D T RB N F P H.

N TT PT N TH P TH L F P H.

L.

DISTURBANCES OF SPEECH.

AN ATTEMPT IN THE PATHOLOGY OF SPEECH.

4

KUSSMAUL.
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P bl D n, l d tz d http: .h th tr t. r pd l

o:gitized by
Goog e Original from
PRINCETON UNIVERSITY
 0
770 KUSS~IAUL.-DlSTURBANCES OF SPEECH.
L.†D T RB N F P H.

ff t n nd d n b l t . Th t p r v l d n xt n v f f ft n
affection ended in imbecility. The autopsy revealed an ertensive focus of soften-
n n th l ft h ph r , n ll t n f f br h h, rd n t nd r,

ing in the left hemisphere, in collections of fibres which, according to Sander,

b l n t th r d t n fr th rp ll .

H PT R XXV .
belong to those radiating from the corpus callosum.
rd D fn .†rd Bl ndn .†D r n nt f th pr v rP r pt v

p h tr n n r l.†l x nd ndr d D r n nt n th pr

h n n f th b l f xpr n.†pr x nd ph .

n d llt r t r f nd r rd d ph h h

h ld n t pr p rl b d n t d b th n , n th

p t nt r t ll bl t xpr th r th ht b p h nd
CHAPTER XXVII.
r t n . Th h dn tl t th p r th r f p n r f

rtn th r n l n r bl , h v r, lth h th h r

n p rf t, t nd r t nd th rd h h th h rd, r,
Word-Deafness.- Word-Blindness.-Derangements of the Impressive or Perceptive
lth h th ht p rf t, t r d th r tt n rd h h
Speech-track in GeneraL-Alexia and Kindred Derangements in the Compre-
th . Th rb d n b l t ll t l , n rd r t h v

hension of the Symbols of Expression.-Apraxia and Aphasia.

th h rt tp bl n t rd p t n, rd d fn

nd rd bl ndn l t rd t v rb l .

Th d f t ld r l t d th r n r ll
In .medical literature we find cases recorded as aphasia which
f
bn d

rd f n
th th r d

n
ph

n t r , r
d r n

th
nt ,

r ph .
th

h v
n n l

should not properly be designated by this na.me, since the

lr d d rb d h, n h h, b d ph nd
patients were still able to express their thoughts by speech and
r ph , th r p r nt n v r n d r f th

writing. They had not lost the power either of speaking or of

blt t nd r t nd th rd h h r h rd r th rtn

h h r d. ,h v r, rr t ppr t n f th r
writing; they were no longer able, however, although the hear-
r bl ph n n n f th r t t p rt n f r th

ing was perfect, to understand the words which they heard, or,
pr h n n n t nl f ph rb d ff t n, b t l f

th h n f p h n n r l, t n r t t
although the sight was perfect, to re~d the written words which
th bj t f p l x n t n.

they saw. This morbid inability we will style, in order to have

the shortest possible names at our disposition, woTd-deafness
ll d t rb n f p h n b br ht nd r t r t

l , rd n th nn t nb t n th n pt n nd

th rd p d d n th d r t n fr th f r r t th l tt r,

and word-bl-i ndness (ccec-itas et surditas verbalis).

rv v r , fr th l tt r t th f r r. l n th f r t h p

p n , th xpr n ff r h n th nd, th nd r t nd
These defects seldom occur isolated ; they are generally
n .

combined with other dysphasic derangements, with genuine loss

of words of an amnesic nature, or with agraphia. We have
4

already described such. cases in which, besides aphasia and

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agraphia, there was impairment in a varying degree of the

l

ability to understand the words which were heard or the writing

pd

which was read. As, however, a correct appreciation of this re-

markable phenomenon is of the greatest importance for the com-
prehension not only of aphasia as a morbid affection, but also of
the mechanism of speech in general, it is necessary to make it
.h th tr t. r

the subject of a special examination.

All disturbances of speech can be brought under two great
classes, according as the connection between tlte conception and
the word is impeded ln the direction from tlte.former to the latter,
or 'Vice rJersa,from the latter to tlwformer. Wlum. the first !tap-
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pens, the expression suffers; wlten the second, tlte understand-

ing.
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 771
RD D FN ND RD BL NDN .

