mills reports that the patient had 
 left homonymous hemianopsia, which I take it refers to 
 the retina, and not to the visual field; in other words, 
 blindness of the right side of the fields.) 
 
 The patient showed optic aphasia by her inability to 
 recognize that a certificate was hung upside down, and by 
 her inability to go on with dressmaking. This sympt 
 in all probability, coincided with disturbance between the 
 cortical area for visual reflection in the cuncus and the 
 area in which visual memories are stored up in the angu- 
 lar gyrus. That the interruption became more profound
 
 2cj2 The Faculty of Speech. 
 
 and extensive is shown by the development of word blind- 
 ness and homonymous hemianopsia ; that it never became 
 absolute is shown by her continued ability to recognize 
 letters; that her sensory speech area became gradually 
 destroyed is shown by the fact that she became almost, if 
 not absolutely, unproductive of voluntary speech. The 
 area of articulatory images was cut off from the centres 
 that excite it to activity and control, and the result was 
 almost the same as if there had been no articulatory 
 kinaesthetic centre a locomotive with steam but without a 
 driver. Moreover, the patient was not wholly agraphic, 
 although she wrote with great difficulty. Now, if there 
 is any one fact substantially proven in sensory aphasia, it 
 is that the cases of aphasia in which the patient is word 
 blind, but still not .agraphic, are dependent upon a lesion 
 in the white matter of the occipital lobe which severs the 
 fibres connecting the higher visual centre with both of the 
 primary visual centres in the two hemispheres. The 
 lesions found on post-mortem examination in this case 
 show, so far as they indicate anything, that they severed 
 the connection of the auditory centre with the visual cen- 
 tre, and the connections of the latter with the primary 
 visual areas. 
 
 In addition to the kind of visual aphasia in which there 
 is loss of memory for written and printed letters, and to 
 which the name verbal amnesia or psychic blindness of 
 words has been given, there is a form of less common but 
 more striking occurrence, known as psychic blindness or 
 mind blindness, the " Seelenblindheit" of the Germans, 
 '' Cecite psychique" of the French, a condition not infre- 
 quently associated with the ordinary form of word blind-
 
 Sensory Aphasia. 293 
 
 ness and letter blindness. In this condition the patient 
 not only does not recognize the significance of letters, but 
 he loses the power to differentiate between familiar ob- 
 jects or persons and to distinguish the use of things. He 
 looks at a member of his own family and sees, apparently, 
 a stranger. He does not recognize the house in which he 
 has lived for years, neither from the outside nor from 
 within, and frequently asks when lying in his own room 
 when he is to be taken home. Such patients do not rec- 
 ognize a washbasin from a drinking-glass, and drink as 
 readily from one as from another. They have no more 
 conception of the use of a fork or of a spoon than has an 
 aborigine. 
 
 The condition known as apraxia, the inability to com- 
 prehend the usage of ordinary objects and things to which 
 one had been accustomed, is analogous to this. Its oc- 
 currence and misinterpretation in former times were often 
 responsible for getting the unfortunate possessor into an 
 asylum. This is not at all surprising when we consider 
 that a very similar symptom often occurs during the very 
 early stages of general paralysis. A patient with the 
 latter disease, now under my care, first showed symptoms 
 of mental illness by persistent and repeated refusals to 
 enter his own house, insisting that the one in which he 
 lived looked entirely different. Even before any other 
 symptoms of mental disorganization were noted, he showed 
 himself quite incapable of finding his house or the street 
 in which it was located, or of recognizing it when brought 
 to it. A similar condition is often seen during the oc- 
 currence of very severe illness, such conditions being 
 looked upon as the visual hallucinations of delirium.
 
 294 The Faculty of SpcecJi. 
 
 The nature of the condition is probably an abolition of 
 the visual memories of objects, which memories have been 
 stored up in the higher visual area, a condition analogous 
 to that of word blindness. The patient who has this 
 condition may see the object; that is, he sees it objec- 
 tively, but he does not see it subjectively. When we are 
 as yet small children, we have no conception of the uses 
 of a great many things that impinge themselves on our 
 visual apparatus, which afterward become very familiar to 
 us. In the acquisition of this familiarity there is stored 
 up in the higher visual centre not only an image of the 
 object itself, but with it a memory picture of its use. 
 This latter may be a combined kinaesthetic-auditory-visual 
 one, the latter being for most objects by far the most 
 important one. When the visual image is lost, the mem- 
 ory picture cannot be rehabilitated. As Wyllie has re- 
 marked, the imprintation or storage of the images of 
 objects does not require such close attention as the im- 
 printation or storage of words, and the images of objects 
 and things are stored in both hemispheres of the brain. 
 This would account in a measure for the infrequent occur- 
 rence of this condition even in cases in which the sensory 
 speech area is very largely destroyed. It would also lend 
 itself to the interpretation of the occurrence of this symp- 
 tom in the early stages of general paresis, in which the 
 lesion is a widespread degeneration of the cortex.
 
 CHAPTER Ml. (Continued-]. 
 
 SUBCORTICAL SENSORY APHASIA. 
 
 THE subcortical forms of sensory aphasia, pure sensory 
 aphasia of Dejerine, are analogous to the subcortical forms 
 of motor aphasia. In discussing subcortical motor aphasia, 
 it was said that the symptom complex attending that con- 
 dition was the result of a lesion that prevented the idea, 
 properly and completely formed, from being externalized 
 in a word or words. In similar fashion the lesion of sub- 
 cortical sensory aphasia is one that interferes with the 
 passage of the spoken and written word to the idea of the 
 word or to where the idea is formed, it being understood 
 that the structures by whose functioning the idea of the 
 word is formed are intact. 
 
 The real components of sensory aphasia are visual 
 aphasia and auditory aphasia, and it follows that the visual 
 cortical area and the auditory cortical area are the parts by 
 virtue of whose activity one gets a visual and auditory 
 idea of words. Therefore, there may be a subcortical in- 
 terruption of the visual and auditory pathways which 
 causes a subcortical visual aphasia and a subcortical audi- 
 tory aphasia. I shall not attempt to discuss these in 
 extcnso here, as I have already referred to them in dis- 
 cussing the true forms of sensory aphasia. 
 
 The symptoms of subcortical or/;/;r visual aphasia will 
 be readily understood if it be borne in mind that the vi-
 
 296 The Faculty of Speech. 
 
 sual centre itself is intact and ready to functionate and that 
 it only awaits the impulses inciting it to function which 
 proceed from the half-vision centres. In subcortical 
 visual aphasia connection with the primary visual centres 
 is severed, and consequently the higher visual centre, 
 although retentive of its anatomical integrity, is perverted 
 in its physiological ability. The connection of the visual 
 centre with the other speech centres is not disturbed, ex- 
 cept in so far as the latter are not properly and customarily 
 influenced on account of the fact that the visual centre it- 
 self does not itself receive customary stimuli. This ac- 
 counts for the occasional occurrence of shortcomings of 
 speech (slight paraphasia, such as noted by Bramwell), 
 which might otherwise seem paradoxical. 
 
 The symptoms of subcortical visual aphasia vary some- 
 what with the seat of the lesion, i.e., with its proximity to 
 the left angular gyrus. Generally speaking, they are verbal 
 blindness, always associated with right lateral homony- 
 mous hemianopsia, as the lesion is either of the primary 
 visual area, in the cortex of the occipital lobe bordering 
 on the calcarine fissure, or of the optic radiations connect- 
 ing the occipital lobes with the left angular gyrus, the 
 higher visual centre. The patient looks at printed and at 
 written letters and sees only black marks on a white sur- 
 face ; he is wholly unable to interpret them, because the 
 visual impulse is prevented from reaching the left angular 
 gyrus, in which such impulses are interpreted by compar- 
 ing them with the residua of other impulses the signifi- 
 cance of which have been registered in consciousness and 
 which are known as memory pictures. The fact that the 
 centre in which are stored such visual memory images is
 
 Subcortical Sensory -Aphasia. 297 
 
 intact, and the images are therefore preserved, can be shown 
 in a variety of ways. In the first place, they can be re- 
 vived through kinaesthetic stimuli. If the patient has 
 been long habituated to writing, it may be possible for 
 him to interpret the significance of written letters and 
 words by tracing them with the finger end. Printed sym- 
 bols remain unintelligible to him, because he has not been 
 accustomed to tracing printed characters, and he has no 
 kinaesthetic memories and association tracts for such im- 
 pulses which can proceed to the angular gyrus. It is not 
 always possible even in one accustomed to writing to re- 
 vivify visual images in this way. In the second place, 
 patients with subcortical visual aphasia retain the capacity 
 to spell. Spelling consists, in most persons, of the memo- 
 rial recall of auditory images which are sent to the other 
 two speech centres, the articulatory and the visual. As 
 these centres are intact, capacity to spell is undisturbed. 
 Patients with subcortical visual aphasia are able to copy, 
 but they delineate without deviation from the copy before 
 them, and copy print in print, script in script. 
 
 These are the prominent symptoms. Spontaneous 
 speech, except occasionally the slight paraphasia already 
 referred to, and capacity to repeat are intact. The pa- 
 tient is able to write voluntarily and from dictation, but 
 he cannot read what he has written any more than he can 
 read what some one else has written, except in those in- 
 stances in which the sense can be gathered from tracing 
 each letter with the finger tip. The patient understands 
 readily what is said to him and can reply intelligently and 
 correctly. 
 
 Subcortical visual aphasia may or may not be accom-
 
 298 The Faculty of SpeecJi. 
 
 panied by a degree of optic aphasia manifested by inability 
 to name objects. Whether or not these patients have any 
 difficulty in spelling needs further investigation. In all 
 probability they do not, save in rare instances. Bramwell 
 has recorded an example of this form of aphasia in which 
 the faculty of spelling was preserved to such a remarkable 
 degree that the patient became the speller for the family. 
 As an example of subcortical verbal blindness which 
 is every way typical I shall cite the following instance 
 studied in my clinic at the Post-Graduate Medical School 
 and later in the City Hospital. 1 
 
 The patient is a male, fifty-eight years old, by occupa- 
 tion an artisan, whose life has been one of uniformity. 
 Although he has not had syphilis, rheumatism, or gout, 
 his blood-vessels show well-marked arterial sclerotic 
 change. His present infirmity dates back five months. 
 He had been complaining somewhat of not feeling well, 
 of headaches, and of some vertigo, when without other 
 warning he became unconscious and lay in a semi-uncon- 
 scious, semi-delirious condition for about three weeks. 
 There was no evidence of hemiplegia. He recovered his 
 mental balance after three weeks, but has not since that 
 time been able to return to his occupation. His wife says 
 that this incapacity is the result of bodily weakness, 
 forgetfulness, and because he does not remark anything. 
 He comes to the clinic on account of a stupid feeling 
 in the head, and because he is unable to work. Exam- 
 ination shows that voluntary speech is without notice- 
 
 1 I regard the case as particularly valuable because of the corroboration 
 which the examination of the brain, thus far made, gives to the statements 
 made from clinical data alone. The patient died six months after the 
 monograph had left the author's hand, and, as will be seen on further peru- 
 sal, the autopsy fully bears out the diagnosis.
 
 Subcortical Sensory Aphasia. 299 
 
 able defects. He talks in a somewhat more confiding 
 way and with a little more emphasis on words than one 
 usually does, and occasionally he misplaces a word. His 
 wife again comes to our aid and says that he misuses 
 words at home, although I must say that I have not been 
 able to remark any considerable paraphasic speech dis- 
 turbance, although if he is not understood quickly he 
 seems to get impatient and with a gesture significant of 
 impotence he turns to his wife. When his wife is asked 
 to cite specific examples she says there are many, but she 
 has difficulty in recalling one. Finally, she says that if 
 she sent him to a shop for soap he would be quite likely 
 to bring back flour. This surely cannot be cited as a 
 paraphasic manifestation. In -repeating sentences there 
 is occasionally sight misplacement of words, but no more, 
 I think, than would be expected in one of his intellectual 
 attainments. Pantomime and mimicry he does not in- 
 dulge in. He understands what is said to him, although 
 he is not quite so alert as formerly. He says that he has 
 to be attentive to what is said to him, and that if the sen- 
 tence is very long he loses the connection. Examination 
 of the eyes shows a complete lateral homonymous hemi- 
 anopsia, which is shown by the accompanying chart. The 
 patient is unable to read, that is, there is complete word 
 blindness. Occasionally he can make out a letter here 
 and there, but there is almost complete letter blindness. 
 He sees the letters very distinctly and is able to tell how 
 many letters there are in a word, but he is totally unable 
 to mark off a word into syllables or to take a number of 
 detached letters and construct a word or syllable out of 
 them. There is no object blindness. He recognizes 
 things and calls them by their right names. Voluntary 
 writing is preserved, but, with the exception of his name 
 and address and a few words, he is not productive. After
 
 ;oo 
 
 77/6' Faculty of Speech. 
 
 writing a few words, he foregoes further efforts with some 
 despairing remark. He writes badly to dictation after the 
 first few words, the writing from dictation showing only 
 two striking features : first, he is apparently unable to 
 retain in mind a sentence sufficiently long to write it ; 
 and, second, he stops the line before he gets to the right 
 side of the page. Writing from copy is very defective ; 
 what he copies he does laboriously and servilely, the let- 
 
 FIG. 14. Complete Lateral Homonymous Hemianopsia. 
 
 ters being an exact reproduction of the copy. Script is 
 copied as script and print as print. There is no optic 
 aphasia or mind blindness. The patient is quite as intel- 
 ligent as are most people of his age and social position ; 
 he is able to compute mentally and to spell, and is in fair 
 possession of his associative faculties. 
 
 In the examination of his eyes, it was interesting to 
 note that when a lighted candle was brought into the 
 right visual field the light of the candle was not seen until 
 after it had passed the median line, although the patient 
 detected at once that the atmosphere was brighter as soon
 
 Snbcortical Sensory Aphasia. 301 
 
 as the candle was brought into the space of a normal visual 
 field. In other words, as soon as the illumination struck 
 the retina he said, " It's brighter," but he did not see the 
 light. 
 
 A specimen of his voluntary writing is reproduced 
 here. It is an attempt on his part to tell me in writing 
 
 ' 
 
 
 
 FIG. 15. Specimen of Voluntary Writing. 
 
 how his sickness came on to tell me all about it. The 
 words have no significance. So far as they can be made 
 out they are : " Dare durg [the last letter is really nothing] 
 akenbeit ist es gekommen ist mochte lesen, ist kann nicht. 
 Die Krankheit ist," etc. When I ask him to read what he 
 has written he begins pointing to each word in turn " Ich 
 mochte gern lesen, ich mochte gern lesen" all this 
 slowly and with some emphasis. On being asked to spell 
 the individual letters entering into the formation of each 
 word he says, pointing to the first, second, third, and so
 
 302 The Faculty of Speech. 
 
 on, " That is e, that is also e, that is e, that is also e," and 
 so on, until he seems to become tired. 
 
 I repeated slowly the first lines of Schiller's poem, 
 " The Casting of the Bell" : 
 
 " Fest gemauert in der Erden 
 
 Steht die Form aus Lehm gebrannt ; 
 Heute soil die Glocke werden," etc. 
 
 and asked him to write them. Although this was re- 
 peated line by line and he could say it himself quite well, 
 the following is a fac-simile of what he produced when he 
 endeavored to write it from dictation (Fig. 16) : 
 
 The letters are formed, and some of the words are real 
 words ; there is no sense in them or any suggestion of 
 the original. He does not give the slightest heed to com- 
 mands addressed him in writing, such as, "Put out the 
 tongue," although he responds quickly when told to do so 
 in spoken words. 
 
 In this case the symptoms are, briefly, word blindness, 
 alexia, right lateral homonymous hemianopsia, inability to 
 copy, and defective writing from dictation. Spontaneous 
 speech and repeated speech are not disturbed, nor is there 
 noticeable defect in the interpretation of spoken words. 
 These symptoms and possessions point to a lesion between 
 the angular gyrus and the half -vision centres in the occi- 
 pital lobes, situated in the posterior end of the left hemi- 
 sphere. The fact that he does not write facilely either 
 spontaneously or from dictation, leads me to believe that 
 the lesion is situated close to the angular gyrus and is 
 perhaps encroaching upon it. 
 
 The lesion, which was originally either a hemorrhage or 
 a thrombosis, must have so completely implicated the white 
 matter of the occipital lobe that it cut across the- fibres
 
 Siibcortical Sensor \ . \plictsia. 
 
 303 
 
 passing from both occipital lobes to the left angular gyrus, 
 involving the optic radiations of Gratiolet. The fact 
 
 tu 
 
 FIG. 16. Specime
 
 304 The Faculty of Speech. 
 
 that there are word blindness, left hemianopsia without 
 agraphia, but no object blindness, shows that the lesion 
 cannot be either in the primary visual centre or in the 
 higher visual centre. For if it were in the primary visual 
 centre there would be object blindness; the lesion to pro- 
 duce hemianopsia would not cause word blindness, because 
 in such a case the higher centre would still be in connec- 
 tion with the primary occipital area of the other side. 
 The lesion is not in the higher visual centre, because if 
 it were there would necessarily be agraphia and pro- 
 nounced disturbance of internal language, while in reality 
 neither of these exists. The general mental infirmity is 
 no greater than would be expected from an intracranial 
 lesion so grave as this must be, and in a patient who pre- 
 sents the striking manifestations of vascular degeneration 
 that this one does. 
 
 So much for the clinical deductions. The patient 
 was admitted to the writer's wards in the City Hospital, 
 where repeated examinations showed no material depart- 
 ures from the above-stated findings. Although appar- 
 ently a docile, tractable individual, it was found that he 
 had but slight control of his temper, and when aroused, 
 oftentimes even when not excited, he indulged in profane 
 and vituperative language, which was directed against his 
 attendants and those about him. His ability to create 
 internal language and to externalize it in spoken words 
 was fully evidenced by numerous letters sent to his family 
 which were dictated to a fellow-patient. His health was 
 considered to be in fairly satisfactory condition until 
 November 8th, 1897. On the afternoon of that date while 
 sitting on a bench in the garden, he fell over suddenly
 
 Subcortical Sensory Aphasia. 305 
 
 and had a more or less generalized convulsion accompanied 
 by frothing at the mouth. He was got into bed imme- 
 diately and seen a few minutes later by the house physi- 
 cian, who reported that the patient did not utter a word 
 or apparently recognize any one after the attack, but grad- 
 ually sank into unconsciousness, and meanwhile a right- 
 side hemiplegia developed. The pupils were uneven, 
 owing to contraction of the left pupil ; the face was flushed 
 and showed a right-side palsy ; the axillary temperature was 
 98.2 F. and alike on both sides ; the respirations were ster- 
 torous, and 32 per minute; the heart was working labori- 
 ously, while the pulse, beating 84 times a minute, was very 
 hard and firm. Both knee jerks were absent. The uncon- 
 sciousness deepened, the patient vomited copiously, and 
 soon the left side of the body ceased to indulge the continu- 
 ous movements that were first noticed. Two hours after 
 the apoplexy he became quadriplegic, and died two hours 
 later, about four hours after the onset of the symptoms. 
 
 An autopsical examination was made a few hours after 
 death, and, aside from the changes in the brain about to 
 be described, there was no noticeable abnormality save an 
 advanced degree of arterio-sclerosis, most noticeable in the 
 heart and large blood-vessels and in the kidneys. 
 
 The skull is of the customary thickness. The veins 
 and ctfploe are well filled. The dura is easily detached and 
 not thickened, and the brain in situ looks normal. The 
 pia is smooth and glistening and its vascular arborizations 
 are very distinct. Even before the brain is removed from 
 the calvarium, but more conspicuously after removal, a most 
 striking abnormality is seen at the posterior pole of the 
 left hemisphere. The entire occipital lobe looks reddish-
 
 The Faculty of Speech. 
 
 yellow, is extremely soft to the touch; in fact, the lobe 
 is replaced by a cystic formation, all save the posterior 
 extremity, where there is a slight cortical mantle, evidently 
 not yet implicated. When the fluid of the cyst escapes the 
 cortex of the occipital lobe sinks in, and the superior 
 
 surface of the left cerebel- 
 lar hemisphere juts prom- 
 inently into view. The 
 same yellowish-red color 
 and the same pultaceous- 
 ness to the touch are ap- 
 on the internal 
 surface of the 
 brain, where the 
 destruction of tis- 
 sue involves nearly 
 
 FIG. 17. Shaded Area Shows Extent of Lesion on n <-u v 1 
 
 Mesial Surface. a11 the "DgUal gy- 
 
 rus and the cu- 
 
 neus, except a very small thin surface at the posterior 
 pole of the latter, which seems to have retained a fairly 
 normal appearance to the naked eye. 
 
 In short, the cystic formation involves the whole pos- 
 terior part of the left hemisphere, save the very apex of 
 the cuneus and particularly the inner surface, being limited 
 on the mesial surface (Fig. 17) anteriorly by the pajieto- 
 occipital fissure, and on the external surface by the pro- 
 longations of the same fissure. The gyri involved are 
 the first, second, and third occipital, the cuneus and lingual 
 gyrus. The remainder of the left hemisphere is apparently 
 normal to the view and to the touch. The accompanying 
 illustrations, made at the time of the autopsy, show the
 
 Subcortical Sensory Aphasia. 307 
 
 location and the extent of the lesion. It will be seen that 
 the destruction of tissue extends anteriorly as far as the 
 posterior limits of the inferior parietal lobule, the pre- 
 cuneus, and the angular gyrus, but spares these absolutely. 
 The temporal lobes are likewise quite unimplicated. 
 
 The depth of the lesion, originally a hemorrhage which 
 had undergone cystic transformation, was almost through 
 
 
 
 FIG. 18. Shaded Area Represents Seat of Lesion. 
 
 the entire thickness of the white matter and into the roof 
 of the ventricle, so that the optic radiations were completely 
 cut across. When the isthmus of the encephalon was 
 separated by a horizontal cut of the pons anteriorly to the 
 apparent origin of the trigeminal nerve, the cross-section 
 showed a distention of the aqueduct with sanious fluid. 
 When the two hemispheres were separated both lateral 
 ventricles were found filled with clots, the left much dis- 
 tended, the foramen of Monro and the middle ventricle 
 also distended, the primary fatal hemorrhage apparently
 
 308 The Faculty of Speech. 
 
 being in the left lateral ventricle. The hemispheres were 
 then cut according to the method of Flechsig and the 
 brain was placed in Miiller's fluid for hardening prepara- 
 tory to further study. 
 
 This observation needs no further remark, save to say 
 that the symptoms which had been present were so accu- 
 rately substantiated by the post-mortem findings so far 
 determined that it amounts almost to the exactness of a 
 mathematical demonstration. 
 
 Subcortical word deafness, or pure word deafness of 
 Dejerine, is characterized especially by inability to un- 
 derstand spoken words, and naturally by inability to write 
 from dictation, because the spoken word of another cannot 
 get to the part of the brain in which the idea of the word 
 is interpreted. It is of much less frequent occurrence 
 than subcortical visual aphasia. The feature that distin- 
 guishes it from cortical auditory aphasia is the fact that 
 spontaneous speech is preserved, there is no amnesia 
 verbalis, the patient is able to read aloud, to write volun- 
 tarily, to copy, and to read understandingly what he and 
 others have written. As in every other form of subcorti- 
 cal aphasia, aphasia in which the zone of language itself is 
 not diseased, every constituent of internal language is 
 intact. It is rarely if ever associated with paralysis of 
 the extremities. 
 
 A classical example of this form of aphasia is that cited 
 by Lichtheim. 1 A journalist had an attack of apoplexy 
 which was accompanied by pronounced sensory aphasia, 
 from which he made a partial recovery. Five years later 
 he had a second attack and again recovered, but this time 
 
 1 Loc. at.
 
 Subcortical Sensory Aphasia. 309 
 
 more completely than before, so that now there was no 
 difficulty in speaking, in reading, or in writing. He 
 went on with his work as a journalist. He was, however, 
 absolutely word and tone deaf, although hearing remained 
 quite undiminished. 
 
 It has been mentioned casually in another connection 
 that recently Bleuler, 1 Freund, and other writers have con- 
 tended that the customary conception of s.ubcortical audi- 
 tory aphasia is entirely too narrow, confined to too limited 
 an area, and that it should be enlarged to include disease 
 of the extracerebral neural structures whose functioning 
 conditions audition ; at least, that disease of the peri- 
 pheral auditory neuron, including the termination of the 
 nerve in the organ of Corti, thus taking in labyrinthine 
 diseases, should be included. 
 
 Freund, 2 in a recent monograph on this subject, cites 
 the following case, in which bilateral disease of the laby- 
 rinth following epidemic cerebro- spinal meningitis caused 
 a form of word deafness : 
 
 A youth, twenty-two years old, by occupation a watch- 
 maker, developed after prolonged physical effort, followed 
 by rapid chilling from lying on the cold, damp earth, 
 symptoms that led to the diagnosis of epidemic cerebro- 
 spinal meningitis. The disease was of the severe type, 
 and the patient did not convalesce until the sixth week. 
 It was then noticed that, in addition to vertigo and pro- 
 found disturbance of equilibration, hearing was very much 
 impaired. Soon after this he was treated in the otological 
 clinic of Professor Gruber for deafmutism. 
 
 'Bleuler: " Zur Auffassung der subcorticalen Aphasieen." 
 logisches Centralblatt, 1892, No. 18. 
 
 2 C. S. Freund : " Labyrinthtaubheit und Sprachtaubheit." ^ 
 1895.
 
 310 The Faculty of Speech. 
 
 An examination made five months after the beginning 
 of the illness showed : Loquaciousness ; speech rasping 
 and of harsh intonation ; no paraphasia ; no optic aphasia. 
 The patient appeared with a pad and pencil for the 
 use of his questioner, as he claimed to be wholly unable 
 to hear spoken words. There was no disturbance of mo- 
 tion, sensation, or vision. There were slight vertigo and 
 difficulty of maintaining equilibrium. Otoscopic exami- 
 nation of the ears did not reveal any departure from the 
 normal. Examination of the sense of hearing showed ab- 
 solute deafness on the left side, while on the right side a 
 few vowels, such as a, e, could be heard when they were 
 shouted into the ear. Aerial conduction of notes of a 
 tuning-fork was entirely unperceived. Bone conduction 
 of the same was unperceived, although the patient was 
 sensible of the mechanical vibration. 
 
 There was no dyslexia or agraphia. His speech was 
 interfered with only in so far as understanding of spoken 
 words was entirely lost, and naturally there was inability 
 to repeat spoken words and to write from dictation. 
 
 All acoustic impressions impinging on the right ear 
 were, when not too low, perceived by the patient, but they 
 were not properly interpreted. 
 
 In order to determine accurately what degree of com- 
 prehension he had for articulatory sounds, the patient 
 was subjected to a painstaking examination. The vow- 
 els and consonants were shouted separately in the right 
 car, and the patient was apprised in writing how to indi- 
 cate when he had heard them, what he had heard, and 
 made to understand fully the test that was to be made. 
 
