APHASIA 
AND OTHER AFFECTIONS OF SPEECH, 
IN SOME OF THEIR MEDICO-LEGAL 
RELATIONS, STUDIED LARGELY 
FROM THE STANDPOINT OF LOCALI- 
ZATION. 
By Charles K. Mills, M. D., 
Professor of Diseases of the Mind 
and Nervous System in the Phila- 
delphia Polyclinic; Clinical Pro- 
fessor of Nervous Diseases in the 
Woman’s Medical College of Phila- 
delphia ; Lecturer on Mental Dis- 
eases in the University of Penn- 
sylvania ; Neurologist to the Phil- 
adelphia Hospital. 
Reprint from The Review of Insanity and Nervous 
Disease for Sept, and Dec. 1891. APHASIA 
AMD OTHER AFFECTIONS OF SPEECH, IN SOME OF THEIR MEDICO- 
LEGAL RELATIONS, STUDIED LARGELY FROM THE 
STANDPOINT OF LOCALIZATION. 
Charles K. Mills, 'M. D., 
Professor of Diseases of the Mind and Nervous System in the Philadelphia Poly- 
clinic ; Clinical Professor of Nervous Diseases in the Woman’s Medical 
College of Philadelphia; Lecturer on Mental Diseases in the 
University of Pennsylvania ; Neurologist to the 
Philadelphia Hospital. 
For many years, and especially since Broca in 1861 located 
the seat of articulate language in the left third frontal 
convolution, aphasia and other affections of speech from 
disease of the brain, have received the close attention of the 
ablest physicians interested in the nervous system and its 
diseases. For a long time the eyes of these observers and 
investigators were too intently fixed on the convolution of 
Broca, and in consequence, advance in the comprehension 
of the nature of speech and its disorders was much retarded ; 
but their view enlarged; and experiment, clinical study, 
and well recorded autopsies, soon showed that the faculty of 
speech could not be limited to a single small centre or area 
in the motor region of the brain, but that large zones, or a 
complexity of centres, both on the receptive and the emissive 
sides of the cerebrum, must necessarily be concerned. Since 
even the partial recognition of this truth the literature of 
the pathology and mechanism of speech has been rapidly 
enriched; and our understanding of aphasia and affection? 4 
APHASIA. 
[Sept.,. 
of speech in general, not long ago clouded by narrow or 
biased views as to localization, has become clearer and more 
practical. 
The nations speaking the three great languages which 
dominate the world—English, French, and German—have 
each contributed a fair share of facts and theories to 
elucidate the interwoven problems of mind and speech; 
and every physician practically interested in these prob- 
lems—for the ends of ordinary diagnosis and treatment,, 
for the purpose of surgical operations, for expert work in 
the courts or elsewhere—should know something of the 
published work of the Ogles, Broadbent, Bastian, Bateman. 
Wilks, Gairdner, Ilughlings-Jackson, Eerrier, and Ross; of 
Hun, Seguin, Wilbur, Amidon, Putnam-Jacobi and Starr; of 
Broca, Trousseau, Baillarger, Bernard, Falret, Legrand du 
Saulle and Charcot; of Spamer, Wernicke, Kussmaul,. 
Kahler, Pick, Benedikt, Berlin, and Wilbrand. 
In spite of tlie achievements of these and others, much 
with reference to the nature of speech remains to be learnedr 
and not a few important points are yet in dispute, but 
knowledge of the subject is now sufficiently systematized 
and certain to promise some success in shaping it to such a 
practical purpose as the solution of questions of mental 
capacity and competency in those who suffer from speech 
deprivation or disorder. The medico-legal aspects of apha- 
sia and of other affections of speecli have not escaped inves- 
tigation and discussion, but they have received but little 
attention from English and American writers, and compared 
with the immense literature of the general subject of 
aphasia, but little from the writers of other nations. Much 
of the work which has been published has been in the 1891.] 
BY CHARLES K. MILLS, M. D. 
nature of a record, with comment, of particular cases which 
have come before a court or other tribunal; and in few, if 
any, of these contributions, has any systematic effort been 
made to separate the now well recognized forms of aphasia 
into classes for medico-legal purposes. I will, however, 
briefly refer to some of the most important contributions to 
this meagre literature of the jurisprudence of aphasia. 
In a few of the valuable papers dealing with the general 
phenomena and mechanism of speech, important medico- 
legal points are developed in a casual or incidental manner, 
as in the writings of J. Hughlings-Jackson, Charcot,2 
Lichtheim,3 and Ross,4 and to some of these reference 
will be made in the course of this article. In the second 
edition of Bateman’s treatise on aphasia, a new chapter on 
the jurisprudence of aphasia is introduced, in which some 
original observations are given, and references are made to 
the work of French and German authors. 
Bateman5 .cites some cases of interest. In 1843, for exam- 
ple, a resident of Munden, Hanover, applied to the govern- 
ment for permission to make a will in favor of his wife by 
signs, and the court acknowledged the validity of the act. 
Another apliasic for five years discharged the functions of 
mayor and municipal councilor, by writing his name to 
necessary documents with his left hand. In the same way 
he also wrote a holographic will which was sustained. 
These and other cases are also referred to by Legrand du 
Saulle. Bateman refers td several cases in which the wills 
of deaf mutes were recognized as valid by the court, because 
1. Hughlings-Jackson: Brain, October, 1878. and July and October, 1879. 
2. Charcot: Le Prog. Med. 1884, and Med. Piess and Circ., London, 1884. 
3. Lichtheim: Brain, January, 1885. 
4. Boss: Aphasia, etc., J and A. Churchill, London, 1887, and Wood’s Medical 
and Surgical Monographs, New York, 1890. 
5. Batein->n: On Aphasia, etc., by Frederic Bateman, M. D., London, J. and A. 
Churchill, 1890. 6 
APHASIA. 
[Sept., 
it was proved that they understood the contents of the will 
either through gesture and pantomime alone, or by these and 
written language combined. He also records the case of a 
man, 63 years old, who was engaged to be married and was 
suddenly seized with right hemiplegia and aphasia, and wish- 
ed to make a will in favor of the lady whom he intended to 
make his wife. The document was written by one of his med- 
ical attendants. The testator’s mark was made and, the will 
was attested by witnesses. 
He communicated his wishes as follows : 
“ He made signs for writing materials; his wishes were in- 
terpreted by means of signs and then written down on a 
card. He held up his hand, extended his five fingers, and 
he was asked if he meant ‘thousand,’ he bowed assent. He 
then closed his hand and opened it in the same way, imply- 
ing ten; this operation was repeated until it amounted to 
thirty, and then he dropped his arm down. Testator was 
then asked whether he wished Miss R. to have thirty 
thousand pounds, and he nodded his head. In order that 
there might be no mistake about his wishes as to details, he 
was asked whether Miss It. was to have this sum absolutely; 
he signified dissent, but on being asked if it was to be hers 
for life and afterwards revert to his family, he bowed his 
head.” 
Unfortunately the testator’s mark was made in the 
middle of the card instead of at the bottom or foot, and so 
did not satisfy the provisions of the statutes relating to 
wills, and the testament was therefore refused probate. 
Little escapes the novelist, and of the guild of roman- 
cers, few have equalled the elder Dumas in the frequent 
and skilful use of history and science. In the “Count 1891.] 
BY CHARLES K. MILLS, M. D. 
of Monte Christo” is an interview with a motor aphasic 
which might have answered as testimony in court in 
a case in which the question was that of testamentary 
capacity. The old Bonapartist, Noirtier, paralyzed and pro- 
foundly aphasic, angered at his son and daughter-in-law, 
determines to change his will. His son, his granddaughter, 
and his old servant, could understand and communicate 
with him through an arranged system of signs—by his 
closing his eyes for “ yes,” by winking them when he meant 
“ no,” and when he had some desire or feeling to express, by 
looking upwards. He signifies his desire for a notary, by 
indicating to his granddaughter, who recites to him all the 
letters of the alphabet, that he wishes, “ n ” and “ o” in suc- 
cession, then with -a dictionary he picks out the word 
“ notary.” The notary at first refuses to incur the responsi- 
bility of making a will for one whose wishes he may not be 
able to understand, but having been shown that the aphasic 
does understand what is said to him and can communicate 
by pantomime, he becomes interested in drawing up the legal 
document, and asks for a brother notary to be brought, in 
order that the will if contested may have the greatest possi- 
ble evidence of its authenticity. The two notaries read the 
formal copy of the will, and then test Noirtier by much the 
same method as Bateman relates was employed in the case 
above cited. Several sums are named before the aphasic, 
who signals “no” until the question is asked, “Do you 
possess 900,000 francs?” In answer to this he closes his 
eyes in assent. He finally succeeds in making a will, of 
the validity of which the notaries are thoroughly satisfied, 
although other characters in the story are not equally satis- 
fied with its contents. 8 
APHASIA. 
[Sept., 
At the meeting of the British Medical Association, at Leeds 
August, 1889, in a discussion of the jurisprudence of apha- 
sia introduced by Dr. Bateman, Dr. Drysdale, of London, 
cited the case of a celebrated civil engineer who had right 
motor paralysis and aphasia, but who wrote his own checks, 
copying them from a former signature of his own, and 
who for many years was a senior partner of the firm. His 
partners, however, did all the work. In this case the 
gentleman retained enough intelligence to play whist with, 
the cards spread out before him, and left a will which was 
not contested. Professor Gairdner at a former meeting of 
the British Medical Association, had mentioned the case of 
a Scottish judge affected with aphasia, who had continued 
in office for some years, and sat on his bench while suffer- 
ing from a form of this malady.1 
Legrand du Saulle,2 in a course of lectures delivered at 
L’iicole Pratique de Paris, in 1868, discussed, among other 
things, the testamentary capacity of aphasics, quoting in- 
stances of the serious difficulties which may arise in making 
a will. 
At La Salpetriere Hospital, in 1882, Legrand du Saulle* 
delivered another course of lectures upon “ Aphasia and 
phasics,” considered from various points of view. These 
lectures, twelve in all, were also published in the Gazette 
des Hopitaux, and about one half of them dealt with matter 
which either directly or indirectly bears upon the jurispru- 
1. New York Med. Ree., September 28,1889, p. 360. 
2. Legrand du Saulle : Gazette des Hopitaux. June and July, 1868. 
3. Legrand du Saulle: Gaz. des Hop., Paris, Voi. LV. 1882. 
Legrand du Saulle in this series of lectures refers in several places to other 
French writers on the mental and medico-legal relations of aphasics. The chief 
of these references are as follows: 
Ch. Sazie: Troubles inteilectuelsdans L’aphasie. Th., Paris. 1879. 
Finance: Etat mentale des aphasiques. Considerations mddico-legales, Th., 
Paris. 1878. 
Legrand du Saulle: Etude mfidico-legale sur i’interdiction des alidnes et sur 
le conseil judiciaire. Paris, 1881, p. 212. 
J. Lefort: Remarques sur l’interdiction des aphasiques. (Bulletin de la 
Soci6t6 de medicine de France.) 1891.] 
RY CHARLES K. MILLS, M. D. 
9 
dence of aphasia. To some of his conclusions I will briefly 
refer. He holds that when the lesion of aphasia is 
•confined exclusively to the left third frontal convolution, 
intellectual disturbance is slight; but according as it has 
•extended to the motor zone, or to the prefrontal region, will 
paralysis, or disorders of the intelligence appear. He 
shows that most aphasics have a certain measure of de- 
mentia as well as paralysis, but the intellectual disorder 
■observed in aphasics is most variable, sometimes not inter- 
fering with the important events of life, at others so wreck- 
ing the intellectual faculties as to cause mental incapacity 
and irresponsibility. The general disorders consist of ex- 
citement or depression; the partial affections, of defect of 
attention, incoherence, hallucinations, or delirious concep- 
tions. Impatience and anger are common among aphasics, 
whose moods are very changeable. The want of attention 
is one of the most marked traits of aphasia. Memory and 
recollection are less alert, and some aphasics exhibit decided 
loss of memory. Legrand du Saulle insists that aphasia is 
compatible with intelligence, but that this is always more 
or less weakened by the loss of language. If the brain 
lesions are extended and multiple, pronounced weakening, 
and even abolition of memory may be observed. Incoher- 
ence of ideas when present is not by any means on a par 
with incoherence of language. To lesions of the prefrontal 
regions he relates the loss of memory and attention, the 
incoherence, hallucinations, and delirium—probably only a 
partial truth. He speaks of hallucinations as frequent 
among aphasics, the most common being those of hearing 
and sight; sometimes these hallucinations are of a 
character that may lead to a crime, or may make the apha- 
sic suspicious of others. 10 
[Sept., 
APHASIA. 
Legrand du Saulle admits three categories of aphasics, 
those in whom intelligence is intact, but slightly touched ; 
those in whom it is manifestly changed, and those in whom 
it is entirely abolished. A physician called to give an 
opinion on an aphasic should give attention to the smallest 
particulars as to his state. He has need also of all of his 
care and knowledge in scrupulously reviewing all the 
different forms of language employed by an aphasic. It is 
always well to make the patient count, to ask his age, to 
test him with money, etc. Legrand du Saulle gives in- 
structive cases bearing upon these methods of examination. 
He further considers in different lectures some of the 
most important questions of a medico-legal character pre- 
sented by aphasics—their obstinancy to suggestions, their 
tendencies at times to injustice to their families, their com- 
paratively rare implication in criminal offenses, their re- 
sponsibility when accused of crime, the necessity at times 
of restraining them in asylums and hospitals, the principles 
and practice of the law with reference to their interdiction, 
their right to enter into marriages, and their testamentary 
capacity. His lectures contain many facts and suggestions, 
observations of cases, and valuable references to French 
law—but in the main they deal with aphasia and aphasics 
from a general standpoint, and not with reference to the 
special changes in mental integrity, which depend some- 
times upon the varying sites of lesions. 
Gallard1 in a volume of clinical lectures, delivered at La 
Pitie, has one chapter on aphasia and apliasics discussed 
from the medico-legal point of view. He recounts, after the 
manner of Legrand du Saulle, points of French law in con- 
1 Gallard: Clinique mcSdicale de la Piti6 par M. le docteur Gallard analyzed 
in le Journal deMddicine et de Ciiirurgie Pratiques, Yol. xlviii, p. 377-330. 1891.] 
BY CHARLES K. MILLS, M. D. 
11 
nection with aphasics. The conclusions arrived at with 
reference to the interdiction of aphasics are: (1) If the 
intelligence of the aphasic is completely obliterated, or, if in 
preserving his lucidity he cannot manifest it by written 
language, pantomime, or speech, he should be interdicted ,* 
(2) if the intelligence of the aphasic not being completely 
alienated, has not all its brightness, and can only be incom- 
pletely manifested, he should be provided with a judicial 
counsel; (3) if the aphasic possesses his intelligence, and 
if he can manifest it sufficiently, whether by word, by 
writing, or by signs, he has no need of judicial protection, 
and should be free to manage himself and his affairs. 
Bateman refers to a communication by Professor Jolly, 
read at a Congress of German alienists, held at Carlsruhe, 
on the capacity of aphasic persons to testate, with a critical 
analysis of the views of German medical jurists upon this 
point—but I have not been able to obtain the original paper. 
The Parish will case is perhaps the most famous medico- 
legal case in this country in which the question of the 
mental power of an aphasic was the main point at issue. 
