Aphasia, hemiplegia, and atrophy of paralyzed side. [Reprinted from the Philadelphia Hospital Reports for 1892.~\ 
A CASE OF HEMIPLEGIA ASSOCIATED WITH ATROPHY 
OF THE MUSCLES OF THE PARALYZED SIDE, AND 
ALSO WITH A PARTIAL MOTOR APHASIA, THE 
PATIENT HAYING A GOOD MEMORY FOR SUB- 
STANTIVES, BUT AN ABSOLUTE LOSS OF ALL 
OTHER PARTS OF SPEECH. 
F. X. DERCUM, M.D. 
The following case is placed on record because of the unusual 
features presented in the atrophy of the paralyzed muscles and 
by the aphasia. It is briefly as follows : 
E, J. H., male; aged forty; married; nationality, Scotch; 
occupation, engineer; admitted to the Philadelphia Hospital, 
November 24, 1892. 
Family history.—Negative. 
Previous history.—Has never been sick in bed except when he 
had a carbuncle on his neck some six or eight years ago. Has 
used alcohol moderately; was married eighteen years ago; had 
five healthy children, one of them dying of diphtheria; wife had 
two miscarriages. He himself has had rheumatism and malaria 
at various times, and eight years ago contracted syphilis. Four 
years ago he had gonorrhoea. About a year ago he was rendered 
unconscious for several hours by smoke in a burning building. 
History of present disease.—About eight months ago he began 
to lose power in the right arm and leg. He noticed the weakness, 
and for several days stopped work, and after this made an inef- 
fectual attempt to work again, but was again obliged to desist. A 
night or two later he had an apoplectic stroke; lost consciousness. 
The next day realized that he had lost completely the use of the 
right arm and leg. He was also unable to talk; could not utter a 
single word. He was confined to his bed for some six months. ATROPHY OF THE MUSCLES OF THE PARALYZED SIDE. 
He was finally able to be about in a rolling-chair, but there was 
never any return of power in the paralyzed side. After several 
months he again recovered a little of the power of speech, and this 
ability has slightly increased up to the present time. On attempt- 
ing to read he found he was unable to do so, and this inability per- 
sisted for some seven or eight months. At times he suffered 
severely from headache. 
Present condition ; Motor symptoms.—There is marked hemiple- 
gia of the right side, involving also slightly the lower third of 
the right face. The loss of power is almost complete, the patient 
being utterly unable to walk. Marked contracture is also present, 
the leg being rigid and extended, the forearm Hexed upon the arm 
with marked contracture of the fingers. There is in addition 
marked atrophy of the deltoid, supra- and infraspinatus muscles, 
some wasting of the arm and forearm, and excessive wasting of 
the thenar and hyperthenar eminences. Fibrillary contractures 
can be elicited by tapping on the supra- and infraspinatus muscles. 
The knee-jerks are excessively exaggerated, as is also the elbow- 
jerk, while a blow upon the tendon of the biceps produces a 
marked clonus of the entire arm. The leg presents marked 
rigidity with tendency to extension, and there is also present some 
atrophy of the thigh and leg. The right thigh is 14J inches, left 
thigh 15J inches; the right calf 11 inches, the left calf 11J inches. 
The atrophy of the limbs is well shown in the cut. There is no 
anaesthesia in either leg or arm. In the right hand, however, the 
patient makes constant errors of location, both as regards the fin- 
gers touched, and invariably refers the impression to a point one 
or two segments above. Ho loss of temperature sense. Pupils 
equal and respond to light. Ho other eye symptoms. Tongue 
protruded somewhat towards the right side. Vessels somewhat 
atheromatous. Ho heart murmurs. Second sound, however, ac- 
centuated. Examination of the urine negative. 
His aphasia presents the following peculiarity. When asked to 
detail the history of his early life, he simply strings together a 
number of substantives, such as “ school, marbles, farm, errands, 
engineer, Glasgow, Philadelphia.” He is apparently unable to 
recollect any other parts of speech, with the rare exception of the 
words “ was” and “ make.” The latter he used but once or twice 
in the course of twenty minutes’ conversation. When asked to 
describe how an engine is to be run says: “ Fire, boiler, steam.” ATROPHY OF THE MUSCLES OF THE PARALYZED SIDE. 
3 
When asked to be more explicit, he uses pantomime to indicate 
that he cannot. When asked, “ Could you show me how to run 
an engine?” answers, “Yes,” with emphatic gesture. Further 
conversation with him proves that his knowledge of substantives 
is quite good. He correctly names all objects that are held up be- 
fore him; also, with eyes closed, recognizes objects by sound, as, 
for instance, correctly names a watch on hearing its ticking, or a 
bunch of keys on hearing them shaken. Understands all that is 
said to him. Does not apparently comprehend readily what is 
written. Is able, however, to pick out readily the substantives 
and to pronounce them. On asking him to write with his left 
hand, he does so successfully as regards substantives, but is utterly 
unable to write words of any other part of speech. He is utterly 
unable to write a complete sentence. The result is the same 
whether I dictate a short sentence to him, or whether I give him 
a printed sentence to copy. He is able to write the substantives, 
but none of the other words. 
This condition persisted with little change from week to week, 
until finally on February Ist he passed from under my observation. 
Recently, however, June 27, 1893, I have again examined him. 
His physical condition presents little or no change; however, the 
aphasia has undergone a slight improvement. Ho has acquired a 
few more verbs, such as “ can” and “will,” On the whole, how- 
ever, the progress made has been slight. 
The above case is interesting for two reasons; first, because of 
the unusual atrophy accompanying the hemiplegia, and also be- 
cause of the peculiar character of the aphasia. 
Cases of hemiplegia associated with atrophy of the paralyzed 
muscles are rare. It will perhaps be useless to speculate regarding 
the cause of this atrophy, but the fact that secondary degeneration 
has been so marked would suggest that the degenerative change 
had for some reason involved the cells of the anterior cornua of 
the gray matter of the cord, just as we know happens in that 
other chronic disease of the motor tract, amyotrophic lateral 
sclerosis. Regarding the initial lesion, it is very probable that it 
was due to a thrombus or embolus rather than to a hemorrhage. 
The marked and persistent character of the hemiplegia, with the 
absence of all recovery, together with the degeneration of the blood- 
vessels and the accentuation of the second sound of the heart, 
would suggest this as the most plausible explanation. The very 4 
ATROPHY OF THE MUSCLES OF THE PARALYZED SIDE. 
curious aphasia, in which the rather unusual condition was present 
of the persistence of the memory of nouns to the exclusion of all 
other parts of speech, may perhaps be explained as follows : It is 
not improbable that in the anterior portion of the third frontal 
convolution we have situated the memory for nouns. May it not 
be that in this case an embolus occluded all the branches of the 
middle cerebral supplying the motor area, and also the posterior 
portion of the third frontal convolution, while the anterior portion 
escaped? That not all of the motor speech centre had been de- 
stroyed is, of course, evident from the fact that the loss of words 
was incomplete. The fact that nouns only were retained would 
suggest that a portion whose exclusive function was the memo- 
rizing of this part of speech had been preserved.