 The examination showed that the patient, who was ap- 
 parently completely speech deaf, possessed the capacity to 
 grasp during the examination a few words correctly and 
 others very nearly correctly. As he expressed it, " I hear
 
 Subcortical Sensory Aphasia. 311 
 
 only the tone of the words, and I then must think what 
 they can be." Perception of rhythm was well preserved, 
 and he had good conception of the number of syllables in 
 the uttered word and the intonation that was given to 
 them. When asked to differentiate between the words 
 "December" and "June," he did so with readiness, al- 
 though he was often unable to differentiate between words 
 that sound somewhat alike, such as December and Sep- 
 tember, or June and July. 
 
 The patient's intact, spontaneous speech confirmed the 
 opinion that he was in possession of his auditory word 
 images. Examination of his music - perception ability 
 showed that he did not hear musical sounds so clearly as 
 before his illness ; for instance, he was unable to tune a 
 violin, but sounds coming from the street, the beating of 
 horses' hoofs, the lumbering roll of heavy wagons, the 
 sprightly sound from light vehicles, the jingle of the 
 tram-car bells were heard and differentiated. He could 
 differentiate whistling, the snapping of fingers, the cluck- 
 ing of the tongue, the clapping of hands, etc., and he 
 very seldom erred in naming the source of such sounds. 
 He could likewise indicate the origin of tones from a 
 violin, a trumpet, a piano, a mouth harmonica, etc. En- 
 tire tones he differentiated with greater readiness than 
 half-tones, and for high tones there was striking impair- 
 ment. 
 
 In response to the question whether he could hear him- 
 self talk, he remarked that he could hear his own words 
 but not clearly and distinctly, and the more trouble he had 
 in hearing them the louder he spoke. When eating he 
 always heard ( ?) the grinding noise of the teeth. 
 
 The absolute deafness in one ear, the diminished bone 
 conduction and loss of perception for high tones in the 
 other, the normal condition on examination with the oto-
 
 3 1 2 The Faculty of Speech. 
 
 scope excluded absolutely middle-ear disease and bespoke a 
 disease of the auditory percipient neural mechanism, due to 
 bilateral labyrinth disease following epidemic cerebro- 
 spinal meningitis. 
 
 I have quoted this case in detail because it may be said 
 that no unsurmountable objection can be raised to the 
 admission that word deafness similar clinically to that 
 found in subcortical sensory aphasia was present. The 
 only question is whether one is willing to admit that the 
 peripheral auditory neuron can be normal for the conduc- 
 tion of ordinary sounds and diseased for the conduction of 
 sounds having highly differentiated significance. Person- 
 ally I see no objection to entering such cases as this in 
 the category of subcortical sensory aphasia.
 
 CHAPTER VII. 
 TOTAL APHASIA. 
 
 OCCASIONALLY cases of aphasia are encountered in which 
 there is a disturbance of all forms of intellectual expres- 
 sion, involving disturbance in the reception of stimuli that 
 condition mental states preparatory to speech, and dis- 
 turbance in the emission of such mental states. To such 
 cases the name total aphasia is given because it includes 
 the phenomena of both motor and sensory aphasia. 
 
 If the location and the relationships of the speech cen- 
 tres be kept in mind, the existence of such a condition will 
 not be at all surprising. The speech area is dependent 
 for its blood supply, and therefore for its functional integ- 
 rity, upon the artery of the fissure of Sylvius, and a lesion 
 of this artery that interferes with the circulation is apt to 
 show its malign consequences in every part dependent 
 upon the artery for nutrition. In individual cases the 
 area supplied by one of its branches may be more pro- 
 foundly affected than another. Thus in cases of total 
 aphasia we sometimes see one or more components of lan- 
 guage less wholly submerged than others, and, on the 
 other hand, cases are seen in which the aphasia in the be- 
 ginning is total, yet after a time the symptom complex 
 becomes so modified that one of the modes of language 
 may be partly recovered.
 
 314 The Faculty of Speech. 
 
 As an example of total aphasia, 1 may cite the follow- 
 ing instance : 
 
 F. C , thirty-eight years old, a native of Italy, by 
 
 occupation a bank clerk. He is married and the father of 
 two unhealthy children. His wife has had two miscar- 
 riages. There is no way of determining whether he has 
 had syphilis. He has been a steady drinker for many 
 years. After he had suffered from a condition which the 
 family physician called influenza and which kept him in 
 bed for about two weeks, he became very dizzy, and ex- 
 perienced the sensation of falling while passing from one 
 room to another. Soon after it was noticed that the 
 right upper extremity was very unwieldy and that the 
 right side of the face was somewhat drawn, and that he 
 rapidly became unable to articulate. In fact, save for 
 complaint of a severe pain shooting through the head im- 
 mediately after the occurrence, of the vertiginous spell, he 
 did not utter a word. His wife says that there was not 
 the slightest loss of consciousness, but that the patient 
 was " out of his head" up until a few days before I first 
 saw him, which was six weeks after the onset of his sick- 
 ness. The slight hemiplegia from which he had suffered 
 disappeared in a few days. His wife, furthermore, states 
 that he has not uttered a word that could be understood ; 
 that he has not understood what was said to him ; and that 
 he has not essayed to read since the beginning of his ill- 
 ness. She says that he is in his right mind, that he does 
 nothing foolish, except to watch her or any other person 
 who may be in the room with embarrassing persistency. 
 Examination shows that voluntary speech is wholly 
 lost, and that he makes not the slightest effort to re- 
 peat when he is instructed to. He never indicates 
 wishes, desires, or other mental states by pantomime, and 
 his wife tells us that he has not done so since the begin- 
 
 f |
 
 Total Aphasia. 
 
 3*5 
 
 ning of the illness. When he is given a pencil and asked 
 to write he makes a few up-and-down strokes, but frames 
 no letters or words. On being requested to take off his 
 coat he looks intently at the one who gives the command, 
 watches his lips most carefully, and grunts (nothing ap- 
 proaching articulation), " Sih, sih." After the request is 
 repeated a number of times, each succeeding time in a 
 louder voice, it would seem that he gets some idea of 
 what is wanted, for he grasps the lapel of the coat, but 
 makes no further effort to remove it. When I suggest 
 my request by aid of pantomime by throwing off my own 
 coat and then pointing to his, he obeys. To the command, 
 "Put out your tongue," a number of times repeated, he 
 closes the eyes. When he is asked to take the doctor's 
 hand, he does not apparently have any conception of what 
 is desired. Under further questioning and commands, he 
 becomes very restless, gives vent to inarticulate sounds, 
 moves the lips as if counting or mumbling, twists the 
 fingers, and then starts to go out of the room as if he 
 wished to go home. To test for visual perception he was 
 shown the following request, first in writing and then in 
 print: "Take out your watch and show me the time." 
 No response. On the contrary, after adjusting his glasses, 
 he reaches forward, takes the pencil from my hand, 
 and begins to copy the words in script. On endeavor- 
 ing to interpret this action on the part of the patient, I 
 learned that some days previously he had been given a 
 letter addressed to his employer which had been prepared 
 by his brother and which he was requested to copy. This 
 letter set forth that the patient was not very ill, was not 
 out of his head as it had been reported to his employer, 
 and to show that his mental faculties were unimpaired, and 
 that his position should be kept open to him, this letter 
 written by his own hand was offered in evidence. The
 
 316 The Faculty of Speech. 
 
 deception, however, did not work, as the concocters of it 
 had never been able to get the patient to do the part 
 allotted to him. He could copy, however, and he copied 
 script in script and print in print. To the written ques- 
 tion, "How old are you?" first in printed and then in 
 written characters, he takes a pencil and points to the 
 individual words, at the same time making this inarticu- 
 late " Sih, sih, sih," and then he starts to copy it, without, 
 however, giving the slightest intimation that he gets the 
 purport of the question. It is impossible to say positively 
 that there is no hemianopsia, but probably there is not, as 
 thrusting the finger abruptly into the visual field causes 
 prompt blinking. 
 
 There is no optic aphasia nor is there mind blindness. 
 The patient fully recognizes the use of things. On being 
 handed a watch, he opens it, looks at the time, compares 
 it with the clock on the mantle, and returns it. On being 
 given a tuning-fork, he sets it in vibration and holds it to 
 the ear. He feeds himself, dresses himself, and goes out 
 alone, and in a general way deports himself as does a 
 person in the possession of his faculties. 
 
 Repeated examinations showed no considerable depar- 
 ture from this condition for some time, but after a num- 
 ber of weeks he became able to articulate " Yes" and 
 " No," to write his name, that of his father, and of his 
 wife, and to give evidence that he understood some things 
 that were said to him, particularly if they were repeated a 
 number of times. Voluntary speech, repetition of speech, 
 still remained wholly submerged. Six weeks after the 
 first examination, on being asked to put out the tongue, 
 he did so ; but when he was asked to go into the next 
 room he deported himself as one unaware of any request. 
 Still, from this time onward, it was noted that he took 
 greater heed of commands and requests directed to him
 
 Total Aphasia. 317 
 
 through the hearing, and a general improvement of the 
 word deafness followed. On being asked to read a simple 
 sentence, he takes the pencil and points to each individual 
 word, accompanying the indications with the utterance of 
 the sounds eh, fa, eh, fa, eh, la, fe, eh, la, fe, and contin- 
 ues to do this throughout an entire page, pointing to each 
 word. If the sentence embodies a simple request, he 
 takes no notice of it. Frequently, after going through a 
 sentence in this way he looks up at the examiner inquir- 
 ingly, then shakes his head, assumes a look of distress, 
 draws a line under the word, and goes on. He is now 
 able to copy fairly well, but copies line for line, word for 
 word, as in a drawing. In the same way he is able to 
 copy simple figures and designs. He is totally unable to 
 write from dictation or from written instructions. If he 
 is given a pencil and left alone, he proceeds to write his 
 name, then the surname of his father, and then that of his 
 wife. On being asked where he lives, he writes his father's 
 name ; to a second request, he writes that of his wife. If 
 the question is asked him in writing, he proceeds to copy 
 the question. He is able to add up a column of figures, 
 but the results are not usually correct ; in fact, they are 
 more often incorrect. He begins at the top of a column, 
 points to the figures, and often says, " Feh, lah, feh, feh, 
 lah," giving a variable intonation to each one of these utter- 
 ances, then scratches his head, looks disturbed, goes again 
 to the top of the column, and begins all over. His wife 
 says that he is able to play cards, and that it tickles him 
 very much to win. He apparently recognizes the numerals 
 on banknotes, and he can tell time. He never essays to 
 read a paper, and on being given a letter from his parents 
 commiserating with him in his illness he takes no inter- 
 est in the matter. To recapitulate briefly, this man has 
 (i) loss of spontaneous speech; (2) inability to repeat
 
 318 The Faculty of Speech. 
 
 after dictation ; (3) inability to indicate desires or feelings 
 by means of mimicry; (4) inability to write spontaneously 
 (except latterly he has regained the ability to write his 
 own name and that of his wife and of his father) ; (5) in- 
 ability to write from dictation ; (6) letter blindness, word 
 blindness, alexia ; (7) partial (in the beginning complete) 
 word deafness he neither understands nor obeys spoken 
 requests. He is able to copy, but copies exactly the words 
 or letters that are put before him. He can interpret re- 
 quests and commands made to him by pantomime ; he can 
 play cards and other games ; he recognizes the use of things 
 and the places and relations of objects; he can look at a 
 watch and transfer to paper by means of figures the hour 
 indicated ; there is no trace of hemiplegia, unless it be a 
 somewhat lessened activity in the muscles of the right 
 side of the face. 
 
 This case shows, therefore, that there was disturbance of 
 all the modes by which one person communicates with 
 another, both receptively and emissively. The only in- 
 terpretation to put upon it is that after the tenancy of an 
 acute infectious disease a thrombosis formed in the left 
 Sylvian artery, which robbed the speech area of the blood 
 necessary for its functioning. That this pathological 
 process did not cause a serious disturbance of other func- 
 tions of the brain is shown by the fact that there was no 
 loss of consciousness. That it did not involve the 
 pyramidal projection is shown by the very slight and 
 transitory hemiplegia which left no sequelae, as organic 
 hemiplegia invariably does. That there was some involve- 
 ment of the motor cortex, however, is shown by the slight 
 paresis of the right side of the face and the right arm, 
 which, it would seem, was dependent upon disturbance of
 
 Total Aphasia. 319 
 
 function of the ascending frontal convolution adjacent to 
 the frontal operculum. After the thrombosis or whatever 
 lesion may have existed was partly removed, or at least 
 after the circulatory disturbance which it produced was in 
 part compensated for, some of the speech centres regained 
 in a very slight way their functions, and this was particu- 
 larly true of the auditory centre, for it was the word deaf- 
 ness more than anything else that showed improvement. 
 To what extent improvement will still go on cannot be 
 prophesied. 
 
 A very important and instructive case of complex 
 aphasia has recently been reported (although not yet in 
 detailed form) by Bastian. 1 A right-handed man had an 
 attack of right hemiplegia with loss of speech three 
 months before coming under observation. Eighteen years 
 after the first apoplectic attack a thrombosis of the right 
 middle cerebral artery caused death. When the patient 
 was first seen he was incompletely paralyzed on the right 
 side, and there was also incomplete hemianaesthesia on the 
 same side. For six years after the first apoplectic stroke 
 he had slight convulsive attacks from time to time. 
 There was then an interval of twelve years, but during the 
 last year of his life he had three severe fits, each of which 
 was followed by a temporary aggravation of the paralysis of 
 the right side. Within two months of his coming under ob- 
 servation his speech defects assumed the form which they 
 maintained during the next eighteen years with remarka- 
 ble constancy. The striking features of the man's condi- 
 tion were as follows : 
 
 i. Voluntary speech limited to a few words. 
 
 1 Bastian: Lancet, vol. i., 1897.
 
 320 The Faculty of Speccli. 
 
 2. Could repeat words that he heard. 
 
 3. Understood everything that was said to him. 
 
 4. Inability to read aloud. (The reporter says that he 
 spent much of his time in reading, and undoubtedly un- 
 derstood what he read, yet many patients with sensory 
 aphasia spend much of their time in reading, without 
 comprehending a word. ) 
 
 5. Inability to write a word from dictation. 
 
 6. Inability to name objects at sight. 
 
 As no mention is made of hemianopsia it is to be 
 inferred that it was not present. 
 
 The autopsy showed a complete atrophy of the convolu- 
 tions in the territory supplied by the left middle cerebral 
 artery. The atrophy had extended inward so as to lay 
 open the lateral ventricle, and the whole of this region 
 was occupied by a large pseudo-cyst. The supramarginal 
 and angular gyri, as well as the posterior two-thirds of the 
 upper temporal convolution, were included in the parts 
 that had completely disappeared. 
 
 The case is regarded by the author as " a very remarka- 
 ble one ; first, because of the complete destruction of the 
 supramarginal and angular gyri and the posterior two- 
 thirds of the upper temporal convolution without the oc- 
 currence of word blindness or word deafness." This would 
 be very remarkable indeed if it were so, and would revolu- 
 tionize in a measure the teachings not alone of aphasia 
 but of cerebral localization. " It is presumed," says the 
 author in attempting to explain these remarkable anom- 
 alies, " that the atrophy of these convolutions must have 
 occurred at some unknown period during the patient's ill- 
 ness ; that it must have occurred gradually, and that func-
 
 Total Aphasia, 321 
 
 tional compensation must also have been gradually brought 
 about through the further development of the correspond- 
 ing centres in the opposite hemisphere." The constancy 
 of the speech defects during a long scries of years and the 
 very exact way in which the original defects were main- 
 tained after some of the functional activity of the lost 
 parts had been transferred to the opposite hemisphere, the 
 writer asserts, are worthy of attention. 
 
 Appreciating the great disadvantage that one is at in 
 endeavoring to put interpretation upon a case from a very 
 scant report of the leading symptoms, I hesitate to do more 
 than to mention this case, which I believe will become an 
 important one in the annals of aphasia when it is prop- 
 erly published (so far it has only been reported to a medi- 
 cal society). Nevertheless, it seems that a very different 
 interpretation can be put upon some of the conditions than 
 that mentioned by Bastian. In the first place, he says 
 there was no word blindness, but the fact that the patient 
 had inability to write from dictation (although he fully un- 
 derstood words), the fact that he could not read aloud, and 
 the fact that he could not name objects at sight seem to 
 me to indicate that he had loss of the visual images of 
 words. If he could repeat words that he heard, there is 
 no other lesion that will explain inability to read aloud 
 except loss of the visual memories of words and naturally 
 the inability to invoke such memories from seeing a word. 
 The fact that he could utter words voluntarily and that he 
 could repeat words after they were said to him shows that 
 the auditory images were capable of being aroused, and 
 that they in turn were able to react upon and evoke the 
 articulatory images; otherwise the patient would not have
 
 322 The Faculty of Speech, 
 
 been able to say a word. But the most convincing feature 
 in leading us to the assumption that the patient had loss 
 of visual memories that are stored up in the angular gyrus 
 of the. left side is his total inability to write. Dejerine 
 has shown that spontaneous writing is the result of arous- 
 ing the visual images here stored and the copying of them 
 by the motor apparatus that holds the pen, while writing 
 from dictation is accomplished in exactly the same way, save 
 that the visual images are evoked in this instance through 
 the auditory. Furthermore, this patient retained the 
 ability to copy, a possession which shows that the visual 
 centre that reflects words, viz., the visual centre in the 
 occipital lobe around the calcarine fissure, was intact ; the 
 patient saw the letter, the word, or the design, and copied 
 just what he saw. The fact that he was unable to name 
 objects at sight, although he saw them, recognized their 
 uses, etc., is explained in exactly the same way inability 
 of the patient to resuscitate the visual memory of the 
 name. Although willing to grant that the uneducated 
 right hemisphere became in eighteen years somewhat edu- 
 cated and functioned vicariously for the part of the speech 
 area that was destroyed on the left side, I am not inclined 
 to believe that this vicarious functioning played a part of 
 such paramount importance in the status of the patient's 
 speech as Bastian would have us believe that it did. It 
 seems to me the interpretation to put upon this case is 
 as follows : The original apoplectic attack was due to a 
 thrombosis of the artery of the fissure of Sylvius, the 
 direct continuation of the internal carotid. The imme- 
 diate result was a partial hemiplegia of a cortical nature, 
 due to the deprivation of blood from the cortical branches
 
 Total Aphasia. 323 
 
 of the middle cerebral artery going to the Rolandic region ; 
 a partial hemiansesthesia, which is to be explained by the 
 fact that the middle cerebral artery supplies in part the 
 posterior limb of the internal capsule. The thrombus in 
 the Sylvian artery caused defective activity or complete 
 overthrow of functions in all the speech centres, and until 
 I hear to the contrary I am prepared to believe that in this 
 patient, before he came under Bastian's care, there were 
 some word deafness, latent or manifest, loss of capacity to 
 read mentally, and much more extensive aphemia than there 
 was three months after the accident. After the substance 
 occluding the calibre of the vessel was removed, or partly 
 removed, some of the speech centres (let us say the audi- 
 tory, for the temporal lobes are less dependent upon the 
 integrity of the middle cerebral than is the parietal), the 
 area in which are stored auditory images, nearly recovered 
 itself, and there were no gross accompaniments of word 
 deafness, but the loss of visual memories remained in part 
 to the end as did the loss of articulatory images. The 
 successive attacks of thrombosis expended themselves in 
 causing softening and pseudo-cystic formation in the area 
 from which blood had been deprived by the original 
 thrombus. 
 
 Thus it seems to me that this is a good example of 
 complex aphasia, in which the symptoms, although per- 
 haps very nearly indicative of complete aphasia, or total 
 aphasia, clear up in one or more modalities of speech as 
 time elapses.
 
 CHAPTER VIII. 
 DIAGNOSIS OF APHASIA. 
 
 To unravel the intricacies of aphasia is at no time an 
 easy task, but it can be made immeasurably more difficult 
 than it is in reality by approaching the examination of a 
 case, and the analysis of the findings, in an improper or 
 unmethodical way. Therefore, the first step in attempt- 
 ing the diagnosis is a simple method of eliciting and asso- 
 ciating the different symptomatic constituents. 
 
 One who takes up the examination of a patient with 
 aphasia should keep in mind that which has been said pre- 
 viously concerning the constitution of the speech faculty 
 that it consists of two parts, the receptive and the emis- 
 sive, and that either of these two parts may manifest the 
 predominance of the aphasic symptoms, but that in true 
 aphasia, that is, aphasia dependent upon lesion of the 
 speech centres, neither can be the sole medium of mani- 
 festation of the speech defects. It should further be re- 
 membered that emissive speech is manifest by articula- 
 tion, by writing, and by pantomime, and that integrity of 
 the receptive side of language is commensurate with the 
 interpretation of visual and auditory stimuli. 
 
 It should not be forgotten that the attitude, the de- 
 meanor, the conduct, of the patient may be of the greatest 
 service in orienting the physician, from the very begin- 
 ning of the examination. Though recognition and inter-
 
 Diagnosis of Apkasia. 325 
 
 pretation of information thus obtained is usually consid- 
 ered aquale of clinical insight, it is one of the cultivatable 
 forms of this desirable qualification. The demeanor and 
 expression of one with auditory aphasia are frequently those 
 of a person who has lost all interest in his surroundings, 
 and his attitude is that of a deaf person who is slightly de- 
 mented. The same is true, though to a lesser degree, for 
 the patient with visual aphasia. But the latter is more fre- 
 quently of the restless, active kind, such as the case on page 
 265, who was so continuously moving and shifting that she 
 gave the impression of one on the verge of acute mania. 
 Moreover, patients who have this form of aphasia are often 
 garrulous, and on the slightest provocation, or without 
 provocation, emit a string of articulate or gibberish sounds 
 that convey no meaning to those about them. This is es- 
 pecially true of cases of not very protracted duration. 
 Patients with cortical motor aphasia and with subcortical 
 motor aphasia, on the other hand, present a very different 
 aspect. They are often absolutely silent but watchful, 
 and the intensity with which they hold every move of the 
 persons surrounding them is often very striking. This is 
 well shown in the case of John Masterson (Case No. 2). 
 His wife repeatedly said that the feature of his progres- 
 sive recovery that impressed itself on her memory more 
 than anything else was the assiduity with which he 
 watched her every movement. This intentness of obser- 
 vation is particularly to be marked in cases of subcortical 
 motor aphasia in which the patient is absolutely speech- 
 less yet capable of the fullest understanding of all that 
 goes on about him and within his hearing and vision. 
 If these facts be kept in mind, the difficulties encoun-
 
 326 The Faculty of SpeecJi. 
 
 tered by the beginner in examining a patient with aphasia 
 will be reduced and the chances of reaching warrantable 
 and legitimate conclusions as the result of the examination 
 will be greatly increased. Before a case can be recorded 
 in such a way that the symptomatic findings can be used 
 legitimately in establishing, or demonstrating, certain 
 claims, it is necessary that the examination be conducted 
 in a manner that searches every centre which must func- 
 tionate for the production of normal speech as well as 
 their connections. To do this it should be systematic, 
 but it need not be done in conformation to any special 
 formula or according to any hard-and-fast system. A 
 number of schemes have been devised to facilitate the ex- 
 amination of aphasic patients, but I have found the follow- 
 ing simple plan most serviceable : After securing a gen- 
 eral history of the patient's life and of his previous illness 
 from some member of the family, and in this way getting 
 information of the character of the disease of which the 
 aphasia is a symptom, the patient's ability to express 
 ideas, to receive and interpret information should be in- 
 quired into. The mental processes apart from the mani- 
 festation of mental states and the capacity for the re- 
 ception of sensory stimuli should then be examined. 
 Although a number of these may be determined simulta- 
 neously, it is best to take each one separately. 
 
 In approaching a patient with aphasia it is natural that 
 the endeavor be made to elicit information by speaking 
 to him. It becomes necessary, therefore, to determine if 
 the patient takes note of what is said to him orally, and, 
 secondly, if he understands what is said. In other words, 
 does spoken speech awaken in his auditory centre corre-
 
 Diagnosis of Aphasia. 327 
 
 spending memories ? This can be done ordinarily by ask- 
 ing some simple question, such as, " How long have you 
 been sick?" or by addressing to him some simple com- 
 mand, such as, "Give me your hand." Care must be 
 taken not to employ too conventional questions or com- 
 mands, such as, "What is your name?" "Put out the 
 tongue," etc. The patient may have lost the auditory 
 apperceptive faculty and still, oftentimes, make reasonable 
 reply to such questions, merely from association or habit. 
 Naturally the patient should get no information of what 
 is being asked . through any other avenues than those of 
 hearing. Such patients are quick to grasp, particularly 
 if they have been aphasic for some time, the significance 
 of even slight emotional expression or pantomime on the 
 part of the interlocutor. If the patient does not reply to 
 such questions or commands, there may be trouble with 
 the receptive or with the emissive speech faculties. If 
 he is word deaf, that is, if the trouble is one that prevents 
 the sound of the word from reaching the centre in which 
 the memories of previous word sounds are stored up, the 
 patient will not endeavor to respond byword or act, though 
 in some instances he does so. Nor will the face show the 
 slightest response or indication of comprehension. If he 
 does respond the diagnostic feature is that his answer, 
 even though it be made up of articulate words, has no per- 
 tinency or bearing on the question. If the patient is not 
 word deaf, he will make some movement, be it of the head, 
 hand, or features, to indicate that though he understands 
 he cannot reply. Generally this gesture is very signifi- 
 cant. It consists of a despairing expression of the coun- 
 tenance and a touching of the lips or the throat with the
 
 328 The Faculty of Speech. 
 
 fingers. Oftentimes the question can be decided very 
 quickly, if there remains some doubt even yet, by asking 
 some absurd or ludicrous question, and noting how the 
 patient receives it. If, in reply to the question, " Are 
 you one hundred years old?" he solemnly says, "Yes," or 
 if he does not see the ludicrousness of a request to turn a 
 somersault when he is so obviously paralyzed, it is rather 
 convincing proof that such speeches do not awaken the 
 proper responses in his mind ; and if there be no demen- 
 tia it is suggestive evidence that the patient is word deaf, 
 and the examination should then proceed from that stand- 
 point. Although other of the speech centres may be 
 simultaneously disorganized, the symptoms attributable to 
 the first one will dominate the character of the speech 
 defect. If the examination so far seems to suggest the 
 existence of word deafness as the leading feature of the 
 sensory aphasia, it should then be determined to what 
 degree of completeness this exists, and the extent and 
 kind of disturbance that it causes in the externalization of 
 language. The amount of diminution of the patient's 
 vocabulary, the degree of inappropriate usage of words, 
 the imperfections of sequence and rhythm, should all be 
 noted. The patient should be tested for his power of 
 recognition of simple words, short sentences, and long 
 sentences. It has already been noted that, perhaps, he 
 may react to conventional questions, such as, " Put out 
 the tongue," etc. Uncommon requests, such as, " Touch 
 the nose with the tip of the index finger," or, " Stand on 
 the chair," should be made. The ability of the patient to 
 interpret sounds should then be noted. Do sounds evoke 
 previous memories of similar sounds and do they incite
 
 Diagnosis of Aphasia. 329 
 
 the auditory centre to revive the name of the object from 
 which such sounds proceed ? When a bell is sounded, or 
 a watch is held behind the ear and apart from the stimula- 
 tion of any perceptual avenue other than hearing, can the 
 patient say, "Bell" or "Watch"? Finally, the existence 
 of any disturbance of bone or aerial conductivity should 
 be demonstrated or excluded. 
 