Henry Parish made his first will when 54 years of age,, 
and the next year had a slight apoplectic attack from which 
he soon recovered. Seven years after making his will he 
had another severe apoplexy which left him for the rest of 
his life, about seven years in all, paralyzed in his right 
limbs, and with the power of articulation lost. After this 
second seizure he also had at intervals epileptic fits. The- 
codicils to his will were contested. The first was made 
about six weeks and executed about five months after the 
severe apoplectic attack; about four years later, a second 
codicil, and about five years after this, a third was mado 12 
APHASIA. 
[Sept., 
The surrogate admitted the first codicil and excluded the 
others. The supreme court and the court of appeals decided 
against all three. The trial of this case was a notable one’ 
and eminent physicians were employed on both sides. Dr. 
Isaac Ray, who was one of the medical experts, testified in 
opposition to Mr. Parish’s testamentary capacity, and has 
contributed a valuable paper on the case.1 
The William T. Beven case is another interesting Amer- 
ican case, reported by Dr. C. H. Hughes.2 Mr. Beven had 
been stricken with right hemiplegia and aphasia, probably 
due to embolism, as he had a cardiac valvular lesion. He 
became defendant in a suit for the recovery of money on a 
Meed of trust, signed by himself with his left hand when he 
was aphasic, four months after his first apoplectic seizure, in 
1873. This deed of trust had been made in fulfilment of a 
promise and purpose entertained before his attack. It was 
against the interest of members of his family that this deed 
-should be allowed to stand, and evidence was adduced to 
prove that he was insane at the time that the deed of trust 
was made. Just before, and about this time, his two sisters 
and brotliers-in-law testified that he did certain things 
which they regarded as evidences of insanity, such as wiping 
his nose on a napkin, bowing to pictures in the parlor, 
unbuttoning his drawers when ladies were in the room, 
striking his mother with a stick, becoming violent and 
angry when the battery was applied, and making grimaces 
before the glass. Dr. Hughes, three years after the attack, 
found that he was suffering from incomplete paralysis of 
motion on the right side and general anaesthesia; that he 
understood oral signs, and tardily and imperfectly written 
1. Ray: Contributions to Mental Pathology. 
2. Hughes: Amer. Jour. Insanity, Vol. xxxv, Jan., 1879, p. 410. 1891.] 
BY CHARLES K. MILLS, M. D. 
•ones; that lie recognized the doctor’s name and wrote his own 
name and that of his attorney and of the doctor; that he 
-either had, or feigned, defective vision, and also impaired 
hearing in the left ear. He had had three paralytic strokes 
altogether, but had grown steadily better. Dr. Hughes 
analyzed the various facts which were brought forward as 
•evidences of his insanity and decided in favor of his 
-competency. 
The recorder of this case, Dr. Hughes,1 has also written a 
paper—the only American contribution of the kind of which 
I have knowledge, although others may have been published 
—on the medico-legal aspect of cerebral localization and 
aphasia. This article reviews the varieties of aphasia with 
some consideration of the lesions causing them, and also 
•considers to some extent the effect of simple and complicated 
aphasia on the judging, comparing, expressing, and other 
faculties of the mind, citing various athorities in support of 
his positions. He refers to a number of the tests of an 
•aphasic’s mental integrity which have been suggested. 
Affections of speech, not aphasias, are also to some extent 
-considered. The Parish case and Beven case, and also the 
Lawler case, which has been put on record by Bartholow, 
are referred to by the writer. Problems arising from a con- 
sideration of the different forms of motor and sensory 
aphasia are not discussed. 
Ray,2 in his text book, as well as in the monograph on 
the Parish case, has given some attention to the medical 
jurisprudence of aphasia, relating several interesting cases. 
The Fillmore will case, reported by Dr. Landon C. Gray,3 
is one which has attained considerable celebrity in this 
1. Hughes: Alienist and Neurologist, Vol. 1, April and July, 1880. 
Hay: Medical Jurisprudneee of Insanity. 
3. Gray: American Jour. Neurology and Psychiatry, Vol. Ill, p. 549. 14 
APHASIA. 
[Sept.,. 
country, both because of its intrinsic interest, and of the distin- 
guished position of the parties concerned. Mrs. Caroline C. 
Fillmore, widow of the ex-President of the United States,, 
in 1877, three years after the latter’s death, began to show 
changes in her character, soon becoming coarse, profane,, 
suspicious, and delusional. She was stricken with hemiplegia. 
She made two wills, the first eighteen months after the changes 
in her character were first noted, and nine months before 
the paralysis; the second will or codicil was made five months 
before this stroke. She developed a form of aphasia and 
showed not only this speech disturbance, but a combination 
of symptoms of general mental impairment. Di\ Gray and 
others testified that she was insane and incompetent. 
It will be seen from this hasty glance at the scanty litera- 
ture of the subject, that the medico-legal questions which may 
arise in connection with the study of apliasics are somewhat 
numerous, although they are by no means all embraced in, 
this review. They include many of those which the insane 
also present for solution, but with others especially belong- 
ing to the aphasias. At the outset it should be borne in, 
mind that we are not dealing with some clearly defined 
entity called “aphasia.” It is not possible to fix upon any 
general standard of capacity or responsibility for one suffer- 
ing from an affection simply labeled “ aphasia.”. Even 
correctly labeling an individual as insane does not decide 
as to his capacity to have certain privileges) or to do, or not 
to do certain acts, for example, to have his personal liberty, 
or the control of his estate, to get married, or to make a will. 
In a practical, as well as in a philosphical sense, questions of 
sanity and insanity are relative, and so likewise are those 
presented by apliasics. They will depend not only on the 
form of the disorder, but also upon its degree and special- 
characteristics in a particular case. 1S91.] 
BY CHARLES K. MILLS, M. D. 
15 
“ The affections of speech met with are very different in 
•degree and kind,” says Iiughlings-Jackson,1" for the simple 
reason that the exact position of disease in the brain and its 
gravity differ in different cases; different amounts of nerv- 
ous arrangements in different portions are destroyed with 
■different rapidity in different persons. There is, then, no 
single, well defined ‘entity’—loss of speech, or aphasia—and 
thus, to state the matter for a particular practical purpose, 
such a question as, ‘Can an aphasic make a will?’ cannot 
be answered any more than the question, ‘ Will a piece of 
string reach across this room?’ can be answered. The 
question should be, ‘ Can this or that aphasic person make 
a will?”’ 
These medico-legal questions may be either criminal or 
■civil, although they are much more frequently the latter. 
Legrand du Saulle says truly that it is rare for aphasics to 
be implicated in major crimes; their habitual infirmity to 
a certain extent saving them from these. Aphasics, however, 
as all who have had to do with them know, are much given 
to impatience and anger; their moods are uncertain and 
changeable, and occasionally dangerous. • They have been 
charged with thefts, and have been implicated in other 
crimes. One remarkable case is referred to by Legrand du 
Saulle. An aphasic and hemiplegic was charged with kill- 
ing his wife; and the case had not only this criminal aspect, 
but later a civil question, that of the disposal of his and of his 
wife’s property arose. The parties had been married with- 
out a contract, and had no children, and each had left to the 
survivor the whole of his or her property. Attempts were 
made to nullify the donation of the wife on account of 
ingratitude, as shown by the assassination, but against this 
1. Jackson: Brain, October, 18T8, p. 314. 16 
APHASIA. 
[Sept., 
it was urged as the man had been pronounced irresponsible- 
he could not be an ingrate. In the end, however, the dona- 
tion was anulled and went to the wife’s heirs. 
Evidently whether or not an aphasic should be exonor- 
ated from the consequences of a crime, is a vital matter, and 
in some cases should be decided on the same principles that 
would govern the decision in a case of alleged insanity, but 
these might not always suffice, and the presence of the 
aphasia, and its form, might need to be particularly consid- 
ered in arriving at a correct conclusion. Many aphasics 
suffer to a greater or less extent from various special forms- 
of mental diseases, the degree of which may be dependent 
somewhat on the location of the lesion causing the speech 
disturbance, or on the extent to which the aphasic lesion 
has extended beyond the speech centres, or, again, it may 
be entirely independent of the aphasia. The lesion which 
causes aphasia, as is well known, in addition usually pro- 
duces a certain, and it may be a large degree of paralysis, 
and less frequently also various sensory disorders. The 
greater the accompanying disease, even though it be of 
physical type, the more likely is it that the mentality of 
the patient will suffer, although this statement must be 
qualified somewhat by the direction which the lesion has 
taken. M. Sazie tells of an aphasic who had anaesthesia of 
his limbs, and who believed that his legs had been ampu- 
tated, and Legrand du Saulle speaks of monomania, 
melancholia, hypochondria, and of impulses to drunkenness, 
suicide, or even homicide among aphasics; everyone who 
has had much experience with aphasics can recall such cases, 
but we must remember, with the above author, that these 
are disorders occurring among aphasics, not a part of the 
aphasia. Recognizing the importance of such facts as these, 1891.] 
BY CHARLES K. MILLS, M. I>. 
17 
and remembering also that aphasics who are not in anyjust 
sense insane, are often greatly misunderstood, it follows that 
the committal of an aphasic to ail insane asylum may some- 
times be a serious question for decision, and might eventu- 
ally lead to a criminal or civil suit. 
Kussmaul1 refers to the fact the word-deaf, possessing at 
the same time the ability to express themselves in words, 
but misplacing and often distorting them, leave the im- 
pression that they are crazed, and he warns the observer to- 
avoid this error, and also the greater one of regarding the- 
patient as both deaf and demented. He cites several inter- 
esting cases—one reported by Baillarger, who demonstrated 
that a woman who had been regarded as both deaf and de- 
mented, was really neither the one nor the other; another 
of Wernicke’s of a paraphasic patient at first supposed to- 
be deaf and crazy. 
An interesting case of aphasia complicated with insanity 
has been reported by Bancroft.2 This patient was an in- 
mate of the New Hampshire Asylum for the Insane. In. 
1872, he had an attack of loss of vision and right sided 
numbness; in 1876, he had another attack which caused in- 
distinctness of articulation, and some disorder of vision;, 
and a week later he was seized with loss of speech, marked 
mental confusion, and apparently a temporary loss of vision. 
His mind, it is recorded, was filled with all sorts of insane 
fancies. The details of the case are well given; it is one of word- 
deafness, with also some word-blindness, and paraphasia, 
although the writer is evidently not familiar with the varieties 
of aphasia. After some months the patient was discharged 
and sent home, but in a short time was readmitted to the 
1. Kussmaul: Zieinssen’s Cycl. Pract. Med., American ed., Yol. XIV, p. 773. 
2. Bancroft: Boston Med. & Med.. Surg-. Jour., Yol. CIV, No. 21, May 36, 1881, 
p. 483. 18 
APHASIA. 
[Sept., 
asylum; because when at home he developed all manner of 
eccentricities, and insisted on doing all things as he chose, 
even using threats of violence. Nearly two years later he 
died in the asylum, valvular disease of the heart having 
been in the meantime discovered. An autopsy was made, 
but for localization purposes is not well detailed. The 
third frontal convolutions were untouched; but lesions are 
described as present in the anterior portion of the middle 
lobe of both hemispheres, but much smaller on the left 
than on the right. Doubtless this patient was properly 
committed, but the effects of his sensory aphasias on his 
mental state may not have been fully considered. 
Among the civil questions which arise in connection with 
aphasics perhaps first in importance is that of testamentary 
capacity, and such allied questions as their competency to 
make deeds of trust or conveyance, to sign powers of attor- 
ney, promissory notes, due hills or checks, to make contracts, 
or to manage any business involving speaking or writing. 
As has been already shown, attacks on their compe- 
tency to make wills or deeds of trust have given rise to some 
of the most interesting legal contests that have been fought 
in this or other countries. 
The marriage of aphasics has been'considered by Legrand 
du Saulle. According to the French law—and the laws of 
other nations are probably much the same—dementia is 
the only thing that interdicts marriage; the presence of 
aphasia is not considered sufficient reason to prevent it. 
Signs are recognized as available to signify consent; but it 
may be necessary to decide as to the true signification of 
the pantomime and gestures employed by an aphasic. The 
question is, whether the husband or wife at the time of the 
marriage had a sufficient degree of intelligence to realize 19 
BY CHARLES K. MILLS, M. D. 
the act, and whether it wa£ of his or her own will. An in- 
teresting case is given of an aged aphasic and hemiplegic 
widow, who, having fallen out with her daughter, contracted 
a second marriage against the wishes of her family. 
I was once called to testify before a register of wills re- 
garding a man whom I had seen in consultation several 
weeks before his death. This man had lived for many 
years with a woman who was not his wife, but by whom he 
had several children. By many he was supposed to be 
legally married to the woman. He was stricken with right 
sided paralysis and partial aphasia; but I found him cap- 
able of answering questions, and of reading a little consec- 
utively. I saw him twice before his death, and between 
my two visits he was married to the woman with whom he 
had been living. The granting of letters of administration 
to his wife was resisted by some of his relatives, who claimed 
that undue influence had been used, and also that he was 
not in a state of mind to know what he was doing. The 
main question was whether the man knew what he was 
doing when he was married, and whether he showed this 
by his speech and acts. After hearing the testimony the 
register gave letters of administration to the wife and the 
case was dropped. 
The question of interdiction may come up for decision 
when an aphasic is alleged to be insane; and the decision 
may result as in the case of the insane not aphasic, in the 
patient going to an insane hospital, or of being put simply 
under the control of a committee or of a guardian. 
Other questions may be of the alleged malingering of 
deafness or deaf mutism by a criminal, a soldier, or an 20 
APHASIA. 
employe wishing to shirk duty. ,An apparent aphasia may 
of course also be one of the phases of an alleged hysteria. 
Occasionally aphasia, the result of traumatism, may have 
a decided medico-legal importance, as in litigation because 
of injuries resulting among other things in aphasias; and 
again, the ability of an apliasic who has been injured with 
criminal intent, to recognize an alleged assailant might be 
questioned. 
In various well known forms of insanity, as paretic de- 
mentia, monomania, katatonia, confusional insanity, mania 
or melancholia, the peculiarities of the speech disorders 
belonging to the affections may assist in the early or late 
diagnosis of such cases, and may thus have a bearing upon 
such legal matters as necessity of restraint, relief from 
responsibility, or discharge after recovery. 
It is not possible to establish fixed rules by which the 
capacity, competency, or responsibility of aphasics can be 
measured. This in given cases is largely a matter for judi- 
cial decision and technical interpretation of the law. In 
all civilized countries, and in different states of a country 
like our own, the administration of the law with reference 
to such matters as wills, deeds of trust, civil contracts, 
restraint in asylums, and particular crimes, whether relat- 
ing to aphasics or others, is based upon precedents, and 
upon legislative and other enactments. These may some- 
times, or in some particulars, be at variance with what is 
just and equitable from a medical or lay point of view. 
The object of a paper like the present is to show the 
methods of gauging the mental status of those affected with 
disorders of speech, which mental status, from the medical 
point of view, would be the criterion of competency and BY CHARLES K. MILLS, M. D. 
21 
responsibility; but such studies might lead us to the conclu- 
sion that a testator in a certain case was competent to make 
a valid will, although his testament might not be sustained 
by a court because of a technical violation—whether due or 
not to the patient’s disorder—of a provision of the law. 
In the case already referred to, cited by Bateman, an aplia- 
sic evidently knew what he wished to do, and his meaning 
was evidently correctly interpreted by others, but because he 
had made his mark in the middle of the paper written for 
him instead of in the position called for by the statute, the 
instrument was held as not properly executed and probate 
was refused. In this case conjoined medical and legal invest- 
igation indicated the just course, which, however, could not 
be followed because of a peculiar statute. 