WORD-DEAFNESS AND WORD-BLINDNESS.

ll th nt r tr t h hl d fr th n rv f n

t th ntr f n pt n th pr v rp r pt v th
We call the entire tract which leads from the nerves of sense
th r, h h p th xpr n f th n pt n, th x

to the centre of conceptions the impressive or percepti1Je; the

pr v . h t t l d t n nd rt l t n v nt r l

p n th xp v tr t. Th pr v tr t rv nl
other, which compasses the expression of the conceptiott, the ex-
f r th r pt n f rd p n r p t nt rtn b th r

pressi1Je. What we style diction and articulation move entirely

h n , th blt t l t p nd t r t d p nd p n

th nt rt f th tr t. Fr th ln lf t th t ll
upon the expressive tract. The impressive tract serves only
pr ntl b nv t t d, th n l n v d nt th t, n th

for the reception of words spoken or put into writing by others;

xpr v tr t r n ll d ff r nt f n t n r ll d nt

t n f r th pr d t n f nd nd rd , n th pr
hence, the ability to learn to speak and to write depends upon
v tr t d ff r nt r n r r r d f r th r r pt n. F r

the integrity of this tract. From the clinical facts that will
th nd r t nd n f r nd nd th t f r p n rd , r th

nd r t nd n f r r tt n l tt r nd th t f r r tt n rd , r
presently be investigated, the conclusion is evident that, as in the
n t n p r bl b nd t th r, b t r d ff r nt th n . Th

expressive tract organically different functions are called into

action for the production of sounds and words, so in the impres-
nd r t nd n f r rd nb l t, nd th t f r nd rl t

t r r t n d. Th p r pt n f nd nd r r h h

r nd v d ll n n v l nd n n nt , nd th r

sive tract different organs are required for their reception. For
the understanding for sounds and that for spoken words, or the
rr n nt nt th t rd h hb th

b l f th r th t d , r d ff r nt f n t n , h h r

p rf r d n d ff r nt p rt f th ntr l t . Th ph
understanding for written letters and that for written words, are
not inseparably bound together, but are different things. The
f L rd t, f h h h v lr d r p t dl p n, n f

th t nt r tn x pl f nt r n blt t p d t

l f th r f r rd th pl t rd d fn nd
understanding for words can be lost, and that for sounds or let-
ters retained. Tl~e perception of sounds and murmurs which
rd bl ndn . ll l n r l ttl l n r v rh .

"J tr v pr v< d l v l rd t l t . l nr t t l

n , l d v n nt pr n tl ,p r j n v n pl d l
are indi1Jidually known as 1Jowels and consonants, and tltei'l'
n r d nt l f ll t l

nt, t tr ,l v t n
rd n r p

rt n
r l

h th r L rd t
xpr nt p n

nt r l d pr v d f th
." Th t t

arrangement into tlte acoustic word-image wldch becomes the

rd b t t lt th r pr b bl th t h , n h n t nl ld
symhol of this or that idea, are different functions, wldch are
n t tt r

p nh
n l

r, lth
rd, b t d t n tl

hh h rn
t t

pr
th t th

rv d nd h
rd f ll n pr h nd d

bl t r fl t
performed in different parts of tl~e central system. The aphasia
ph n nd ph l ph r p n h nd t n. n th B th tr r f
of Lordat, of which we have already repeatedly spoken, is one of
the most interesting examples of entire inability to speak d?.te to
rtn r l dt h th v n l .H ld tp , t  tr ,b t ld n t

r d. " n p rd nt l v nrd l nf t nd t nt nd ,j v p rd

l d l r n v bl .L nt x v td p r v l t , ^ lph b t
loss of the memory for words with complete word-deafness and
4

t d rr t tr t l j n t nd l ttr p rl f r t nd t ( t t n

word-blindness. We will linger a little longer over his case.