 If word deafness can be excluded, and the patient still 
 makes no reply, that is, if he remains completely speech- 
 less, the examination should be to determine whether or 
 not internal language is defective, for it must be readily 
 seen that the question has then narrowed itself to a deter- 
 mination of whether or not the aphasia is cortical motor 
 (kinaesthetic word-image) aphasia, or whether it is sub- 
 cortical motor aphasia. In other words, is the inability to 
 speak due to a lesion of the storehouse of kinaesthetic 
 memories of articulated words, Broca's area, or is it due 
 to a lesion of the neurons that conduct the motor word 
 impulses from the Rolandic area to the parts that exter- 
 nalize the word ? The essential thing then is to determine 
 if the patient is in the full possession of internal lan- 
 guage! If internal language in any of its components is 
 disordered, then the patient has true cortical motor aphasia. 
 If, on the other hand, there be no such disturbance, the 
 lesion is elsewhere than in the zone of language. In 
 some patients the differentiation will be an easy one. 
 They will show, as did Case No. I, that they have the 
 proper idea of words and that they can evocate them 
 promptly, by the ease and rapidity with which they write, 
 or by the exquisiteness of pantomime, as did the patient 
 just referred to. On the other hand, however, the task is
 
 330 The Faculty of Speech. 
 
 oftentimes an extremely difficult one. It is particularly so 
 because the test to determine if the legitimate idea of words 
 can be evoked in the internal language, the test of Proust 
 and of Lichtheim, is not one of universal application, be- 
 cause in the first place many of our hospital and dispensary 
 patients are not of sufficient scholarship to know anything 
 of syllables, or of counting the number of letters forming 
 them, and word construction is an exercise that has never 
 been indulged in. In the second place, there is very often 
 associated with aphasia, and a concomitant of the disease 
 giving rise to the latter, a degree of deficiency in the 
 associative faculties that amounts to a slight degree of 
 dementia. In such patients it is oftentimes extremely 
 difficult to make them understand just what is meant by 
 telling them to press the physician's hand as many times 
 as there are syllables in the word Constantinople, or some 
 other equally resonant and polysyllabic word. Nor is the 
 substitute suggested by Dejerine, of asking the patient to 
 make voluntary expiratory efforts as many times as there 
 are syllables or letters in a word more applicable. But 
 even when we cannot get the patient to respond to these 
 tests, there is a general atmosphere about the patient with 
 subcortical motor aphasia that one cannot be long in with- 
 out recognizing that the patient is in full possession of 
 his intellect and internal speech. The only shortcoming 
 of the subcortical motor aphasic is inability to articulate. 
 He understands everything that is said to him ; he inter- 
 prets information received through the visual sphere; he 
 is capable of expressing his thoughts fully, facilely, and 
 correctly, by writing and by pantomime, or, at least, he 
 would be were it not that the right half of the body is
 
 Diagnosis of Aphasia. 331 
 
 usually paralyzed and he is obliged to portray mental 
 states by the pantomimic activity of the left, the less 
 dextrous half of the body. 
 
 Physicians oftentimes find some difficulty in properly 
 assigning cases of cortical motor (articulatory kinaesthetic) 
 aphasia, because the patient is still able to articulate some 
 words. I have often been made aware of this by con- 
 versation with my house physicians, who work apparently 
 with the following formula : " If the patient can think of 
 the word and is unable to say it, he has motor aphasia; 
 but if he cannot think of the word, though he is able to 
 say it, then he has sensory aphasia. " If one had to choose 
 between this formula, and nothing at all, it might be well 
 to choose the formula, although it is only half the truth. 
 If it be kept in mind that the patient with cortical motor 
 aphasia (articulatory kinaesthetic) need not be absolutely 
 deprived of the power to articulate words ; that he fre- 
 quently retains the ability to say one or several words, 
 which he uses at all times and under all conditions, perti- 
 nent and impertinent alike ; and that frequently these 
 words take the form of recurring utterances ; that there is 
 always agraphia, which may be very evident or which may 
 be difficult to bring out because the patient pleads paraly- 
 sis of the right hand as an excuse for not making an effort 
 to write ; that the agraphia is usually proportionate to the 
 aphasia ; that it is manifest in voluntary writing and in 
 writing from dictation, but not in writing from copy ; and 
 that the patient in copying copies print in script and 
 script in script, showing that the copying is not a mechani- 
 cal but an intellectual act ; and that there is defective in- 
 ternal speech, as shown by the test of Proust and Licht-
 
 332 The Faculty of Speec/i. 
 
 heim then the diagnosis of articulatory kinaesthetic 
 aphasia will not be a difficult matter. 
 
 After voluntary speech has been satisfactorily exam- 
 ined, tests should be made to determine the patient's 
 capacity to repeat. There is inability to repeat in both 
 sensory and motor aphasia, and if word deafness has been 
 excluded there will be no difficulty in interpreting this in- 
 ability which is co-existent with loss of voluntary speech 
 in articulatory kinaesthetic aphasia. 
 
 Particular attention should be given, in every case of 
 aphasia in which the symptoms point to destruction of 
 Broca's area, to the faculty of writing. Following De- 
 jerine, it has been maintained, and I venture to hope con- 
 sistently, that lesion of this area causes agraphia. Re- 
 cently Bastian has reiterated the statement that the 
 agraphia that sometimes accompanies articulatory kinaes- 
 thetic aphasia is not dependent upon lesion in Broca's 
 area which prevents the patient from getting the correct 
 notion of the word. He contends that it is an occasional 
 phenomenon only, and when it occurs it is due (like 
 alexia) to temporary or more or less permanent disable- 
 ment of the visual centre. I readily admit that in some 
 instances this does occur, but this in no way invalidates 
 the explanation of the occurrence of agraphia, which, I 
 believe, occurred in every case of cortical motor aphasia 
 that has been given. The fact that such contradictory 
 beliefs are held as to the occurrence of agraphia with 
 motor aphasia demands the very careful examination of 
 such cases in the future. - 
 
 Of course, when a patient who has had articulatory kin- 
 aesthetic aphasia has partially recovered and has regained
 
 Diagnosis of Aphasia. 333 
 
 quite an extensive vocabulary, it will require care and re- 
 peated examinations satisfactorily to establish the diag- 
 nosis. The one suggestion that I have to make in such 
 cases is that there will always be found some degree of 
 every one of the symptoms enumerated as occurring with 
 this form of aphasia, if sufficiently careful and patient 
 search be made for them, and if the physician is trained 
 to recognize these slight defects they are of great service 
 in orienting him. 
 
 After having tested the patient's capacity to perceive 
 and interpret words through the auditory apparatus, he 
 should be examined with the view of determining if there 
 is any disability of acquiring and interpreting information 
 through the visual apparatus. To do this requires patience 
 and circumspection. In the first place it should be estab- 
 lished that the patient has no trouble with the peripheral 
 visual apparatus. This can be done by an ophthalmo- 
 scopic examination. Tests should then be made to deter- 
 mine the existence of hemianopsia. This is not an easy 
 matter to do if the patient is aphemic or if he has word 
 deafness ; in fact, it is extremely difficult to do satisfac- 
 torily. With a patient who can understand what is said 
 to him and who can indicate when he perceives the en- 
 trance of an object into the visual field, who can tell when 
 the indicator of a perimeter passes beyond the range of 
 vision, testing for hemianopsia is a very simple matter. 
 If the patient is word deaf and if he has visual blindness, 
 which of course he is apt to have if he has hemianopsia, 
 one finds himself unable to convey to the patient by writ- 
 ten or spoken word that which he wishes him to do or to 
 observe. In such cases one must content himself with the
 
 334 The Faculty of Speech. 
 
 information that is to be derived from forcibly and sud- 
 denly thrusting some object into the visual fields, from the 
 right side (for right-handed patients invariably have right 
 lateral homonymous hemianopsia when they have any), and 
 taking note whether or not the patient blinks, as he should 
 do if the object be perceived. If he does not it is rather 
 certain that he has hemianopsia. Each eye should be 
 examined separately and the findings noted on a chart. 
 The form of hemianopsia that may be found will be read- 
 ily interpreted if one has clearly in mind the course of the 
 optic nerve and the tract to the cortex (see Fig. 6). A 
 destructive lesion of the cortex in the vicinity of one cal- 
 carine fissure, or of all the optic fibres leading to it, the 
 radiations of Gratiolet, produces blindness on the opposite 
 sides of the visual field. If the left one is destroyed there 
 will be right hemianopsia, and as the hemianopsia is on 
 relatively the same sides of the visual field, that is the 
 right temporal and the right nasal, the hemianopsia is 
 called homonymous. If the right cuneus is destroyed 
 just the same condition will prevail, only it will be mani- 
 fested on the other side ; and if both cunei are destroyed 
 there will be true cortical blindness. If these facts be 
 kept in mind there can be no difficulty in properly inter- 
 preting the occurrence of hemianopsia. If there is de- 
 struction of the cortex in the vicinity of the calcarine 
 fissure, that is, destruction of a half-vision centre, there 
 will be lateral homonymous hemianopsia, but not word 
 blindness, as the higher visual centre is still in intact 
 connection with the half- vision centre of the other cuneus. 
 If there is lesion of the bands of Gratiolet connecting both 
 half -vision centres with the primary visual centre and one
 
 Diagnosis of Aphasia. 335 
 
 cuneus with homonymous parts of both visual fields, then 
 there will be hemianopsia and word blindness, complete 
 alexia, merely because the patient cannot send impulses 
 coming in from both half -vision centres to the angular gyrus 
 where they are interpreted, although the latter is intact 
 and shows this intactness by the undefectiveness of inter- 
 nal language and the ability to write spontaneously and 
 from dictation. Such a patient copies mechanically, print 
 in print, script in script, as one traces a drawing. This, 
 and one other fragment of knowledge concerning hemi- 
 anopsia, are all that is necessary properly to interpret its 
 occurrence. Sometimes a lesion that destroys the angular 
 gyrus extends sufficiently deep to sever the optic radia- 
 tions of Gratiolet, which are immediately subjacent on 
 their way to the occipital lobes; in such cases there will 
 be true word blindness with all its entailment of disturb- 
 ance of internal language, disturbance of intellection, 
 agraphia, etc., plus hemianopsia, but the latter symptom is 
 merely an accident, a superadded phenomenon, and it never 
 occurs with destruction of the angular gyrus, except in 
 some such way as I have indicated. 
 
 In testing the patient to determine the integrity of the 
 visual mechanism one may begin by showing him familiar 
 objects. If he does not recognize them, or show by act 
 or deed that he comprehends their use or purpose, if he 
 looks upon them as does one who sees them for the first 
 time, then he has object aphasia and the lesion is of the 
 occipital cortex. Such an individual may obtain informa- 
 tion through the medium of other special senses, such as 
 the tactile, gustatory, etc., that will enable him to recog- 
 nize the object, the person, or the thing. If he is shown
 
 336 The Faculty of Speech. 
 
 familiar objects and he recognizes them, knows what they 
 are for, but cannot name them, then he may have either 
 an interruption in the pathway leading to the higher 
 visual centre in the angular gyrus, or there may be lesion 
 of the angular gyrus itself. If it be of the former, inter- 
 nal language* will be preserved and spontaneous speech 
 may be intact, although there is usually some paraphasia 
 and possibly jargonaphasia, and this preservation is shown 
 most conclusively by the retention of ability to write. 
 He may write easily and moderately well, not only volun- 
 tarily but from dictation, but the patient is unable to 
 read what he writes. If it be of the latter and complete, 
 the patient will be absolutely agraphic. This agraphia is 
 to be considered a part of the disorder of internal lan- 
 guage, loss of the visual image, the visual idea of the 
 word. There is inability to arouse the visual image of 
 the word. In such a case, as arousal must precede the 
 transmission to the part of the Rolandic cortex that in- 
 nervates the member holding the pen, there is complete 
 agraphia. There is no more strikingly illustrative case of 
 this on record than one communicated to the Royal Medi- 
 cal and Chirurgical Society in 1872, which was one of the 
 first, if not the first, in which subcortical word blindness 
 was the striking symptom. Although this case was used 
 by Broadbent then, and is still to-day, to bear evidence in 
 favor of a naming centre, it must be apparent to him 
 who interprets the genesis of speech in the light of our 
 present knowledge that in reality it is a most recalcitrant 
 witness in behalf of Broadbent's claim. The history of 
 the case, if space permitted us to quote it in detail, would 
 be very instructive to show the typical picture of subcor-
 
 Diagnosis of Aphasia. 337 
 
 tical sensory aphasia. " The patient after an acute cere- 
 bral attack (?) showed absolute inability to read printed 
 or written words (except his name), while he wrote cor- 
 rectly from dictation and spontaneously." There was in- 
 ability to recall the name of the most familiar object pre- 
 sented to his sight, while he conversed intelligently, 
 employing an extensive and varied vocabulary, making 
 few mistakes, but occasionally forgetting names of streets, 
 persons, and objects. There is no note of whether or not 
 hemianopsia existed, but it may be taken for granted, I 
 think, that it did, for in every published case, without ex- 
 ception, in which this condition was examined for it has 
 been found. In regard to Broadbent's statement that it 
 bears evidence in favor of a naming centre, it need only be 
 said that the case shows that there was a lesion that severed 
 the visual percipient centre from the visual interpreting 
 centre, and if he prefers to call the latter a naming centre 
 no adequate reason has ever been offered why he does so. 
 One then proceeds to examine to see if the patient has 
 word blindness; that is, can the patient read (i) print, (2) 
 script, (3) figures and other forms of notation. I have 
 already described the significance of inability to do all or 
 one of these. It can need no repetition to show that in- 
 ability to read is not of itself an important localizing 
 symptom ; it may be produced by lesion in many parts of 
 the optic projection and of the parts that the optic projec- 
 tion goes to. It is the association of the inability to 
 read that facilitates localizing the lesion. If, for instance, 
 a person's primary visual centres are intact, he sees the 
 written or printed word, the figure or symbol, in all its 
 details ; it merely has no significance for him. This bears
 
 338 The Faculty of Speech. 
 
 testimony that the lesion is centralward to the primary 
 visual area. He can decide at once whether it be far 
 enough centralward to be in the angular gyrus, the higher 
 visual centre, or not, by determining if there be disturb- 
 ance of internal language. If there is not (and as a mat- 
 ter of fact one may say if there be no agraphia the lesion 
 is not in the zone of language), then the word blindness 
 is the result of a subcortical lesion. One word of caution 
 must be sounded for the inexperienced in determining 
 visual blindness. Some patients who have word blind- 
 ness, particularly those in whom the symptom is depen- 
 dent upon lesion of the higher visual centre, on being asked 
 to read, take up a book or paper, or whatever is handed to 
 them, and essay to read it understandingly. If they are 
 made to read it aloud it will quickly be seen that they 
 cannot read a word, that they " make up," as children do, 
 as they go along. Oftentimes the assurance with which 
 they take hold of a paper or letter and apparently read it 
 deceives even an experienced examiner. It cannot do so, 
 however, if the physician will show them writing or print 
 embodying a request set forth in such a way that cannot 
 escape their recognition if they read it, such as : " If you 
 are able to read this then put your left hand in mine." 
 Another test often employed is for the physician to read 
 aloud the last lines of a page and request the patient to 
 turn the page at the proper time. Naturally, he is unable 
 to do so, as he cannot read, although if he is not at all 
 word deaf, that is, if he can appreciate the quantity and 
 
 
 
 amount read, he may very closely approximate the time 
 when he should turn. 
 
 In cases of complete aphasia the examination is very
 
 Diagnosis of Aphasia. 339 
 
 difficult and to one not accustomed to such a task it seems 
 very unsatisfactory, as he is apparently unable to communi- 
 cate with the patient or receive any information from him. 
 Oftentimes it is thought that such patients have not re- 
 covered consciousness completely. I have such a patient 
 at the present time under observation : A married man, 
 fifty-six years old, of good habits, was seized one day with 
 a feeling of numbness and beginning powerlessness in the 
 right leg, which after a few minutes showed itself in the 
 right upper extremity. In less than a quarter of an hour 
 he became unconscious and completely hemiplegic. There 
 had been no premonitory symptoms save recurring head- 
 ache, which, his wife now recalls, had been complained of 
 for several weeks previous to the apoplexy. On the third 
 day after the attack signs of returning consciousness began 
 to show themselves, and at the end of a week there was 
 apparently complete restoration of consciousness. The 
 hemiplegia continued complete, the face being least 
 severely involved. 
 
 The following notes of the examination show the com- 
 pleteness of the aphasia in this case : 
 
 What is your name? No response; looks at me 
 blankly and staringly. 
 
 Is your name ? No reply, slight shifting or rest- 
 lessness of the patient. 
 
 Are you seventy years old ? No reply. 
 
 Would you like to go home with your wife ? No reply, 
 no interest. 
 
 Then these same questions were addressed to him in 
 writing and in print, but he took no more heed of them 
 when endeavor was made to bring them to his notice in 
 this way than when they were spoken. It was impossible
 
 34-O The Faculty of Speech. 
 
 to establish with any degree of certainty the existence of 
 hemianopsia. The impression, as the result of repeated 
 and careful testing, was that it did not exist. There was 
 apparently no object, no mind blindness. The patient 
 took a piece of candy that his wife brought, carried it to 
 the mouth, and ate it with apparent relish. When given 
 a pencil he grasped it and handled it in a familiar way, 
 likewise a watch, a key, and other common objects. He 
 recognized members of his family, and when his wife 
 came to see him he would grasp her hand and carry it to 
 his lips. He would try to detain her from leaving, and 
 manifested appreciation of visits. 
 
 Persistent efforts to get him to write a word are 
 wasted. He grasps the pencil as if he were about to 
 write, but instead of proceeding to form a letter he 
 scratches the paper, just as an infant does who is given a 
 pencil for the first time. If I guide his left hand which 
 holds the pencil to outline his name, or the names of 
 familiar objects, and then show them to him, he does not 
 understand the one or recognize the other. If I guide 
 his hand over the letters of a word to trace it, he may 
 trace the next word alone, but he does it mechanically and 
 takes not the slightest interest in it. When he is given a 
 number of bills of different denominations, it is impossible 
 to say that he understands the difference in value of them, 
 for he takes with the same readiness a twenty-dollar bill 
 and a two-dollar bill. He does not utter a word or the 
 semblance of a word. He does not indulge in any form 
 of pantomime or mimetic action. There seems to be ab- 
 solutely no way of communicating information to him or 
 of receiving wishes or desires from him. In other words, 
 he has total aphasia. In another connection, it may be 
 recalled, it was stated that sometimes such cases of 
 aphasia clear up on one side of language, the receptive or
 
 Diagnosis of Aphasia. 341 
 
 the emissive, and the residue of the aphasic symptom com- 
 plex constitutes sensory or motor aphasia. 
 
 In this patient it would seem that the middle cerebral 
 artery had ruptured and that the speech area has suffered 
 so severely that restitution will not follow, as sufficient 
 time has already elapsed to have it show itself if the 
 vital forces were sufficient to do so. The fact that he 
 has an advanced degree of chronic interstitial nephritis, 
 and the fact that, despite most careful dietetic and vigor- 
 ous medicinal treatment, he is continually emaciating, 
 augurs ill for him. 
 
 Sufficient has already been said of dyslexia in the chap- 
 ter on " Sensory Aphasia" to make reference to it here, as 
 a factor in diagnosis, unnecessary. I am disposed only to 
 reiterate, particularly since reading the first of Bastian's 
 recent lectures on problems in aphasia and other speech 
 defects, which appeared after this monograph was written, 
 the necessity of the most painstaking examination to re- 
 veal latent defects of internal reading in every case of 
 aphasia. After the condition of the functional state of 
 the different speech centres and the immediate conducting 
 tracts leading to and away from them have been inquired 
 into, and a general survey has been taken of the patient, 
 two things remain to be clone ; namely, an examination of 
 the patient's capacity to externalize mental contents by 
 pantomime or mimicry, and a study of the manifestations 
 of emotion in melody, instrumental music, profanity, in- 
 terjections, and gestures. It is believed that sufficient 
 has already been said of these to make reconsideration 
 of them unnecessary. 
 
 It is necessary to say one word concerning the time of
 
 342 The Faculty of Speech. 
 
 examination of patients with aphasia. The complexity of 
 symptoms that may be determined one or two weeks after 
 the restoration of consciousness following the apoplectic 
 insult, or the confusion and delirium which may be the 
 introductory symptoms of the aphasia, may be quite dif- 
 ferent from that found when the examination is made later. 
 The morbid vascular changes that go on secondarily to the 
 lesion, whatever it may be, will subside in part after the 
 acute manifestations of the disease or accident have disap- 
 peared, and if they have not been of sufficient severity to 
 cause destruction of the parts the area that was for a time 
 obscured will again functionate with more or less integ- 
 rity. It is well, therefore, to compare the results of the 
 clinical status made early with those made after the symp- 
 toms have continued for a time, and thus to establish the 
 permanent degree as well as the kind of aphasia.
 
 CHAPTER IX. 
 ETIOLOGY. 
 
 BEFORE enumerating the individual organic diseases or 
 functional conditions of which the different varieties of 
 aphasia may be a symptom, I wish to direct attention very 
 
 
 FIG. 19. Vascular Supply of Cortex. 
 
 briefly to the boundaries and blood supply of the zone of 
 language, which contains the centres of auditory, visual, 
 and articulatory (kinaesthetic) images. The locations of 
 these centres in this zone of language are now definitely 
 assigned. Their relative position on the surface of the 
 brain is shown in Fig. 7, page 99. Their boundaries 
 and interrelations are considered in Chapter IV., " Con- 
 ception of Aphasia."
 
 344 
 
 The Facility of Speech. 
 
 A comprehensive knowledge of the vascular supply to 
 this portion of the brain is necessary for A full under- 
 standing of the mode of development and the lesions of 
 aphasia. Such knowledge can best be obtained by a study 
 
 FIG. 20. Cortical Blood-Vessels of Foetal Brain. 
 
 of the fresh brain. The accompanying illustration (Fig. 
 19), taken from the well-known work of Duret, will convey 
 an idea of the distribution of the blood-vessels to the exter- 
 nal surface of the brain. It shows the middle cerebral 
 artery, which supplies the side of the cortex in all its ramifi- 
 cations. It will be seen that this one artery supplies 
 through its trunk, its principal branch, and its terminals
 
 Etiology. 345 
 
 the zone of language and the three centres lying therein. 
 Fig. 20 shows the cortical vessels of the foetal brain par- 
 ticularly in their relation to the fossa of Sylvius. When 
 one considers the importance of the middle cerebral artery 
 to the zone of language, it is no longer surprising that we do 
 not oftener encounter cases of aphasia whose symptoms can 
 be interpreted as due to lesion of an individual centre. 
 The middle cerebral artery, the largest and most important 
 branch of the internal carotid, in fact, the continuation of 
 the latter, supplies other parts than the zone of language, 
 and enumeration of these parts facilitates interpretation of 
 the accompanying symptoms in many cases of aphasia. The 
 antero-lateral arteries which are given off from the middle 
 cerebral immediately after leaving the carotid artery pass 
 through the foramina of the anterior perforated space to 
 the base of the corpus striatum and form the most impor- 
 tant supply of that region. The lenticular branch sup- 
 plies the inner and middle segments of the lenticular 
 nucleus and the internal capsule. The lenticulo-striate 
 arteries supply the outer segment of the lenticular nucleus 
 and external capsule and the caudate nucleus, and the 
 lenticular-optic arteries supply the outer part of the optic 
 thalamus. The vessel then passes to the cortex. 
 
 The cortical branches of the middle cerebral artery, or 
 the Sylvian artery, the continuation of the main trunk of 
 the internal carotid, are the interior external frontal, dis- 
 tributed to the outer part of the orbital surface of the 
 hemisphere and adjacent frontal convolutions; the ascend- 
 ing frontal, distributed to the convolution of the same 
 name and to the root of the middle frontal convolution ; 
 the ascending parietal to the parietal convolution and to
 
 346 The Faculty of Speech. 
 
 the forepart of the superior" parietal lobule; and the 
 parieto-temporal, which runs backward in the posterior 
 limb of the fissure of Sylvius and ramifies upward over 
 the angular gyrus and downward over the superior and 
 upper part of the middle temporal convolution. 
 
 Contrasting the distribution of this artery on the cortex 
 with the relative position of the different speech centres, 
 it will be seen that a lesion of the trunk at its entrance 
 into the fossa of Sylvius, and particularly a lesion of the 
 first branch, will be very apt to destroy Broca's convo- 
 lution, in which are stored the kinaesthetic memories 
 of articulation. If the lesion is not of sufficient sever- 
 ity to destroy the centre it may materially pervert its 
 functions, and this perversion may be transient or lasting. 
 Simultaneously with the occurrence of such a lesion the 
 integrity of the circulation in the posterior parts of the 
 vessel, in the terminal branches, the one bending up over 
 the angular gyrus and the other down over the temporal 
 convolution, may be disturbed, though to a very insignifi- 
 cant degree compared with the disturbance of Broca's 
 centre, but yet sufficient to add a sensory element to the 
 aphasic symptom complex. Thus, in the beginning of 
 some cases of aphasia, the symptoms may indicate a mixed 
 form, but the slight sensory or motor element, as the case 
 may be, may disappear, leaving the other dominant to con- 
 stitute the form of aphasia. It is not in place here to 
 point out that the aphasic symptoms vary not alone with 
 the seat of the lesion, but with the intensity of the lesion, 
 the rapidity of its progress and development, or, in other 
 words, with its nature. This may be inferred from what 
 has just been said.
 
 Etiology. 347 
 
 With the exception of destruction of the speech areas 
 that are the result of injury and new growth, organic dis- 
 ease of the zone of language is almost always the result of 
 vascular lesion. These vascular lesions are rupture of 
 the blood-vessels and occlusion of their calibres, whether 
 from embolus cr thrombus, and the consecutive changes 
 dependent thereon. The lesions of the blood-vessels may, 
 however, be due to inflammatory conditions of the vessels, 
 but even then it is not at all improbable that the pathogene- 
 sis of the lesion is the direct result of a septic or infec- 
 tious process that causes infectious emboli and thrombi. 
 The traumatic conditions that may produce aphasia are 
 bullet and stab wounds, depressed fractures of the skull, 
 and injuries producing meningeal hemorrhage. 
 
