Aphasia, or Aphasic Insanity, Which? 
A MEDICO-LEGAL INQUIRY. 
By Dr. C. H. HUGHES, St. Eouis, Mo. 
[From the American Journal of Insanity, for January, 1879.] APHASIA, OB APHASIC INSANITY, WHICH? 
A MEDICO-LEGAL INQUIBY.* 
DR. C. H. HUGHES, ST. LOUIS, MO. 
Aphasia, within the last few decades, has been 
brought quite prominently before the profession, and I 
know of no subject of more importance in its bearings 
on certain recently mooted questions in cerebral physi- 
ology, touching the localization of function. Our faith 
in the conclusions of Fritsch, Ferrier, Hitzig and Bar- 
tholow, and their laurels may be somewhat dimmed or 
brightened according to the conclusions finally reached 
on this subject. I believe in the localization of cerebral 
function, but there are many who, like Broca, before his 
conviction, are still skeptical, and strenuously contest the 
evidence of overwhelming facts. You will recollect, Mr. 
President, the circumstances under which M. Broca, who 
had been an opponent of the teaching of Bouillaud* 
became a convert to the doctrine of a speech center? 
having its location within the brain, and the famous 
challenge made by M. Aubertin before the Anthropo- 
logical Society, of Paris, in regard to one of Broca’s 
patients, then in the hospital for incurables, deprived of 
the power of speech, and how the confident Broca, 
accepting Aubertin’s challenge, subsequently found the 
lesion in his patient’s head to occupy the left anterior 
lobe of the cerebrum, renounced his former views, and 
located the seat of aphasia in the convolution which 
now bears his name. 
* Read before tbe Association of Medical Superintendents of Asyluips for 
tbe Insane, at Washington, D. C., May 17tli, 1878. 2 
The subject of aphasia may often acquire important 
meclico-legal significance, as was the fact with the case 
I am about to read. The question of mental compe- 
tency to do certain acts, such as the signing of import- 
ant papers, and the conveying of power of attorney, 
may arise. A question as to the degree of concomitant 
mental impairment, if any, will almost invariably be 
raised, if important acts are performed by these patients, 
involving great pecuniary interests, or questions of re- 
sponsibility to law are in question. Aphasia may be 
simple and uncomplicated, or complicated with hemi- 
plegia, imbecility or insanity. 
On the 13tli day of March, 1873, Mr. Wm. T. Bevin, 
a few months after the death of his wife, was stricken 
wTith right hemiplegia and aphasia. A cardiac valvu- 
lar lesion preceded the paralysis and is still persistent. 
At the time of my last examination, February 7, 1876, 
I found his respirations, without discoverable pulmonary 
lesion, to be twenty-one per minute, and the heart and 
wrist pulsations asynchronous, the latter counting as 
high as one hundred and eight, and the former some- 
times ten to eighteen more, per minute. At this time 
there was incomplete paralysis of • motion. on the right 
side and general anaesthesia. He was insensible to the 
pricking of a pin in both, hands and feet. The sub- 
lingual temperature, on either side, was 96° F. He 
correctly and promptly comprehended oral signs, but 
tardily and imperfectly understood written ones. He 
soon recognized my name and wrote it for me, with his 
left hand. He likewise wrote his own name and the 
surname of his attorney (Mr. Rainey), upon my asking 
them. An H, written by myself, and an imperfectly 
erased tracing of my surname, were on the card on 
which he wrote my name. He first attempted to attach 
“ ughes ” to the H, I had written, but afterwards 
changed his mind and made an H of his own, which 3 
accounts for the somewhat disjointed appearance of 
the word Hughes: 
His tongue was clear, but he said he always had a 
disagreeable taste in his mouth. He either really had, 
or feigned, defective vision. When the thumb was held 
up before him, looking with one eye, the other being 
blind-folded, he would say it was two, and when the 
thumb and little finger were held up, he would say they 
were three. I intended making an ophthalmoscopic ex- 
amination, but before I had opportunity the case came 
to trial,* and my testimony not being satisfactory to the 
family, I did not offer to examine him further. He either 
had defect of hearing in the left ear, or feigned it. I 
could not certainly determine which. He signed that he 
could not hear the ticking of a watch half an inch from 
his ear, yet he distinctly understood a remark addressed 
to him by his sister in quite an ordinary tone, at least 
twelve feet off from him, at the time I was testing his 
hearing. None of the family spoke to him in a very 
high tone, as is customary when one is deaf. He re- 
peated the word nin-nin, accompanied by a nod of the 
head, to signify yes and by a horizontal turning to indi- 
cate no. When I wrote W. T. Bevin and asked if that 
was his name, he shook his head and taking the pencil 
wrote Wm. T. Bevin: 
* William T. Bevin vs. Powell et al. Circuit Court No. 2, October Term, 1878. 4 
He had three paralytic strokes, and was seen hy his 
relatives after each attack. He has grown steadily bet- 
ter, and they now regard him as perfectly rational, 
but considered him unsound of mind on the fifteenth 
day of July, 1873, four months after his first seizure, 
when he signed with his left hand a deed of trust of his 
portion of some houses he was building jointly with some 
other parties, and in fulfillment of a promise and pur- 
pose, made and entertained prior to his attack. He could 
not write with his left hand before he was stricken. 