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t d 4f r .L r j v l j t r n pd l r l l vr j l ,
l

nd l d v t tt nt, j v d n l p b l t d n l r l t tr .

"Je me trouvai priv~ de la valeur de tousles mots. S'il m'en restait quelques-
pd

una, ils me dcvenaient presque inutiles, parceque je ne me souvenais plus de la ma-

ni~re dont il fallait les coordoner pour qu'ils exprimassent ma pen~e." Thls state-
ment, it is true, leaves it uncertain whether Lordat was entirely deprived of the
word-images; but it is altogether probable that he was, since he not only could
not utter a single word, but distinctly states that the words fell uncomprehended
.h th tr t. r

upon his ear, although his hearing was preserved and he was able to reflect as a
physician and philosopher upon his condition. In the same way the treasures of
writing were closed to him 1\S with seven seals. He could 1pell, it i8 true, but could not
read. "En perdant le souvenir de la signification des mots entendus, j'avais perdu
celui de leurs signet! visib1es. La syntaxe avait disparu avec les mots, l'alplwhet
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1eul m'etait ruti; mais la jonction des lettres pour la formation des mots ~tait une
T

«!tude ll faire. Lorsque je voulus jeter un coup d'oeil sur le livre que je lisais,
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quand ma maladie m'avait atteint, je me vis dans l'impossibiliU! d'en lire le titre.
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772 KUSSJ\IAUL.-DISTURBANCES OF SPEECH.

L.†D T RB N F P H.

f ll p l r l nt nt l pl p rt d t ." H d rb th d p

Il m'a fallu ~pelcr lentement la plupart des mots." He describes with deep emo·
t n th h pp nt h n, ft r v r l r t h d ,h ll dh z t

nd r v r h l br r , nd n xp t dl , fr t f rn r th rd "H p
tion the happy moment when, after several wretched weeks, he all~wed his gaze to
p r t p6r " fl h d p nh fr th b f f l .T r b r t fr h
wander over his library, and unexpectedly, from out of a corner the words "Hip·
. Th t nt r d th n nt f th pr v nt, h h f n ll

pocratis opera" flashed upon him from the back of a folio. Tears burst from his
eyes. That moment marked the commencement of the improvement, which finally
nd d n r v r .

n th r n t l p rt nt b rv t n r p rt d b Dr.

h dt, f n t r f ld, h th t rd d fn nd
ended in recovery.
rd bl ndn n p n n n d r n nt f p h

f n nt n r d , h h n th nf t d t lf b

Another not less important observation reported by Dr.

ph , p r ph , t l t n nd d t rt n f rd , nd

r t . Th rd r nl p r v d nf d
Schmidt,' of Miinstermaifeld, shows that word-deafness and
r r, lth h th h rn v r d l t , nd lth h

word-blindness can accompany an amnesic derangement of speech

th v l nd n n nt ld n t nl b r nz d h n

l n ,b t l ld th tr bl b b n d nt rd .
of an intense grade, which in this case manifested itself by
n, t nt f v r f ,b dd nl n n ,d rn v r

aphasia, paraphasia, mutilation and distortion of words, and

agrammatismus. The words were only perceived as a confused
t nn t t l, t n d ft r nf n nt. ft r n n r t rn d h

n t p r l z d, b t ff r d fr ph nd p r ph . h f nd th rd

th d ff lt r n t t ll, r v r d r t l t d th , d "b tt r" n t d f

murmur, although the hearing was very delicate, and although

the vowels and consonants could not only be recognized wlten
"d t r," thr t l tt r nd ll bl , n rt d th r , d th nf n t v n t d

f th pr p r d, nd nj t d rr l r v rb r l rl . h th ht

t b d fb t f r t h d d n t nd r t nd n l rd. t nd

alone, but also could witlt some trouble be combined into words.
v r d, h v r, th t h h rd n n t th d r r th t n f t h

A woman, twenty-five years of age, became suddenly unconsciOU$, during severe

l rl ll p r n, th t h ld d t n hb t nt h l b

th t n , t . rd , n th th r h nd, h ft r rd t t d, r p r v d

nl nf d r r. h h rd p r t v l nd r p t d th .
st: aining at stool, ten days after confinement. After collsciousness returned sl1e was
h n rd f n ll bl p n n th rd n r , h d d n t nd r
not paralyzed, but suffered from aphasia and paraphasia. She found the words
t nd t, b t h n th d ff r nt l tt r r p r t d d t n tl fr h th r,

with difficulty or not at all, reversed or mutilated them, said "butter" instead of
th t th t d f rth n th pr n n t n, h bl t r p t th rd.