 Etiologically, aphasia may be classified into organic and 
 dynamic. The principal organic forms have just been 
 enumerated. Under the dynamic forms may be included 
 those in which no organic lesion is responsible for the 
 development of aphasic symptoms. The term dynamic is 
 used merely as a convenience in preference to the conven- 
 tional " functional." The dynamic variety includes aphasia 
 occurring with neuroses and psychoses which are not yet 
 proven to be dependent upon recognizable brain lesion, of 
 which epilepsy, neurasthenia, and hysteria may be taken 
 as examples. It also embraces most of the cases of aphasia 
 occurring with toxihaemia, such as uraemia, diabetes, and 
 gout ; although aphasia in some of these cases, especially 
 aphasia occurring with uraemia, is often dependent upon 
 organic vascular lesion of the cerebral blood-vessels. 
 Aphasia caused by the vegetable poisons, santonin, bella- 
 donna, tobacco, etc., is almost invariably of the dynamic
 
 348 The Facility of Speech. 
 
 form. The aphasia that sometimes occurs in individuals 
 who have been poisoned by lead, copper, etc., may be of 
 the dynamic variety, or it may be a focal manifestation of 
 the encephalopathy that these poisons occasionally cause. 
 The dynamic aphasias also include the aphasic speech 
 disturbances occurring with neuralgic affections of a 
 migrainous order, those occurring with forms of insanity 
 that have no known anatomical basis, and, finally, the 
 comparatively insignificant number which are attributed to 
 fright, anger, so-called reflex causes, such as intestinal 
 worms, and the transitory aphasias from loss of blood. 
 
 Ordinary etiological factors, such as age, sex, occupa- 
 tion, etc., have no bearing on the causation of aphasia, 
 because it is itself a symptom, and it results only when 
 the diseases of which it is a symptom occur or are prone 
 to occur ; but as aphasia is so often associated with cere- 
 bral apoplexy, and as cerebral apoplexy occurs usually in 
 late maturity and advanced age, it follows that aphasia is 
 seen oftener in people beyond fifty years of age. Never- 
 theless, it would be misleading to leave this statement 
 unmodified, for the reason that three diseases which not 
 infrequently have aphasia as a symptom, namely, uraemia, 
 acute hemorrhagic encephalitis, and tuberculous menin- 
 gitis, are particularly liable to occur in the young. More- 
 over, aphasia sometimes develops in the wake of the infec- 
 tious diseases, typhoid, diphtheria, and pertussis, and, as 
 these occur more frequently in youth than at any other 
 time, it follows that the aphasias of this variety will be 
 seen oftenest at this time of life. 
 
 It is my intention to enumerate the more prominent 
 diseases of which aphasia is an important symptom, and
 
 Etiology. 349 
 
 to dwell upon a few of these only. In addition to those 
 already mentioned, it may be said that aphasia of any kind 
 may be referable to some such disease of the skull as 
 exostosis and bony tumor; in short, to any condition of 
 the skull bones or the meninges, such as pachymeningitis, 
 that produces pressure on or irritation of the speech area. 
 It is an occasional symptom of thrombosis of the dural 
 sinuses, particularly thrombosis of the lateral sinuses. 
 
 Aphasia is one of the most important and constant 
 symptoms of acute non-purulent encephalitis. A case re- 
 cently reported by Leva 1 is a good illustrative example. 
 The patient had pronounced sensory aphasia, total 
 alexia, and agraphia, but no articulatory aphasia. At 
 the autopsy there was found diffuse encephalitis, with 
 softening in the first and second insular gyri of the left 
 hemisphere, in the adjacent convolutions of the inferior 
 hemispherical convolutions, and some disintegration of 
 the first temporal gyrus adjacent to the insula. In the 
 right hemisphere similar areas of softening were found 
 in the right temporal gyrus. 
 
 Depending upon the locality of the abscess, a variety of 
 aphasia is frequently an important symptom of purulent 
 circumscribed encephalitis, and especially the form com- 
 plicating purulent disease of the middle ear. In fact, in 
 cases of brain abscess it is oftentimes a localizing symp- 
 tom of most exquisite value. This is well illustrated by 
 a case recently published by Zaufal : 2 
 
 1 Leva : Virchow's Archiv, vol. cxxxii., part ii. 
 
 5 Zaufal and Pick : " Otitischer Gehirnabscess im linken Temporallap- 
 pen, optische Aphasie, Eroffnung durch Trepanation. Heilung." Prager 
 med. \\~ochenschr. , Xos. 5, 6, 8, 9, 1897.
 
 35<3 The Facility of Speech. 
 
 A young woman, twenty-five years old, complained of 
 headache, pain in the left ear, nausea, and vomiting. 
 Eight days later there was a discharge of pus from the 
 left ear. Examination revealed acute suppuration of the 
 middle ear, inequality of the pupils, progressive stupor, 
 and vomiting. Shortly after this, the patient was unable 
 to name objects shown to her, although she knew them 
 well and could describe their appearance ; that is, there 
 was optic aphasia, pointing to a lesion severing the con- 
 nections of the primary visual area with the area of word 
 memories; in other words, a pure, or subcortical visual 
 aphasia. The lesion was localized by Pick, and an opera- 
 tion revealed an abscess of the size of a hen's egg in the 
 region indicated, namely, in the left second and third tem- 
 poral convolutions far back and in the white substance. 
 The patient made a complete recovery. In this case it is 
 to be noted that there was no hemianopsia, which showed 
 that the primary visual area around the calcarine fissure, 
 as well as the radiations of Gratiolet were not affected. 
 
 Another most instructive instance of the same kind, 
 but in which the outcome was not so gratifying, is that of 
 a case related by Lannois and Jaobulay. 1 In this case 
 there were, in addition to symptoms of ear disease and 
 brain abscess, alexia, agraphia, word blindness, right-side 
 hemianopsia, and slight facial paralysis. The patient was 
 operated on but no pus was found. A second operation was 
 made three weeks later, and a collection of pus was evac- 
 uated. Eleven days later the patient died, and on autop- 
 sical examination a large abscess was found in the centre 
 of the left occipital lobe. There were also a number of 
 foci of diffuse encephalitis, some of them purulent, proba- 
 
 1 Lannois and Jaboulay : Revue de Medecine, August, 1896, p. 659.
 
 Etiology. 351 
 
 bly metastatic, in other parts of the left hemisphere. In 
 this instance, the symptoms were of such absolute localiz- 
 ing significance, pointing to destruction of the left occi- 
 pital lobe and of the radiations of Gratiolet, that it would 
 have been fully justifiable to lay open that part of the 
 brain instead of endeavoring to draw off the pus by punc- 
 ture. 
 
 Of the other intracranial inflammatory conditions, that 
 of meningitis of the convexities and meningeal tubercu- 
 losis are the two diseases sometimes accompanied by 
 aphasia. In purulent leptomeningitis secondary to optic 
 disease aphasia often develops, and, were it not for the 
 teachings of Hugenin, it is probable that aphasia would 
 not be considered of infrequent occurrence in tuberculous 
 meningitis. To show the extent and complexity of the 
 aphasic symptoms in tuberculous meningitis, I need only 
 refer to a case communicated by Carriere, 1 in which a 
 tuberculous meningitis (the lesion predominating in the 
 posterior part of the fissure of Sylvius) was accompanied 
 by verbal blindness, ageusia, anosmia, and, finally, total 
 blindness. This case is interesting also for the reason 
 that a spot of recent softening was found in the hippo- 
 campal gyrus. The anosmia was probably dependent 
 upon this lesion, as this would tend to corroborate 
 the claims of Jackson, Beevor, Carbonieri, ct al., who 
 place the cortical centre of smell in the hippocampal 
 gyrus. 
 
 Aphasia may occur as a symptom of direct injury to the 
 brain, and in times of war and riot such cases are of com- 
 mon occurrence. A remarkable instance of destruction of 
 
 1 Carriere, G. : Archives Cliniques de Bordeaux, 1^96, p. 135.
 
 352 The Faculty of Speech. 
 
 Broca's convolution by a foreign body is shown by a case 
 of Simon. 1 The patient had been injured by a fall from 
 a horse. After death a splinter of bone, which had been 
 detached from the inner table of the skull, was fountt in 
 the left third frontal convolution. Aside from the cases 
 in which there is solution of continuity of the skull, it 
 may result from injury to the head, such as from a blow, 
 a fall, a kick, unaccompanied by fracture of the skull. 
 Whether or not the lesion in some of these cases is a 
 dynamic one cannot be said. Usually the aphasic symp- 
 toms in such cases are neither so complete nor so contin- 
 uous as is aphasia depending upon vascular lesion. This 
 is shown by an instance published by Cameron. 2 A young 
 man fell a distance of fifteen feet and struck on the head. 
 He was unconscious for a time and later very restless. 
 On the seventh day after the accident he had a series of. 
 mild convulsions, manifest on both sides of the body, but 
 with special involvement of the mouth and eyes. After 
 this the stupor became greater, but from the eighteenth 
 day there was a gradual clearing up of consciousness. 
 On the nineteenth day he was able to say " Yes" and 
 "No." On the twentieth day there were aphasia, alexia, 
 and agraphia. These symptoms disappeared gradually, 
 and about six weeks after the accident the patient was 
 quite well. In a case of this kind, it is much more likely 
 that there was no considerable organic lesion, and that 
 the anatomical condition may be compared to that which 
 is supposed to exist in some cases of traumatic neurosis. 
 
 'Simon: "A Case of Aphasia." Johns Hopkins Hospital Bulletin, 
 Baltimore, 1889-90, i., p. 48. 
 
 * Cameron : " Notes of a Case of Traumatic Aphasia." Glasgow Medi- 
 cal Journal, August, 1896, p. 126.
 
 Etiology. 353 
 
 Therefore the aphasia is properly considered to be of the 
 dynamic variety. 
 
 The dynamic aphasias may be dependent on functional 
 disorders of the brain, that term being used in its widest 
 sense to cover not alone states of nervous exhaustion, but 
 to include such diseases as epilepsy, hysteria, and migraine. 
 They, as well as the aphasias of toxihaemia, are character- 
 ized by the variability of their manifestations, the inter- 
 mittency of their course, the transitoriness of their dura- 
 tion, but especially by their favorable outcome. The form 
 of aphasia that occurs with the neuroses varies, and we 
 are not in position to s.tate the conditions governing such 
 variation. In some instances, the aphasia will be typical 
 articulatory kinaesthetic aphasia, while in others the sensory 
 elements will predominate. The most common symptom 
 of the aphasic speech disturbance attending migraine 
 would seem to be paraphasia and inability to name objects. 
 Not long ago, a hard-working physician, about forty years 
 of age, who had been for a time under my treatment for 
 epilepsy, developed under the auspices of an acute infec- 
 tious influenza a profound status epilepticus, which lasted 
 nearly sixty hours. He then gradually recovered con- 
 sciousness, but for the next five days had aphasic symp- 
 toms characterized particularly by loss of articulatory motor 
 memories, as he has since then decided with me. After 
 he recovered consciousness he was wholly unable to speak, 
 although there was no word deafness, no word blindness, 
 nor was there the slightest trace of disturbance of motility 
 in any part of the body. He was at this time agraphic, 
 although able to copy. I labored with him for some time 
 to get him to pronounce the simple words " Yes" or " No" 
 23
 
 354 The Facility of Speech. 
 
 in response to questions which he apparently understood ; 
 showed him how to say them by fixing his lips and by 
 example, but all to no purpose. He regained ability to 
 speak fluently and correctly within a week. 
 
 Another case of epilepsy, but in which the aphasic 
 symptoms were the result of bromide intoxication, has 
 been for me an instructive example. The patient is a 
 young woman of social position, who desires above every- 
 thing else not only to remain free from the convulsive 
 attacks of her infirmity but to keep her friends ignorant of 
 it, and to do this she is willing to take very large doses of 
 bromide. Occasionally if hydriatic and other restorative 
 procedures necessary to keep up the tone of the nervous 
 system are at all neglected, she develops symptoms of 
 sensory aphasia, characterized especially by verbal am- 
 nesia and mild degrees of word blindness and object 
 blindness. I have had her maid make notes on numerous 
 occasions of the mistakes of utterance that are noticed at 
 these times, and I quote here a few of them. Wishing to 
 say, " I am going to my room," she said, " I thick, think, 
 that's the stick thick." For " I am going down stairs," 
 she said, " I am going down town." When she desired 
 the maid to hand her a cup, she said, " Will you give me 
 that window ;" and at table, desirous of living up to the 
 mandates of her physician, in refusing dessert she said, 
 " I do not care for interest." She says that oftentimes 
 she finds herself conning a printed page or a letter trying 
 to make out what it means, to decipher the words, and 
 then, all at once, after looking at them for a time, it will 
 quickly dawn upon her that they are symbols, letters, and 
 words with which she is familiar. It has also been noted
 
 Etiology. 355 
 
 that at such times, on preparing to go for a walk or a 
 drive, she will insist that she cannot go without her hat, 
 while all the time the hat rests on her head and she may 
 be apparently looking at it in a mirror. There is no de- 
 mentia or trace of insanity ; her conduct and her actions 
 are in keeping with her breeding; and when the bromides 
 are diminished in amount and restorative measures applied 
 vigorously the aphasic symptoms disappear. 
 
 The genesis of aphasia occurring with epilepsy is not 
 an easy matter to interpret, but it should not be forgotten 
 that some cases of epilepsy of which it is a symptom are 
 dependent upon organic disease, such as a tumor, and 
 vascular lesion, and in every case of epilepsy in which 
 aphasia occurs a very careful examination is demanded. 
 A case recently reported by Hay prompts me to this state- 
 ment. A man, thirty-nine years old, free from syphilis, 
 suffered three attacks of influenza in rapid succession, and 
 immediately afterward complained of great weakness, 
 headache, depression, which brought him to a very dis- 
 tracted state. Shortly afterward a condition of status 
 epilepticus developed, and when this terminated he had 
 aphasia of a sensory type and agraphia. Six months after 
 the beginning of the symptoms status epilepticus devel- 
 oped a second time, and from this he did not recover. 
 The autopsy showed a spot of softening in the left tem- 
 poral convolution. 
 
 It does not need the recitation of individual examples 
 to show that aphasia in some of its forms, and particularly 
 sensory aphasia, characterized by verbal amnesia and par- 
 aphasia, is a common attendant upon states of mental ex- 
 haustion, especially when associated with physical fatigue,
 
 356 The Faculty of SpcecJi. 
 
 and upon preoccupation. Almost every one who has been 
 overcome by the former is in possession of a personal ex- 
 ample. Naturally I do not mean to say that preoccupation 
 produces aphasia. What I mean is that a person's cogni- 
 tive areas maybe so intent upon/subjects that engross 
 him that the zone of language is temporarily ungeared. 
 A very good illustration of this is related of Emerson. 
 It is well known that this immortal transcendentalist was 
 wont to accompany himself with the traditional New Eng- 
 land umbrella in his walks. On occasions when more 
 engrossed in absorbing thought than usual, he would hesi- 
 tate on going out, search various corners, the hatrack, 
 etc. , where the cotton rain guard was usually to be found, 
 and not finding it he would stand, solemnly tap the tem- 
 ple or the brow, and say, half to himself and half to a by- 
 stander, if there happened to be one, " Oh, where is , 
 where is, where is, my, oh where is that thing that 
 honest people take or borrow and never think it necessary 
 to return ?" When the word umbrella was suggested, 
 " Yes, my umbrella." Although this has been utilized as 
 a contribution to " Umbrella Pleasantries," it reminds one 
 of the patient described by Trousseau, who, desiring the 
 same article, was wont to say, " Where is my u u u 
 sacrt matin ! " " Your umbrella ?" " Yes, my umbrella." 
 Genuine aphasia is a very rare accompaniment of hys- 
 teria, as rare correspondingly as mutism is frequent. 
 Why this should be so, I am at loss to understand. It 
 appears to me that the most reasonable interpretation of 
 most, if not all, hysterical phenomena is one that posits 
 the partial abolition or perversion of function of one or 
 more of the cortical areas. When the involved cortical
 
 Etiology. 357 
 
 area is the somaesthetic or Rolandic area, there result 
 perversions of sensibility and motility; when of the pri- 
 mary visual areas, we have hysterical blindness ; when of 
 the auditory area, we have hysterical deafness ; and when 
 of the frontal lobes, we have diverse and protean psychi- 
 cal manifestations. Thus it would seem to me that a 
 dynamic perversion of the zone of language analogous to 
 the condition that forms the basis of the above-mentioned 
 phenomena might produce aphasia; but as a matter of 
 fact there are very few examples of hysterical aphasia on 
 record. 
 
 Hysterical aphasia is usually less transitory than are 
 other forms of dynamic aphasia, but, unlike hysterical 
 aphonia, it does not extend over months and years. It 
 may be the only major symptom of hysteria or it may be 
 associated with hysterical hemiplegia and contracture or 
 with contracture in other parts of the body. It is more 
 frequently seen accompanying traumatic hysteria, than 
 with the so-called idiopathic form. Aphasia analogous to 
 the hysterical form has been artificially produced in per- 
 sons by hypnotism. 
 
 In studying the aphasic speech disturbances which 
 sometimes accompany neuralgic affections of the migrai- 
 nous order, it is well to keep in mind the genetic relation- 
 ship existing between migraine and epilepsy. Usually 
 the aphasic disturbances of migraine are of a sensory 
 character and very transitory. In discussing the relation 
 of amusia to aphasia, I have cited one or two examples of 
 the aphasia of migraine, and shall here refer only to one 
 example recently published by Pick. 1 A young physician 
 
 1 Pick : Berliner klinische Wochenschrift, 1894, No. 47.
 
 358 The Faculty of Speech. 
 
 who had lived a very irregular life developed suddenly 
 symptoms of ophthalmic migraine, with which were asso- 
 ciated motor aphasia, word deafness, and echolalia, all of 
 which disappeared with the attack. 
 
 It has been suggested that the genesis of migrainous 
 aphasia is in reality a vascular one, a contraction of the 
 cortical blood-vessels of the left hemisphere, which causes 
 a perversion of function of the zone of language. This is 
 a very plausible supposition, considering the very striking 
 evidences of vasomotor instability in other parts of the 
 body that occur with migraine, but it is easily understood 
 that there are insurmountable difficulties in the way of 
 adducing proof of this hypothesis. 
 
 There is an amount of very convincing evidence on 
 record to show that certain drugs, such as santonin, bella- 
 donna, tobacco, etc., of the vegetable poisons, sometimes 
 produce aphasia when given in toxic doses. There is 
 nothing especially characteristic of such aphasia to aid us 
 in differentiating it from other dynamic forms, and the 
 aphasia can be suspected to be of such origin only when it 
 is known that the patient has exposed himself to one of 
 these poisons. If the cause can be discovered and re- 
 moved, the aphasic symptoms soon disappear, and this, 
 more than anything else, stamps their origin. 
 
 This leads me to speak of other toxic conditions that 
 iviay cause aphasia, particularly uraemia, diabetes, and 
 gout, as well as more uncommon forms of poisoning, such 
 ag snake bite, etc., and of the aphasia which sometimes 
 occurs with Raynaud's disease. Aphasia is an extremely 
 uncommon complication or coincident symptom of Ray- 
 naud's disease, symmetrical gangrene. I have been able
 
 Etiology. 359 
 
 to find but two references to it in the literature, one by 
 Weiss; ' another by Osier. 2 Personally I have seen one 
 case. A young man was brought into the hospital suffer- 
 ing from symmetrical gangrene of both feet, slight cyano- 
 sis of the tip of the nose and the upper part of both ears, 
 and with the general-collapse symptoms attending the 
 advanced stage of this disease. He was thought to be 
 demented or amented by some members of the house staff 
 who saw him, because it was impossible to extract any in- 
 formation from him. He could not tell his name, age, 
 residence, occupation, or anything about his illness, 
 neither could he be got to write or read. Ability to 
 articulate words was preserved, for he would occasionally 
 use words, but they could not be understood or interpreted, 
 i.e., they were without sense. Under tonic and stimulat- 
 ing treatment, including large doses of nitroglycerin, he 
 improved slowly, and eventually the sensory aphasia dis- 
 appeared. 
 
 The patient with Raynaud's disease described by Osier 
 had three attacks of transitory right-side hemiplegia and 
 aphasia, and died six months after the third attack. In 
 my patient there was no trace of hemiplegia. It is not 
 at all unlikely that the aphasia in these cases is dependent 
 upon vascular conditions in the brain similar to those in 
 the extremities that become blanched and then cyanosed. 
 Unless the disease is very severe the aphasia is not com- 
 plete, and may manifest itself only in paraphasia and diffi- 
 culty in interpreting spoken and written language. When 
 the affection of the cerebral blood-vessels is so profound 
 
 1 Wiener Klinik, 1882. 
 
 8 American Journal of the Medical Sciences, vol. cxii., 1896.
 
 o 
 
 60 The Faculty of Speech. 
 
 as to cause hemiplegia the aphasia is usually total. In 
 my patient the disturbance of speech was mainly on the 
 receptive side of language, and there was no disturbance 
 of locomotion except that conditioned by the peripheral 
 manifestations of the disease and the asthenia which is 
 always such a profound symptom. 
 
 Of the toxic aphasias, that produced by uraemia is by 
 far the most common. It may be a mistake to include it 
 in the dynamic aphasias, for it must be classed with the 
 cerebral symptoms of a paralytic order, provoked by a toxic 
 substance in the blood. Uraemic aphasia is seen oftener 
 in the old than in those of middle age, and oftener in chil- 
 dren than at any other time of life. The frequency of 
 ursemic aphasia in children is accounted for by the fact 
 that post-scarlatinal nephritis and nephritis following other 
 infectious diseases are more common at this time of 
 life. During the years of fullest maturity, uraemic symp- 
 toms are more liable to be dependent upon cirrhotic kidney 
 than upon any other form of kidney disease. Clinically, 
 uraemic aphasia is more commonly of a mixed form than it 
 is visual, auditory, or articulatory, but of course this de- 
 pends, as does the determination of the variety of aphasia 
 in any given case, upon the part of the zone of language 
 that is predominantly affected. 
 
 In cases of transitory aphasia, accompanying grippe, 
 pneumonia, etc., the aphasic symptoms frequently come 
 on after the patient has been " flighty" or delirious, and 
 usually the motor form predominates. A case of this 
 kind is reported by Isager. 1 A child ceased to speak after 
 
 1 Isager : " Et Tilfalde af Afasi i Tilslutning til en krupos Pneumoni " 
 Hosp. Tid., 1894, p. 42.
 
 Etiology. 361 
 
 the crisis of a croupous pneumonia. He understood fully 
 what was said, he could not speak voluntarily, he could 
 not repeat, nor could he read aloud. There was no paral- 
 ysis, and after a week he began to use individual words, 
 and in the course of a few days the faculty of speech was 
 quite restored. 
 
 It is not at all unlikely that cases of aphasia occurring 
 with lead poisoning are in reality dependent upon a lead 
 encephalopathy, and the aphasic symptom complex may 
 be looked upon as a focal or localizing symptom. This 
 leads me to say another word anent the aphasic speech 
 disturbances of the specific fevers. A great deal of atten- 
 tion has been devoted to this subject, and it is by no 
 means settled that the majority of cases belong to the one 
 form of aphasia, organic, or to the other, dynamic. It is 
 likely that some are of the first kind and others are of the 
 second. It is known that the infectious diseases predis- 
 pose very materially to septic states of the blood, to phle- 
 bitis, to endocarditis, and to other conditions directly 
 causative of embolism and thrombosis, and thus in- 
 directly to organic aphasia by producing an obstruc- 
 tion of the middle cerebral artery and its branches 
 which supply the zone of language, and which leads to 
 softening. 
 
 The aphasic speech disturbances that are sometimes, 
 though rarely, associated with chorea, primary degenera- 
 tive tic, and with different forms of peripheral irritation, 
 usually called reflex, such as from intestinal worms, phi- 
 mosis, etc., are very uncommon, although the existence of 
 cases of this kind seems to be well substantiated. They 
 do not call for particular discussion. The aphasia is to
 
 362 The Faculty of Speech. 
 
 be looked upon as the result of reflex inhibitory phenom- 
 ena and purely dynamical in constitution. 
 
 Aphasic symptoms occasionally develop after a consid- 
 erable loss of blood, such as from epistaxis (Berthold), 
 rupture of varix (Storp), post-partum hemorrhages, or sim- 
 ilar conditions causing acute anasmia. Hallervorden 1 de- 
 plores that so little attention is given by writers on the 
 etiology of aphasia to acute anaemia. As a matter of fact, 
 unless the loss of blood causes a marantic thrombus in 
 some cortical branch of the left Sylvian artery, genuine 
 aphasia is an excessively rare symptom of such hemor- 
 rhages. Sudden partial exsanguination is often accom- 
 panied by dysarthria, sometimes by anarthria, but these 
 are bulbar symptoms, just as the syncopal attacks that 
 often occur from the same cause are bulbar manifesta- 
 tions. True aphasia, the result of loss of blood, is usu- 
 ally partial, and may be manifest through both the recep- 
 tion and the emission of speech. It is usually transitory 
 and is one of the first exhaustion symptoms to disappear. 
 
 There remain to be discussed in the etiology of aphasia 
 two of the most important organic diseases of which 
 aphasia is a symptom. These are tumor of the brain and 
 cerebral apoplexy. Aphasia as a localizing symptom of 
 new growth in the brain is one of the most important and 
 trustworthy guides. As a rule, tumor presents the ideal 
 lesion to cause a strictly confined destruction of one of 
 the centres in the zone of language. At least, I mean to 
 say, that it is so at the beginning of the tumor. Tumors 
 begin in the great majority of cases in one of two ways : by 
 a proliferation of the tissue of the part which is pathologi- 
 
 1 Hallervorden : Deutsche med. Wochenschrift, vol. xxii., No. 5, 1895.
 
 Etiology. 363 
 
 cal from the beginning, or by the appearance of a tissue 
 that is foreign to the part. In the beginning the abnor- 
 mality is small, perhaps microscopical. It maybe strictly 
 confined to an area that has such highly individualized 
 function as the angular gyrus, the first temporal convolu- 
 tion, or to a definite part of the motor area, and at such 
 time it will produce symptoms of almost mathematical 
 precision. These symptoms may occur before the symp- 
 toms of brain tumor, that are so consecrated by time that 
 they are called cardinal, develop. If the physician takes 
 proper recognition of them and gives proper interpretation 
 to them, such perspicuity on his part may be rewarded by 
 the life of the patient. It is not necessary to point out 
 in detail what these varicus symptoms are. If one has in 
 mind the topography of the surface of the cortical sub- 
 stance, and the functions allotted to it, as well as an un- 
 derstanding of the connecting pathways of these cortical 
 areas, it is unnecessary to make explicit recitation of such 
 symptoms. 
 