The French law recognizes three kinds of wills—that by 
public act before notaries and witnesses; the holographic 
will, or that written by the testator’s own hand unguided by 
another; and the secret will (testament mystique.) The secret 
will may be written entirely by the hand of the testator like 
the holographic will, or be written by another person and 
only signed by him. It is then given in charge of a notary 
in presence of a stated number of witnesses, who counter- 
sign the envelope, and close and seal it; and upon this the 
testator writes, or causes to be written, that this is his will 
duly signed by him. Thus if the writing and signing of 
this will is illegible or difficult to read, this act acquires the 
value even of a holographic will. (Gallard.) 
Under even these, or similar laws, an apliasic who, medically 
speaking, might be entirely competent to do certain acts, as 
could be determined by careful medical examination, would 
be shut out from carrying out his own recognizable wishes. 22 
APHASIA. 
Even expressive and correct pantomime would not suffice in 
such a case. Cases of this kind are mentioned by Legrand 
du Saulle and others. 
I am not, however, concerned in this paper with the appli- 
cation of the facts of science to exact statutes and decisions, 
but rather with the consideration of the various degrees of 
preservation of mental integrity by those suffering from 
aphasia and other affections of speech, and the discussion of 
the direct or indirect bearing upon various medico-legal 
questions of such affections. 
It is not written solely for alienists and neurologists, but 
for all who may be interested in tlie problems witli which it 
deals; still it will be necessary to take for granted a consider- 
able knowledge of aphasia and other speech disturbances, or 
otherwise the article would be extended to extreme length, 
and the special subject for consideration would be lost in a 
labyrinth of explanations. It will be necessary, how ever, at 
the risk of being too elementary for some of my readers, to 
define certain terms and to give a few of the most important 
facts with a reference to the nature and mechanism of speech 
and its disorders, and also regarding the sites of lesions pro- 
ducing aphasias and infra-cortical speech defects, in order to 
make clear the subsequent treatment of the subject which 
will be largely from the standpoint of localization. While 
it is impossible to make explicit statements with reference 
to the mental status—or legal status which is sometimes a 
very different matter—of aphasics, basing such statements 
upon the location of a lesion in a certain centre, zone, or 
commissure, something can be done in this direction, and 
one object at least, is to show how far capacity and compe- 
tency may be influenced by the site of an aphasia-producing 
lesion. BY CHAKLES K. MILLS, M. D. 
23 
Before the term aphasia was fully engrafted upon medical 
nomenclature, and to some extent since, numerous other 
terms have been used to describe disorders of speech from 
cerebral disease. Alalia was employed by Lordat in the 
same general sense afterwards accorded to aphasia, but it is 
now not used or restricted to the meaning given it by Kuss- 
maul, that is, an entire inability to utter articulate sounds, 
ranking it under the heads of losses and defects of enuncia- 
tion. Aphemia has also been used by Broca and others for 
cerebral speech disturbances in general. Ross still uses it to 
describe the commonest form of motor aphasia, the loss of 
the power of communicating thought by articulate words; 
but Bastian has suggested that apliemia be confined in its 
definition to defects of speech from lesions of those fibres 
which connect the motor, or as he would say “ kinaesthetic ” 
centres, of the cerebrum, with the nuclei of the bulb. 
McLane Hamilton has suggested asemasia, which means an 
inability to communicate by signs or language, and etymo- 
logically this is one of the best names to describe the affec- 
tions of speech, writing and pantomime, whether loss or 
defect, from disease of the brain; but as Huglilings-Jackson 
has said, it is too late to displace the word aphasia, which 
will be used in this paper in its commonly accepted and 
general sense to indicate cerebral loss or defects both in 
language and signs. 
Formerly the terms ataxic aphasia, and amnesic aphasia 
were employed almost universally, and these expressions are 
retained by high authorities. Ataxic aphasia has been used 
to describe the aphasia of common type resulting from 
lesions of Broca’s convolution and the immediately adjacent 
region, on the supposition that the affection of speech is an 24 
APHASIA. 
inability or incapacity for the motor co-ordination of words; 
but as it is a matter of dispute whether the affection should 
not be regarded as paralytic, or even sensory, rather than 
ataxic, it is best not to continue the use of this expression. 
Amnesia is loss of memory, and amnesic aphasia is the term 
which has been applied to those affections of speech which 
are the result of lesions on the sensory, or receptive side of 
the brain. Kussmaul defines amnesic aphasia as the inca- 
pacity for the recollection of words as acoustic aggregates of 
sound; but objections have been also urged to this term 
based upon theoretical considerations. 
Disregarding for the present differences of opinion of 
almost equally high authorities, the best practical subdivision 
of the aphasias is into sensory or receptive, and motor or emis- 
sive. Bastian holds that all forms of aphasia are in effect 
sensory regarding the centres for speech and writing usually 
termed motor, as kinaesthetic, that is, sensory centres con- 
cerned with the registration of muscular sense impressions 
derived in the one case from the organs of articulation, and 
in the other from those concerned in writing. In a paper 
concerned with the practical application of our knowledge of 
aphasias, it will only be necessary to understand the signifi- 
cation in which the terms selected are used, and without 
committing ourselves positively to theory on the subject, we 
will speak of motor aphasia and sensory aphasia with the 
same meaning as such authorities as Kussmaul, Charcot, 
Broadbent and Ross. Under the general term sensory 
aphasia I will therefore include those affections of speech 
which are dependent upon disease located in the receiving 
part of the brain. Sensory aphasia has, therefore, necessarily 
several varieties, as word-deafness, and word-blindness, terms 25 
BY CHARLES K. MILLS, M. D. 
which define themselves, and apraxia sometimes called soul- 
blindness, mind-blindness, or object-blindness. Apraxia—an 
important form of brain disease from a medico-legal stand- 
point—is defined by Kussmaul as an affection in which “the 
memory for the uses of things is lost, as well as the under- 
standing for the signs by which the things are expressed.” 
“For this general symptom of inability to recognize the 
use or import of an object,” says Starr,1 “the term apraxia is 
now employed. And since apraxia is a symptom which is 
very frequently associated with aphasia and which, in fact, 
may lie at the basis of the aphasia, it should always be 
looked for in a patient. To test for apraxia it is only neces- 
sary to present various objects to a person in various ways 
and notice whether he gives evidence of recognition. Have 
him watched by his friends, and they will be able to tell 
whether he still clioses his articles of food at the table intel- 
ligently ; whether he still knows how to put on his clothes, 
to use various toilet articles, to sew, knit, or embroider if the 
patient is a lady, to admire pictures or flowers, or perfumes, 
as before the illness began. The patient may, or may not 
be able to name these objects; that, at present, is not the 
question. But it is evident that the subject awakens an 
idea in the mind.” 
Motor aphasia includes the common form of disorder of 
speech sometimes known as Broca’s aphasia, or ataxic 
aphasia, and in addition agraphia, or loss of the power of 
writing when this is due to disease of the graphic centres or 
tracts in the motor cortex. Amimia may be regarded as a 
variety of motor aphasia in which the patient has lost the 
1. Starr: N. Y. Medical Record, October 27, 1888. 26 
APHASIA. 
power of expressing his thoughts by sign or pantomime. 
This, however, may be due to disease either on the sensory 
or on the motor side of the brain. It is usually a part, but 
a very important part, of speech and graphic aphasia, and a 
consideration of pantomimic speech should receive careful 
and close attention from those engaged in studying the 
subject for medico-legal purposes. 
Besides the varieties of aphasia resulting from lesions 
affecting only, or chiefly, cortical centres of speech, on which- 
ever side of the brain these may be situated, other affections 
must result from the breaking through of the commissures 
or lines of connection between the various centres. These 
give us what are known in general terms as paraphasias or 
conduction aphasias, which may be of as many types as there 
are commissures. Sensory and motor centres and commis- 
sures may all be affected at the same time, and this gives 
the total aphasia of some writers, or what is perhaps better 
called by Ross, combined sensory and motor aphasia. 
Other terms in use are those descriptive of the peculiarities 
of symptomatology exhibited by the different varieties of 
aphasia to which reference has been made—thus we have 
alexia, dyslexia, paralexia and paramimia. Some of the 
symptoms thus designated may be produced by either sen- 
sory, motor or conduction disease, or by combinations of 
these. Alexia is abolition of the power of reading, as agra- 
phia is of that of writing; dyslexia refers to difficulty Or 
fatigue in reading; ''paralexia to the misuse by transposition 
or substitution of either syllables or words, while paramimia is 
the misuse of signs or pantomine. BY CHARLES K. MILLS, M. D. 
27 
Although the terms used in describing the different 
varieties of cerebral speech disturbance are numerous, each is 
descriptive of some clearly defined symptom or syndrome, 
which in its turn can be referred to a more or less restricted 
and a localizable lesion. The medico-legal problems, crimi- 
nal or civil, which may arise in connection with aphasic 
disorders, could be considered without any discussion of the 
sites of the lesions which cause these affections. In other 
words, a knowledge of the symptomatology of aphasias 
might be sufficient to enable the physician or jurist to draw 
conclusions as to the influence of these disorders upon mental 
resistance and capacity; nevertheless, some acquaintance wTitli 
their pathology and morbid anatomy should serve at least to 
make more precise and clear the comprehension of these cases, 
as it should aid in materializing them to the mind of the 
investigator. One should be able not only to define word- 
deafness, word-blindness, psychical blindness, or psychical 
deafness, agraphia, amimia, aphemia, paralexia, etc.; but he 
should be able also to picture before his mental vision the 
localities in the brain where the damage of disease or accident 
lias led to the production of these symptoms. 
A brief consideration, therefore, of the relations of these dis- 
orders to the particular locations of lesions in the brain may 
serve to make the medico-legal aspects of the subject more 
tangible and comprehensible; for it will thus be more clearly 
seen that we are not dealing with mere names and specula- 
tions, but with theories which have either been developed 
from, or corroborated by, observed facts. Various schemes 
and diagrams of the centres, and tracts of speech, and of their 
possible lesions, have been suggested, and almost any one 
of these might answer for the separation of aphasias in a 28 
APHASIA. 
study of them for medico-legal or other practical purposes. 
Lichtheim1 indicates at least seven localities for diagnostically 
separable lesions without including the visual or concept 
centres, or some of the hypothetical inner commissures. It 
may easily be necessary to consider ten or more locations in 
the cerebrum of such lesions in a paper like the present. 
One, and a prominent object of the paper, is to deal more or 
less fully witli the effects of each or any of these separable 
lesions upon intelligence, mental resistance, and the ability 
to express thought. The task is one of exceeding difficulty 
although it would be comparatively easy if we had only to 
treat of neatly limited lesions of centres or tracts; but brain 
disease rarety favors us with precise experiments, and there- 
fore we are most frequently compelled to reason upon the 
effects of lesions variously combined and unusually extended 
or complicated. 
In what will follow, I cannot of course go at any length 
into a description and discussion of the tracts, centres and 
commissures concerned with speech, and of the various 
lesions to which they are liable. The monographs of Jack- 
son, Lichtheim, Kussmaul and others, should be consulted 
by those desiring full details and elaborate explanations. 
The principal brain centres or areas concerned with the 
phenomena and mechanism of speech are (1) Auditory 
(centre of auditory images); (2) Visual (centre of visual 
images); (3) Concept; (4) Propositionizing (centre of motor 
images); (5) Utterance; (6) Graphic or Writing; (7) Inhib- 
itory higher prefrontal centres. 
Of receptive centres I have mentioned only the auditory 
and visual for the sake of simplicity, although of course im- 
1. l.iolitheim: [train, Yol. VII, January, 1885. BY CHARLES K. MILLS, M. D. 
29 
pressions received by the cerebral centres for touch, taste, 
and smell, and particularly by those for touch, may some- 
times enter into the mechanism of speech. 
The chief cerebral tracts and commissures concerned 
with speech are (1) The entering auditory tract which con- 
veys inward impressions to the auditory centre; (2) The 
entering visual tract; (3) The commissures between 
the auditory and concept centres; (4) The commissures 
between the visual and concept centres; (5) The com- 
missure between the auditory and visual centres; (6) The 
commissures between the concept and propositionizing 
motor centre; (7) The direct tract, sometimes used, between 
the auditory and propositionizing centre, instead of the 
innervation passing by the way of the concept centres; 
(8) The short commissure between the propositionizing and 
utterance centres; (9) The similarly short commissure 
between the propositionizing and graphic or writing 
centres; (10) The direct tract, sometimes used, from the 
visual sensory centre to the motor graphic, or writing 
centre; (11) The tract or tracts connecting the motor 
cortical centres concerned with speech and writing with 
the centres in the bulb and spinal cord. 
Restricting ourselves to this number and arrangement 
of cerebral speech centres and pathways, the first cerebral 
tract involved in spoken and written language would be the 
entering auditory tract—the path between the primary 
auditory centres in the bulb or cerebellum and the cortical 
centre for words, which is situated in the posterior thirds 
of the first and second temporal convolutions. Lichtlieim 
has placed this path in the left temporal lobe, and believes 
that the radiations from both acoustic nerves and nuclei 30 
APHASIA. 
come together in this side of the brain. Word-deafness 
would be the chief characteristic of a lesion of this entering 
pathway, as it would be also of a lesion of the auditory 
centre itself, but in the latter case paraphasia and paralexia 
would also be present, as the patient would be unable to 
verify the correctness of his spoken words by hearing. 
The entering tract for vision passes by way of the optic 
radiations of Gratiolet which are chiefly in the occipital 
lobe, from the primary optic centres in the thalamus to the 
cortical centres for words in the angulo-occipital region. 
Word-blindness would be caused by lesion either of this 
entering tract or of the visual centre for words. Experience 
shows that other symptoms, such as mind-blindness 
and hemianopsia, are often associated with the word- 
blindness, because the tracts and centres concerned with 
the functions of sight impaired in the latter disorders 
are closely associated with those which take part in word- 
vision. It is clear that one form of alexia or abolition of the 
power of reading, and also, of course, one form of impair- 
ment or abolition of the ability to write would be present 
in cases of word-blindness produced by lesions thus situated ; 
but it must be remembered that the word-blind can some- 
times write from dictation or spontaneously, largely by the 
aid of tactile or muscular sense; and that they can also 
sometimes copy printed or written text which they may not 
be able to read or understand, probably as they would copy 
a geometrical or other figure. 
Aii important variety of aphasia from the medico-legal 
point of view, and one not yet defined in this paper, is that 
known as verbal amnesia, or the aphasia of recollection. Those 
suffering from this may be neither word-deaf nor BY CHARLES K. MILLS, M. D. 
31 
word-blind, nor be directly disturbed in motor speech, 
although the affection may be and often is combined with 
other forms of aphasia. Pure verbal amnesia is inability to 
recall the name of an object, quality, or event, although the 
conception or idea of it is present in consciousness. This loss 
of word memory may be almost or absolutely total, or it may 
be so slight as to be little more than a species of absent- 
mindedness. The proper word is not revived in the 
memory, although the person or thing is actually heard 
or seen, and is recognized. Nouns, and especially proper or 
general names, are the parts of speech most commonly lost, 
because they are the last and the least organized in the brain. 
Many instances of this disorder have been reported by 
writers. 