" th rd f r th n n ll bl t n r f r t t pr n n n l
"doctor," threw out letters and syllables, inserted others, used the infinitive instead
l bl d t n tl , th n n th r, th n th t t th r, r h ld n t nd r t nd of the proper mood, and conjugated irregular verbs regularly. She was thought
th rd. t th th n th r dn . h t d d th rd v r r

to be deaf because at first she did not understand a single word. It was soon dis-
covered, however, that she beard a knocking at the door or the ticking of a watch
f ll , nd tr d t pr n n th tfr t p r t l , nd th n t th r. R v

r t pl l l . h d d n t nd r t nd h rt nt n nt l ft r th l p

f h lf r, nd th n nl h n th r pr n n d l l nd d t n tl .
as clearly as a well person, that she could distinguish between two house-clocks by
v n t th l t th r r n d l ttl d ff lt n p n .
the tone, etc. Words, on the other hand, as she afterwards stnted, were perceived
4

P t nt h ff r fr rd d fn nd p t th

only as a confused murmur. She heard separate vowels and repented them.
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t th blt t xpr th lv n rd , b t

When a ·word of one syllable was spoken in the ordinary way, she diu not under-
l

ll . Z t hr. f. P h tr . 8 . Bd. XXV . . 04.

stand it, but when the different letters were separated distinctly from each other,
pd

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!.'ary first to pronounce one syl-
lable distinctly, 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 care·
fully, and tried to pronounce them at first separately, and then together. Recov-
.h th tr t. r

ery took place 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 little difficulty in speaking.

Patients who suffer from word-deafness and possess at the

same time the ability to express themselves in words, bnt use
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1
Allg. Zeitschr. f. Psychiatric. 1871. Bd. XXVII. S. 304.
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 RD D FN ND RD BL NDN .

WORD-DEAFNESS AND WOIW-BLINDNESS. 773

n rd n th r n pl , nd ft n d t rt th ,l v

n th nd f b rv r th pr n th t th r r z d.
many words in the wrong places, and often distort them, leave
Th b rv r tb nh rd t v d f ll n nt th rr r,

on the minds of observers the impression that they are crazed.

r nt th t ll r t r rr r, h hh l b n tt d, f

r rd n th p t nt t n d f nd d nt d. Th
The observer must be on his guard to avoid falling into this error,
p t nt h v p rf tl rr t d , b t th rr t xpr

or into the still greater error, which has also been committed, of
regarding the patients as at once d~af and demented. The
n f r th nt n th rd , nd n t th th ht , r

nf d. Th ld v n nd r t nd th d f th r f

th ld nl nd r t nd th rd . Th r n th p t n

patients may have perfectly correct ideas, but the correct expres-
fp r n dd nl td n n th d t f p p l t n h h

th nd , b t d ff r nt rd , th tr n p n
sion for them is wanting ; the words, and not the thoughts, are
th r r n n nt ll bl l tt r. Th tt pt th lv

confused. They would even understand the ideas of others if

they could only understand the words. They are in the position
t p th l n , h h p rh p th h d n l rn d

d rn h ldh d, b t h d l t nt r l f r tt n l n b f r .

Th n l n r, h v r, f nd th r ht rd , nd th h h

of persons suddenly set down in the midst of a population which

uses the same sounds, but different words, these striking upon
th f nd r tt r d n d t rt d nd n pr h n bl h p .