 Aphasia may be a prominent symptom of a recoverable 
 form of tumor, gumma, and therefore the importance of 
 recognizing it and applying appropriate treatment is ap- 
 parent. A most instructive case, showing not alone the 
 amenability to treatment of very profound forms of sensory 
 aphasia when due to syphilitic lesion, but also the accu- 
 racy with which such a lesion can be localized from the 
 clinical data, is one recently reported by Bramwell. 1 A 
 young widow, who had had several miscarriages and abor- 
 tions, complained after repeated exposure to the sun's rays, 
 while working in the fields, of severe headache, worse at 
 
 1 Bramwell : " Illustrative Cases of Aphasia." Lancet, 1897.
 
 364. Tke Faculty of Speech. 
 
 night ; mental stupidity and loss of memory (she stated 
 that she felt as if she was in a misti ; and dimness of 
 vision. On examination there were found slight optic neu- 
 ritis, right-sided homonymous hemianopsia, almost com- 
 plete word blindness, complete agraphia. She could not 
 write spontaneously, from dictation, or from copy. There 
 was inability to name objects correctly, and when she tried 
 to name she nearly always applied the wrong name, al- 
 though she recognized when others called things by the 
 wrong name. The auditory speech centre was practically 
 normal, as was likewise the articulatory speech centre. 
 Soon after iodide of potassium was prescribed the symp- 
 toms began to be ameliorated, the headache was relieved, 
 the mental condition cleared up, the word blindness and 
 the agraphia disappeared, and the fields of vision gradually 
 enlarged until at the date of her discharge they were quite 
 normal. She regained possession of the modes of speech 
 in the following order: First, ability to name objects; 
 then ability to read letters and words, but at this stage 
 she was completely unable to write spontaneously, to copy 
 letters, or to write from dictation; then she gradually 
 found herself able to read a little more each clay, and in 
 the course of a few days to write a few letters. It is 
 worthy of remark that before she regained the ability to 
 write letters she seemed to have an idea of the letters, 
 that she wished to write ; in other words, she could evoke 
 them in her mind. This is shown by the fact that when 
 she was asked if she did not know the letter a she said 
 that she did, that it was an o with a crook. Finally, she 
 regained the power of writing fully, and at the time she 
 was discharged from the hospital every one of the aphasic
 
 Etiology. 365 
 
 symptoms, without exception, had yielded to antisyphilitic 
 treatment. 
 
 I have recently had a very similar experience. A young 
 married woman whose manifestations of constitutional 
 syphilis were repeated abortions and exfoliating necrosis 
 of the palatal region of. the upper jaw began to complain 
 of headache, nervousness, flightiness, depressed states 
 of mind with frequent crying-spells, and of trouble in see- 
 ing. Later, she complained of a subjective feeling of 
 numbness and unwieldiness in the right hand. This was 
 followed after a few weeks by a convulsive attack begin- 
 ning in the right hand and involving the entire extremity, 
 without loss of consciousness. After the convulsion 
 ceased she was unable to speak and to write for several 
 hours. There was no hemianopsia, apparently no disturb- 
 ance on the receptive side of language, and she could under- 
 stand what was said to her. She had three attacks simi- 
 lar to this, and after the last of them I saw her. The 
 twitching of the right upper extremity had ceased and 
 there was no evidence of hemiplegia, but the patient had 
 well-marked symptoms of cortical motor aphasia, which 
 gradually disappeared after several hours. She made a 
 complete recovery under treatment by mercury and the 
 iodides. All the symptoms, including a slight degree of 
 choked discs, had disappeared at the end of two months' 
 energetic antisyphilitic and restorative treatment. 
 
 This, then, shows clearly that the etiology of aphasia, 
 and that, too, of organic aphasia, has a most important 
 bearing on the course and outcome of the symptom and 
 on determining the treatment. In Bramwell's case the 
 lesion, although it did not destroy the higher visual centre
 
 366 The Faculty of Speech. 
 
 in the angular gyrus, made such inroads upon the latter 
 that it determined its functional overthrow, as indicates 
 the agraphia, writing in all of its modes having been lost, 
 while the homonymous hemianopsia and the alexia, the in- 
 ability to apply the proper names to objects, showed that 
 the way from the primary visual centres in the gray mat- 
 ter of the occipital lobes around the calcarine fissure to 
 the higher visual centre was severely encroached upon. 
 
 The efficaciousness of prompt and energetic treatment 
 directed against the luetic meningitis or the gummatous 
 encroachment upon the cortex is shown very strikingly by 
 the disappearance of the symptoms in my own patient. 
 
 Of the large number of examples of cases of brain 
 tumor whose existence was directly pointed by the pres- 
 ence of aphasic symptoms, I shall cite but one example, 
 and that recorded by Walton. The patient was a man, 
 forty years old, who suffered from gradually increasing 
 attacks of headache, at first of brief duration, later continu- 
 ous, together with difficulty in speech ("ataxic aphasia"). 
 He complained of red spots in the field of vision, and ex- 
 amination showed word deafness, word blindness, and 
 right-side hemianopsia, in addition to double optic neuritis 
 and paralysis of the left abducens. The patient was tre- 
 panned, but after the skull was opened it was decided that 
 the tumor was too deeply seated and too extensive to war- 
 rant interference. The patient died two months after the 
 operation. The autopsy showed a more or less lobulated 
 pear-shaped mass, occupying the region of the posterior 
 parietal and anterior part of the occipital lobe on the left 
 side, loosely attached in some places to the brain sub- 
 tance, infiltrating it in others. The temporal lobe was
 
 Etiology. 367 
 
 pushed downward, the occipital backward. The growth 
 reached practically to the mesial surface, and on micro- 
 scopic examination it was found to be a glioma. 
 
 In this case, therefore, the symptoms were most path- 
 ognomonic and suggested with great accuracy the locus of 
 the growth. A lesion that will produce word blindness, 
 left-side homonymous hemianopsia, and word deafness 
 can be situated only in the angular gyrus, extending far 
 enough centrally to sever the radiations of Gratiolet, and 
 downward to impinge upon the auditory centre in the first 
 temporal convolution of the left side. This case furnishes 
 opportunity to say another word concerning the laxity in 
 the use of terms by even those most worthy of the name 
 of cultured neurologists. In this case it was said that 
 there was ataxic aphasia. Now, in addition to the fact 
 that no designation of medical terminology is more indefi- 
 nite than ataxic aphasia, it may also be said that for the 
 reader who would judge of the speech defects in the case 
 from the published report there was nothing to point the 
 existence of articulatory motor aphasia ; nor was there any 
 lesion found on autopsy that would point to the existence 
 of such a condition. Moreover, it is difficult to say from 
 the autopsy report alone whether or not the cortical sub- 
 stance of the angular gyrus was completely destroyed. 
 One infers that it was not, because the tumor was appar- 
 ently out of the reach of the surgeon and could not have, 
 therefore, forced its way to the surface ; otherwise a part, 
 at least, of it would have been removed. I wish hence to 
 reiterate that, in the report both of the clinical side of a 
 case and of the anatomical side of a case, those who would 
 contribute to the real study of aphasia and thus to the
 
 368 The Faculty of Speech. 
 
 tomes of physiology, psychology, and biology, should be 
 mindful ever of the need of accurate statements and of 
 detailed description. 
 
 So frequently is aphasia an accompaniment of apoplexy, 
 a term which I use to include rupture of a blood-vessel, 
 obliteration of its calibre, and acute softening, that in the 
 minds of many physicians the word aphasia suggests 
 apoplexy. The genetic and anatomical relationship exist- 
 ing between the zone of language and the middle cerebral 
 artery has already been mentioned, and, as the subject will 
 be considered in extenso in the chapter on " Morbid 
 Anatomy of Aphasia," it is referred to here in the briefest 
 manner. Nor do I think it necessary in a chapter on the 
 etiology of aphasia to remark on the causative factors of 
 cerebral apoplexy. 
 
 Of the organic mental diseases that aphasia may be a 
 symptom of, general paresis is the most important. In 
 the beginning of this disease, which is pathologically a 
 widespread degeneration of the cortex, the most prominent 
 symptom may be aphasia. This probably coincides with 
 a beginning degeneration in some part of the zone of lan- 
 guage. Usually the aphasia is of the sensory type. 
 
 There remains but one form of aphasia to be mentioned, 
 and this chapter is finished, and that is the form known as 
 congenital aphasia, or congenital limitation of speech de- 
 velopment. These cases are not very uncommon. Kuss- 
 maul described a number of instances more than a quarter 
 of a century ago, and recently Gutzmann has studied the 
 subject very carefully. Congenital aphasia may be partial 
 or it may be complete. I do not include in this catesrorv 
 lack of speech development dependent upon porencephalia
 
 Etiology. 369 
 
 or other gross lesions of the cerebral hemisphere. Aside 
 from the disturbances in the organs of perception which 
 are a part of idiocy, there is a not inconsiderable number 
 of cases in which, without any disease of the peripheral 
 percipient sensory apparatuses, or of the central sensory 
 perceptual areas, there is a condition of speechlessness, 
 and that, too, entirely divorced from any apparent disturb- 
 ance of intelligence. It is to these cases that Coen 1 gives 
 the name of auditory dumbness in contradistinction to 
 deafness and dumbness. Although these children do not 
 present gross mental or psychical defect, usually careful 
 examination shows that there are always a certain amount 
 of abulia, tardiness in learning to walk, slowness in ac- 
 quiring skill of any kind, and '/arious other manifestations 
 of psychic and somatic degeneration. A very remarkable 
 feature, and one that should be borne in mind when in the 
 presence of such cases, is that in about one-third of them 
 there have been found adenoid vegetations. The only 
 other etiological factors that can be enumerated are that 
 this condition has been met with more frequently in males 
 than in females, and that there is almost always a neuro- 
 pathic heritage, particularly from the father's side, and 
 that, although a great many of these patients acquire con- 
 siderable speech facility, it is often later in life associated 
 with stammering. 
 
 1 Coen : Wiener klinische Rundschau, 1893, No. 6 
 
 24
 
 CHAPTER X. 
 MORBID ANATOMY OF APHASIA. 
 
 WERE one to write the morbid anatomy of aphasia in 
 detail, he must needs consider the various disease processes 
 forming the basis of all the organic and functional dis- 
 eases, enumerated in the chapter on etiology, with which 
 aphasia may be associated symptomatically. Such de- 
 scription would carry us far beyond the limits put upon 
 this work. Indeed, I doubt if such consideration could be 
 made to serve any useful purpose in elucidating the intri- 
 cacies of aphasia. Never for a moment should we forget 
 that aphasia is a symptom; and, although 'it is the most 
 comprehensive symptom that a physician has to deal with, 
 it nevertheless always remains a symptom. It has already 
 been said that one associates in his mind almost invol- 
 untarily the symptom aphasia with the disease apoplexy, 
 because it is with apoplexy, using this term generically 
 to include hemorrhage, occlusion of the cerebral blood- 
 vessels, and acute softening, that aphasia most frequently 
 occurs. Notwithstanding this, a discussion of the various 
 forms and stages of cerebral hemorrhage and cerebral soft- 
 ening cannot be attempted here. 
 
 In reality aphasia due to lesion of the speech centres, 
 true aphasia, is not often dependent upon cerebral hemor- 
 rhage, and this for the reason that cerebral hemorrhage 
 limited to the cortex is an extremely rare condition. On
 
 Morbid Anatomy of Aphasia. 371 
 
 the other hand, acute softening following the occlusion of 
 one of the cortical vessels is not so rare. Aphasia is 
 rarely dependent upon hemorrhage in the basal region, for 
 rupture of the trunk of the middle cerebral artery before 
 it gives off the ganglionic arteries is such a serious con- 
 dition that its occurrence is rarely consistent with the 
 continuance of life. In young persons, however, the main 
 trunk of the Sylvian artery may be occluded at any level 
 beyond the branching ganglionic branches, and yet no 
 softening take place. This accounts for the transient- 
 ness of aphasia in young people and for the rapidity 
 and completeness of their recovery. The first of the 
 author's cases cited in this monograph is an excellent 
 example of such speedy recovery, even in a very severe 
 form of intracerebral vascular disease. A more convinc- 
 ing example, because accompanied by an autopsical report, 
 has been published by Ross. 1 A young girl, while suffer- 
 ing from endocarditis, had, first, embolus of the femoral 
 artery, and in rapid succession embolus of the kidneys, 
 spleen, and left Sylvian artery, occlusion of the latter 
 being evinced by an attack of right-side hemiplegia and 
 combined motor and sensory aphasia. The patier\t died 
 from exhaustion about a fortnight after the attack of 
 aphasia. There was found in the main trunk of the 
 Sylvian artery, a little outside the anterior perforated 
 space, but proximally to any of the cortical branches, a 
 very firm occlusion. Not the slightest amount of soften- 
 ing could be discovered, although Ross states that it is 
 very likely that the nerve cells supplied by the Sylvian 
 
 'Ross: "Aphasia." Wood's "Medical and Surgical Monographs," 
 vol. vi.. No. I, 1890.
 
 372 The Faculty of Speech, 
 
 artery had undergone fatty degeneration. There can be 
 little doubt, judging from the outcome of analogous cases, 
 that, had the patient lived, the nutritive and functional 
 activity of the tissues of this area would have been grad- 
 ually restored. Such an outcome should not be at all sur- 
 prising when we consider that the cortical branches of 
 this artery, unlike the ganglionic branches, are not ter- 
 minal ones. 
 
 Although the study of the morbid anatomy of aphasia 
 really began with Broca when he made an autopsy on his 
 first aphasic patient, Leborgne, previous writers on the 
 subject of speech and its defects were not without anatom- 
 ical data to fortify their contentions, and of these may be 
 mentioned Bouillaud ' and Dax," who based their infer- 
 ences on not an inconsiderable pathological experience. 
 Broca's first case was one that is usually looked upon as a 
 typical example of cortical motor aphasia, but to-day it 
 would, I believe, be considered one of subcortical motor 
 aphasia, as the lesions found were widely distributed on 
 the surface and in the substance of the left hemisphere. 
 Although one of his cases showed extensive involvement 
 of the auditory area, the father of aphasia persisted in the 
 belief that the seat of lesion causing aphasia was in every 
 instance in the posterior part of the third frontal convolu- 
 tion on the left side. 
 
 It would be supererogatory to enumerate even a part of 
 the great number of autopsies to show that destruction of 
 Broca's convolution is attended by symptoms constituting 
 the symptom complex of cortical motor or articulatory 
 
 1 Bouillaud : " Traite Clinique et Physiologique de 1'Kncephalite," 1823. 
 
 2 Dax : Gazette Hebdomadaire, .April, 1895, No. 17. Republished.
 
 Morbid Anatomy of Aphasia. 373 
 
 kinaesthetic aphasia. This is something that every one 
 admits. In the chapter on etiology of aphasia the rela- 
 tion of the area of Broca to the first cortical branch of the 
 middle cerebral artery has been alluded to, and likewise 
 the liability of this part of the cortex to be diseased. 
 When it is diseased, a complexity of symptoms is produced 
 that varies with the completeness of destruction. The 
 lesions that are found there, constituting the organic 
 basis of cortical motor aphasia, circumscribed encephalo- 
 malacia, localized gummatous meningitis, tumors, abscess, 
 purulent leptomeningitis, penetrating wounds, were also 
 discussed in the chapter on etiology and need no further 
 enumeration here. 
 
 Future study of morbid changes accompanying motor 
 aphasia should be particularly with two ends in view : first, 
 to separate closely subcortical or pure motor aphasia from 
 motor image aphasia, due to destruction of the area of 
 Broca ; and second, to show that when the disease process 
 is limited to the latter area there is absolutely no second- 
 ary degeneration in any projection tract such as has been 
 described by Pitres, Raymond, Brissaud, and many others 
 as occurring in the inferior pediculo-frontal fascicle. To 
 do this microscopical study of every case is necessary. In- 
 vestigation of this kind can do for the motor side of 
 aphasia what the microscopical studies instituted by De- 
 jerine have done for the sensory side of aphasia. One 
 cannot overestimate the importance of such microscopical 
 study until he examines the literature and finds how easy 
 it is to put different interpretations on the same case, if 
 only the gross lesion is described. Incomplete anatomical 
 investigation must account in some instances for the in-
 
 374 The Faculty of Speech. 
 
 terpretations of some of the cases that have been cited by 
 authors to prove the existence of a graphic-motor centre, 
 such as that of Henschen, 1 for example. The patient suf- 
 fered from word blindness and agraphia, and after death 
 there was found not only destruction of the foot of the 
 second frontal but also a softening of the angular gyrus. 2 
 
 1 Henschen : " Klin. u. anatom. Beitrage zur Pathologic des Gehirns," 
 Upsala, 1890-94. 
 
 2 I am constrained to mention again, at the risk of wearying the reader 
 beyond justification, the fact that just so long as writers on aphasia refuse 
 closely to differentiate cortical from subcortical forms of motor aphasia, just 
 so much longer will it be before the question, " Does destruction of Broca's 
 convolution entail agraphia?" is settled to the satisfaction of .every one. I 
 am prompted to these remarks from an examination of the first of Bastian's 
 recent lectures, which are now appearing in The Lancet. No one can be 
 more profoundly cognizant of the fact, that, as a writer on speech disturb- 
 ances, Dr. Bastian should rank with the Fathers of Aphasia, with Broca and 
 Wernicke. It is not hazarding the truth to say that he has contributed 
 more to the elucidation of the genesis of speech than has any English 
 writer. My astonishment is therefore the greater that the following case, 
 quoted from Wadham, should be offered in evidence to negative the claim 
 that cortical motor aphasia always entails agraphia. I venture to state that 
 if there has ever been a case published which is a mirror held up to the 
 symptom complex and morbid anatomy of subcortical motor aphasia, it is 
 the one just mentioned and which I now proceed to quote. 
 
 " A youth, aged eighteen, left-handed and ambidexterous, became partly 
 hemiplegic on the left side and completely speechless after long exposure to 
 cold. Twelve days later, on being given a slate and pencil, he wrote 
 readily the word 'orange,' and when asked his name wrote it correctly with 
 the right hand, although his mother asserted that she had never previously 
 seen him do so. He and four of his brothers were left-handed. About a 
 week after this, being still absolutely speechless, when asked whether he 
 tried to speak and was unable, he wrote, ' Yes.' Asked if when well he 
 wrote with his left or right hand, he wrote ' Both,' and then added, ' Fight 
 with left.' In six weeks' time the hemiplegia had much diminished, but he 
 still never had spoken a word, and continued to write all his wishes on a 
 slate. His manner gave the impression of a very intelligent and rather 
 facetious young man. At the expiration of three months he left the hos- 
 pital, and when seen at his home later it was noted that the boy repeated 
 after his mother's dictation various words and sentences with the intonation 
 of one who endeavors to speak without moving the tongue. This power 
 gradually increased until he was able to talk with sufficient distinctness to
 
 Morbid An atomy of Aphasia. 375 
 
 The clinical history of Bastian's case stamps it as one of 
 subcortical motor aphasia. Personally I should have been 
 willing to make the diagnosis on one fact alone, viz., the 
 patient's ability to write. I appreciate, however, that 
 many physicians doubt the momentousness of this posses- 
 sion as a diagnostic indicator, and to those it might be said 
 that a patient with cortical motor aphasia of such severity 
 that it causes absolute speechlessness, and who is " very 
 intelligent and rather facetious," and who passes through 
 the stammering stage in learning to talk, and finally talks 
 like one whose tongue is fixed in the mouth, has yet to be 
 recorded, if the present writer's excursions afield into the 
 literature of aphasia have been properly interpreted. A 
 person to be facetious must be in the possession of inter- 
 nal speech at least, and if one of his speech centres is de- 
 stroyed the integrity of internal speech is destroyed with 
 it. The autopsy record puts the case in the right light, 
 " a lesion in the white substance beneath tJic Rolandic 
 area." That is what the writer of these pages means by 
 the term subcortical ; therefore his astonishment that the 
 case has been cited by Bastian in support of the statement 
 that cortical motor aphasia does not entail agraphia. 
 
 We are in the early stages of positive knowledge con- 
 cerning the exact limitations and seat of the lesions that 
 produce aphasia, and of the conclusions that can be drawn 
 from such lesions. If any one thing is needed to make 
 the data of aphasia more reliable in the future and more 
 
 be perfectly understood by those accustomed to him. He subsequently 
 suffered from necrosis of the jaw and died. At the necropsy a large area 
 of softening was found in the right hemisphere, involving part of the white 
 substance beneath the Rolandic area and the island of Reil. The left 
 hemisphere was normal."
 
 376 77*6* Faculty of Speech. 
 
 utilizable as scientific evidence in support of, or in behalf 
 of, certain theories of the genesis of speech and its locali- 
 zation, it is that the patient be studied methodically and 
 carefully, and when the case comes to autopsy that the 
 findings be recorded in definite, conventional, and scien- 
 tific language, particularly the seat, extent, and nature of 
 the lesions that are found, and that there be depicted on a 
 chart which represents the usual convolutional relations 
 and fissuration of the brain the seat and extent of the 
 lesion as it manifests itself on the cortex. A study of 
 the subcortical lesions, to be of any considerable value, 
 must be done with the microscope after the tissues are 
 properly hardened and stained. 
 
 In the conduct of an autopsy of this kind a number of 
 points are to be noted. After the removal of the calva- 
 rium, the condition of the pia should be particularly re- 
 marked, as knowledge to be obtained from its color, its 
 adherence, and its consistence may be of much help in 
 interpreting the nature as well as the duration of the 
 lesion in the brain, especially if the lesion be of the 
 cortex. Not infrequently aphasic patients will have a 
 complexity of symptoms that indicates the destruction of 
 one or more of the speech centres, and yet before death 
 such a patient may develop symptoms that are to be ex- 
 plained only by positing disease of other parts of the 
 brain. Observation and study of the macroscopic appear- 
 ances of the lesions in such a case, their color, consistence, 
 etc., will allow us to say with much positiveness that one 
 lesion is so recent that it could not have been the cause of 
 symptoms of long standing, and that another lesion bears 
 the imprint of ancientness, and therefore must account
 
 r 
 
 Morbid Anatomy of Aphasia. 377 
 
 for the symptoms of similar duration. To be noted, then, 
 are the color of the softening, the consistence, the exact 
 location, particularly as contrasted with the undiseased 
 hemisphere of the other side, the extent and number of 
 the lesions, and the state of the blood-vessels. After this 
 the consistence of the parts surrounding the area of soft- 
 ening should be carefully determined in order that one 
 may estimate how extensive the secondary changes are 
 which, though not sufficiently advanced to produce soften- 
 ing, may yet have reached a pathological state that robs 
 the area of its function. 
 
 It should be particularly noted if the lesion limits itself 
 to areas of the brain to which have been allocated by phy- 
 siologists and clinicists special centres for language, or if 
 a number of such areas are involved, thus constituting the 
 anatomical foundation of mixed or compound aphasia. 
 After the surfaces of the hemispheres have been carefully 
 examined and any lesions found there specifically noted, 
 then the degree to which such cortical lesions have ex- 
 tended into the substance of the brain and the subcortical 
 location and extent of the lesions should be determined. 
 This is by far the most difficult part of the autopsy. It is 
 especially these subcortical lesions that should be most 
 carefully studied, both in their extent and in their relation 
 to, and separation from, the superambient cortex. Sev- 
 eral cases of subcortical motor aphasia have been carefully 
 studied, but the authors of such studies have interpreted 
 them on the basis that the symptoms were due to the 
 destruction of fibres of projection going from the foot of 
 the third frontal convolution of the left side; that is, 
 lesion of the fibres which are described as constituting the
 
 378 The Faculty of Speech. 
 
 inferior pediculo-frontal fascicle. Now, if the existence of 
 this fascicle is denied, that is, if the third frontal convolu- 
 tion has no projection fibres, then the aphasic symptoms 
 resulting from destruction of the parts of the cortex sub- 
 jacent to it must be explained in another way. I believe 
 they can be more convincingly interpreted in a way that 
 has already been indicated. 
 
 The differentiation of subcortical motor aphasia from 
 cortical motor aphasia has been most serviceable in widen- 
 ing our conception and in expanding our knowledge of the 
 entire subject of aphasia, but much that is desirable can 
 still be done in this direction. The lesions accompanying 
 subcortical motor aphasia have been considered to some 
 extent in the chapter on motor aphasia, so that it is un- 
 necessary to enter very fully into the subject here. To 
 show the distance that such lesions may be from the cortex 
 in cases of clinically typical subcortical motor aphasia, I 
 may refer to an instance published by Banti. 1 A man, 
 sixty-two years old, who had never been able to read or 
 to write, developed immediately after an attack of apo- 
 plexy hemiplegia of the right side and inability to talk. 
 He understood questions that were asked him, but when 
 he endeavored to respond the only sound that came forth 
 was a confused unintelligible sound resembling " ti ti 
 ti ti ti." He died five years after the first attack, there 
 being in the mean time no essential change in his condi- 
 tion. At the autopsy there was found an apoplectic cica- 
 trix of a brownish-yellow color at the level of the internal 
 capsule between the lenticular nucleus and the thalamus ; 
 that is, in the anterior part of the posterior segment of the 
 1 Banti : Loc. tit.
 
 Morbid Anatomy of Aphasia. 379 
 
 capsule. Dejerine 1 has published an observation very 
 similar to this. The patient was a man sixty-seven years 
 old, who had right-side hemiplegia and aphasia of a 
 number of years' standing, and who was absolutely unable 
 to speak aloud. He could, however, whisper some words 
 that were recognizable. There was no agraphia or para- 
 graphia. He died eleven years after the beginning of the 
 illness, and'on autopsy there were found three small foci of 
 softening situated in the interior of the hemisphere, one 
 in the middle of the internal capsule, another in the 
 caudate nucleus, and a third in the fibres of the white sub- 
 stance subjacent but some distance removed from the foot 
 of the third frontal convolution. Although some writers, 
 such as Brissaud, are unwilling to admit this case to the 
 category of true subcortical motor aphasia, there would 
 not have been any objection to its admission if all fibres 
 coming from the articulatory areas of the cortex had been 
 involved. 
 