Recent authorities are agreed as to the necessity of some 
area and mechanism on the sensory or receptive side of the 
brain, or intermediate between it and the motor cerebrum, 
for a higher intellectual process than the mere registration 
of auditory and visual impressions—for the formation of 
concepts in contradistinction to percepts which are repre- 
sented in the true cerebral centres of hearing and sight; for 
the organization in consciousness of definite ideas and the 
identifying of these with names. As to the existence of 
topographically separated centres or regions for this higher 
process, considerable difference exists. Some, with Broad- 
bent, advocate a special naming, idea, or concept centre. 
Others do not consider that a centre for the elaboration of 
concepts is localized in any particular spot or area of the 
brain, but that this process is rather the result of the 
combined action of the whole sensorial sphere, and that the 
commissures between the sensory and motor speech centres 32 
APHASIA. 
and this conceptual sphere consist of converging radiations 
from various parts of the cortex to the receptive and emissive 
centres. 
The views of Ross1 on this subject are worthy of quotation, 
because of their intrinsic interest, and because, also, of their 
bearings on those problems of mental capacity and com- 
petency which are the chief concern of this paper. 
“And on passing from thinking by percepts to thinking 
by concepts, and from that to thinking by abstracts,” says 
Ross, “ there are no new centres introduced, but only a 
complication upon complication of one perceptive centre. 
All that can be said is that the correlative of perceptive 
thinking is excitation of that portion of the cortex of the 
brain which is directly connected with the sensory inlets, 
of conceptive thinking excitation of portions of the cortex 
which are indirectly connected with them, and of abstract 
thinking excitation of portions which are still more remotely 
connected with them. It must, however, be remembered 
that the effective working of the portions of the cortex 
which are remotely connected with the sensory inlets will, 
in a great measure, depend upon the integrity of those 
which are in direct relation with them. 
“ Let us now attend to the effects of dissolution of this 
structure. A destructive lesion of the portions of the cortex 
which are most remotely connected with the sensory inlets 
would destroy the capacity of the patient for highly abstract 
reasoning, and would no doubt inflict considerable damage 
on the language in which abstract thought is embodied, but 
this condition would not be recognized as an aphasia; and 
even the intermediate portions of the cortex in which con- 
1 Ross: Aphasia; in Wood’s Medical and Surgical Monographs. Vol. vi, 
No. 1, April, 1890, New York. BY CHARLES K. MILLS, M. D. 
33 
ceptive thought is carried oil might be seriously damaged 
without giving rise to a special speech disorder, inasmuch 
as any impairment of speech which might be present would 
only be regarded as a part of a general decay of the reason- 
ing faculties. When, however, the lesion is situated in or 
near to the sensory inlets, a disorder of language results 
which is out of all proportion to the general impairment 
of the reasoning faculties. There are several reasons why 
the power of thought is comparatively spared under such 
circumstances. Thinking by means of percepts is correlated 
with the activity of both hemispheres, and consequently one 
hemisphere will carry on thought on the low level when 
the other is injured. And, although speech is organized in 
one hemisphere, a destructive lesion of one of its sensory 
inlets does not cut off the patient altogether from communi- 
cation with the external world. The portions of the cortex 
the activity of which is correlated with thinking by concepts 
and abstracts can be reached by the word-deaf through the 
eye, and in the word-blind through the ear, and in those 
who are both word-deaf and word-blind through the nerves 
of muscular sense and those of the other special senses, 
so that thinking on the middle and high levels is not com- 
pletely arrested. Inasmuch as speech is first organized in 
connection with the sense of hearing, a lesion in or near the 
auditory cortical centre will cause, as already remarked, 
a greater disorder of speech than does disease of other 
sensory centres. Now, suppose that the auditory centre 
itself is spared, and the lesion is situated in the cortex near 
it. The patient can now appreciate a general name uttered 
in his hearing as an acoustic image, and he can immediately 
repeat it. The verbal sign, however, never sounded in his 34 
APHASIA. 
ear without reviving some kind of concept, the two being 
inseparable. The concept evoked by the verbal sign may 
be, indeed, and probably is, a very undeveloped and 
imperfect one, but it suffices for the purposes of identifying 
the corresponding percept. When, however, the excitation 
of what remains of the auditory centre, which is caused 
by the falling of the verbal sign on the ear, fades away, the 
percept is not capable of reviving in memory either the 
concept or the general name which embodies it. We see 
nothing in this except that less resistance is offered by the 
nervous structures to the passage of nerve currents from the 
less organized structure representing the concept to the 
more organized one representing the percept, than from the 
more organized to the less organized, but this is only a 
particular example of a general law. There is no occasion, 
therefore, to postulate the existence of a complicated 
mechanism of centres and conducting paths for what can 
be so simply accounted for.” 
Broadbent,1 on the other hand, believes that a certain con- 
volutional area which might be called the “ idea centre,” or 
“namingcentre,” exists on the sensory or upward side of the 
nervous system, and conjectures that it is situated on the 
under surface of the temporo-sphenoidal lobe near its junc- 
tion with the occipital lobe, as it seems to him that fibres 
from all the convolutions in which perceptive centres have 
been placed converge to and end in the gray cortex of this 
region. 
Rosenthal2 lias recorded a case of verbal amnesia without 
word-deafness in a patient suffering from general paralysis, 
which defect of speech was ushered in by an apoplectiform 
1. Brain, Vol. 1, January, 1887. 
2. Cited by Boss. BY CHARLES K. MILLS, M. D. 
35 
attack, and persisted unchanged for upwards of two years. 
At the autopsy, besides evidence of a chronic leptomenin- 
gitis, on old focus of softening was found in the second and 
third temporo-sphenoidal convolutions, the first temporo- 
sphenoidal convolution being quite free from disease. 
After all, the existence of a special development or 
organization of the cortex for thinking by concepts and for 
the clothing of ideas in names, is recognized by authorities 
like Ross, Bastian and others, who only differ from Broad- 
bent, Charcot, Kussmaul, and the school of believers in 
separate concept centres, in not restricting this organization 
to an area absolutely set apart. It is neither improbable nor 
unphilosophical that a region conveniently intermediate 
between all the receptive and emissive centres concerned in 
the mechanism of speech may constitute a special, but not 
narrowly limited, area of the cortex, which is the anatomical 
substratum for concepts and the names which they awaken. 
Either the temporo-occipital regions indicated by the observa- 
tions of Broad bent and Rosenthal, or perhaps this region 
and also the island of Reil and retro-insular convolutions, 
and the cortex above and behind the posterior extremity 
of the Sylvian fissure, would meet the requirements. The 
parts played by the ganglia—the thalamus, the lenticular, 
and the caudate nucleus, and the amygdala — in brain 
action, are still obscure and almost unknown, and these 
may eventually be shown to play an important part 
either in connection with the incoming or outgoing streams 
of impressions and impulses that are concerned with speech; 
but at present we can only reason with reference to known 
facts, which relate almost entirely to cortical centres and their 
commissures. 36 
APHASIA. 
The chief affections of speech and of thought due to lesion 
I 
of this naming, or concept cortex, whether it is regarded as 
an isolated area or as a complication of centres and paths 
spread over the whole sensorial sphere, are varieties of 
verbal amnesia or the aphasia of recollection, with usually 
additional symptoms, such as loss of understanding of spoken 
or written language, or of volitional speech or writing, 
because of the almost necessary involvement of commissures 
to other centres, sensory and motor. 
Various degrees of loss of understanding of both spoken 
and written language—various affections of bearing and 
speech, or of vision and speech—may be due to lesions of the 
inner commissures between the auditory and visual centres, 
or between these and the concept centres; and likewise 
various degrees of disturbance of thought and speech from 
lesions of the paths between these concept centres and the 
motor regions for speech ; and these disorders will partake 
of the impressive, receptive, or sensory character, on the 
one hand, or of the expressive, emissive, or motor character, 
on the other, according as the lesion is respectively towards 
the sensory or motor side of the brain. 
Isolated word-blindness, according to Lichtheim and 
other observers, is the result of a break between the visual 
and auditory centres of word-representation. 
Paraphasia and paragraphia, or disturbances in speaking 
and writing shown in the misuse and jumbling of sounds 
and words, result from interruption in the commissure 
between the auditory and motor speech centre, or in the 
arc which unites visual, auditory and motor centres. 
Beside word-deafness and word-blindness, disorders known 
as psychical deafness and psychical blindness occur from BY CHARLES K. MILLS, M. D. 
cerebral disease; the word-disturbances are perhaps best 
regarded as degrees or varieties of the more comprehensive 
psychical affections. The case of psychical deafness, how- 
ever, may in addition to word-deafness, or perhaps in- 
dependently of it, have lost general auditory memory for 
objects, and for sounds of definite import. In psychical 
blindness the visual memory of forms and colors, and of 
things in general, may be lost, or the power of recognizing 
by sight the special properties of objects may be impaired 
or destroyed; although even such patients may preserve 
sight of a lower kind, that, for instance, which would 
■enable them to avoid obstacles placed in their path, as the 
psychically deaf may also by lower centres appreciate 
vibration or noise. 
Apraxia already defined as the inability to recognize the 
use or meaning of objects, it will be seen might be the result 
-either of psychical blindness or psychical deafness or of 
both. Apraxia and verbal amnesia are not necessarily 
present in the same case. It is conceivable that an in- 
dividual might be able to name an object the use of which 
he did not recognize; and in a common form of verbal 
amnesia the patient is conscious of the uses and properties 
of things the names of which it is impossible for him to 
revive in memory. 
It is difficult to affirm positively as to the location and 
extension of the lesions which produce these conceptual 
disorders of speech and thought. If we acknowledge the 
existence of concept areas as practically distinct centres or 
regions, or even if we take the view that they exist as com- 
plications or elaborations of the true auditory and visual 
and other receptive centres, then lesions of these higher 38 
APHASIA. 
cell-clusters, particularly if extensive, might, of course, give 
rise to the disorders in question. Severance of association 
tracts between the concept and the perceptive centres may, 
however, often be the cause of different varieties of these 
psychical disorders according to the tracts dissevered. To 
give a simple illustration, one of my patients who was both 
object-blind and word-blind, could not recognize a purse 
by sight, but on handling it, examining its clasp, etc., she 
at once named it correctly; probably the tracts between the 
visual perceptive and higher visual areas were destroyed 
as well as the word centres, while the tactual centres and 
the lines of communication from them to the concept region 
were unaffected. 
Dyslexia is probably most frequently due to a partial 
break or lesion in the commissures between the visual and 
the motor apliasic centres, although imperfect destruction 
of the commissure between the visual and auditory centres, 
or between those for word-hearing and Broca’s convolution 
might cause some degree of this disorder. Paralexia, like 
paraphasia, may be due to severance of the communications 
between either the auditory or visual centres, and the motor 
speech regions. 
The disturbances of the power of expressing thought by 
signs or pantomime known as amimia and paramimia, like 
the disorders of speech, may be both sensory and motor and 
may be due to lesions variously situated. Loss or impair- 
ment of pantomime is in many cases proportionate to the 
disturbance in speech, but the two do not always go hand 
in hand, and some patients recover pantomimic power more 
speedily than ordinary speech. Using the terms sensory 
and motor in the same sense that we have employed them 39 
BY CHARLES K. MILLS, M. D. 
in speaking of aphasias proper, pantomime may also be 
either sensory or motor, or it may be mixed or even total; 
so that its seat may be in almost any part of the arc con- 
cerned with receptive, conceptive, or emissive processes. 
If the visual centres or entering visual tracts are destroyed, 
the patient will not be able to use sight in the execution 
of manual or other forms of pantomime in so far as they 
may be dependent upon vision. Even impairment or 
destruction of the entering auditory tracts, or of the centres 
for auditory images, might impair pantomime which would 
otherwise be called out in response to sounds and words 
heard. The most distinctive interference with pantomime 
will, however, be from destruction of centre for proposition- 
izing and of the tracts connecting it with the concept centres 
on the one side, or the centres for movements of the limbs 
or face on the other; or from the destruction of the concept 
areas and their commissures. Pantomimic disorders may 
therefore be either amnesic or motor, or a combination 
of both. Some of the most interesting cases of aphasia 
associated with impairment or destruction of pantomimic 
■or gesticulatory speech indicate these differences both in the 
form of the disorder, and in the site and extension of the 
lesion causing them. In an aphasic who nodded affirm- 
atively with the head when she wished to answer in the 
pegative, and used two fingers to express four, and made 
similar mistakes of pantomime, a was found destroying 
a great part of the third left frontal convolution, the entire 
left island, and the neighboring medullary substance and 
anterior third of the corpus striatum1. This patient knew 
that she expressed herself wrongly, and the disorder was 
1 Perroud, cited by Kussmaul in Ziemssen’s Cyclopaedia. 40 
APHASIA. 
therefore not amnesic; but many amnesic cases have been 
reported. 
The purest forms of motor speech defect will, of course,, 
be due to an isolated lesion either of Broca’s convolution, 
the propositionizing centre of Broadhent, or of the utter- 
ance centres at the foot of the central convolutions, or 
of both together. Such cases although not very numerous 
have been reported; some which are well known in the 
literature of aphasia which seem to clearly prove that only 
the loss of propositionizing power is present when the lesion 
is absolutely limited to Broca’s convolution. 
While it is true that the power of building and rehearsing 
in the mind a phrase or sentence, and the power of uttering 
are commonly lost together, still such a combination does 
not always exist in aphasic cases. Doubtless two processes 
of this kind which are so intimately connected and so often 
jointly lost have their anatomical substrata in closely 
adjoining localities, and one so-called centre might be 
considered, after the manner of Ross, simply as a complica- 
tion or extension of the other, but still the more elaborated 
area is separated, even if it be by only the shortest distance, 
from the other. 
Aphasia from destruction of Broca’s convolution should 
give loss of volitional speech, and volitional writing, and if 
the utterance centre, or utterance portion of the compound 
centre, is destroyed also, the power of repeating and of read- 
ing aloud should also be lost. Spoken, and written words, 
however, could be understood and the faculty of copying 
retained. 
The destruction of the short commissures between proposi- 
tionizing and graphic centres must nearly always take place BY CHARLES K. MILLS, M. D. 
41 
in lesion of Broca’s convolution and its sub-cortex, and hence 
give both motor aphasia and agraphia. 
I have reported an interesting case which shows clearly 
that utterance may be largely abolished from a limited 
cortical lesion while propositionizing power remains intact. 
This was a case of oro-lingual monoplegia in which a focus 
of strictly cortical yellowish softening was found involving 
the lower extremities of the central convolutions, both on 
their external and Sylvian surfaces, and a spot one-half inch 
in diameter about the middle of the internal portion of the 
island of Reil. This softening reached into the fissure 
of Rolando, and also into the precentral fissure, but it did 
not reach to the anterior branch of the Sylvian fissure, its 
anterior limit being one-fourth of an inch from this 
fissure. In this patient the muscles of articulation were 
distinctly involved, giving an oro-lingual mono-paresis. 
He could talk, but pronounced certain words indistinctly. 
He comprehended objects and words by hearing and sight, 
and could read understandingly, but could not pronounce 
well owing to the above described articulatory defect. He 
had no difficulty whatever in propositionizing.1 
Clearly in most cases of destruction of the motor speech 
centres, as the sub-cortex usually to some extent takes part 
in such lesions, commissures of some kind must be involved, 
and hence varieties of commissural or conduction aphasia 
are nearly always blended with the motor disorders, but 
these are often recovered from in part or whole. 