About the time of, and prior to the signing of this deed 
of trust, he is said, by some of the members of his 
family—principally his two sisters and a brother-in-law 
with whom he lived and is now living—to have done 
some things which they swore they regarded as evi- 
dences of insanity, such as on one or two occasions 
(none of the witnesses testifying to more) bowing to 
pictures in the parlor, when he knew members of the 
family were present, and with a pleased, but silly smile 
on his countenance. Once he is said to have wiped his 
nose on his napkin, and once or twice, in the early stage 
of his paralysis, they say he spat on his plate. Once 
he unbuttoned his drawers when his sister and an- 
other lady were in the room. It was said that once, 
shortly after his first stroke of paralysis, he defecated 
in bed. Once, he is said to have struck his mother with 
a stick, though one of his brothers, who swore there 
would have been no suit if he had got his three per 
cent commission, as promised for taking his afflicted 
brother’s place in conducting the work, never saw or 
heard of his bowing to pictures, striking his mother, or 
unbuttoning his drawers. 
Some time in the June following the stroke of paral- 
ysis, he recognized and pointed at the picture of the 
crucifixion, and other objects when asked to point them 5 
out. At this time he could not, the family say—all but 
one brother—distinguish letters or tell if they were 
upside down or not, but readily recognized them if 
their names were called. As early as the first of May, 
1873, he could sit in a chair and get about the room. 
In June lie appeared to one of his physicians to be 
silly, “ because he smiled peculiarly ” and was exceed- 
ingly violent and irritable when the battery was applied. 
To another of his physicians he appeared demented, 
though he was able to go unaccompanied in the follow- 
ing November, a long distance to this physician’s office, 
correctly select and count his money and pay his medical 
bill, and take and put away carefully a receipt for the 
same. It was said also that he made grimaces before a 
glass once or twice, and pulled out his hair, and he ate 
things, when set before him, that he never ate before. 
He handled his food with his fingers (he could not use 
a knife and fork), and his manners and tastes at table 
were changed in some other respects, he having been 
formerly very fastidious and precise. 
When he first learned to write his name he would 
make signs to visitors for a slate, write his name for 
them, and express his pleasure at the accomplishment 
by a peculiar smile. After the description of his prop- 
erty, mentioned in the deed of trust, was read to him, 
he pointed in the direction of it and gave an assenting 
nod, pointing immediately after in the direction of other 
property not alluded to in the document, and indicating 
his understanding that it was not included, by the 
usual turning away of the head indicative of dissent. 
He was attended by different physicians during 
the first attack. The physician who first saw him 
at the time of his first seizure found him only par- 
tially paralyzed on the right side, with consciousness 
still remaining, and helped him home. In six hours 6 
after this physician saw him, he was hemiplegic and 
unconscious, and so remained for several days. He 
commenced to improve in two or three weeks. He was 
then annoyed by movements about the room and 
exhibited u not much, but some signs, of intelligence in 
his countenance.” He made signs and efforts to convey 
ideas, and would mumble unintelligibly in answer to 
questions and had difficulty of deglutition. He never, 
at any time, had delirium, delusion or hallucination. 