 The plan suggested by Dejerine for the conduct of the 
 autopsy after the superficies of the cortex has been studied 
 is probably the most useful one, although no hard-and-fast 
 rule can be laid down for one's guidance in this matter. 
 Dejerine's plan is the one that was followed by Vialet and 
 Mirallie, whose labors have done so much to put sensory 
 aphasia, cortical and subcortical, on a satisfactory founda- 
 tion. The exact position and extent of the lesions having 
 been noted, a division of the brain should be effected that 
 leaves the diseased region intact. The usual method of 
 division is that recommended by Flechsig, which consists 
 of a horizontal cut passing through the head of the cau- 
 
 1 Dejerine : Loc. fit.
 
 380 Tlie Faculty of Speech. 
 
 date nucleus and the median part of the thalamus. It is 
 done in the following way : After the skull cap has been 
 sawed in the usual way it is left in place, and a knife 
 introduced between the borders of the severed bone cuts 
 the brain horizontally, en bloc, from without inward. 
 This method of section facilitates particularly study of the 
 central masses and of the internal capsule. The brain is 
 then hardened and a plaster cast taken of the two pieces 
 of the hemisphere. This gives an exact representation 
 of the convolutions and is of the greatest service in 
 orienting one later when the microscopical sections are 
 made. The further handling of the tissues to render them 
 susceptible for coloration is the same as that for ordinary 
 brain tissue, and does not call for special description. 
 Naturally, a special microtome is necessary to make the 
 sections, which are cut horizontally through the length of 
 the hemisphere, and particular care is called for in hand- 
 ling these large sections. Mirallie has pointed out that, 
 to use the method systematically and regularly and to get 
 the greatest service from it, it is necessary to take every 
 twentieth or thirtieth section and make a counter-drawing 
 of the surface of the section on a piece of polished glass. 
 This counter-drawing, used in connection with casts of the 
 cortex that have been taken, makes it very easy to tell just 
 what levels and what parts of the cortex the various 
 numbered sections represent. 
 
 The investigations that have been carried out in this 
 manner by Dejerine, by Vialet, Mirallie, Redlich, Wyllie, 
 and others have been the means of advancing our knowl- 
 edge of sensory aphasia, and especially of subcortical 
 sensory aphasia, to a degree that is not easy to overesti-
 
 Morbid Anatomy of Aphasia. 381 
 
 mate. In fact, it must be said that the reliable ana- 
 tomical data of sensory aphasia have come from the 
 investigators whose names have just been mentioned, 
 although we do not mean to say that those of other 
 pathologists and clinicians, such as Bastian, Seguin, 
 Uenschen, Pick, Wilbrand, and others, are not of the 
 greatest importance. 
 
 The monograph of Vialet which appeared in 1893, em- 
 bodying the report of several cases of sensory aphasia 
 which the author had studied personally and with Dejerine, 
 marked an epoch in the knowledge not only of the cere- 
 bral centres of vision and the intracerebral visual mecha- 
 nism, but also of sensory aphasia. These cases and a few 
 others which I shall presently mention are of such im- 
 portance in exposing the pathological anatomy of sensory 
 aphasia that every writer who essays to describe the mor- 
 bid anatomy of aphasia must cite them. 
 
 I shall first refer to the findings in one of Vialet's 
 patients, in whom the symptom was left homonymous 
 hemianopsia, pure cortical hemianopsia. On removal of 
 the brain an ancient spot of softening was found in the 
 anterior one-fourth of the cuneus. Serial sections, made 
 in the manner described above, showed that destruction 
 of tissue was very much more extensive than the appear- 
 ance of the lesion on the cortex indicated. The softening 
 involved the anterior two-thirds of the cuneus, the an- 
 terior part of the calcarine fissure and the tissue in which 
 the parieto-occipital fissure pushes its way, and the foot 
 of the cuneus reaching as far as the foot of the hippo- 
 campus. In short, there was softening of the entire area 
 supplied by the anterior branch of the occipital artery.
 
 382 The Faculty of Speech. 
 
 The consequent secondary degeneration involved the optic 
 radiations of Gratiolet and the interhemispherical asso- 
 ciation fibres of the fibrae callosae. The internal genicu- 
 late body, the thalamus with the exception of the outer 
 part of the pulvinar, the anterior quadrigeminal tubercle, 
 and the entire internal capsule, as well as the foot of the 
 peduncle, were entirely spared. 
 
 In a case of this kind there was naturally no aphasia, 
 and no disturbance of reading except that conditioned by 
 loss of vision. It is for this reason that I refer to the case 
 here. The disability of such a patient to read is entirely 
 the same as that which might result from destruction of 
 one-half of the retina or other peripheral defect, and it is 
 grossly misleading to speak of it as " disturbance of read- 
 ing." 
 
 One of the cases described by Dejerine and Vialet was 
 one of pure word blindness. The patient had right homony- 
 mous hemianopsia, associated with inability to read letters 
 and words. He could write voluntarily and from dicta- 
 tion, but he could not copy correctly. The autopsy 
 showed a focus of softening evidently of long standing, 
 situated in the base of the cuneus and the posterior por- 
 tion of the lingual and the fusiform gyri. Examination 
 of microscopical sections of the brain showed that the 
 softening did not confine itself to the cortex, but that it 
 could be traced in the depths of the white substance from 
 the calcarine fissure to the ependyma of the ventricle, 
 where there was complete destruction of the tapetum, the 
 optic radiations of Gratiolet, and the inferior longitudinal 
 fascicle at the level of the lower wall of the occipital horn. 
 In addition, there was found secondary degeneration of
 
 Morbid Anatomy of Aphasia. 383 
 
 the radiations of Gratiolet, that pass beneath the field of 
 Wernicke in the auditory area. 
 
 Another case was one of complete sensory aphasia, the 
 patient being both word blind and word deaf. The area 
 of softening involved the posterior parts of the first and 
 second temporal gyri, the angular gyrus, the larger part of 
 the external surface of the occipital lobe, the pole of the 
 lobe being spared. In this case microscopical examina- 
 tion showed that not only the cortex but the white sub- 
 stance of the parietal and occipital lobes was affected. 
 The three layers of fibres which border the external sur- 
 face of the lateral ventricle were degenerated. The in- 
 ferior longitudinal fascicle and the optic radiations were 
 only partially destroyed. In fact, the inferior longi- 
 tudinal fascicle was remarkably well preserved in all its in- 
 ternal parts and in the interior walls of the ventricles. The 
 lesion destroyed the cortex of the posterior part of the first 
 temporal and all the inferior parietal, reaching as far for- 
 ward as the foot of the ascending parietal and the pos- 
 terior part of the island. The posterior part of the in- 
 ternal capsule from its beginning in the lower part of the 
 ovale, as far as the inferior^part, was degenerated. The 
 optic radiations were matted by the first lesion to the upper 
 part of the thalamus, and this seemingly had served to 
 preserve the integrity of these fibres at lower levels. In 
 contradiction to case three, this case showed that the 
 anterior part of the field of Wernicke was degenerated. 
 
 The fifth case was one of true sensory aphasia, word 
 blindness. On autopsy a spot of softening the size of a 
 silver dollar was found in the angular gyrus. Microscopi- 
 cally it was seen that the lesion began at the point of the
 
 384 The Faculty of Speech. 
 
 ventricle which penetrated the softened mass, and the de- 
 generation involved the bundle of the white sagittal sub- 
 stance, the radiations of Gratiolet in varying degrees of 
 severity, the fibnis callosre, and the long occipito-temporal 
 association fibres. The two forceps were intact. The 
 fibres situated on the external border of the ventricle 
 suffered particularly. In the upper part of the thalamus 
 there were two kinds of lesion : the posterior one very 
 marked, extended into the zone of the optic radiations ; 
 the anterior occupied the corona radiata at the level of 
 the posterior part of the thalamus, the secondary degener- 
 ation following along the course of the inferior longi- 
 tudinal fascicle and the optic radiations, although the 
 tapetum was preserved. 
 
 A communication concerning a case of pure word blind- 
 ness, reported by Hoisholt ' as a case of word blindness and 
 music blindness without agraphia, is accompanied by a 
 report of the autopsy, which shows how a lesion beginning 
 in the posterior pole of the brain and producing symp- 
 toms of subcortical or pure sensory aphasia may extend 
 forward until it implicates some of the speech centres 
 themselves. 
 
 Hoisholt's patient was a musician, sixty-three years old, 
 addicted to alcohol. Entirely cognizant of time and place, 
 he was somewhat confused and his memory of recent 
 events was impaired. His language was coherent, and 
 speech was normal, both in form and arrangement. The 
 intelligence of the man, and the comprehension of what 
 was spoken to him, likewise seemed to be normal. He 
 
 'Hoisholt: " A Case of Pure Word Blindness." Occidental Medical 
 Times, vol. vii., p. 483, 1893.
 
 Morbid Anatomy of Aphasia. 385 
 
 was able to spell words correctly, and also to write properly 
 from dictation his name and a number of short English 
 words, but there was an inability to read what had been 
 written, even his own name. He would generally read 
 the letters of the alphabet correctly, but was unable to 
 read the smallest words. The ability to see and to recog- 
 nize objects at a distance was preserved. He played from 
 memory the most difficult passages without a fault, but 
 when requested to play by note he tried to do so and 
 failed, hesitating and playing something not before him. 
 He was unable to name correctly any written notes. 
 There was no trace of paralysis. Hearing was impaired 
 and there was complaint of imperfect vision. Careful 
 examination showed that there was left homonymous 
 hemianopsia. For a time there was some improvement in 
 his general condition, but finally the visual defect became 
 more pronounced, the fields of vision becoming more and 
 more contracted until there was total blindness, while the 
 pupils grew larger and failed to react to light. Death 
 resulted from cystitis. Upon post-mortem examination 
 the whole occipital lobe of the left side of the brain pre- 
 sented a yellowish-green color, and, viewed from above, 
 appeared to be depressed below the general level. The 
 convolutions of this area were reduced in size. These 
 changes extended forward and upward as far as the angu- 
 lar and supramarginal gyri, upon which they impinged, and 
 inward along the median surface of the occipital lobe, the 
 tip of which was considerably softened. The posterior part 
 of the right hemisphere was of a yellowish-red color, from 
 the occipital lobe upward and forward, a little beyond the 
 limits of the change of color upon the left side. The con- 
 volutions were flattened, but not so narrow or contracted 
 as those of the opposite side. The cortical substance 
 around the posterior extremity of the temporo-sphenoidal 
 
 25
 
 386 The Faculty of Speech. 
 
 convolution (angular gyrus) was somewhat depressed below 
 the level of the surrounding surface, and presented several 
 hemorrhagic spots varying in size from that of a pinhead 
 to a pea, some of them extending through the whole thick- 
 ness of the cortex. Smaller hemorrhages were also visi- 
 ble on the median surface of the occipital lobe in the 
 fusiform lobule. 
 
 Although it is out of place to discuss here the clinical 
 features of this case in relation to the anatomical lesion, 
 it is appropriate to call attention to the fact that in the 
 beginning the lesion of the posterior cerebral artery mani- 
 fested its destructive effect in the interior of the occipital 
 lobe and as the lesion extended posteriorly and anteriorly 
 it caused respectively true cortical anopsia and true word 
 blindness. 
 
 A case of sensory aphasia reported by Dejerine and 
 Mirallie is accompanied by the results of a most carefully 
 conducted autopsy and microscopical examination of the 
 diseased focus and its consequent secondary degeneration. 
 The patient had presented typical symptoms of sensory 
 aphasia, associated in the beginning with right hemiparesis, 
 which soon disappeared. The course of the disease was 
 attended with considerable amelioration of the word deaf- 
 ness, but the complete alexia, total agraphia, paraphasia, 
 and jargonaphasia were very pronounced and remained 
 until the end. There was no optic aphasia or mind blind- 
 ness, but on account of the difficulty of communicating 
 with the patient it had been impossible to determine the 
 absence of hemianopsia. 
 
 The autopsy showed a lesion of the supramarginal and 
 of the angular gyrus, and also of the part immediately ad-
 
 Morbid Anatomy of Aphasia. 387 
 
 jacent to the latter in the inferior parietal lobule of the 
 left side. On microscopical examination a large focus of 
 softening was found surrounding the marginal fissure of 
 the island, and destruction of that part of the inferior 
 parietal lobule known as the angular gyrus. In the white 
 substance of the ascending frontal convolution there were 
 three foci of degeneration. There was also descending, 
 retrograde degeneration in the optic radiations, the inferior 
 longitudinal fascicle, the pulvinar, the external geniculate 
 body, and of the internal capsule and the foot of the 
 peduncle. 
 
 In this case the three distinct and primitive foci were : 
 i. A focus, by far the most important, situated in the 
 posterior marginal fissure of the island, which had severed 
 the base of the inferior parietal convolution just at the 
 point of junction with the island. This focus comprised 
 all the supramarginal gyrus, and destroyed the white fibres 
 of this convolution and the cortex as far forward as the 
 fissure of Sylvius. 2. A focus of softening occupying the 
 base of the Rolandic operculum at a point where it is 
 continuous with the island. 3. A focus measuring only a 
 few millimetres in diameter, just at the crest of the 
 angular gyrus, and which caused a degeneration very 
 strictly confined in the middle part of the white substance 
 of this convolution. These foci had each caused secon- 
 dary degenerations, the principal one of which had sev- 
 ered completely the retrolenticular segment of the internal 
 capsule, the radiations of the thalamus, and the inferior 
 longitudinal fascicle. Behind this point the degeneration 
 followed the external face of the lateral ventricle and 
 reached to the occipital lobe. The fibres of the corpus
 
 388 The Faculty of Speech. 
 
 callosum which turn about the posterior extremity of the 
 lateral ventricle were degenerated, forming at this level a 
 zone of translucent fibres, standing out in contrast to the 
 normal fibres of the corpus callosum. Anteriorly the de- 
 generation penetrated the posterior part of the thalamus. 
 The pulvinar was much atrophied, and its radiating fibres 
 had, disappeared. The external geniculate body and the 
 white fibres surrounding it showed slight departures from 
 normal. 
 
 In this case, the original lesion occupying the posterior 
 marginal fissure of the island had separated the angular 
 gyms and all its connections from the zone of language. 
 Although the visual images of words which are stored in 
 the angular gyrus were in a measure preserved, they were 
 no longer accessible to the zone of language, and this iso- 
 lation of the angular gyrus had caused from the standpoint 
 of its function bearing on internal language the same re- 
 sults as a direct lesion of the centre for the visual images 
 and words would have. Mirallie, in reporting the case, 
 says very truthfully that this is the first time that a case 
 of this kind had been studied microscopically, and the 
 scientific accuracy with which the lesion and its subse- 
 quent secondary degeneration were depicted allows of true 
 interpretation of the symptoms of the case, for without 
 such microscopic examination the totality of the symptoms 
 would have been much less intelligible. The anatomical 
 findings in a case of sensory aphasia under personal obser- 
 vation have been detailed in connection with the history 
 of the case, and need not be repeated here. 
 
 The morbid anatomy of a case of subcortical sensory 
 aphasia of the verbal type (pure verbal blindness of De-
 
 Morbid Anatomy of Aphasia. 389 
 
 jerine, subcortical alexia of many writers) has recently 
 been studied with great care by Redlich. The patient, 
 a sixty-four-year-old man, had had for a considerable time 
 loss of visual acuteness, dependent upon optic atrophy, but 
 this did not prevent him from discharging the duties of 
 a scrivener. Later he developed a right-side motor and 
 sensory hemiparesis, right-side hemianopsia, and word 
 blindness. The hemiparesis was transitory. After the 
 first fleeting disturbances following the shock there was 
 total literal and verbal alexia, but no mind blindness. 
 Writing was undisturbed, both voluntarily and from dic- 
 tation. 
 
 At the autopsy there was found a spot of softening in 
 the left occipital lobe immediately around the calcarine 
 fissure in the lingual and fusiform lobules, extending as 
 far forward in the medullary substance as the posterior 
 horn of the ventricle. The splenium of the corpus cal- 
 losum, the posterior part of the thalamus, and the tail of 
 the caudate nucleus were softened. Microscopical exami- 
 nation showed destruction of all the optic radiations ; and 
 the forceps major as well as a part of the forceps minor 
 were degenerated. The inferior longitudinal fascicle was 
 also the seat of degeneration. The cortex of the angular 
 gyrus was entirely intact. The left fornix, the anterior 
 portion of the cornu ammonis, and the tapetum showed 
 some spots of softening, which, according to Redlich, had 
 interrupted the connection between the right visual area 
 and the left visual centre, the author believing with H. 
 Sachs that this pathway is through the tapetum. On ac- 
 count of the interruption of the inferior longitudinal 
 fascicle, the connection between the left visual centre and
 
 390 The Faculty of Speech. 
 
 the zone of language was interrupted. This case is in 
 reality one of the most important that have yet been con- 
 tributed to the fund of exact knowledge concerning the 
 pathology of aphasia, and although its reporter draws what 
 I believe to be some unwarrantable inferences, which are 
 criticised in the chapter on " Sensory Aphasia," particularly 
 concerning the neural basis of writing, it nevertheless puts 
 beyond doubt the existence of this form of aphasia. 
 Redlich is of the opinion that cases of this kind would be 
 better designated by the term intercortical aphasia than 
 subcortical. 
 
 There are a number of other observations that have 
 been of great importance in corroborating the conclusions 
 of Dejerine and his pupils in regard to sensory aphasia. 
 Wyllie has published the report and autopsy findings of 
 a patient with subcortical visual aphasia, the two promi- 
 nent symptoms having been word blindness and homony- 
 mous hemianopsia. The lesion was found to be a soft- 
 ening of the white matter in the floor of the posterior horn 
 of the left lateral ventricle. It was due apparently to oc- 
 clusion of one of the branches of the posterior cerebral 
 artery. The softening confined itself strictly to the white 
 matter, and, though the gray substance of the convolutions 
 immediately over it was in a somewhat sunken and 
 atrophied state, there could be no doubt that this was 
 merely a condition consequent to the destruction of tissues 
 underneath. 
 
 Examination of the sections of the brain showed that 
 the atrophy extended from the tip of the under surface of 
 the occipital lobe, where the dilated posterior horn of the 
 ventricle reached to within an eighth of an inch of the sur-
 
 Morbid Anatomy of Aphasia. 391 
 
 face forward as far as the middle of the crus cerebri. 
 That is to say, the convolutions affected were the lingual 
 and fusiform, together with the posterior half of the gyrus 
 hippocampus. There was no involvement of the angular 
 gyrus. In this case the disease of the white matter of the 
 occipital lobe had involved the fibres connecting the an- 
 gular convolution with the right and left primary visual 
 areas, thus causing word blindness ; and on account of the 
 interruptions of the radiations of Gratiolet from the pri- 
 mary centre for vision in the left occipital lobe there 
 resulted hemianopsia. 
 
 A second case recorded by the same writer is no less 
 interesting. A man seventy years old developed a slight 
 motor and sensory hemiplegia with well-marked right 
 lateral homonymous hemianopsia. The hemiplegia soon 
 almost completely disappeared, but the hemianopsia and 
 total word blindness continued. There were a slight de- 
 gree of word deafness and amnesia of nouns. At the 
 autopsy the zone of language macroscopically was entirely 
 normal. The chief morbid appearances were found on 
 the under surface of the occipital lobe, involving princi- 
 pally the fourth temporal lobe, bordering the occipital con- 
 volution, the hippocampal convolution, the lingual con- 
 volution, the anterior part of the cuneus, and the calcarine 
 fissure. On section of the brain, it was seen that beneath 
 the thin cortex there was such marked atrophy of the 
 white matter that the cortex was in direct connection with 
 the ependyma of the ventricular horn. At this region of 
 greatest atrophy, i.e., the under surface of the occipital 
 lobe, about the middle of the inferior temporal occipital 
 or the fourth temporal convolution, there was a marked
 
 392 The Faculty of Speech. 
 
 depression on the surface of the brain about two inches 
 in length and an inch in breadth. This depression marked 
 the situation of a cyst-like cavity where the gray matter 
 and the subjacent white matter had been almost entirely 
 destroyed. 
 
 Serieux has recorded a case of word blindness with 
 agraphia caused by destruction of the angular gyrus, and, 
 although the report is not accompanied by the details of 
 a microscopical examination, the strictness with which the 
 lesion was confined to the inferior parietal lobule makes 
 it a very important and valuable case, more, however, 
 as substantiating the allotted function of the angular 
 gyrus than as a contribution to the morbid anatomy of 
 aphasia. 
 
 The same writer has also published a detailed account 
 of a case of mind blindness associated with word blind- 
 ness. The patient, a woman, sixty-two years old, had a 
 stroke followed by transient paralysis, word blindness, and 
 agraphia, mind blindness, word deafness, and paraphasia. 
 The patient's condition had bettered somewhat, when she 
 died suddenly from an intercurrent pneumonia. Unfor- 
 tunately, the lesions in the brain were multiple, there 
 being oh the left side a softening in the inferior parietal 
 and also a limited focus of softening in the posterior ex- 
 tremity of the first and second temporal convolutions. On 
 the right side of the brain a softening, somewhat more 
 extensive, was found in practically the same areas. 
 
 A very similar observation to this has been communi- 
 cated by Bruns, 1 except in this case the clinical phenomena 
 
 1 Bruns : Neurologisches Centralblatt, Nos. 17 and 18, 1888; Nos. i 
 and 2, 1894.
 
 Morbid Anatomy of Aphasia. 393 
 
 were those characteristic of complete sensory aphasia, with 
 right homonymous hemianopsia. The autopsy showed 
 that the greater part of the white substance of the first tem- 
 poral convolution and the adjacent parietal convolution 
 were in a state of advanced softening. 
 
 There are few better cases to illustrate' the lesions of 
 sensory aphasia, type of word deafness, than a case pub- 
 lished by Leva. 1 The symptoms pointed most unerringly 
 to a lesion of the auditory centre, and on autopsy there 
 was found a yellowish, fluctuating sunken-in area of soft- 
 ening in the middle segment of the left upper temporal 
 convolution and almost exactly two millimetres from the 
 upper border of the second temporal convolution. The 
 softening was found to be a cyst rilled with milky, cloudy 
 fluid. It measured in every diameter about three centi- 
 metres. Anteriorly it extended to one centimetre from 
 the tip of the first frontal gyms and posteriorly to two 
 centimetres from the posterior end of the same gyrus. 
 Internally it approached the two external segments of 
 the lenticular nucleus. In the second frontal convolu- 
 tion of the left side there was another small focus of 
 softening. 
 
 Although there are on record many cases of aphasia ac- 
 companied with more or less autopsical details, I shall have 
 to content myself with the relation of one more case taken 
 from the literature, and that a case of subcortical word 
 deafness, published by Pick. The patient was a typical 
 case clinically. She could understand neither spoken 
 
 1 Leva : " Localisation der Aphasien." Arch. f. path. Anat. und Phys. 
 und f. klin. Med.. Berlin, Mai, Bd. cxxxii. (Folge xiii., Bd. ii.), H. 2, 
 p. 333, 1893.
 
 394 The Faculty of Speech, 
 
 speech nor melodies. On removal of the brain, no de- 
 parture from normal could be made out save that the con- 
 volutions seemed to be a little sunken. Examination of 
 the superior gyri of the temporal lobes showed that they 
 were somewhat abnormal in consistence and color. On 
 the right side the first temporal and a large part of the 
 second temporal, the island of Reil, and the adjacent parts 
 of the anterior central convolution and of the inferior frontal 
 convolution were transformed into a whitish-yellow firm 
 mass. The environment of these softened parts was more 
 dense. The lateral ventricle of this side was slightly dis- 
 tended and contained some yellow serum. Section of this 
 hemisphere made after the plan of Pitres showed that the 
 cortex of the affected convolutions and the white substance 
 were the seat of yellow softening. This softening com- 
 prised, in a section made through the ascending frontal 
 convolution, the region just in front of the external cap- 
 sule and most external part of the lenticular nucleus. 
 The globus pallidus and the internal capsule were intact. 
 In the left hemisphere the posterior part of the first tem- 
 poral convolution and the supramarginal gyrus were 
 softened, the same as on the right side. Frontal sections 
 of this hemisphere showed that the softening was super- 
 ficial and affected no part of the external capsule or the 
 central nuclei. The island of Reil was intact. The 
 softened areas in this hemisphere had a more gelatinous 
 aspect and the substance of the adjoining convolutions 
 was firmer. On account of the meagreness of the ana- 
 tomical details in this case, and on account of the exten- 
 siveness of the lesion, it bears only indirect testimony in 
 behalf of the exact localization of the aphasia lesions.
 
 Morbid Anatomy of Aphasia. 395 
 
 In a word, the pathology of true aphasia is the pathology 
 of a lesion that injures the zone of language, and of sub- 
 cortical aphasia a lesion of the immediate incoming and 
 outgoing pathways by virtue of whose integrity the speech 
 centres manifest their function.
 
 CHAPTER XI. 
 REMARKS ON THE TREATMENT OF APHASIA. 
 
 I SHALL discuss the treatment of aphasia very briefly, 
 from the standpoint of the physician and surgeon, and 
 from the pedagogue's point of view. 
 
 Unhappily neither the physician nor the pedagogue can 
 be of considerable assistance to the vast majority of aphasic 
 patients. The medicinal treatment depends entirely upon 
 the nature of the lesion that causes the aphasic symptom 
 complex. If the lesion be a focus of encephalomalacia, then 
 all that can be expected of medicinal treatment is to assist 
 nature to prevent further destruction of tissue, and par- 
 ticularly to assist in preventing a repetition of the imme- 
 diate exciting cause of the softening. On the other hand 
 if the lesion be a gummatous meningitis, or an isolated 
 gummatous formation, in the zone of language or the sub- 
 cortical speech tracts, and these can be diagnosticated as 
 such, medicinal treatment is of the greatest value. A 
 case of sensory aphasia recorded by Bramwell and cited 
 in another chapter is in evidence. This patient had the 
 profoundest symptoms of sensory aphasia, yet 'she fully 
 recovered under the influence of antisyphilitic medica- 
 tion. Another case in which the results of antisyphilitic 
 treatment were most gratifying, even though the symp- 
 toms did not completely yield to medication, has very
 
 Remarks on the Treatment of Aphasia. 397 
 
 recently been published by Mantle. 1 The difficulty in 
 cases of this kind is oftenest with the etiological diagnosis. 
 Usually the patient is not in condition to vouchsafe any 
 information concerning himself, and as his family is, as 
 a rule, ignorant of such matters, the physician is compelled 
 often, if he has not been familiar with the patient's his- 
 tory, to make a diagnosis of previous syphilitic infection 
 on less satisfactory data than are ordinarily considered es- 
 sential. Personally I am inclined to suspect a luetic 
 origin in every case of aphasia coming on abruptly that 
 occurs before the fifth decade of life, when valvular trouble 
 of the heart, the^rjeeeTTf^possession of acute disease, and 
 injury can be excluded. 
 
 It would be a work of supererogation to repeat in detail 
 the treatment applicable to the different forms of aphasia, 
 for it will occur to every one who has in mind the various 
 causes of aphasia. The treatment for aphasia in one pa- 
 tient may be just as different from the treatment appli- 
 cable to the next one as the causes are different. For in- 
 stance, in the beginning the treatment of a uraemic patient 
 is venesection if the patient has not an organic form of 
 renal disease ; yet this kind of treatment would be fatal 
 to a patient whose aphasia was dependent upon autoch- 
 thonic thrombosis. 
 