Agraphia, or the loss of the power of writing, which may, of 
course, be of the highest importance in various medico-legal 
directions, may be due to lesions variously situated, and 
University Medical Magazine, November, 1889. 42 
APHASIA. 
may therefore be of several varieties. I have already spoken 
of what might be termed the sensory forms of agraphia due 
to lesions of the visual centres or of the entering visual 
tracts; but even motor agraphia is of several kinds. The 
patient, for example, may be unable to write spontaneously, 
although he can from dictation, and he may at the same 
time be able to copy either written or printed text; or again 
he may not have the ability to write either from dictation 
or by copying. Lesions situated in several places may give 
rise to motor agraphia; for instance, in the first place, a lesion 
of the special motor centres concerned with writing. Agraphia 
may again be dependent upon lesions of the tract uniting 
the concept with the speech and writing centres, and if a 
direct separate tract exists between the visual and graphic 
centres, the power of copying may in such a case be retained. 
As propositionizing is as necessary to volitional writing as to 
volitional speech, destruction of the left third frontal will 
cause more or less agraphia as well as aphasia. 
“The same result,” says Gowers1, “ follows an isolating 
lesion just beneath the cortical centre, and hence the path 
to the arm centre must be by the ‘associating fibres’ of the 
subjacent white substance, and not the gray matter of the 
cortex. But it is conceivable that a sub-cortical lesion may 
be so placed as to interrupt the paths to the internal capsule 
and to the opposite hemisphere, and not that to the arm 
centre. In such a case there would be permanent loss of 
uttered speech without loss of the power of writing. Such 
a condition has actually been observed.” 
The form of infra-cortical affection of speech which 
results from lesion of the tract or tracts connecting 
1 Manual of Diseases of the Nervous System, American Edition, Page 546. 43 
BY CHARLES K. MILLS, M. D. 
because of the frequent disturbance either by pressure or 
destruction of this portion of the cerebrum. In many 
cases of hemiplegia, aphasia, at first very prominent and 
positive, after a time disappears in large part or even 
almost entirely, the paralysis of the leg and arm remaining 
very pronounced. Some of these cases are to be explained 
by the fact that the intra-cerebral facial tracts are only 
affected by pressure, and in others even when they are more 
or less destroyed, the opposite hemisphere assumes the work 
of both. The common view is that the bilateral movements 
which occur during speech may be innervated from each 
hemisphere. More or less complete destruction of the 
fibres which connect the oro-lingual and other facial areas 
of the cortex with the nuclei of the various nerves con- 
cerned with articulation and phonation, does sometimes 
give a disorder of speech, which has been variously 
described as pseudo-bulbar paralysis, labio-glosso-pharyngeal 
paralysis of cerebral origin, aphemia, etc., and cases have been 
reported by Kirchoff, Ross, Hobson, Bastian, the writer and 
others. These patients articulate with difficulty ; paresis or 
paralysis of the tongue is present; labials and gutturals and 
linguals may be all troublesome to pronounce; drawing of 
the face will usually be present; swallowing may be diffi- 
cult, the movements of the jaws may be impaired; and 
drooling is a frequent symptom. In such cases interference 
with speech is sometimes extreme amounting almost to 
complete speechlessness. While such a train of symptoms 
usually accompanies a generalized hemiplegia, it is occasion- 
ally observed unconnected with paralysis in parts other 
than the face. 
This pseudo-buibar paralysis is a more decided and per- 
manent affection when the result of bilateral disease, but 44 
APHASIA. 
a form of it can occur from a deep seated lesion of the left 
hemisphere only. Strictly speaking, Broca’s convolution 
is not directly connected with the basal nuclei, but indirectly 
through the utterance or glosso-labio-pharyngo-laryngeal 
cortical centres, and the larger portion of the fibres which 
go down from these centres to the bulb pass by way of the 
left hemisphere, although a partial decussation probably 
takes place. If a commissure connects the speech or 
utterance regions of the two hemispheres, it will be com- 
paratively close to the cortex, and destruction of this 
commissure as well as of the fasciculus to the bulb, would 
account for some of the infra-cortical speech, or articulatory 
disturbances. 
The following quotation from Lichtheim1 is of value as 
throwing light upon the peculiarity of disturbances of 
speech from lesions of the white matter of the cerebrum: 
“Lesions of the deeper portion of the brain, followed 
by disturbance of speech, moreover, do not bring about 
aphasia with its characteristics as a verbal trouble; the 
formation of sounds is more or less prominently interfered 
with. This verbal characteristic of the cortical symptom 
is a natural consequence of the functions now usually 
attributed to the cerebral centres in general and of the 
innervation of those concerned in language especially. 
If we presume that Broca’s sphere is the seat of acquired 
motor word-representation (kinaesthetic centre), and that 
its lesions obliterate these memories, and so give rise to 
aphasia, it follows that its destruction must affect words and 
not sounds; for those representations acquired during child- 
hood are associated with words only. It is at a much later 
period of development that we have learned to decompose 
1 Lichtheim: Brain, January, 1885, p. 481 and 482. 45 
BY CHARLES K. MILLS, M. D. 
words into sounds. As the elements for the formation 
of words are deposited in the cortical centres of speech, 
so the dispositions for the production of sounds are made 
in the bulbar nuclei. The paths, therefore, between Broca’s 
centre and the nuclei will have to undergo a corresponding 
conversion. The question is now where this conversion 
takes place; whether low down in the pons, as Wernicke 
supposes, or, as I think, much higher up, basing my 
opinion on the fact that disturbances of speech, arising 
from lesions of the deeper cerebral regions, do not, as just 
mentioned, partake of a purely verbal character. 
“All these considerations compel us to assume that 
only a short extent of the efferent tract from Broca’s centre 
is so constructed as to give rise, on being injured, to real 
aphasic disturbances. We shall therefore have to look also 
for the lesion of aphasia without agraphia in the white 
matter of the hemispheres, though we can yet scarcely con- 
jecture its localization. Two new contributions, the results 
of which, however, are scarcely concordant, point, not to a 
simple radiation of the fibres from Broca’s convolution 
towards the internal capsule, but to a more complicated 
arrangement.” 
Before taking up for consideration special forms of 
speech disorder, beginning with the receptive or sensory 
affections, a few general remarks might be made on the 
mental status and integrity of cases of sensory or 
receptive aphasia as compared with cases of motor or 
emessive form. In general terms it is doubtless true, as 
various authors have expressed themselves, that mental 
capacity and its manifestations are more impaired in those 
forms of amnesia or aphasia which are the result of lesions 
on the sensory side of the brain, that is, in word-deafness, 46 
APHASIA. 
word-blindness, in the various forms of apraxia or mind 
blindness, and in those combined forms of speech and panto- 
mimic disturbance which are due to lesions of the receptive 
or impressive mechanism of speech. Words seen or heard 
fail to revive the ordinarily appropriate ideas in memory. 
Mind-blindness is not always associated with word-blindness, 
nor psychical deafness with word-deafness, but when such an 
association is present it would require the closest scrutiny of 
the particulars of a case of alleged capacity or incapacity to 
determine the true status of the individual, and the pre- 
sumption would be rather against than in favor of the pres- 
ervation of mental power for definite purposes. More 
commonly than otherwise, word-blindness and word-deafness 
are present in the same case, and quite often the more 
serious psychical disorders are also associated. While, 
however, all this is true, it is not correct to teach that word- 
deafness, or word-blindness, or even mind-blindness or 
psychical deafness necessarily destroy mental integrity to 
such an extent, as to shut out testamentary capacity, the 
ability to make contracts, to testify as a witness, or to take 
care of one’s person or property. 
What is the mental status of a case of word-deafness? 
With what voluntary acts would such an affection interfere? 
Perhaps first in importance comes the question of test- 
amentary capacity and similar exercises of mental power 
in assenting or dissenting to legal papers. Gowers says 
that word-deafness is incompatible with will-making, 
because it is impossible to know whether the testator really 
understands what is said to him, but this is putting the 
matter too strongly. If the individual is only word-deaf 
from lesion of either the entering auditory tracts or of the 
auditory centre, but still preserves full cerebral visual power, BY CHARLES K. MILLS, M. D. 
47 
and intact lines of communication between the visual 
centre and the motor areas for speech and writing—a will 
might be made, or other legal papers, such as deeds of trusts, 
contracts, etc.,—be drawn up and express the real intentions 
of the individual in question. It ought not to be necessary, 
in other words, for competency that the person should be 
responsive by every channel of communication. This as 
so many other cases of the kind we are discussing, 
should be studied on its own merits, and testimony as to 
how the disputed act was done should be clear and unmis- 
takable. Evidently a completely word-deaf patient could 
not express either assent or dissent by hearing, and peculiar 
statutes might have some bearing on the capacity of a case 
of word-deafness; for instance, if it was required by statute 
that the testator should be addressed by spoken words. 
If he was capable of assenting or dissenting with certainty 
by any of the legitimate or legal means of communication, 
he might be competent. 
According to Bastian, word-deafness, when caused by a 
lesion of the left auditory word centre, must always be as- 
sociated with aphasia and agraphia—that is, a completely 
aphasic condition. This is because names cannot be re- 
l 
called voluntarily or by association. This assertion of 
Bastian’s is probably too sweeping, but has in it a large 
measure of truth. Some word-deaf patients are or become 
able to communicate in spoken or written language, but if 
the lesion is complete the interference with all methods of 
communication will also be nearly complete until new 
centres are educated and new lines of communication 
opened, or compensation takes place through the other 
hemisphere. Complete word-deafness is therefore a serious 
affection in its direct effects on thought and its expression, 48 
APHASIA. 
and also because of conditions with which it is likely to be 
complicated. Bastian says that a totally word-deaf patient 
might perhaps not understand written language, but 
acknowledges that this ability might persist to some extent 
through the action of the opposite hemisphere. In spite 
of the seriousness of word-deafness, it is, however, a mistake 
to conclude too hastily that the individual is either incom- 
petent, or in any technical sense insane. I have already 
referred to several cases regarded as demented chiefly 
because of their word-deafness, but who were demonstrated 
not to be in any true sense insane. 
Word-deafness is one of the forms of hearing and speech 
disturbance from which partial recoveries are frequently and 
total recoveries sometimes made. In a number of the cases 
of combined sensory and motor aphasia which I have 
observed at the Philadelphia Hospital, word-deafness at an 
early period almost complete, rapidly or gradually dis- 
appeared, but not always fully. Many of the patients 
responded to the last with difficulty or slowness to spoken 
words. I am referring now particularly to cases which 
persist as marked instances* of hemiplegia and motor 
aphasia. In the consideration of the medico-legal aspects 
of word-deafness that patients improve or recover should 
be constantly borne in mind. The most conflicting 
testimony might be truthfully given about the condition 
and the competency and responsibility of an individual, if 
such testimony was based upon observations made over a 
period of a few years or even a few months. 
The case of the French Professor Lordat, which has 
become classic in works on aphasia, is interesting in this as 
in other particulars. After a fever he suddenly lost his 
powers of speech and was word-deaf. Words fell unrecog- 49 
BY CHARLES K. MILLS, M. D. 
nized upon his ear, but after many weeks he recovered, 
resumed his professorial work, and wrote a valuable analysis 
of his own case. The following case of Schmidt, quoted by 
Kussmaul, is interesting as showing the characteristic symp- 
toms in a word-deaf case, and also illustrates the fact that 
word-deafness and high grades of verbal amnesia can in 
large part disappear: 
“A woman, 25 years of age, became suddenly unconscious, 
during severe straining at stool, ten days after confinement. 
After consciousness returned she was not paralyzed, but 
suffered from aphasia and paraphasia. She found words 
with difficulty or not at all, reversed or mutilated them, said 
'‘butter” instead of “doctor”, threw out letters and syllables, 
inserted others, used the infinitive instead of the proper mood, 
and conjugated irregular verbs regularly. She was thought 
to be deaf because at first she did not understand a single 
word. It was soon discovered, however, that she heard a 
knocking at the door or the ticking of a watch as clearly as 
a well person, that she could distinguish between two house 
clocks by the tone, etc. Words on the other hand, as she 
afterwards stated, were perceived only in a confused 
murmur. She heard separate vowels and repeated them. 
When a word of one syllable was spoken in the ordinary 
way, she did not understand it, but when the different 
letters were separated distinctly from each other, so that they 
stood forth in the pronunciation, she was able to repeat the 
word. With words of more than one syllable it was neces- 
sary first to pronounce one syllable distintly, then another, 
then the two together, or she would not understand the 
word. It was the same thing with reading. She studied 
the words very carefully, and tried to pronounce them at 
first separately and then together. Recovery took place 50 
APHASIA. 
slowly. She did not understand short sentences until after 
the lapse of half a year, and then only when they were 
pronounced slowly and distinctly. Even at the last there 
remained some difficulty in speaking.” 
A word-deaf patient might be able to write a will under- 
; he might retain or soon acquire sufficient 
powers of speaking to give assent, or dissent or even to 
express an opinion; he might retain certain powers of 
pantomime, visual centres and connecting tracts remaining 
undiseased and pervious, and the motor areas for panto- 
mimic speech not being destroyed. It must not be sup- 
posed, however, that his condition would be as high mentally 
as that of a deaf and dumb patient from peripheral disease 
as scarlet fever, who had with the aid of vision trained him- 
self in the use and comprehension of sign language. 
Although secondary atrophy of hearing or speech centres 
occurs in cases of peripheral deafness, a disturbance of 
mental equilibrium occurs and to some extent persists in 
cases of cerebral deafness which is not present in the 
ordinary deaf and dumb. Cerebral centres and lines of 
communication are at first untouched in the latter cases, 
and the visual and manual training which is pursued takes 
possession of and utilizes everything possible. 
Lichtheim records a valuable case of word-deafness from 
lesion of the cerebral entering auditory tract, a rare form of 
recorded lesion. This patient, although word-deaf, differed 
in striking particulars from a case of word-deafness or 
speech-deafness from lesion of the centre for auditory images. 
While, for example, he could not understand spoken 
language, had lost the faculty of repeating, and that of 
writing to dictation, he preserved intact volitional speech 
and writing, the understanding of writing, the ability to BY CHARLES K. MILLS, M. D. 
51 
copy words, and finally, the faculty of reading aloud prop- 
erly, these last being lost in cases of auditory centre deafness. 
He had neither paraplirasia nor paragraphia, because the 
arc uniting auditory, concept, and motor centres was 
unbroken. This man’s available mental power was greater 
than that of an ordinary case of word-deafness. He was in 
fact a teacher and journalist, and continued with success the 
business of writing articles for the newspapers. He could 
not understand speech, but could noises and other sounds 
of definite import. He spoke with absolute accuracy, 
but with a slight drawl; he could find substantives, even 
complex ones, and proper names; he copied and read aloud 
correctly and fluently and his intelligence of written language 
was intact. He copied an I. 0. U., written by Lichtheim, and 
gave it to his wife, remarking “You see, you have money.” 
A variety of curious problems may be presented by 
patients suffering from pure word-blindness, or from this 
and some of its usual complications, as word-deafness, 
psychical blindness or deafness, verbal amnesia or paralexia. 
I have already stated for instance, that the word-blind can 
sometimes write spontaneously or from dictation, or even 
be able to copy writing which he does not understand. 
Such matters as the simple signing of a name to a check, 
to a will or other document are often the points in dispute, 
and yet the ability to do this is retained in many cases 
where the patient is not only word-blind, but so completely 
as to be able to do nothing else but make his autograph. 