He recognized Dr. Mudd generally when he visited 
him. One attending physician thought his mind was 
impaired, because “there seemed to him to be an 
absence of the power of expression and clear concep- 
tion of subjects.” This was just after the stroke. This 
mental confusion was a natural concomitant of the great 
commotio cerebri incident to such a severe, extensive 
and sudden involvement of a cerebral hemisphere in 
disease, even though that disease were solely at its base, 
which was here not the case. He might, at this stage 
even, have been demented, as he was considered to be, 
later, by one of his physicians but it could not be the 
real and permanent dementia which results from gen- 
eral degeneration and destruction of the cerebral cortex, 
as the improvement which soon began to appear and all 
the sequelae—his learning to write with his left hand, 
recognizing and designating friends, pictures, etc., 
within four months, conclusively proved. 
When we reflect that his hemiplegia embraced one- 
half of his face, in paralysis, it is not strange that he 
should have appeared silly and smiled peculiarly in 
May. His being irritable and violent when the battery 
was applied at that time, indicates only that the degree 
of paralysis of sensation has increased since then. It 
is not strange that he could not distinguish letters or 
tell if a book or paper were upside down, confusion of 7 
vision being the rale rather than the exception, after 
hemiplegic strokes. The great length of the tractus 
opticus, and of the optic nerve within the brain, and 
the manner in which they are supplied with blood 
vessels, expose the apparatus concerned in sight to 
great disturbance of function from pressure, etc.; for 
this reason disturbances of vision are common in 
morbid conditions of the brain. This patient might 
have been totally blind from pressure consequent 
upon the cerebral oedema, which generally follows em- 
bolic closure of a vessel in other parts of the brain than 
the spot primarily implicated in the thrombosis, if we 
take no account of possible similar, simultaneous closure 
of other arteries of the brain. We have but to remem- 
ber how closely related are the nuclei of the two optic 
nerves, in the corpora quadrigemina, to see how easily 
double impairment of vision may result, at least for a 
time, from a cause sufficient to engender hemiplegia. 
In regard to dementia, which only one of his physi- 
cians asserted that he had (Dr. Benkendorf), it is 
difficult for the practiced alienist, accustomed to observe 
the phenomena and progress of this profound form of 
mental disorder, to conceive how a patient could have 
really been demented in June, in consequence of a 
cerebral vascular lesion grave enough to cause hemi- 
plegia, paraplegia, confusion of vision and aphasia, and 
yet, be so recovered by the next following November, 
as to fully appreciate the services he had received from 
his physician, and go unaccompanied to his office, and 
settle in an intelligent manner his bill, even though he 
could not speak. 
It was singular that of all the acts testified to by 
Bevin’s brother-indaw and sisters, who were living 
with him and interested in the success of his suit, 
none of them should have been observed more than 8 
once or twice during the whole time of his afflic- 
tion. Many of these acts, had they occurred oftener, 
would have been explicable otherwise than on the 
theory of insanity, and all of them, as the testimony 
gives them in this case, are explainable without invok- 
ing the presumption of insanity, though a medical 
gentleman, of practical experience with the insane, for 
whose opinions I have a high regard, and whom the 
courts justly recognize as an expert in questions of 
sanity, thought these acts indicated mental incapacity 
on the part of Bevin. Another medical gentleman 
of large practical experience with the insane, no less 
eminent in psychiatry before the courts and in my own 
esteem, concurred with me in the opinion that these 
acts occurring before the signing of the deed—some of 
them, as the bowing to pictures, etc., within a month or 
two—did not indicate sufficient mental impairment to 
disqualify him for a full appreciation of the nature, 
quality and purport of the transaction. 