 When aphasic symptoms develop slowly without fever 
 and with symptoms of increasing intracranial irritation and 
 pressure, then tumor and abscess must be thought of. In 
 making the diagnosis and the differentiating diagnosis one 
 must be guided by the general rules applicable to the 
 solution of these problems. When there are grounds for 
 
 1 Mantle : British Medical Journal, February 6th, 1897, p. 325.
 
 398 The Faculty of Speech. 
 
 the belief that the lesion is of a luetic nature, then the ad- 
 ministration of mercury and iodide of potassium cannot 
 be carried out with too great promptness and attention. 
 Syphilitic lesions that develop some years after the pri- 
 mary infection are, it is universally conceded, more 
 amenable to the iodide of potassium than to all other 
 measures combined. If, however, the date of the primary 
 lesion is not very remote, then the administration of iodide 
 should be simultaneous with the mercury, or the one 
 should follow the other in the shape of a course of the 
 ope and then of the other. 
 
 The treatment of aphasia dependent upon organic dis- 
 ease such as tumor, abscess, purulent meningitis, and focal 
 disease of any nature, does not differ from the treatment 
 of these conditions when aphasia is not present. When 
 their presence is attended by symptoms which seem to 
 indicate that they are amenable to surgical treatment 
 their removal should not be delayed. In fact, the 
 aphasia is oftentimes the localizing symptom that 
 makes diagnosis positive and operation possible. The 
 case which I have cited of Zaufal and Pick, an abscess 
 of the brain successfully treated by operation, is in 
 evidence. 
 
 To enumerate the symptoms caused by focal, cortical, or 
 subcortical disease that may cause aphasia would be a 
 repetition of much that has been said in the chapter on 
 " Diagnosis," and elsewhere. The seemingly widespread 
 belief that aphasia is almost exclusively an on-hanger of the 
 apoplectic state seems to necessitate, however, emphasizing 
 the fact that some manifestations of the complexity of 
 symptoms constituting aphasia are of great diagnostic im-
 
 Remarks o?t the Treatment of Aphasia. 399 
 
 portance in nearly every disease affecting the brain. It is 
 a common symptom in the recently recognized and de- 
 scribed disease acute hemorrhagic encephalitis ; it is per- 
 haps the most constant symptom of abscess of the brain, on 
 account of the pathogenetic relationship of disease of the 
 middle ear and cerebral abscess, and it is not uncommon 
 at some stage in the career of general paresis and of mul- 
 tiple, insular, and diffuse cerebral sclerosis; while its 
 occurrence after injury which may cause localized inflam- 
 mation of the meninges or of the brain itself, hemor- 
 rhage, depression of bone and spicules, is not unusual. 
 Naturally, in order to produce aphasia, these factors 
 must manifest their injurious activity on the speech 
 centres, their interconnections, projections, or the imme- 
 diate pathways leading to them ; to be less specific, on 
 the left hemisphere in right-handed persons and vice 
 versa. The form of aphasia that any of these diseases and 
 accidents may cause will depend upon the location of the 
 lesion and not on its nature. The only variety dependent 
 upon any of the above-enumerated conditions that is very 
 uncommon is the subcortical form of motor aphasia ; while 
 the subcortical sensory variety is correspondingly frequent. 
 This is readily understood, if we recall that the part of the 
 brain which must be diseased to cause subcortical motor 
 aphasia is well protected from injury and has no par- 
 ticular relationship to the important factors that condition 
 abscess of the brain. 
 
 Oftentimes a careful consideration of the symptom 
 aphasia in these diseases will be the most important factor 
 in determining whether or not an operation shall be done, 
 i.e., whether the lesion is sufficiently localizable to warrant
 
 400 The Faculty of Speech. 
 
 advising the surgeon to trepan the skull and attempt to 
 remove the materies morbi. 
 
 Taking it all in all, the question of the medicinal treat- 
 ment of aphasia never comes up for consideration. The 
 question that does present is : How shall we treat the con- 
 dition of which aphasia is the symptom ? To answer that 
 question satisfactorily requires an intimate knowledge of the 
 therapeusis of all the diseases, functional and organic, that 
 have been enumerated in the chapter on " Etiology" with 
 which aphasia may be associated. Treatment may consist 
 of such a simple matter as the interdiction of alcohol in a 
 case of toxic dyslexia, or it may require the combined 
 skill of the physician and surgeon to diagnosticate and re- 
 move an abscess or tumor. The treatment of the dynamic 
 aphasias is a different matter from the treatment of the 
 organic aphasias. In the former all that is necessary is to 
 remove the cause and the symptom will disappear, while in 
 the latter the cause may be removed and the pathological 
 condition which it has excited still continues and with it 
 the aphasia. 
 
 The pedagogical treatment of aphasia is a matter of re- 
 cent development. It has been the legitimate result of an 
 inquiry into the physiological and psychological antece- 
 dents of articulate speech, and of clinical observations that 
 when a young person became aphasic, even though the 
 lesion was a very severe and extensive one, the faculty of 
 speech was restored to him. Moreover, almost from the 
 very beginning of the history of aphasia, it has been 
 recognized that, even when the so-called " speech centre," 
 meaning Broca's area, was completely destroyed, the patient 
 regained occasionally some capacity to speak individual
 
 Remarks on the Treatment of Aphasia. 401 
 
 words or a number of words. Various hypotheses have 
 been formulated to explain these occurrences, the most 
 widely accepted apparently being that of Jackson, who 
 suggested twenty years ago that the " uneducated centre" 
 of the opposite side is in a way related to conventional, 
 emotional, and other forms of what he terms " degraded" 
 speech, in contradistinction to intellectual speech. This 
 is the theory accepted by many writers to-day. Recently 
 Wyllie has framed a theory along somewhat the same lines 
 on the " overflow of education into the opposite hemi- 
 sphere;" the hemisphere that contains the zone of lan- 
 guage takes up all that it can in the way of education, and 
 that which it is not equal to taking up flows over into the 
 other hemisphere. As I have said in a previous chapter, 
 the entire subject of the repossession of the speech faculty 
 in patients in whom it has been lost must needs be looked 
 at to-day from another standpoint than it was a few 
 years ago, when the various forms of subcortical aphasia 
 had not been satisfactorily differentiated. It seems to me 
 that in the light of our present knowledge of aphasia it 
 must be granted that not only do the areas of the opposite 
 hemisphere sometimes under the stress of education un- 
 dertake, in a very incomplete way, the speech function of 
 the destroyed area of the hemisphere phylogenetically and 
 ontogenetically prepared to carry on the speech faculty, but 
 that the immediate environmental areas of the speech 
 centres of the left hemisphere may take up the function in 
 part ; secondly, that the opposite hemisphere, the one that 
 has the zone of language ontogenetically developed, is not an 
 uneducated hemisphere at all, but that it is in one sense 
 just as much educated as the hemisphere in which the 
 26
 
 4O2 The Faculty of Speech. 
 
 zone of language is situated. It must needs be admitted 
 that there are a general auditory area, a general visual area, 
 and a general kinaesthetic area in the right hemisphere as 
 well as in the left hemisphere, and that in-coming stimuli 
 make a similar impression on it as they do on the so-called 
 " educated" hemisphere. These impressions are bilateral 
 in reception but unilateral in interpretation. This uni- 
 laterality of interpretation is determined by commissural 
 fibres of the corpus callosum. Now the same factors 
 that determine right-handedness determine also that the 
 left hemisphere shall be the executive speech side, but the 
 elementary work is done on both sides. It seems to me 
 that so far every one who is willing to accept the sugges- 
 tions of experimental physiology must go. How many are 
 willing to admit that the execution of speech is an auto- 
 matic act and requires no conscious preparation, if process 
 of anatomical completion is not considered " preparation," 
 is another matter. Those who believe that the execution 
 of speech is an automatic act find it easier to explain how 
 an approach to or an unfinished automatism can be as- 
 sumed by the opposite hemipshere which is educated but 
 which is not intended to be automatic, and especially in 
 young children, in whom the habit of automatic activity 
 has not become fixed by continued practice. I do not 
 think it at all improbable that if a healthy child should 
 be kept mute until it was from five to six years of age, 
 that is, until such a time as the neuro-muscular appa- 
 ratus subserving speech was fully developed, he would go 
 through the lalling and other stages of speech imperfec- 
 tions as do children who begin " to learn" to talk be- 
 fore the executive parts are fully developed. The words
 
 Remarks on the Treatment of Aphasia. 403 
 
 that such a child used (which would, of course, depend 
 upon the words that he had heard) might, I believe, be 
 perfectly formed. In other words, the execution of speech 
 would be as automatic as breathing, and that in mankind 
 speech is an endowment more than an acquirement. 
 Furthermore, the factors that determine the seat of this 
 automatic activity are the conditions that we have here- 
 tofore supposed determined the education of the left 
 hemisphere. 
 
 A most remarkable case bearing on this matter has re- 
 cently been published by Bastian. The patient was a boy, 
 twelve years old, who had been subject to epileptic fits at 
 intervals. The first of these occurred in infancy, when 
 the patient was about nine months old. Toward the end of 
 the second year the fits seemed to have ceased. The hear- 
 ing was good and the child appeared to be of average intelli- 
 gence to be well, in fact, in all respects, except that he did 
 not talk. When nearly five years old the little fellow had 
 not spoken a single word, and about this time two eminent 
 physicians were consulted in regard to his " dumbness." 
 But before the expiration of another twelve months, on the 
 occasion of an accident happening to a favorite toy, he 
 suddenly exclaimed, " What a pity !" although he had 
 never previously spoken a word. The same words could 
 not be repeated, nor were others spoken, notwithstanding 
 all entreaties, for a period of two weeks. Thereafter the 
 boy progressed rapidly and speedily became most talkative, 
 and spoke without the least sign of impediment or defect. 
 
 One other point that has previously been mentioned. A 
 number of the cases that have been reported to show the 
 assumption of speech function by the opposite hemisphere
 
 404 The Faculty of Speech. 
 
 have, I hope, been conclusively shown to be dependent upon 
 a subcortical lesion and not upon destruction of a speech 
 centre, and the partial or complete recovery of speech was 
 commensurate with a disappearance of the conditions that 
 had determined the partial interruption of the conducting 
 fibres. In these cases recovery of speech has gone on pari 
 passu with disappearance of other symptoms, such as hemi- 
 plegia, for instance. In other cases in which the lesion - 
 has been of the speech centres the partial repossession of 
 speech has been due to the fact that the entire speech 
 centre, which in the beginning of an aphasic attack was 
 completely overthrown, has in a slight measure righted it- 
 self after the exudative and -occlusive conditions have sub- 
 sided. Then the patient finds himself in possession, to a 
 very insignificant degree, of his previous speech endow- 
 ment. In other cases there can be no question that the 
 educated areas of the other hemisphere develop some ex- 
 ecutive capacity. This is determined artificially, i.e., by 
 education, and not ontogenetically as it is normally, except 
 tp-the very slightest degree. 
 
 \In^ brief, then, the education of an aphasic patient 
 should consist in endeavoring to cause the centre or cen- 
 tres in the left side of the brain that are not destroyed 
 by the lesion which causes the aphasia to take the in- 
 itiative in the primary recall of words, and complete the 
 " circuit" necessary for speech by forcing the educated 
 opposite side to supply a centre similar to that which has 
 been destroyed^ For example, if the articulatory kinaes- 
 thetic centre is detroyed, the primary revival of the word 
 that should be spoken is through the auditory centre, and 
 this calls up in temporal coincidence or succession the
 
 Remarks on the Treatment of Aphasia. 405 
 
 visual and the articulatory centres. The articulatory cen- 
 tre, being destroyed, the speech impulse of the formed 
 word cannot be completed, and the kinaesthetic articu- 
 latory centre of the opposite side is acted upon through 
 commissural fibres in just the same way as the articulatory 
 centre of the left side was through intercentral fibres, 
 
 r~~~^ 
 
 in the beginning. [TJ^- process of education is very slow 
 and must be given artificial aid in the way of showing the 
 patient what movements to make in order to get the variety 
 of kinsesthesis of which it is desired to store up memories.! 
 The utilization of this suggestion is in reality at the bot- 
 tom of educating patients with cortical motor aphasia to 
 speak. 
 
 In these cases in which it is desired to supply the articu- 
 latory kinaesthetic memories, everything is to be gained by 
 the use of the physiological alphabet, educating the patient 
 to master the letter sounds. Even the briefest considera- 
 tion of the physiological alphabet would require more 
 space than can be given, and I prefer to say nothing in 
 the way of explanation of it rather than give a faulty and 
 imperfect exposition of the subject. To those who would 
 have a most readable article on the subject, the first 
 chapter of Wyllie's "The Disorders of Speech" is recom- 
 mended. 
 
 When the auditory centre is diseased, then the task 
 is to get a primary revival of the idea of words in the 
 visual or the articulatory centre. This is a very much 
 more difficult matter, because in the vast majority of 
 peoples the primary revival takes place in the auditory 
 centre, and when this is destroyed the patient is stranded, 
 from a speech standpoint. The plan of education is in
 
 406 The Facility of Speech. 
 
 reality that which is used for deaf-mutes, who are taught 
 to think by the revival of the word impulse by the visual 
 centres, the revivification of visual symbols prompted by 
 hand or lip movements. In case of those born deaf and 
 blind the primary revival is in the articulatory kinaesthetic 
 centre, which, in cases like that of Laura Bridgman, is con- 
 ditioned by the tactile sense. In fact, it is in all those 
 defectives who learn to read aloud by the use of raised 
 type. 1 
 
 Patients with the auditory form of sensory aphasia 
 should be patiently taught to repeat words the meaning of 
 which is conveyed to them through other senses, the 
 visual, tactual, and olfactory. In this way it is believed 
 that generally the auditory area of the same side that is 
 not destroyed or of the opposite side may develop some 
 executive capacity. 
 
 The treatment of sensory aphasia conditioned by destruc- 
 tion of the visual centres is most unsatisfactory, and very 
 little can be done to ameliorate the condition of such pa- 
 tients, even though all modes of education be assiduously 
 employed. An effort should be made to teach the patient 
 the recognition of forgotten symbols in connection with 
 the arousal of other memories of them, the auditory and 
 the articulatory. 
 
 In short, the pedagogical treatment of aphasia embraces 
 the methods of the kindergarten and the methods for the 
 instruction of those defective in one or more of the special 
 senses. Even with their aid but little can be done. 
 
 1 I am aware that these cases are somewhat opposed to the contention 
 that the primary revival of words is never in the articulatory centre, and 
 possibly the position I have taken may have to be modified or altered by 
 further investigation:
 
 CHAPTER XII. 
 
 REMARKS ON THE MEDICO-LEGAL ASPECTS OF 
 APHASIA. 
 
 APHASIA is so frequently a symptom of mortal disease, 
 and it is of so much more frequent occurrence in the aged 
 than in the young, that its presence and occurrence often 
 give rise to exigencies necessitating disposition of posses- 
 sions in such a way as to satisfy later tribunals of justice. 
 On the other hand, patients with aphasia are oftentimes so 
 changed in demeanor, in conduct, and in appearance, and 
 they respond to environmental conditions in a manner so 
 different from that habitual to them when in health, that 
 they are adjudged insane by the laity, and, unfortunately, 
 occasionally by physicians as well. These two facts ne- 
 cessitate a discussion of the testamentary capacity and the 
 mental status of patients with aphasia. 
 
 The literature bearing on the testamentary capacity of 
 aphasic patients is not very extensive, and, by way of intro- 
 duction, it may be said that much of it is valueless. A 
 quarter of a century back the subject was discussed by 
 Legrand du Saulle, 1 by Gallard/ by Bateman 3 and others, 
 but, as these discussions were held before the subcortical 
 
 1 Gazette des Hopitaux, June and July, 1868, and idem, vol. lv., 1882. 
 '-' ( 'Unique Medicale de la Pitie, reviewed in Le Journal de Medecine et de 
 Chirurgie Pratiques, vol. xlviii., pp. 377-3 8 - 
 cit.
 
 408 The Faculty of Speecli. 
 
 forms of sensory and motor aphasia were separated clini- 
 cally and established on a firm anatomical basis, they are 
 of comparatively slight value. For example, a case re- 
 ported by the last-named of the trio mentioned above : 
 An elderly man, about to be married, was stricken with 
 right hemiplegia attended with aphasia. He, in anticipa- 
 tion of death, desired to make a will for the benefit of his 
 fiancee. The instrument was prepared by his physician, 
 with whom the testator communicated by means of signs 
 which the former understood. The testator put his corrob- 
 oration on communications to the physician by making 
 an affirmative or negative gesture when the latter repeated 
 them after having written down what he understood the 
 deponent to say. For instance, he held up the hand and 
 extended five fingers ; then closed the fingers and extended 
 them again ; and repeated this performance three times 
 to indicate thirty. On being interrogated if he meant 
 " thousand" he nodded affirmatively. He was then asked 
 if he wished }\\^> fiancee to have .30,000 ; he again nodded 
 assent. When asked if it was his wish that she should have 
 this sum absolutely, he made a nod of negation. When 
 asked if she was to have it during her life and then to 
 have it revert to his own family, he signified assent. He 
 signed the document by making his mark, but owing to the 
 non-satisfaction of a technicality of the law the will was not 
 admitted to probate, although it must be evident to every 
 one that the mental faculties of the patient were intact 
 and that he had subcortical motor aphasia. As I have 
 already hinted, it is around the differentiation of the sub- 
 cortical and cortical forms of aphasia that this entire ques- 
 tion of testamentary capacity revolves. If it were neces-
 
 Medico-Legal Aspects of Aphasia. 409 
 
 sary to define the status of the aphasic patient's testamen- 
 tary capacity dogmatically and in a few words, I should 
 say that, although every case is a law unto itself, no one is 
 of sound and disposing mind who has true aphasia aphasia 
 due to lesion of the zone of language; while a person 
 who has any form of subcortical aphasia, be it motor or 
 sensory, may be, and usually is, capable of indulging in 
 civil transactions, although there are exceptions to the 
 rule. If the integrity of the primary speech centres con- 
 stituting the zone of language is necessary for the full and 
 legitimate genesis and notion of the word, then disease of 
 any of them must be attended by disorder in the conception 
 and in the idea of the word. And as it is necessary to 
 employ words or their motor equivalent in the making of a 
 will, it will readily be seen that the patient with true 
 aphasia cannot do this in a way to satisfy the law. Yet a 
 person may have had true aphasia, and have recovered 
 sufficiently, either by the education of the opposite side of 
 the brain, or by the assumption of function by unde- 
 stroyed portions of the diseased centre, to know the cor- 
 rect application of words and to use them rationally and 
 intellectually. It is in these cases that the observations 
 of the physician and the completeness with which he has 
 examined and studied the case should have the greatest 
 weight in deciding as to the patient's testamentary 
 capacity. 
 
 Given a person with subcortical aphasia, the matter is 
 very different. In a case of uncomplicated subcortical 
 motor aphasia, that is, not associated with lesion of other 
 parts of the brain that might interfere with intellectual 
 functioning of the brain, the individual may be in full-
 
 410 The Faculty of Speech. 
 
 est possession of his faculties, including internal speech, 
 and have simply a supreme inability to externalize his 
 mental content. For purpose of contrast he may indeed 
 be compared with a man who is bound and gagged. 
 Probably no one would contend that the latter is incapa- 
 ble of making a will, although the inability to do so with- 
 out outside aid must be very apparent. The testamentary 
 capacity of patients with subcortical motor aphasia may, 
 however, be impaired by coincident lesion of a nature 
 similar to that causing the speech defect, occurring in 
 other parts of the brain. For instance, a thrombus of lue- 
 tic origin located subjacent to the executive motor speech 
 centre may cause symptoms of subcortical motor aphasia, 
 while coincident luetic disease of the blood-vessels in 
 other parts of the brain may cause a degree of dementia 
 inconsistent with the making of civil contract. But, as 
 I have said, such superadded deficiencies must be detected 
 or eliminated by the examination of the physician. 
 
 Subcortical sensory aphasia, be it of the auditory or 
 visual kind, offers a more serious obstacle to the testa- 
 mentary capacity of the patient than does the subcortical 
 motor form, because in the former the indifferent attitude 
 and the inattentive and unnoticing demeanor, which these 
 patients so often have, lead those about them, and others 
 with whom they may come in contact, to look upon them 
 as insane. The testimony of these of the laity before a 
 Surrogate, or before twelve of their peers, often has great 
 influence even though it is contradicted by testimony 
 which has the misfortune to be called "expert." But if 
 the aphasic symptoms be wholly of a subcortical nature 
 and uncomplicated, the patient has no defect of internal
 
 Medico-Legal Aspects of Aphasia. 4 1 i 
 
 speech, and because of the shortcomings of internal speech 
 he should not be forced into the category of those of un- 
 sound mind because he is obliged to borrow another's 
 eyes or ears. It would be just as legitimate to contend 
 that a highly myopic or deaf person is incapable of mak- 
 ing a will because he cannot lay hands on his glasses or his 
 trumpet. As has been said before, the analogy is over- 
 drawn, because uncomplicated forms of subcortical sensory 
 aphasia are extremely uncommon, and it is the complica- 
 tions or coincident symptoms that add to the complexity 
 of the question. 
 
 Thus it will be seen that my position in this matter is 
 materially different from that of many writers on this 
 subject. For instance, I cannot agree with Cowers, who 
 says : " Word deafness is incompatible with will-making, 
 because it is impossible to know whether the testator 
 really understands what is said to him." If the auditory 
 pathways were the only ones through which a patient could 
 be communicated with, this would be true ; but word deaf- 
 ness may be complete without involvement of the higher 
 auditory centre and with the central visual mechanism in- 
 tact, and therefore the patient can be communicated with 
 by writing. Even in a case of word deafness and word 
 blindness there might still be no optic aphasia and the pa- 
 tient could be communicated with by pantomime, sign 
 language. Neither can I agree with Diller, 1 who says by 
 way of introduction to a brief discussion on the medico- 
 legal aspects of aphasia : " In such a study neither the site 
 of the lesion nor the particular division or subdivision of 
 aphasia present need be considered." For my part, I be- 
 
 1 Journal of Mental and Nervous Disease, May, 1894.
 
 412 The Faculty of Speech. 
 
 lieve that the determination of the variety of aphasia that 
 the patient has is the most important thing in determin- 
 ing the patient's capacity to make contracts, wills, checks, 
 and indulge in other civil matters. No more can I sub- 
 scribe to the statement that " Motor aphasia does not of 
 necessity incapacitate the patient in will-making, etc. " If 
 by motor aphasia is meant aphasia due to lesion of the cen- 
 tre in which are stored the memories of articulation, then 
 such aphasia does incapacitate the patient, for in every 
 case of this kind there is some disturbance of internal 
 speech, not to speak of external speech. In fact the ma- 
 jority of cases that have become famous in this country 
 on account of the litigation connected with them, in 
 which physicians have given testimony of the testamentary 
 capacity of the patient, such as the Beven case, analyzed 
 by Hughes; 1 the Parrish case, referred to by Ray; 2 and a 
 case recorded by Clark, 3 will be found on close scrutiny to 
 be cases of subcortical aphasia, and it was because of the 
 symptoms of the latter that such testimony could be given, 
 although at the time when some of the cases occurred the 
 subcortical forms of aphasia had not been separated. 
 
 The need of making such differentiation in every case 
 of aphasia when it is necessary to determine the testa- 
 mentary capacity, or to make a determination of the 
 mental status for other purpose, is well illustrated by the 
 pertinent words of Hughlings Jackson on the subject: 
 " Such a question as ' Can an'aphasic make a will ? ' cannot 
 be answered any more than the question, ' Will a piece of 
 
 1 American Journal of Insanity, January, 1879, p. 410. 
 
 3 " Medical Jurisprudence of Insanity." 
 
 3 American Journal of Insanity, 1892-93, p. 291.
 
 Medico-Legal Aspects of Aphasia. 4 1 3 
 
 string reach across this room ? ' The question should be, 
 can this or that person make a will ?" And the determina- 
 tion of the variety of aphasia that he has will do more to 
 answer this question than will anything else. 
 
 Physicians are rarely called upon to decide the question 
 of the responsibility of an aphasic in criminal processes ; 
 but when they are, the same precepts should guide them 
 in estimating the patient's mental responsibility as were 
 laid down to determine his testamentary capacity. It 
 should never be forgotten that the majority of cases of 
 organic aphasia occur with diseases of the brain that put 
 great inhibition upon the unfortunate victim's passions and 
 emotions, and for the indulgence and manifestations of 
 these he should not be held responsible in the same way 
 as a normal man is. The physicial infirmities of patients 
 with aphasia alone, especially the motor forms, usually 
 spare them from crimes against person and State; while 
 the speech shortcomings of sensory aphasia are of such a 
 nature that patients must be cared for by others, and are 
 therefore kept from indulging any such tendencies that 
 might be prompted. Personally, I believe that a patient 
 with subcortical aphasia, it matters not of what form, is 
 as capable of determining between right and wrong, mctim 
 and tuum, as a normal person, coincident disease of the 
 brain that might impair his faculties being excluded. 
 The same cannot be said for a patient who has lesion of 
 the zone of language ; but in cases of this sort the even- 
 tual determination must be reached from personal study of 
 the case and not from its conforming to any hypothetical 
 conditions.
 
 APPENDIX I. 
 CONDUCTION APHASIA. 
 
 IN the body of this work I have limited myself to a dis- 
 cussion of the varieties of aphasia that have been substan- 
 tiated by morbid anatomical changes found post mortem. 
 No one doubts the reality of the forms of aphasia discussed 
 in the text, although different interpretations have been 
 put upon the symptomatic accompaniments of each of 
 them by different writers, but all are in accord as to their 
 occurrence. A number of writers, prompted mainly by 
 theoretical considerations, have described several varieties 
 of aphasia dependent upon lesions situated between the 
 different speech centres. To these varieties they have 
 given different names, according to the posited seat of the 
 lesion. The most plausible of these subdivisions is one 
 described originally by Wernicke, to which he gave the 
 name " Leitungsaphasie," conduction aphasia (inter- 
 central aphasia, connection aphasia). 1 Personally, I be- 
 lieve that theoretically there are very good grounds for 
 the differentiation of this form of sensory aphasia, but as 
 
 1 Bramvvell distinguishes two varieties of conduction aphasia: (i) con- 
 nection aphasia due to interruption of the connection between the different 
 cortical speech centres; and (2) commissural aphasia, due to interruption of 
 the commissural connections between corresponding speech centres in the 
 opposite hemispheres. He remarks that in the present state of our knowl- 
 edge it is impossible to distinguish these commissural forms. The second 
 distinction seems to me scarcely warranted.
 
 Conduction Aphasia. 415 
 
 yet there is no convincing anatomical evidence to prove 
 its existence. Therefore it is referred to in an appendix, 
 instead of in the body of the work. I shall cite briefly, 
 and without critical comment, some cases that have been 
 contributed to establish the reality of this form of aphasia. 
 Even the most casual reader of the chapter " Conception 
 of Aphasia" will recognize that the explanation of the 
 occurrence of the one symptom of conduction aphasia, 
 viz., paraphasia, given by those who have written on the 
 subject is not in harmony with what has been contended 
 for in that chapter. The cases of conduction aphasia that 
 have been reported can all be explained as symptoms of 
 sensory aphasia, and the variations in the clinical picture 
 depend on the different locations of the lesion in the zone 
 of language. 
 