Letters may be understood when wTords are not. The under- 
standing for figures may be lost or retained. A patient 
reported by Broadbent—a case which, after a time, fell into 
my own hands—could not at first tell how many two and 
two made, but in two weeks learned to add together two low 52 
APHASIA. 
figures, and rapidly thereafter gained in his understanding 
of figures. Trousseau has recorded the case of an accountant 
who could read off the sum 766, figure for figure, but did 
not know what the figure 7 meant before the two 6s. 
Proust, cited by Kussmaul, records another aphasic, who,, 
although he could no longer count in words, could add and 
subtract on paper and even multiply pretty well. 
That an individual is not able either to read or to 
write because of word-blindness, should not absolutely invali- 
date the writing or signing of a will or other document, 
although such a patient is not in exactly the same condition 
as one who has never been educated to read or write, or has 
lost sight through extra-cerebral disease. The general 
mental impairment which goes with such disease, the 
possibility of the existence of hallucinations or delusions, 
and the disturbance of the equilibrium of thought processes 
must all be taken into consideration. 
Some cases of interest in connection with the discussion of 
wrord-blindness and of agraphia are mentioned by Le Grand 
du Saulle and Bateman. An aphasic, 50 years old, wished 
to make a will, and desired to leave an old domestic a 
remembrance of some importance. He made the most 
strenuous efforts to get together words and express on paper 
his will in the matter, but the words would not form an 
intelligible sentence, and the writing was incorrect and in 
some places undecipherable. This defect of co-ordination, 
of the will and of movement, could not be overcome, and 
he died before lie could make the will lie so much desired, 
to the grief of the testatrix. 
Boucher (de Sancergues) tells of a similar case. In 
January, 1865, lie was called in by Dr. Poinset to see a 
hemiplegic affected with word amnesia. He wished to- 53 
BY CHARLES K. MILLS, M. D. 
make a will and give a certain sum of money to a relative 
who had taken great care of him. In spite of the most 
expressive gestures and pantomime he had great difficulty 
in making himself understood. He succeeded, however, 
and the clue found, he was able to carry out his wishes. 
I have already referred to the Hotfbauer’s, a case 
of a man, in Munden, in 1843, who demanded of the 
Hanoverian government to make a will and dispose, by 
signs, of his property to his wife. His request was written 
from his dictation, although he could neither speak, read, 
nor express his thoughts in writing. On the advice of the 
legal physician Holman, three interpreters took his testi- 
mony, and his wife obtained possession of the property. 
The proof of the testamentary capacity of a word-blind 
patient, or the validity of a written instrument alleged to 
have been prepared by or for him, and having his signature, 
would have to depend largely upon collateral evidence. If, 
for example, it could be shown that such a patient had 
written a short contract, will or other document, and then 
had had it read to him, and had signified his assent to its 
contents, and if the evidence was in favor of his general 
mental stability, his testamentary and general mental 
capacity should be sustained. If it should be attempted to 
prove that such a patient had read a document in question 
and thereby assented to it before signature, the evidence 
would be against its validity and his capacity. A word-blind 
patient recognizing his defect, but not being word-deaf, and in 
possession of his general mental faculties, might have a will 
or other legal paper written for him, and then read to him, 
and signify his assent to its contents by gesture, by his 
autograph, or by his mark. The possibility of deception 
having been practiced upon the writer or testator in such a 54 
APHASIA. 
case, should, of course, be taken into consideration, and 
eliminated. 
Word-blindness, like word-deafness, often improves so as to 
change the visual receptive powers, and possibly the capacity 
and competency of the patient. The following case of Van 
den Abeele, cited by Kussmaul, is interesting in this and in 
other respects. 
“A woman, 45 years of age, was struck with apoplexy 
while in the enjoyment of the most blooming health. After 
some hours consciousness returned, but she was paralyzed 
upon the right side and had pain over the left eye; her intel- 
ligence was somewhat dull, the memory weak, the speech 
free. Six weeks later, the paralysis and weakness of mem- 
ory and intelligence had almost disappeared. Two months 
after the attack she discovered that she could neither read 
printing nor writing; she saw the text, distinguished the 
form of the letters, and could even copy the text, but was 
incapable of translating the words into spoken words and 
thoughts. She comprehended pictures and could decipher a 
rebus; she understood consequently ideographic represent- 
ations, but not writing. When Van den Abeele published 
this observation, the patient had already regained the power 
to read some words of one or twro syllables.” 
Both the visual centre and one or more of its commissures 
were probably injured. 
The following unreported case was seen by me only once, 
and the history is wanting in details, but it will serve 
to illustrate some of the points likely to arise in the settle- 
ment of problems associated with conditions of word-blind- 
ness and verbal amnesia. 
The patient was a married woman, 66 years old, wdio had 
always had fairly good health, although for several years in BY CHARLES K. MILLS, M. D 
55 
the spring she had suffered with rheumatic pains, and a 
few years before coming under observation she had passed 
a renal stone of large size, and a second smaller one two or 
three years later. In June, 1887, during the first attack of 
renal colic, she had a partial loss of power in the left arm 
from which she had never entirely recovered ; she also had 
a scarcely perceptible weakness of the left leg. In June, 
1887, she was taken with violent headache and vomiting. 
The pain was worse at the back of the head at the left side 
and continued for a week to come and go, after which time 
she noticed some loss of memory and peculiarity of vision. 
Examination showed that she had right lateral hemia- 
nopsia without Wernicke’s pupillary inaction. Testing her 
in a variety of ways, it was found she could recognize ob- 
jects seen, heard, felt, smelled or tasted. Until a short time 
before the examination, she had been able to recognize 
persons on the street although she could not name them, 
but this power of recognition of persons was leaving her. 
She understood what was said to her. She had four sons 
and evidently could tell one from the other, but could not 
correctly name them, just as likely as not calling one 
by another’s name. She understood what was read to 
her, but could not read, as she did not understand printed 
or written words. She could sign her name and write a 
few short words at dictation, although the writing except 
her name was so imperfect as to be almost illegible, except 
in the case of a small word like “cat.” She could recognize 
an object by sight, hearing or touch; she could not name it 
correctly from seeing it, but could do so from touch, or, 
after it was told to her, she would indicate that she knew 
the name but could not recall it. She called a stamp held 
before her a “ticket” or a “letterand said she knew what 56 
APHASIA. 
it was, but could not name it. She called pills, “ pencils,” 
but knew wliat they were used for although she named 
them wrongly. When a paste bottle was held up before 
her she named it correctly, but called a postal card a 
“stamp,” although she knew what it was. She called a 
watch a “key,” and said it looked like a key. When some 
keys were held up before her she said they were “locks”, and 
evidently knew their uses. On holding a pocket-book 
before her, she could not name it, but named it quickly when 
she took it in her hand. She called a green stamp, “brown;” 
a pale blue one, “pink ;” a dark red one, “red;” an olive 
green, “blue;” and red, “blue.” She said a “G” looked 
like an “I.” When shown the word “royal,” she said each 
letter was “I.” She could not name the separate letters or 
recognize the word; and did not show that she appreciated 
her mistakes as to words and letters when she was corrected. 
In this case the centre for word-vision and the commissures 
between it and the concept centres were impaired by disease, 
and probably also to some extent the concept centres them- 
selves. 
The medico-legal bearings, civil and criminal, of verbal 
amnesia, or the aphasia of recollection, open an interesting 
field and one not altogether unexplored by writers on 
disorders and disturbances of speech. It is rarely an isolated 
symptom. It is frequently associated with apraxia in some 
of its forms, or with word-blindness or word-deafness or 
both ; it may indeed be combined in the same case with 
almost all other aphasie affections. Most commonly, as 
would be expected, it is combined with the sensorial aphasias 
and apraxias. I have already discussed the question of 
special naming or concept centres, leaning to the views of 
those who hold to the aggregation of these concept centres BY CHARLES K. MILLS, M. D. 
57 
into a more or less isolated field or zone; but I do not believe 
that this concept field is limited to one spot in the sensorial 
sphere. When our more perfect knowledge of localization 
is attained, it will probably be found that the concept region 
of the brain is a comparatively large but connected area, 
interlacing among various centres for percepts in such a way 
as to make certain portions of it conveniently intermediate 
anatomically between particular percept centres and the 
special motor or emissive centres with which they are most 
intimately correlated. Lesions somewhat variously dis- 
tributed and extended will, therefore, give rise to forms of 
amnesia and apraxia; and strange symptom-pictures, 
difficult to analyze and to refer to these lesions, will some- 
times be presented to the clinician and medical jurist. 
The loss of the faculty of recalling words must interfere to 
some extent with the acts of thinking as well as with ex- 
pression. Kussmaul, commenting on several well studied 
cases, shows that verbal amnesia, and the more profound 
derangements of memory with which it is often associated, 
may interfere with the evolution and processes of thought; 
and that in some of its severer grades it makes well regulated 
thinking aloud impossible, although even in these cases the 
affection is not always incompatible with silent thought. 
Mental combinations consummated without wrords, as, for 
instance, those used in games are not always impossible. He 
holds, and doubtless correctly, that amnesic aphasia in its 
more severe forms must render thought mixed and confused, 
and unless the affection be merely a light form of the 
aphasia of recollection, it is almost always accompanied by a 
pronounced diminution of the intelligence. We should not, 
however be satisfied with a generality like this, important as 
it may be; but should, in studying individual cases, separate 58 
APHASIA. 
the varieties of verbal amnesia and apraxia into classes, 
based upon a study of the relations of the symptoms 
presented to the sites and extensions of the lesions on which 
these symptoms are dependent. Those deep disturbances of 
speech and thought which are dependent upon large lesions 
destroying and disrupting various percept and concept 
centres, and the lines of communication between them, must 
so weaken and confuse the mental powers as to make sanity 
and responsibility in criminal, and competency in civil cases, 
often a matter of gravest doubt. 
Many illustrations of forms of verbal amnesia and its 
most frequent associations have been recorded in the 
classical treatises on aphasia, and here and there in journals 
and text-books, but I will only refer to two or three. 
Kussmaul cites Bergmann’s case of a hind, 40 years old, 
who was unconscious for four weeks after a severe injury to 
the head, and then regained his recollection of things and 
places, but his memory for names was lost. The nouns had 
disappeared from his vocabulary, but he still had command 
of the verbs. A pair of scissors he called that with which 
one cuts; the window, that through which one sees, through 
which the room is illumined, etc. He had forgotten most 
of his songs and prayers. He recovered his memory sub- 
sequently. 
The same author also gives the well-known case reported 
by Hun of Albany, that of a farrier who suffered from heart 
disease, and was seized one day with congestion of the brain, 
which threw him into a state of stupor lasting several days. 
He recovered consciousness and understood what was said 
to him, but although his tongue was freely movable he 
could not find words, and had to make himself understood 
by signs. He understood words that were said to him but BY CHARLES K. MILLS, M. D. 
59 
could not find those necessary to give expression to his 
thoughts. He could not repeat words that were pronounced 
before him. When the doctor pronounced the word which 
he sought he was much rejoiced, but his efforts to repeat it 
were fruitless. If Dr. Hun wrote it out for him he was able 
to spell it and could pronounce it after a few attempts. He 
made for himself a tablet on which the necessary words 
were written out, and took refuge in this during speaking. 
Finally he learned to do without it. When he was able to 
pronounce a word, he was also able to write it. 
Bateman1 records the case of a merchant who had been 
failing mentally for some time, and had had a “fainting 
fit,” and soon afterwards began to get confused in conversa- 
tion. He would let objects drop from his right hand, and 
do awkward things at the table—on one occasion he used 
vinegar instead of pepper. It was soon observed that he 
could not write a letter. During the doctor’s lengthy inter- 
view with him, he never initiated any subject of con- 
versation. When questioned, he got confused, and was 
conscious of this, saying he could not find words to 
describe his symptoms. The answers he made, however, 
were coherent, but in the fewest possible words. He seemed 
to understand everything that was said, but had to a certain 
extent lost the memory of words, and would call things by 
their wrong names—for instance, when the fire was burning 
particularly brightly he said, “How bright the poker looks.” 
Some one said, “You mean the fire,” “Yes,” he said, “I 
mean the fire.” He would be thus confused in the choice 
of words to express his thoughts, and the knowledge of 
this defect was a source of distress to him. The idea was 
conceived but the means of communication with the ex- 
1 Bateman: Aphasia, etc., p. 109. 60 
APHASIA. 
ternal world did not exist. He complained of numbness in 
the right arm and leg, and the tactile power of the right 
hand was impaired. 
An autopsy was had, and a cystic and softened area 
found, which is described as located at the point of union 
of the middle third with the posterior third of the convex 
surface of the left hemisphere. 
Lichtheim reports in elaborate but important detail, a 
case of lesion of the paths between both the auditory and 
visual centres and the concept sphere with an interesting 
medico-legal experiment. Such a break should give us 
according to his analysis, loss of the understanding of spoken 
and written language, with the preservation of volitional 
speech, which would, however, be parapliasic, and of 
volitional writing which would be similarly paragraphic; 
also the retention of the faculty of repeating words, of read- 
ing aloud, of writing to dictation, and of copying words, with, 
however, a loss of intelligence for what is repeated, read 
aloud, or written to dictation. The case bears out fully this 
'analysis. Verbal deafness was present, but litttle or no 
deficiency in the man’s vocabulary, although he was in great 
difficulty when he had to name objects shown to him ; he 
could repeat what was said to him without understanding; 
he understood nothing printed or hand-written ; he could 
make up letters into words, and could read aloud by spell- 
ing, but the sense of the words remained closed to him. His 
other losses and preservations were in accordance with the 
analysis just given. This case and that of Hun, illustrated 
a point which must be always borne in mind when giving 
testimony, and one to which 1 have already referred, 
namely, that improvement in various ways both on the 
impressive and expressive sides often takes place in aphasic BY CHARLES K. MILLS, M. D. 
61 
cases. Word-deafness, paraphasia, paragraphia, and intelli- 
gent comprehension changed markedly for the better; but 
even after much improvement, writing to dictation remained 
obscure. Lichtheim dictated to him an I. 0. U. for 20,000 
francs, which the patient wrote down and allowed the doctor 
to put in his pocket without giving the least sign of emotion. 
In less than a month, however, when much greater improve- 
ment had taken place, the experiment with the due bill no 
longer succeeded. 
Starr1 has reported several interesting cases—one of 
paraphasia progressing to total aphasia, in which the patient 
was anxious to give directions about financial affairs and 
about his will, and although he knew what he wished it 
was impossible for others to learn his desires either by 
speech or writing. Another patient, a physician, would 
sometimes write the name of one drug in a prescription for 
another, and was also, likely to write the quantities wrong, 
so that he never failed to read his prescriptions several 
times. This shows another peculiar medico-legal phase 
which such a subject may have. 
The discussion already had and illustrated by these cases 
makes it unnecessary to go in detail into each peculiar 
variety of conduction or commissural disorder of speech. 
The medico-legal bearings of alexia, dyslexia, paralexia, 
paragraphia, and paramimia, become evident in the 
general discussion of paraphasic disorders. 