In this case, I. think, there was undoubted mental 
impairment to the extent at least of a crippled power 
of expression. There was impairment of executive 
mental power to such a degree as to incapacitate the 
individual from profitably engaging in the pursuit of 
his avocation, after he had finished up the business 
which occupied him before his affliction. Mr. Bevin 
seemed himself cognizant of this fact, and conducted 
himself after his affliction strictly in harmony with his 
surroundings, and does so still. He learned to write 
his name with his left hand, attached his signature to 
an important document, as it was necessary for him to 
do in order to complete the undertaking he had been 
engaged in, and after that signed no more documents, 
nor attended in person to any business, but relied on 
the proxy of his next friend. 9 
Let us look at liis acts and see how far they tend to 
establish insanity. In the first place they are limited 
in number, not a single habitual action appears in his 
history that is at all singular. He defecates once in his 
bed at the time it is testified by his family physician 
that he is paraplegic. This was more likely an accident 
due to his paralyzed condition at a time when no one 
was present to assist him than the result of mania. No 
one was present at the time it occurred. Maniacs have 
often filthy habits. Accidental occurrences of this kind 
are seldom, if ever, observed. The spitting in his plate 
once or twice before he. had learned to so co-ordinate the 
muscles of oral expulsion, or to adapt his position at 
the table to the changed circumstances of disease, was 
due to the facial paralysis rather than insanity. 
Then as to his irritability. Recovering paralytics are 
known to be irritable, and not very reasonable at all 
times when irritated. They can not make their many 
wants understood, and while they understand them- 
selves well, can not well understand why those about 
them do not comprehend their gestures and grimaces 
more readily. That he should once strike his mother, 
under such circumstances, does not then appear as an 
act of insanity. He was at that time an irritable, child- 
ish paralytic, but gradually improved, and never struck 
her again. He would not have struck her after he 
had sufficiently recovered to write his name with his 
left hand. He never attempted to strike anyone then. 
In regard to the bowing to pictures which he had 
not seen since he was stricken and carried to his bed* 
room a helpless paralytic, it would have been more 
singular if he had not, when taken into the parlor, the 
first time since his affliction, have sought to indicate in 
some way to his friends that he recognized the objects 
about him. This act showed an appreciation of his 10 
condition not common to insane people, and a desire to 
impress the fact of liis mental improvement upon those 
about him, just as did the frequent calling for paper or 
slate and pencil, writing his name, and showing them 
to visitors with manifestations of pleasure on his coun- 
tenance, even though “his smile looked silly.” If he 
smiled at all it must have been a silly looking smile, by 
reason of his physical facial disability. How could a 
hemiplegic face put on a beautiful or intelligent looking 
smile? If, smiling, or in mental repose, his face had 
even habitually shown the risus sardonicus, this would 
not have proven him mad. 
The motive for the making of grimaces before the 
glass, and pulling out his hair once or twice, does not 
appear in the testimony; nor does it appear that he 
had no- motive. A desire to discover to himself the de- 
gree of muscular facial paralysis would not have un- 
reasonably led him to view himself thus in a mirror, 
and move the muscles of his face, and chagrin at the 
disagreeable revelations reflected, might lead, without 
the concurrence of insanity, to the pulling out of some 
hair. It does not appear that he pulled out much hair, 
or that he often repeated the operation. I have seen the 
insane pluck out every hair of the head, and repeat the 
process, allowing no single hair to remain. It is unus- 
ual for an insane person to pull once or twice at his 
hair and never repeat the operation. It is not common 
for an insane person to go to a mirror for the purpose 
of plucking out the hair, and going to a mirror for the 
purpose of making grimaces is certainly an anomaly 
among the insane. There is too much of rational 
motive in it. It is too much like desiring to see how 
it looks. And this was Bevin’s motive. He wanted to 
see how he looked, and what muscles of his face were 
still paralyzed. This would be only a rational proceed- 
ing on the part of any man convalescing from a para- 11 
lytic stroke, which had involved, and still to some 
extent, implicated his face. It is possible that in- 
sane persons, under the dominion of a delusion, might 
go before a glass and pull at their hair, though not 
usual, but no delusion appears in this case, in this con- 
nection, or in any other relation. I have seen my own 
son study the play of his facial muscles, and when I 
was a student of anatomy I did the same thing, before a 
mirror too. 
The circumstances connected with wiping of the nose 
on the napkin or table-cloth do not appear. He wiped 
his nose once or twice. It was not shown that he had 
a pocket-handkerchief, or that he had never used his 
napkin in lieu of a handkerchief before his affliction, or 
that he did not do it to annoy, rebuke and chagrin 
those who should have given him a handkerchief. 