 Every one must admit the possibility of the existence 
 of a lesion in the zone of language between the auditory 
 centre and the articulatory kinaesthetic centre, without de- 
 struction of either of these centres. On the other hand, 
 the proximity of the visual and auditory centres and sub- 
 jacency of the radiations of Gratiolet make it very im- 
 probable that a lesion could exist between these two 
 centres and not implicate either of them. 
 
 A number of the most reliable writers on the subject of 
 speech disturbances have given this form of aphasia ex- 
 tensive consideration. Wernicke, Lichtheim, Pick, and 
 other writers have recorded examples in support of its oc- 
 currence and differentiation. Personally the writer is of 
 the opinion that conduction aphasia can rarely be differen- 
 tiated from sensory aphasia, of which it is a part. It is 
 possible that such differentiation may be made when the
 
 416 The Facility of SpeecJi. 
 
 lesion is of the island, but careful observations are needed 
 before this can be decided. When the lesion is of the 
 island, the connection between the auditory centre and 
 Broca's convolution may be only partially interrupted and 
 some impulses sent from the former reach the latter. All 
 of them do not. This remaining partial anatomical con- 
 nection has been taken by some writers (Ziehen) to explain 
 the occurrence of paraphasia in conduction aphasia. Be- 
 fore reciting the symptomatology that has been attributed 
 to conduction aphasia, it should be stated that if the artic- 
 ulatory centre is dependent absolutely upon the excitatory 
 influence of the auditory centre, as so many physiologists 
 believe it to be, then an intercentral lesion (a Leitungs 
 lesion of Wernicke) should produce as complete inability 
 to speak spontaneously or on repetition as does destruc- 
 tion of the area of Broca itself. 
 
 In the conduction aphasia of Wernicke the lesion which 
 is posited as the cause of the aphasia is one that inter- 
 rupts the conducting fibres that unite the centre for audi- 
 tory and articulatory word images. Anatomically such a 
 lesion is generally in the floor of the fissure of Sylvius or 
 in the island of Reil. In this form of aphasia the speech 
 centres themselves are intact. It is only their connections 
 that are interfered with. Thus neither will such a patient 
 have true word deafness nor will there be inability prop- 
 erly to speak out the words ; but, as the connection be- 
 tween these two centres is interfered with, the controlling 
 influence which the one, the auditory, has upon the other, 
 the articulatory speech centre, will be lost, and therefore 
 there will be defect in the proper use of words. Wernicke 
 assumes that the images stored in Broca's centre are re-
 
 Conduction Aphasia. 
 
 rived directly by the centre in which primary revival 
 takes place from the object representation. The speech 
 disturbance which such a lesion gives rise to is techni- 
 cally known as paraphasia and occurs in repeating as well 
 as in spontaneous speaking. Patients with this form of 
 aphasia understand and appreciate everything that is said 
 to them. In fact they are responsive to all forms of audi- 
 tory stimulation, and such auditory stimulation calls up in 
 the natural way the proper auditory image and helps to 
 give rise to the proper percept. On the other hand, the 
 patient is not prevented from attempting to communicate 
 his ideas and thoughts, and the thoughts which are formed 
 for communication are, it is said, the correct ones. When, 
 however, he endeavors to embody these in words the pri- 
 mary revival of the auditory centre cannot send a stimulus 
 to the articulatory centre, because the conduction is inter- 
 rupted. This being impossible, the motor centre en- 
 deavors to do the work unguided and the result is a mis- 
 use of words. The patient may himself be cognizant of 
 the shortcomings in his speech and endeavor to correct 
 them, and to convey his meaning by pantomime. These 
 cases are very rare, and when they occur they are to be 
 diagnosed principally by the absence of symptoms point- 
 ing to lesions of the individual speech centres. Occasion- 
 ally paragraphia has been noted in this form of aphasic 
 speech disturbance. When the latter occurs, the explana- 
 tion that has been suggested i-s that such patients have 
 been accustomed in writing to transcribe the word 
 which has been revived primarily by the articulatory 
 centre and passed on by the auditory. Thus anything 
 which prevents the association between the last two 
 27
 
 4i 8 The Faculty of Speech. 
 
 causes disturbances in writing analogous to those of 
 paraphasia. 
 
 The diagnosis of these cases is led up to more by the 
 absence than by the presence of symptoms. If there are 
 paraphasia and absence of word deafness, and nothing 
 more, the diagnosis of conduction aphasia is said to be 
 justified. 
 
 An abstract of the case of Lichtheim, which was re- 
 ported as one of conduction aphasia, is as follows : 
 
 A man, forty-six years old, with incomplete right-side 
 hemiplegia. No history could be obtained. Examination 
 showed that the patient understood spoken, written, and 
 printed speech. The most remarkable feature of the case 
 was paraphasia, which was so great that spoken speech 
 was quite unintelligible. He was aware of the mistakes 
 in his production and tried to assist himself by panto- 
 mime. Writing was very imperfect ; he disarranged the 
 order of the letters and words, and it was difficult to get 
 him to make efforts of writing. The same defects were 
 manifested in attempting to repeat as when he endeavored 
 to speak voluntarily. He retained the ability to copy. 
 The autopsy showed extensive lesions, the chief one, 
 according to the writer, being of the island and of the 
 floor of the Sylvian fissure. 
 
 The extensiveness of the lesion robs this case of the 
 weight it might otherwise have in contributing to a sub- 
 stantiation of the diagnosis of conduction aphasia. 
 
 The following is, in brief, the history of a case that Pick 
 has recently recorded as a contribution to the study of 
 insular aphasia : 
 
 A woman, Franciska Dillkins, sixty-six years old, 
 had suffered from infancy with epilepsy. Otherwise she
 
 Conduction . \phasia. 4 1 9 
 
 had been well until her sixty-fourth year, when she de- 
 veloped symptoms of insanity; spoke falsely; would not 
 .work ; was very restless at night, and during the day was 
 absolutely uncommunicative. On admission to the hos- 
 pital she answered the general questions correctly, in 
 monosyllables, but often made use of the same answer. 
 The countenance was staring and unexpressive, and she 
 made the impression that she did not understand questions 
 and commands addressed to her. After being taken into 
 the hospital, she remained most of the time in bed, and 
 when things were shown to her she took no notice of them 
 or held them unobservingly in the hand. At other times 
 she seemed to recognize things and to name them cor- 
 rectly, i.e., objects presented to the visual and tactile senses. 
 Once she designated money, " motarische Sprache" 
 (the words " motorische Sprache" had been used a short 
 time before). Physical examination showed slight pupil- 
 lary inequality, incomplete right-side hemiplegia with- 
 out facial involvement, increased patellar reflex, but no 
 ankle clonus. 
 
 ILvamination. What is your name ? Franziska. Your 
 last name? Franziska. Are you not a Dillkins? Yes. 
 How old are you? Answered correctly and also the ques- 
 tion as to her last residence, where she had lived for four 
 years. In response to the question if she had suffered a 
 stroke, she raised the right arm and said : " There is where 
 the stroke affected me." In response to the question if 
 she could read she said : " Formerly I could read but not 
 now." Shown some money and asked what it was, she 
 said: "That is a watch." Is it not money ? No. Shown 
 paper money. "That is two gulden." Shown a glass. 
 "That is two gulden." Then she took it in the hand and 
 said : " From that one drinks water." What is it called? 
 " From that one drinks water." Shown a watch. Looked
 
 420 The Faculty of Speech. 
 
 at it for a long time and then said slowly : " I do not 
 know what that is." When the name was said in her 
 hearing, she said : " Yes, that is a watch." Shown a ring. 
 That is a watch." For what purpose is it? " A watch." 
 Is it a ring? "Yes, that is a ring." Although she was 
 shown the ring immediately afterward she again re- 
 sponded " That is a watch. Shown a knife. " That is a 
 watch." Then she took it in her hand and said in re- 
 sponse to the repeated question : " Yes, I know what one 
 does with that," but she gave no evidence that she under- 
 stood what it is for. A burning match. " That is ein 
 Masche (a mesh?)." She did not concern herself when it 
 was brought close to her face. Afterward she made 
 several inarticulate sounds which had no significance for 
 those who heard them. Ability of repetition was 
 markedly impaired, and what she said in endeavoring to 
 repeat could not be understood. Oftentimes she would 
 harp on the last word that was spoken. 
 
 Tests for writing and reading were not made, as she 
 said that she could not read (formerly she could). When 
 requested to point to the scissors, she pointed to a key. 
 Almost all of the objects surrounding her she called " A 
 watch." When her attention was called to pictures on 
 the wall she called them "A watch," but apparently was 
 not satisfied and said " Watches." 
 
 Soon after this she was seized with general convulsions, 
 which began with conjugate deviation of the head and 
 eyes toward the right. The pupils were widely dilated and 
 reactionless. Immediately after the attack there was 
 deviation of the eyeballs toward the left, and the knee- 
 jerks were not elicitable. Later the knee-jerks were ex- 
 aggerated. After the convulsive attacks the patient was 
 very mute. The defectiveness of speech became more 
 apparent. The hemiparesis was followed by profound
 
 Conduction Aplictsia. 421 
 
 hemicontracture. After another convulsive attack she 
 developed an extensive bronchitis and soon died. 
 
 Autopsy. The left hemisphere (opened after the 
 method of Pitres) showed in the lenticular nucleus, ex- 
 tending so as to involve the claustrum and the internal 
 capsule, an old focus of softening of the size of a walnut. 
 The micioscopical examination showed that the entire 
 island in its total transverse diameter was interrupted by 
 the focus. 
 
 In conclusion Pick remarks that he does not offer this 
 as a pure case of insular aphasia, because of the fact 
 there were other changes, including a universal atrophy of 
 the brain. In spite of this he says the case may be cited 
 as a " negative case," particularly in reference to the 
 patient's capacity to repeat. These cases are both so in- 
 completely reported clinically and anatomically that it is 
 unwise to attempt criticism of them.
 
 APPENDIX II. 
 A CASE OF ARTICULATORY-KIN^STHETIC APHASIA. 
 
 IN the text only as many cases were cited as was thought 
 absolutely necessary to illustrate different types of aphasia. 
 The clinical findings in the patient whose case I am about 
 to relate mirror so completely, however, the exact conditions 
 found in true cortical motor aphasia, articulatory-kinses- 
 thetic aphasia, that I am prompted to make brief note 
 of them here. Moreover, I believe that the case is of no 
 small importance in substantiating the claim made in the 
 text, that Broca's convolution sends no projection fibres 
 directly to the internal capsule or to the capsular irradia- 
 tion, and that it is in reality a sensory area. 
 
 Mrs. X , a widow, sixty-three years old, the mother 
 
 of eight children, has had a vigorous, active life, free from 
 ill health, save that twelve years ago she suffered severely 
 from attacks of renal calculi. During the past year or two 
 she has complained of indigestion and more recently of a 
 dull, aching sensation in the back of the head and neck, 
 with occasional attacks of very severe pain in the left 
 temple. For a few weeks previous to the beginning of 
 her present symptoms she suffered from insomnia, from 
 irritability, nervousness, and forgetfulness. Her son, a 
 physician, gives the following account of the onset of her 
 aphasic symptoms. One week before consulting me she 
 discovered, while making a call, that her speech had be-
 
 Articulatory-Khucsthctic Aphasia. 423 
 
 come, without warning, very much embarrassed. She 
 could not finish the sentence that she had started to speak. 
 She forgot what she wanted to say. She chafed under 
 this impotence and got very much excited. She returned 
 home in a street car, and was much astonished to discover 
 on looking at the signs with which the cars are lined 
 that she was quite unable to comprehend their significa- 
 tion. She could see the letters and words, she knew that 
 they were letters and words, but they conveyed no mean- 
 ing to her. When she got home she tried to tell her 
 family about her disability, but was able to say only a few 
 words, and these were entirely disconnected. After trying 
 to speak for a time she became excited and began to cry. 
 On the following day, when she awakened, she could say 
 only " Yes" or " No," but as the day wore on her vocabulary 
 became somewhat larger. It was particularly remarked 
 that when she was excited or very emotional sometimes 
 words would flow out of her mouth in an astonishing 
 manner. From that time until I saw her there had not 
 been very much change in her capacity for speech pro- 
 duction. 
 
 The following is a stenographic report of the exami- 
 nation to determine disorder of voluntary speech. In 
 response to the question to tell me all that she could 
 concerning the onset and course of her symptoms, she 
 said : 
 
 " Well, mem-mem three weeks, m-m-em feel-m-em- 
 em sometimes [prolonged pause, seems to be thinking] 
 couldn't thought no thought forget but eh last Fri- 
 day [another prolonged pause] am no noticed they I 
 couldn't eh I [prolonged pause] I couldn't tell, am, I 
 don't, I can't, can't express [explosively] I can't tell I 
 cannot [points to her head and looks weary]. It seems, I 
 can't, last Monday, con-con-nects sentence, two or three
 
 424 The Faculty of Speech. 
 
 words gone. Was gone, blank, didn't know. Can't 
 think, was gone, forget forget everything. Couldn't, 
 couldn't, can't." 
 
 To test her capacity to repeat, I asked her to say after 
 me: "I stood on the bridge at midnight." Her reply 
 was : 
 
 " I stood the night," said with great effort, and with 
 apparent endeavor to repeat each word as quickly as they 
 fell from my lips. 
 
 " Still sits the schoolhouse by the road ?" 
 
 "Forget yes the the s' s' s' forget road." 
 
 " Waterloo was a battle of the first class, won by a cap- 
 tain of the second." 
 
 " The bat-tie, ah, me, ah me, ah. " 
 
 It is particularly noticeable that when I speak she en- 
 deavors to say the words after me very rapidly one word 
 after another, but it is quite imposible for her to repeat 
 more than a word or two. The patient is an English lady 
 who formerly was able to speak German very fluently, but 
 when I recite the first verse of Schiller's " Bell," begin- 
 ning, " Fest gemauert in der Erden," etc., she is not able 
 to repeat a word of it. I then ask her to repeat the Lord's 
 Prayer. She assures me by nod of the head that she can- 
 not do so, but when encouraged to try she says : " Fa' 
 
 a' ther our fa ' [gets excited and I believe tries 
 
 to convey to me that she was unable to repeat it last 
 evening]. I then ask her to say it to herself. She again 
 indicates that it is entirely impossible. I ask her if it is 
 impossible, and she says " Yes." It is interesing to note 
 that when I encourage her to say it to herself after I have 
 told her that I am going to say it in my internal language 
 to determine if we reach the end simultaneously, she 
 adopts the conventional attitude and manner, probably 
 thinking that they will prompt the recalcitrant words, but
 
 A rticula tory-Kincestketic Aphasia. 425 
 
 all to no purpose. She is quite unable to read, either in 
 a loud voice or to herself, although she can say a word of 
 what she reads here and there, but words and sentences 
 convey no meaning to her. She takes up the newspaper, 
 cons it carefully, then puts it down with an expression of 
 dissatisfaction and disgust. In other words, there are 
 manifest verbal blindness and profound alteration of men- 
 tal images. There is no trace of hemianopsia. 
 
 When I request the patient to write her name, she does 
 so promptly. When I ask her to write the name of her 
 son, she does so; likewise the street and number where 
 she resides. She is absolutely unable to write spon- 
 taneously. Her capacity to write from dictation Is 
 tested by asking her to write, " When in the course 
 of human events," but she is absolutely unable to 
 do so. The only word that is produced after numer- 
 ous attempts and repetitions of the sentence is the word 
 "When." 
 
 Writing from copy is done without trace of hesitation 
 or error; and when she is asked to copy printed letters in 
 writing she does so with great readiness. 
 
 She comprehends spoken speech, but oftentimes it is 
 necessary to repeat before the meaning of what is said 
 fully dawns upon her. In other words, although there is 
 no word deafness, there seems to be some difficulty in 
 calling up auditory images quickly and readily. 
 
 She has no trace of hemiplegia, unless we call a slight 
 asymmetry of the angles of the mouth an indication of 
 defective cortical innervation, as the right angle of the 
 mouth seems to be a trifle lower than the left. There is 
 no ataxia or inco-ordination of the extremities ; the knee- 
 jerks are lively and of equal intensity on both sides; the 
 pupils react to light and shadow ; there is no tone deaf- 
 ness or object blindness. The urine contains albumin
 
 426 The Faculty of SpeecJi. 
 
 and casts ; the pulse is regular, the arteries are hard and 
 incompressible, and the second sound of the heart is very 
 much accentuated. In other words, she has extensive 
 arterio-capillary fibrosis. 
 
 The interpretation which I put upon the case is as fol- 
 lows : Pathological diagnosis, general arterio-capillary 
 fibrosis, with consequent encephalomalacia of Broca's 
 convolution. Clinical diagnosis, true cortical motor 
 aphasia, articulatory-kinaesthetic aphasia. I need not re- 
 peat that the elicitable symptoms parallelize in every de- 
 tail those which have been proven to be typical of this 
 form of aphasia. The chief deficiency of internal lan- 
 guage seems to be an inability to evoke the articulatory- 
 kinjesthetic images of the word, and this constitutes a gap 
 in the circuit of internal-speech impulses. No more illus- 
 trative case could be cited to show that spontaneous writ- 
 ing and writing from dictation are disordered commensu- 
 rately with voluntary speech in this form of aphasia. 
 Moreover, the case shows with uncommon clearness that 
 a striking degree of verbal blindness occurs with cortical 
 motor aphasia. It is probable that in time this at pres- 
 ent manifest verbal blindness will become latent, and, 
 if the pathological process on which the symptoms are 
 dependent does not progress, that a future careless exami- 
 nation might fail to reveal it. 
 
 In the text I have stated that hemiplegia is almost con- 
 stantly associated with cortical motor aphasia, and that it 
 is dependent upon extension of the lesion to the Rolandic 
 cortex. This case is an exception to the rule, and I ven- 
 ture to believe that it is an important exception, going to 
 demonstrate that Broca's convolution has no direct repre-
 
 Articiitatory-Kin&stketic Aphasia. 427 
 
 sentation in the capsular irradiation, and finally that the 
 products of its activity are not sent directly to be exter- 
 nalized, but are sent to the Rolandic representation of the 
 speech musculature and to the area of representation for 
 other modes of language communication.
 
 NDEX. 
 
 Abstract thought, development of, 55 
 Acoustic sensations, 74 
 Agraphia, S 
 
 early explanation of, 179 
 
 localization of, 26 
 Amimia, in cortical motor aphasia, 
 
 165 
 Amnesia, articulatory, 173 
 
 verbal is, 175 
 Amusia, 259 
 
 clinical forms of, 259 
 Anatomy of the brain, remarks on, 
 
 86 
 
 Aphasia, articulatory kinsesthetic, 
 160 
 
 as a localizing symptom, 362 
 
 associative or transcortical, 15 
 
 classification of, 9, 12 
 
 conception of, 86 
 
 definition of, 3, 6 
 
 diagnosis of, 324 
 
 dynamic forms of, 353 
 
 etioiogical classification of, 347 
 
 etiology of, 343 
 
 history of, 17 
 
 medico-legal aspects of, 47 
 
 morbid anatomy of, 370 
 
 of emission, 7 
 
 of reception, S 
 
 pathology of, 
 
 pedagogical treatment of, 406 
 
 testamentary capacity in, 407 
 
 treatment of, 396 
 Aphasic patient, education of, 404 
 
 Aphemia, 84 
 
 Apperception, definition of, 10 
 
 Apraxia, 293 
 
 Articulate speech, dependency on, 8 1 
 
 during sleep, 117 
 Articulation, mechanism of, 78 
 Articulatory kimvsthetic aphasia, 160 
 
 a case of, 422 
 Articulomoteur, 44 
 Asemia, 2 
 
 Association centres of Flechsig, 107 
 Association fibres, diagram of, 101 
 Association pathways of the brain, 
 
 99 
 
 Asymbolia. 2 
 Asynergia verbale, 21 
 Asynergia verbalis, 1 75 
 Auditif. 44 
 Auditory aphasia, 244 
 
 symptoms of, 247 
 
 variations of symptoms in, 258 
 Auditory apparatus, constitution of, 
 
 75 
 Auditory centre, symptoms of lesion 
 
 Of, 222 
 
 Auditory pathway, development of, 
 
 5i 
 
 Auditory sphere. 
 Autopsy, conduct of, 376 
 
 Brain, fissures of, 88 
 
 Broca, dictum of and hypothesis, 19 
 
 original contributions of, i ~ 
 Broca's convolution location of, 91
 
 430 
 
 Index. 
 
 Ciphers, acquisition of memory for, 
 
 277 
 
 central representation of, 63 
 Color, perception of, 73 
 Concept centre, 288 
 Conduction aphasia, 414 
 Congenital aphasia, 368 
 
 adenoid vegetations in, 369 
 Connection aphasia, 414 
 Cortical and subcortical aphasia, as- 
 sociations of, 215 
 
 differentiation of, 214 
 Cortical motor aphasia, 160 
 
 disorder of writing in, 176 
 
 essential accompaniments of, 
 164 
 
 Diagnosis of aphasia, 324 
 Dynamic aphasia, 353 
 Dyslexia, 278 
 
 due to alcohol, 279 
 
 in motor aphasia, 182 
 
 occurrence of, 132 
 
 Epilepsy, relation of, to aphasia, 
 
 354 
 
 Etiology of aphasia, 343 
 Expressive' reactions, 40 
 
 Fascicular anarthria, 192 
 
 Fissure of Sylvius, kind and appear- 
 ance of, 88 
 relations of, 90 
 
 Flechsig's method of dividing the 
 brain, 379 
 
 Flechsig's theories of localization, 102 
 
 Fossa of Sylvius, 88 
 
 Frontal convolutions, 90 
 
 Frontal lobes, functions of, 46 
 
 General paresis, aphasia in, 368 
 Graphic motor centre, existence of, 
 136 
 
 Hemianopsia, homonymous, in vis- 
 ual aphasia, 264 
 
 Hemiplegia and cortical motor apha- 
 sia, 426 
 
 Hysteria, relation of, to aphasia, 356 
 
 Infant, cries of, 50 
 
 Inferior pediculor-frontal fascicle, 
 
 102 
 Intellectual expression, disorders of, 
 
 I 
 
 Intercentral aphasia, 414 
 Internal capsule, constitution of, 84 
 reading, disorder of, in aphasia, 
 
 131 
 Island of Reil, 89 
 
 Jargonaphasia, 23, 223 
 
 Kinsesthetic memories, registration 
 of, 116 
 
 Laryngeal muscles, cortical repre- 
 sentation of, 125 
 
 Larynx, central representation of, 
 1 20 
 
 Light, 71 
 
 Lips, central representation of, 120 
 
 Localization of speech centre, onto- 
 genetic importance of, 128 
 
 Logagraphia, 8 
 
 Logaphasia, 8 
 
 Medico-legal aspects of aphasia, 407 
 
 Memory residua, 43 
 
 Migraine, relation of, to aphasia, 353 
 
 Mimic reactions, 40 
 
 Mind blindness, associated with word 
 
 blindness, 392 
 
 Morbid anatomy of aphasia, 370 
 Motor aphasia, emotional language 
 
 in, 171 
 general considerations, 153
 
 Index. 
 
 Musical deafness, 259 
 
 Musical memories, allotment of, 93 
 
 Musical sounds, constitution of 76 
 
 Naming centre, 288 
 
 Nerve fibres of the hemispheres, 
 
 myelination of, 87 
 Noises, constitution of, 76 
 
 Object, perception of, 43 
 Olfactory sphere, 105 
 Opercula, divisions of, 89. 
 Optic aphasia, 287 
 Optic nerve, intracranial course of, 
 94 
 
 Palate, central representation of, 120 
 Pantomime, genesis of, 112, 114 
 Paramnesia verbale, 21 
 Pathology of aphasia, 395 
 Pedagogical treatment of aphasia, 
 
 400 
 
 Percepts, genesis of, 57 
 Physiological alphabet, 405 
 Projection centres, connections of, 
 
 1 06 
 
 Propositionizing centre, 289 
 Proust-Lichtheim test, application 
 
 of, 155 
 Psychic blindness of words, 286 
 
 Respiratory muscles, cortical repre- 
 sentation of, 126 
 Responsibility of aphasic patients, 
 
 413 
 
 Revival of words, site of, no 
 Reynaud's disease, aphasia in, 359 
 Righthandedness, determining 
 
 causes of 97 
 
 relations of, to speech centres, 
 95 
 
 Seelenblindheit, 292 
 
 Sensory amimia, 283 
 
 Sensory amusia, 283 
 
 Sensory aphasia, components of, 295 
 definition of, 216 
 disorder of reading in, 249 
 general considerations, 216 
 general features of, 2 1 9 
 subdivision of, 217 
 
 Sensory asymbolia, 283 
 
 Sensory pathways, time of medulla- 
 tion of, 102 
 
 SomEesthetic area, 51, 103 
 
 Speech, analysis of the genesis and 
 function of, 40 
 
 Speech faculty, unilateral represen- 
 tation of, 169 
 
 Speech mechanism, constitution of, 
 
 54 
 
 diagrams of, 45, 47, 49 
 Spelling, psycho-genesis of, 297 
 Subcortical aphasia, distinction of, 
 
 from cortical, 180 
 Subcortical motor aphasia, 192 
 location of lesion of, 198 
 symptoms of, 194 
 Subcortical sensory aphasia, 295 
 Subcortical visual aphasia, symptoms 
 
 of, 295 
 Subcortical word deafness, lesion of, 
 
 393 
 Syphilis in aphasia, 365 
 
 Tactile sphere, 103 
 
 Temporal convolutions, enumera- 
 tion of, 92 
 
 Testamentary capacity in aphasic 
 patients, 407 
 
 Tone deafness, 259 
 
 Tongue, central representation of, 
 120 
 
 Total aphasia, 313 
 
 Toxic aphasir., 358 
 
 Trr.nsitory aphasia, 360
 
 43 2 
 
 Index. 
 
 Treatment of aphasia, remarks on, 
 396 
 
 Verbal blindness, 261 
 Verbal deafness, 244 
 Visual aphasia, 261 
 
 disorder of writing in, 224 
 Visual area, location of, 263 
 Visual centre, location of, 93 
 Visual mechanism, component parts 
 
 of, 70 
 
 Visual memories for form, 74 
 Visual sensation, 70 
 Visual sphere, 105 
 Visuel, 44 
 
 Word blindness, 261 
 
 Word blindness, first use of, 25 
 
 intensity of, 274 
 Word deafness, 244 
 
 accompaniments of, 248 
 
 associations of, 249 
 
 first use of, 25 
 
 Words as phonetic phenomena, 84 
 Writing, development of, 64 
 
 loss of capacity for, in sensory 
 aphasia, 281 
 
 Zone of language, 55, no 
 anatomical basis of, 94 
 blood supply of, 218 
 boundaries and blood supply of, 
 
 343 
 shape of, 98
 
 
 IN1VERS// 

 
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