Commonly and correctly, mental integrity and com- 
petency, whether considered with reference to the depriva- 
tion of liberty, the care of an estate, the making of a 
contract, the preservation of testamentary capacity, or other 
questions which may arise in connection with apbasics, are 
1 Starr: N. Y. Medical Record, October 27, 1888. 62 
APHASIA. 
not regarded as affected by the existence of motor aphasia 
even when associated with considerable paralysis, and per- 
haps even with other forms of aphasia. I am, of course, 
now speaking of those forms of motor aphasia which are 
not part of or imposed upon insanity of definite type. Each 
such case should, however, be studied on its own merits, and 
the evidence pro and con should be carefully sifted. Ray, 
Bastian, Ferrier, Hamilton, Hughes, Bateman, and many 
others, have expressed the opinion that aphasia from 
destruction of the motor speech centres does not of necessity 
mentally incapacitate the individual, and many cases have 
been recorded by these and other authors, to illustrate the 
retention of mental power by such patients. One of the 
general conclusions of Kussmaul is that “ mental combina- 
tions which bear upon business affairs, and can only be set 
in operation by the aid of speech, are at times even 
admirably carried out notwithstanding the existence of a 
high degree of ataxic aphasia.” 
Even for motor aphasics, however, general conclusions 
are not sufficient. Such cases separate themselves into sev- 
eral classes according to the site and extent of the brain 
disease producing them. A sharp distinction must be made 
with reference to all aphasics, but particularly those in 
which the motor type predominates, between having mental 
power and being able to make known this possession 
to others; between the capacity to wish and will certain 
things, and the ability by speech, writing, or panto- 
mime to show the desire and intention. In pure motor 
aphasia, due either to lesion of Broca’s convolution, or the 
utterance centres at the base of the central convolutions or 
of both, the patient is usually able to make his wishes and 
purposes known. Usually such aphasia is associated with 63 
BY CHARLES K. MILLS, M. D. 
agraphia, but expressive pantomime is likely to remain in 
some degree so that the patient can often communicate in- 
telligibly with others. The impressive and concept spheres 
of language are not interfered with, and if any clear means 
of expression and communication remain, the capacity and 
competency of such a patient *will be scarcely questioned. 
Cases which ilhistrate this standpoint are to be found in all 
articles and treatises on aphasia and need not lie quoted. 
Even cases of pure motor aphasia, however, may be some- 
times misunderstood, if care is not taken in communicating 
with them, as any defect in the mechanism of thought and 
expression, renders the human being, fallible even in 
health, liable to make mistakes and to be misapprehended. 
Bastian,1 in the following quotation, indicates an import- 
ant matter—the bearing of the personal equation of the 
aphasic upon the question of mental impairment,—and he 
also in it tersely expresses the status of most cases of pure 
motor aphasia and agraphia: 
“In pure agraphia thought is least of all interfered with. 
In pure aphasia it is more or less hampered, because the 
non-revival of glosso-kinaesthetic impressions seems to 
interfere somewhat with the free and thorough revival of 
words in other functionally related word centers, even during 
the processes of silent thought. Still in regard to both these 
forms of word revival, namely, of sensations accompanying 
the pronunciation and the writing of words, it should be 
borne in mind that for most persons no very definite recol- 
lection is possible, although unconscious memorial recall 
may occur with unfailing regularity, so as to lead to their 
proper sequences in the form of speech or writing. It is 
quite possible that the degree of impairment of thought in 
1 Bastian: Brit. Med. Jour., Yol. II, 1887, p. 934. 64 
APHASIA. 
different individuals suffering from pure aphasia may be 
subject to some variation in accordance with a varying 
relative importance (for such different individuals) of revived 
kinaestlietic impressions as compared with revived auditory 
and visual impressions. (Bernard, De PAphasie, p. 48.)” 
Motor agraphia is usually associated with aphasia of the 
motor type, and, like the latter, is also variously combined 
with conduction or even conceptual and sensorial affections, 
and its importance will of course depend largely upon its 
combinations and complications. 
Cases of either motor aphasia or agraphia, of pure type, 
and unassociated with paralysis, are rare. By far the most 
common association is motor aphasia, or motor aphasia and 
agraphia, combined with types of conduction aphasia, and 
well marked hemiplegia. These hemiplegic aphasics easily 
separate into three classes with reference to the presence and 
persistence of the aphasia: (1) Cases in which the aphasia, 
complete or nearly complete at first, in the course of days, 
weeks, or months, totally or almost totally disappears; (2) 
Cases in which the aphasia is nearly or quite absolute, and 
remains permanently; (3) Cases which improve slowly, and 
largely through a tedious process of training and re-educa- 
tion. The nervous wards of the Philadelphia Hospital 
almost always contain some cases of these different types. 
Those cases of the first category, in which the hemiplegia 
persists although the aphasia passes away, are probably most 
frequently from lesions of the internal capsule, at a point 
well removed from the cortex, and compressing, or only par- 
tially destroying the fibres for the facial centres. The 
patients recover their speech because of the escape in large 
measure both of projection and commissural fibres. The 
mental integrity of patients of this class, after the apoplectic BY CHARLES K. MILLS, M. D. 
65 
period, is always retained, and is, as a rule, soon easy of 
determination. The ability to write and to express thought 
by pantomime is fully preserved on the non-paralyzed side, 
and to some extent when the paralysis is not absolute, the 
paralyzed limbs may be made to do service in expression. 
In the second class of hemiplegic aphasics, in which the 
aphasia remains nearly or quite absolute and permanent, 
the determination of the mental status of the crippled 
individual is often a matter of great difficulty. I have seen 
autopsies on a number of these cases, as also on cases 
illustrating other varieties of aphasia. Generally the lesion 
is one of large size involving and destroying both internal 
and external capsules, and to a greater or less extent both 
striate bodies and the insula; in other words, one which 
according to our best lights, disrupts entirely the inter- 
nuncial tract for speech, and also largely the commissures, 
both direct and indirect, between the sensorial and motor 
centres, or between the latter and the centres for concepts. 
This lesion, moreover, is often so close to the cortex for 
speech as to destroy the commissures which would otherwise 
connect the left hemisphere with the right through the 
corpus callosum. Although motor aphasia and motor 
paralysis of face and limbs are prominent, the case is in 
reality one of badly mixed type, and presents phenomena at 
first sight as confusing to the investigator as the disturb- 
ances of thought and speech are to the suffering patient. 
It is in such a case particularly that a vast difference exists 
between the possession of thinking power, and the ability 
to communicate with others and make them appreciate this 
position. As a rule, writing and pantomime are lost in 
equal degrees with speech; but every means should be 
exhausted and every channel of communication tested, 66 
APHASIA. 
before arriving at a decision, and even then such decision 
might be incorrect or unjust. 
In the third class of cases, those which improve slowly 
and tediously, but nevertheless make great advances, the 
lesions, while large and similarly situated, have not been as 
extensive as those present in the second class. In the third 
class, also, the original capacity, the education, and the 
strength of mind of the aphasia may play an important 
part. The ability to exhibit capacity and competency will, 
of course, vary at different stages, as the patient progressively 
improves. 
The certainty and uniformity with which an aphasic ex- 
presses even simple assent and dissent, by word or gesture, 
when questioned with reference to his wishes or with refer- 
ence to facts, must be taken into full consideration. During 
the preparation of this paper, some cases of aphasia, which 
were certainly not word-deaf or only partially so, were care- 
fully tested at the Philadelphia Hospital, with reference to 
their ability to certainly and consistently exhibit assent or 
dissent to questions relating to matters easy of comprehen- 
sion. The results were variable and sometimes contradict- 
ory, puzzling, or amusing. One patient whose only vocab- 
ulary was the word “no,” evidently used this word to ex- 
press both assent and dissent, but accompanied its use with 
such an appearance of countenance, and such gesticulation 
as*to make it impossible to decide as to her real intention. 
Sometimes she seemed to instantly and clearly comprehend 
what was asked, and showed this by her countenance, but 
oftener her look was one of annoyance, confusion, or impa- 
tience, rather than of either assent and dissent. Another 
patient seemed to understand most of what was said to her, 
particularly at first, but after a few queries she became BY CHARLES K. MILLS, M. D. 
67 
emotional, excited, confused, and decidedly impatient of in- 
vestigation. A third, whose accompanying paralysis was less 
complete than that of the other two, but whose vocabulary 
was chiefly confined to the word “no,” assented or dissented 
by means of facial expression, nodding her head and panto- 
mime of fair correctness, and yet on continuing the examina- 
tion frequently made foolish and absurd assents and dissents. 
A fourth patient possessed expressive gesture and patomime 
in a much higher degree. She not only understood all that 
was said to her, but within the limits of her original capacity, 
education, and experience could so far as her unparalyzed 
members would permit, express her meaning clearly and 
distinctly by the most significant pantomime. With the 
instruments which nature had left unimpaired she could 
promptly indicate what she wished to convey, and yet she 
was tremendously crippled so far as ordinary speech was 
concerned, and had as a most common method of vocal reply 
a routine, recurring utterance “come-on-to-nong.” Her 
pantomime had high propositional value. In studying her 
pantomimic powers, for instance, I asked her age, and with 
her unparalyzed left hand she opened and shut it fourteen 
times, the movement becoming a little slower and more 
emphatic as she approached the end. She told us in this 
that she was seventy years old, and when I said to 
her you mean you are seventy years old ; she nodded her 
head “yes” in a most emphatic manner. I asked her how 
long she had been sick, and with her hand she promptly 
told me fifteen years. I said to her you mean twenty, she 
shook her head “no”, and again opened and shut her hand 
three times to indicate fifteen. 
The explanation of some of these cases is that although 
the receptive centres are sound, owing to the invasions of 68 
APHASIA. 
the disease from the motor side of the brain, the association 
channels between the receptive and emissive centres are 
impaired or functionally inactive, and the patients seem to 
sink into a condition of language or speech fatuity from 
disuse, and carelessness as to speech. Even some patients 
who retain a considerable vocabulary and have only a 
moderate degree of paralysis, who clearly understand the 
import of questions put to them, and are clearly capable of 
certainly and consistently assenting and dissenting, show 
undue emotionality from trivial cause, and a weakness of 
grasp upon the ideas presented. Mixed apliasics, particu- 
larly if they have had little education or original brain 
capacity, who develop conditions of confusion, obstinacy, 
and impatience, probably do this in part as the result of the 
infrequent exercise of their mental powers through the 
vehicle of language. 
Some knowledge of the most frequent methods of com- 
bination in the mixed aphasias will be of service in attempts 
at the solution of the medico-legal problems of speech. 
Brain lesions, usually vascular, are likely to extend over 
areas and tracts which are associated in functioning, and 
have, in accordance with a general law, a more or less com- 
mon source of blood supply. Different varieties of psychical 
blindness and deafness, partial or complete, may occur to- 
gether; motor aphasia, agraphia and amimia, partial or 
complete, are usually associated with paraphasias; and fre- 
quently partial word-deafness is found in conjunction with 
one or several of the varieties of motor defect in expression. 
Total sensory and motor aphasia is sometimes observed, and 
is of course accompanied by the completest form of speech, 
graphic and pantomimic disorder—complete aphasia, 
agraphia and amimia. BY CHARLES K. MILLS, M. D. 
69 
Close studies of these compound cases will doubtless enable 
us after a time to better separate them into different classes 
guided by localization facts and theories; to distinguish cases 
in which either the direct sensori-motor, or the concept- 
motor commissures, or both, or the hemispheric commis- 
sures, are damaged at the same time that the lesion attacks 
or not cortical centres and cortico-bulbar tracts. The path 
from concept to motor, or from auditory to motor centres, is 
certainly frequently broken and probably most frequently 
near the motor end of the line. Pure or almost pure cases 
of concept-motor aphasia have been reported in considerable 
number. 
Disorder of speech, the result of damage to the socalled 
internuncial fibres or tracts between the cortical and bulbar 
centres, is of the nature of an anarthria or disturbance in 
articulation, rather than a genuine aphasia. This speech 
defect I have already described under the name of pseudo- 
bulbar or labio-gloso-pharyngeal paralysis of cerebral origin. 
The most marked examples of it are due to bilateral lesions 
or degenerations. Whether unilateral or bilateral, all cere- 
bral centres and commissural channels are undisturbed; 
volitional speech, word repetition, and reading aloud are 
lost or greatly impaired simply because of interruption to 
speech impulses in the out-going roadways below the cortex. 
Mental capacity and competency need not be in the least 
diminished, as the patient preserves his receptive and con- 
ceptive faculties, and unless through great accompanying 
paralysis of face and limbs, large powers of communication 
by means of pantomime and writing. 
It is necessary both for their positive and their negative 
importance, to briefly consider the various disorders of 
speech from mfra-cerebral disease, such as, bulbar palsy, 70 
APHASIA. 
insular sclerosis, and focal lesion between the cord and 
cortex, a large class of affections sometimes described under 
the general name of anarthrias. 
In true bulbar paralysis, in which the changes in articula- 
tion are sometimes slight, and at others so complete as to 
almost abolish articulate speech, mental soundness, if the 
cases are uncomplicated, is not in any degree impaired, and 
various methods of expression and communication remain. 
The method of progressive deterioration in the patient’s 
speech, with the continued retention of mental integrity, is 
beautifully described by Kussmaul1 in the following para- 
graph : 
“As in the course of these degenerative changes one 
ganglion cell after another is slowly destroyed in the bulbar 
nuclei we perceive consonants and vowels successively 
crumbling away, as it were, from the patient’s speech, while 
his intellectual powers may be perfectly retained. His 
words grow more and more indistinct and mutilated, his 
stammering passes into an unintelligible muttering, until at 
last he is only able to emit grunting noises, and perhaps 
not even these. So long as his hands and arms escape 
paralysis, he continues to communicate his feelings and 
ideas by writing. The disorder of speech is invariably 
limited (when there is no cerebral complication) to the 
power of forming articulate sounds; the stammering may 
pass into complete loss of speech but it is never associated 
with a blundering enunciation of syllables (Sylbenstolpern), 
or with aphasia. The degree in which the formation of syllables 
and words is interfered with is always proportionate to the dis- 
order of literal phonation; the architecture, so to speak, of the 
words is not impaired; they continue to be correctly put 
1 Kussmaul: Op. cit., p. 654. 71 
BY CHARLES K. MILLS, M. D. 
together, though the materials—the elementary sounds of 
which they are made up—may be inadequate.” 
The various but allied forms of speech disturbance which 
result from insular sclerosis, and focal lesions of other sort 
in the intra-cerebral tracts, are not necessarily accompanied 
with any loss of mental strength or clearness, although, as 
is well known, mental ehanges are somewhat common in 
this affection because of its diffuse and destructive character. 
It is scarcely necessary to refer to the peculiar varieties of 
speech defect found in this well known disease, which have 
been well described under a variety of names such as 
drawling, syllabic, scanning, staccato, and hesitating. 
The study of speech disturbances which are associated 
with the various forms of insanity, have of course great im- 
portance in connection with the particular topic of this 
paper, but would need an article of considerable length for 
their full discussion. 1 can scarcely more than refer to them. 
As lias been said by Dr. Hughes, and as even a careless 
study will show, aphasia dissociated from marked mental 
impairment is of more frequent occurrence than in asso- 
ciation with evident insanity; so that in a case of sus- 
pected mental disease the burden of proof will fall on those 
who might maintain the co-existence of mental aberration, 
and the legal presumption would be in such a case in favor 
of sanity. While this is true it must not be lost sight of 
that aphasia is found among those who are clearly insane. 
Broca’s first two cases were observed in an institution 
devoted to the treatment of mental disease, and not a few of 
the recorded cases have been observed in hospitals for the 
insane. Every physician in charge of an institution of this 
character, should carefully inquire into the history and 
symptomatology of cases showing special forms of speech 72 
APHASIA. 
disturbance. The two cases referred to by Kussmaul will 
be remembered—patients suffering from aphasia, but not 
insane, and yet confined in an asylum. 