Laying aside the reasonable presumption made by 
one of the attorneys, that the testimony to the out- 
rageous and indecorous acts detailed, was the prejudiced 
evidence of interested relatives, enjoying the benefit of 
the property placed in jeopardy by the suit, I did not 
believe this man to be non compos mentis for the trans- 
action in which he was concerned, because— 
First. The paralysis alone was sufficient to account 
for most of his acts, his improvement and gradual re- 
covery for the remainder; he being now sound in mind 
and able to go about with no affliction save the aphasia. 
Second. Because the lesion was one involving but a 
portion of one hemisphere of the brain. Atrophy or 
destruction of a whole hemisphere, especially if gradu- 
ally brought about, not even necessitating mental disease, 
the sound hemisphere being capable of vicariously sup- 
plementing the one diseased, in the performance of the 
mental functions. 
Third. The grey matter, even on the affected side, 
seems not to have been greatly involved, as shown in 12 
the absence of incoherence, delirium, delusion, illusion or 
hallucination, during the whole progress of the case, 
and retention of memory, and ability to learn, for a 
purpose, to write his own name, in a few months after 
the stroke, with his left hand. 
Fourth. With the absence of incoherence, delirium, 
delusion, etc., there was marked involvement of the face 
and extremities, absence of muscular twitcliings in the 
limbs, and of rigidity of the neck and other parts of the 
body, which usually accompany paralytic lesions involv- 
ing also the cortex cerebri. The lesion was mainly an 
obstruction of the left middle cerebral artery at the base 
of the brain, as revealed by thz aphasia and gradual 
coming on of the paralytic attack. 
Fifth. The nature of the lesion with the.part of the 
brain mainly implicated in this case, is one from which 
persistent intellectual aberration seldom results; the 
equilibrium of the disturbed cerebral circulation being 
soon re-established, even when the circle of Willis is 
obstructed, instead of one of its branches, as in the case 
before us; and— 
Lastly. For a reason which some may not deem of 
any weight, namely, because that portion of the brain 
which has to do, in all probability, with the highest 
intellection, is the posterior lobes of the cerebrum, and 
they are not nourished by the artery mainly concerned 
in the lesion before ns; “a conclusion which, however 
contrary it may be to generally received opinion,” to 
use the language of Charlton Bastian, “ has been strength- 
ened by observations made independently in different 
directions, and by different persons. It seems to agree, 
moreover, with clinical and pathological evidence,” * 
Dr. Hughlings Jackson and other authorities on the 
subjects of brain disease agreeing with him. 
* Bastian on Paralysis, from Brain Disease, p. 239. THE 
AMERICAN JOURNAL OF INSANITY. 
The American Journal of Insanity is published quarterly, at the 
State Lunatic Asylum, Utica, N. Y. The first number of each volume 
is issued in July. 
Editor, 
JOHN P. GRAY, M. I)., LL. I)., Medical Superintendent. 
Associate Editors, 
JUDSON B. ANDREWS, M. D., 
EDWARD N. BRUSH, M. D., 
T. F. KEN RICK, M. D., 
WORTHINGTON W. MINER, M. D., 
Assist an t Ph ysicians. 
THEODORE DEECKE, Special Pathologist. 
TERMS OF. SUBSCRIPTION, 
Five Dollars per Annum, in. Advance. 
Exchanges, Books foh Review, and Business Communications 
may be sent to the Editor, directed as follows: “Journal of 
Insanity, State Lunatic Asylum, Utica, X. Y.” 
The Journal is now in its thirty-fifth year. It was established 
by the late Dr. Brigham, the first Superintendent of the New York 
State Lunatic Asylum, and after his death edited by Dr. T. Romeyn 
Beck, author of “Beck’s Medical Jurisprudence;” and since 1854, by 
Dr. John P. Gray, and the Medical Staff of the Asylum. It is the 
oldest journal devoted especially to Insanity, its Treatment, Juris- 
prudence, Ac., and is particularly valuable to the medical and legal 
profession's, and to all interested in the subject of Insanity and Psy- 
chological Science