Probably in paretic dementia, and senile dementia, the 
study of speech defects has more diagnostic and medico- 
legal value than in any other of the well recognized types of 
insanity. In the early stages of the former disease it may 
serve to make clear the true nature of the case; in the latter 
affection it may be of decisive importance in the determina- 
tion of questions of competency. In mania, melancholia, 
paranoia, katatonia, idiocy and imbecility, the peculiarities 
of speech might have some bearings upon medico-legal 
problems in connection with the diagnosis of the nature, 
depth, or stage of the affection. 
About the hallucinations and delusions among apliasics 
much of interest might be written. The hallucinations are 
usually of hearing and sight, and may in not a few cases be 
dependent upon irritation of sensory centres ; while various 
delusional states may have their origin in disease both of 
sensory and concept centres, or in the disruption of various 
lines of communication between the different areas of the 
brain concerned with speech. 
A consideration might be here in place of the inhibitory 
speech centres, or centres for abstract thinking, which I 
have included in the list of centres taking part in the 
phenomena of speech, but which are not usually so 
included. They are probably located in the prefontal 
region. Hughlings Jackson,1 Mercier, and others hold 
that anterior to the Rolandic motor region, are the highest 
motor centres, and that these with corresponding sensory 
centres, make up the highest level of the central nervous 
Hughlings Jackson, M. D., New York, Med. Rec., August 31, 1889, Vol. xxxvi., 
p. 227, 228. BY CHARLES K. MILLS, M. D. 
73 
system. Jackson contends that these higher centres 
represent all parts of the body; and Mercier that the 
highest nerve processes which form the substrata of the 
most elaborate mental operations, represent at the same 
time not only the most elaborate forms of conduct and 
muscular movements, but also every part of the organism 
in some degree. Accepting such doctrines, speech, like 
every other function of the body must, of course, be influ- 
enced by anything which affects these highest centres. 
Affections of speech, however, due to lesions of these pre- 
frontal areas are a part of the general mental impairment 
which goes with the destruction of this region; and the 
mental status of the individual will be recognized as much 
by other phenomena as by those of speech. 
The following quotation from Hughes1 may serve ttf cover 
some points with reference to the medico-legal aspects of 
affections of speech, not otherwise included in the present 
paper: 
“ The hysterical, the choreic, the cataleptic, the emotional, 
the hyperaemic, and reflex forms of speech failure have 
neither distinct clinical significance, nor are they often likely 
to have medico-legal importance, separate from the diseases 
with which they may be associated. They need not, there- 
fore, be considered here, and we mention them mainly to 
exclude them, as we likewise do the speechlessness of night- 
mare. Marc and others, however, have noted the temporary 
impairment of the mental faculties in chorea, and the defect 
in the speech power in this disorder, is, probably, as much 
dependent upon the cerebral disorder implicating the 
speech centre along with other portions of the cortex, as on 
disturbance of the motor area for the organs of articulation. 
1 Hughes: Alienist and Neurologist, July, 1880, Vol. I, No. 3, p. 315-316. 74 
APHASIA. 
There are circumstances, too, under which aphasia occurring 
in the course of cerebral hyperaemia, might have corrobor- 
ative significance in a question of doubtful sanity, but if we 
were to discuss all these possibilities, we might transcend 
the limit of the evening. We may say, however, in order 
to be understood as not underrating the matter, that such 
a degree of general cerebral congestion, if persistent for any 
length of time, as would paralyze the speech co-ordinating 
power, would probably also simultaneously impair the 
higher psychical faculties. 
“The occasional aphasia of drunkenness has never been 
pathologically defined with sufficient distinctness. It is 
often, no doubt, a sort of incomplete and transient glosso- 
labial paralysis, like the other forms of inco-ordination seen 
in inebriates, or the peculiar and more permanent defects of 
speech displayed by general paralytics. This latter form of 
speech defect, also, need not be considered apart from the 
graver disease with which it is associated, and which has 
other characteristic signs. Nor need we note, any of the 
glosso-plegias causing speech defect.” 
“The momentary speechlessness, sometimes occurring in 
persons overcome by fright or profound surprise, at being 
the unwilling or unexpected witnesses of some horrible 
tragedy, might possibly have to be considered where an 
innocent person is indicted as particeps criminis from the fact 
of his being present, and uttering no protest or cry of alarm; 
but, in such cases, the proper explanation, I believe, has 
always been, and is still likely to be, made and received; so 
well understood is the fact, by the common mind, that 
intense fear may for a time, paralyze the power of speech, as 
well as of motion.” 
The disease known as echolalia, or coprolalia, and by 
various other names, might have some medico-legal BY CHARLES K. MILLS, M. D. 
importance. This is an affection in which convulsive or 
choreic movements are associated with a sudden explosion 
of speech. The patient with a grimace, contortion, or 
violent movement of some kind, suddenly bursts into an 
obscene, profane, or absurd expression. This expression 
may be the echo of something overheard, hence the name, 
echolalia, or it may be a spontaneous outcry. It is con- 
ceivable, although I do not know that it has happened, that 
such a patient might be arrested for the use of obscene or 
insulting language in the presence of others, and physicians 
and jurists should therefore bear in mind that such a disease 
exists, and that the impulse to burst forth in this way is 
sometimes irresistible. It is not simply an hysterical 
affection, controllable and curable, but is a true mono- 
mania, the affection of speech being beyond the patient’s 
volition. One patient of mine, a boy about twelve years 
of age, at times, without warning, would in a street car or 
other public place as well as in private, suddenly give 
utterance to a filthy expression two or three times, accom- 
panying it with a violent movement of the head, shoulders, 
and one arm. Another patient, a lady of good education, 
and fine personal appearance, would in the midst of a con- 
versation, or on introduction to another, or at any most 
inopportune time, suddenly, with violent gesticulation, 
shout, “Damn it!” “Damn it!” “Damn it!” Gilles de la 
Tourette, Dana, Seguin, and others, have reported numerous 
cases of this kind, and the affection certainly has a possible 
medico-legal aspect. 
The association of aphasia with epilepsy, and the occur- 
rence of what might be termed an epileptic or epileptiform 
aphasia without spasm, or without the usual type of convul- 
sion with unconsciousness, is a phase of one subject which 76 
APHASIA. 
has some important medico-legal bearings. Disturbances of 
speech in connection with epileptic attacks are, of course,, 
very common, and may occur before or after, or even during 
a fit, when loss of consciousness is not profound. Sometimes 
a seizure is preceded, as is well known, by muttering or con- 
fusion of speech, by “thickness of tongue”, by the utterance 
of certain expressions, by an unusual talkativeness, or by an 
absolute inability to talk. The aura of the attack may be 
apliasic in various ways. They are so well known and they 
have been so often studied and detailed, that it is not worth 
while to go in detail into the numerous perversions of 
speech and thought which so commonly follow epileptic 
attacks; they are simply the evidences of the exhaustion 
and disorder of the cerebral mechanism which has resulted 
from the terrible explosion of nervous energy which had 
occurred during the fit. In addition to these affections of 
speech, however, are others of rarer occurrence, and of special 
interest. In some of these the aphasia itself is the fit, just as 
we may have instead of the motor paroxysm, which is the 
usual epileptic manifestation, a substitutional attack of 
mania, of vertigo, of pain, of running, or of other automatism. 
The nature of such cases of sudden loss or abrupt dis- 
turbance of speech is sometimes obscure and needs careful 
investigation. In the first place, the affection might be 
absolutely assumed or malingered, as, for instance, where it 
is part of a scheme for dissimulation of insanity, or to 
present a more serious picture in a litigation case; secondly, 
such loss or disturbance of speech might be neuro-mimetic 
or hysterical, but not absolutely simulated; and, thirdly 
it might be the result of a genuine discharge of cortical or 
ganglionic areas of the cerebrum, or the result of a local 
cerebral ischaemia, and therefore properly to be classed as a 
epileptic phenomenon. BY CHARLES K. MILLS, M. D. 
77 
Many years ago I was sent for in haste to see a 
young woman, whose virtue was not equal to her 
appearance. She had suddenly become totally speech- 
less, causing great consternation to her lover and the 
other residents of the house. No facial or limb paralysis 
could be made out and she had none of the usually 
associated phenomena of either an apoplectic or an 
epileptic attack. I learned that this abrupt loss of speech 
had come on after a quarrel with her lover, in which 
both he and she had exhibited violent rage, although 
no physical force had been used. In this case it was 
somewhat difficult to decide, but I concluded that the 
case was one of hysterical aphasia, the result of nervous 
excitement attendant upon the quarrel, and that the patient 
would soon recover, which she did as abruptly as she 
had been attacked. A form of mutism is, as is well 
known, quite common as a phase of hysteria, but the cases 
here referred to are those in which the loss of speech comes 
on as a sudden attack. 
The presence or absence of speech disturbances with 
•conscious epileptic automatism—which is perhaps a some- 
what contradictory expression—may have some medico- 
legal importance. Stevens and Hughes1 have reported such 
a case, and many more as similar are to be found in the 
•books and journals. This patient, a physician, on several 
•occasions got up in the night, dressed himself and went out 
■of doors to look at his stock, or perhaps simply without any 
purpose. During part of the time at least he realized that 
he was doing something which he should not although 
•conscious of what was occurring. He had had many real 
•epileptic seizures preceding these attacks. He was put 
1 Stevens and Hughes: Alienist and Neurologist, April, 1880. 78 
APHASIA. 
under treatment and greatly improved, but on another 
occasion in a similar seizure he was asked a question 
which he understood perfectly but could not answer, 
although he continued to talk for about twenty minutes 
attempting to explain what he was trying to say. The 
night following this incident he had a severe epileptic 
attack. He afterwards could recall much of what he had 
* 
said and done when in this confused, automatic state. The 
reporters of the case ask what would have been the result 
had some acts been done by this same patient during his 
apparently conscious somnambulism, something, for instance, 
involving him in a pecuniary obligation, as the signing of a 
deed, or the doing of any act making him liable to the law ? 
Every neurologist of experience has seen similar cases. 
In a discussion of the medico-legal aspects of aphasia, the 
simulation of dumbness by criminals or others should not be 
overlooked, as it is in fact a simulation of aphasia, or in 
some cases of both aphonia and aphasia. It may be resorted 
to by criminals feigning to be insane in order to escape the 
consequences of their crimes, or by prisoners to avoid duties 
or punishments. Ray1 mentions the case of a man who had 
cut off his wife’s head and had or assumed the demeanor of 
an imbecile. Among other manifestations he carried a 
piece of wood about with him which he represented by signs 
to be a sword. He would not speak or answer any questions 
except by now and then repeating the word “ cabbage ” 
without any meaning. Another French homicide, who was 
adjudicated insane, would not answer questions although he 
heard and understood them. Jean Gerard murdered a 
woman at Lyons, in 1829, and immediately after his arrest 
ceased to speak altogether, and appeared to be in a state of 
1 Ray: Medical Jurisprudence of Insanity. BY CHARLES K. MILLS, M. D. 
fatuity. The use of the actual cautery for several days 
brought him to terms, and after some urging he spoke 
declaring his innocence of the crime with which he was 
■charged. A man convicted of pocket picking and sentenced 
to four years penal servitude, on hearing the sentence fell 
down in the dock in a fit of apoplexy, and when removed to 
the jail was found to be hemiplegic and apparently mind- 
less, but whether he was aphasic is not mentioned. He 
subsequently effected his escape in a manner which made 
it clear he had been simulating. An Italian criminal 
apparently became insane soon after he had been betrayed 
by his accomplices, and to any question whatever, he 
merely uttered the words, “ book, priest, crown, crucifix.” 
Many other details are connected with this case, but it was 
finally decided that he was insane. It is not impossible 
that he may have been insane and also simulated some of 
his symptoms. 
In suspected shamming of dumbness or of aphasia, the 
genuineness of the phenomena should be patiently tested 
from the standpoint that the defect of speech might be due 
to the mental state, that is, an aphrasia or dysphrasia, and 
also from the standpoint that it might be primary, that is, 
a true aphasia or dysphasia. As far as possible, the test 
for the determination of the presence of insanity or its 
■simulation should be applied, resorting to surprises, strategy, 
and perhaps even in some cases to anaesthesia or to stern 
methods. The apparent aphasia or aphrasia should also be 
tested and studied as would any ordinary case of this 
■affection in the same. Word-deafness, word-blindness, 
alexia, dyslexia, motor aphasia, and agraphia, should, if 
possible, be investigated and included or excluded; and 
the existence or non-existence of accompanying paralysis, 
anaesthesia, hemianopsia, etc., should be given full weight. 80 
APHASIA. 
Let me say a few words in conclusion about the methods 
of examining patients suffering from aphasia and other affec- 
tions of speech, for medico-legal, or indeed for any practical 
purpose. Such an examination to be of real value should be 
carried out systematically and should be of the most thor- 
ough character. Reports of trials in which aphasia has 
been the issue, or of papers based upon a study of medico- 
legal cases of this kind, show how meagre, uncertain and 
unsystematic, have often been the investigations of patients 
whose mental state has been the issue upon which has 
hung the disposal of large fortunes. 
Starr1, who lias written various important papers on 
aphasia, in one of them makes the following practical 
suggestions with reference to these examinations: 
“ To examine an aphasic thoroughly, it is necessary to 
test : 
1. The power to recall the spoken or written names of 
objects seen, heard, handled, tasted, or smelt. 
2. The power to understand speech and musical tones. 
3. The power to understand printed or written words. 
4. The power to speak voluntarily. Does he talk clearly ? 
Does he mispronounce words? Does he misplace words? 
Does he talk jargon ? 
5. The power to repeat a word after another. 
6. The power to read aloud. Does he understand what 
lie reads ? 
7. The power to write voluntarily. Can he read what 
he has written ? 
8. The power to write at dictation. 
9. The power to copy. 
10. The power to recognize the use of objects seen, 
heard, felt, tasted, or smelt.” 
1 Starr: Apraxia aud Aphasia. Med. Rec., New York, October 27, 1888. 81 
BY CHARLES K. MILLS, M. D. 
The investigator should constantly keep before his mind 
that he is to determine not only what the patient has lost, 
but what he retains of language and of thought. 
“The comparative study of nervous diseases,” says Jack- 
son1, “the study of them as dissolutions—is a process of 
generalization. To attempt this generalization without 
prior careful analysis of the things concerned, needing 
minute clinical study of individual cases, is not likely to 
lead to anything of permanent value. To compare and 
contrast the mere local lesions and the symptoms directly 
dependent on them only is not good method. It is one 
merit of the method I am urging that it deals not only 
with the local lesion—with that, I mean, which disease 
(in the strict sense of pathological change) causes—which 
alone is dissolution, but also with the healthy rest; that 
is, it takes into account the evolution going on in the 
undamaged remainder of the nervous system. The full 
symptomatology of a case of ocular paralysis is not to be 
intelligently stated even unless activities of healthy centres, 
including the highest (all centres above the peripheral 
lesion) are considered ; and a case of insanity is not properly 
analyzed unless undiseased parts of the highest centres and 
all lower centres are considered.” 
Lichtlieim, in the admirable paper so often referred to by 
me, gives a series of synopses in connection with his schema 
of types of aphasia. Such synopses, showing at a glance, 
what is lost and what is left of speech and thought, are of 
great value for the purposes of methodical examination. 
1 Hug-klings Jackson, M. D., New York, Medical Record, August 3 1889, Vol. 
xxxvi., p. 226.