B ll r r d n tr t d n th t p r n h h db n

r rd d b th d f nd d nt d, r ll n th r n n r

their ears as an unintelligible clutter. They attempt themselves

to speak tllis language, which perhaps they had · once learned
th th r. H n l d d, fr th xpr v t r th

h h th n, h ddn t v n n h r nn n

r , p n dh rd nn t dd r , th t p rf tl
during childhood, but had almost entirely forgotten long before.
They no longer, however, find the right words, and those which
d tn t d x t d b h nd th pp r nt nf n. nl

n n n p r n, b lr d n l d f Jt r n nd t n,

nd n v r d d n th n ll .
they find are uttered in distorted and incomprehensible shapes.
Baillarger 1 demonstrated once that a person who had been
rn d rb dt v r n tr tv f th nd.

n f th n h h tr t d f r th d n

d r d b th tt nd nt t b d f.
r egarded as both deaf and demented, was really neither one nor
the other. He concluded, from the expressive gestures with
B th n r dv n d n r . n p rf l x n t n, n f

th d th pr n th t h n n , p rtl b h r n r ddn t

rr p nd t th n f th t n , p rtl b h d nv rt d nd d
which the woman, who did not even know her own name any
t rt d

f
rd . Th

nd t b r t n l
nn fh r

r
nt n

v r, h r nt r b h v r
,h v r, ld b

l
nr v l d nd

n bl . h n
more, accompanied h er disconnected discourse, that perfectly
x t d h ft n p t rr tl . h n h tr d t rt h nl d
distinct ideas existed behiud the apparent confusion. Unlike
l
p nd d

t th
n tr

blt t r
, nd

d.
n l n r bl t pr d l tt r h h d l

an insane p erson, she betrayed a knowledge of her own condition,

r d ll h l rn d t p l t rr tl n nd t r d l d th
and never did anything silly.
4

B ll, d l d. d d. T. XXX. p. 828.

Wernicke, d escribed two very instructive cases of this kind.

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D r ph t h pt n pl x. Br l . 8 4. F ll . 2.
l

One of the women whom he treated for this disease was con-
sidered by the attendant to be deaf.
pd

R·,th women were advanced in years. On a superficial examination, one of

them made the impression that she was insane, partly because her answers did not
correspond to the sense of the questions, partly because she used inverted and dis-
torted words. The meaning of her sentences, however, could be unrav.eled and
.h th tr t. r

was found to be rational ; moreover, her entire behavior was always sensible. When
excited she often spoke quite correctly. When she tried to write she only made
up and down strokes, and was no longer able to produce letters; she had also
lost the ability to read.
Gradually she learned to speak almost correctly again and to read aloud with-
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1 Bull. de l'acad. de med. T. XXX. p. 828.

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774 KUSSMAUL.-DTSTUHB.ANCES 0~' SPEECH.
L.†D T RB N F P H.

th t t n. h l r n dt xt nt th p r fâ   rtn h ld

out hesitation. She also regained to some extent tho power of writing; she could
p fr r tt n n r pt, b t ld pr d n rtn nl f lf h n

rd t t d rd .
copy from written manuscript, but could produce in writing only a few self-chosen
Th th r p r n, h l ff r d fr p r ph , tfr t pp dt b
or dictated words.
d f nd r z . t th t p th r f nd, t th r th tr ph f ll th
The other person, who also suffered from paraphasia, was at first supposed to be
deaf and crazy. At the autopsy there was found, together with atrophy of all the
nv l t n , p lp , thr b t ft n n f th f r t, nd f r t p rt f th

nd l ft t p r l nv l t n.

Tl rd d fn n nl b nf nd d th n n
couvolutions, a pulpy, thrombotic softening of the first, and of a great part of the
d fn h n th b rv r nt nt h lf th p rf l
second left tempoml convolutiou.
x n t n, n t t v r f th f t th t th p t nt

p r v nd p tt nt n t ll , n , nd r r .B

TILls word-deafness can only be confounded witlL genuine

d , th b n t n f ph th d fn x dn l

r r n n t n f t ll b f nd n f p pl x r
deafness when the observer contents himself with a superficial
p rt d b B n . Th f t tr n , h n b r n nd

examination, since it is easy to verify the fact that the patients

th fr nt lt n pp r n f ph nd n ,*

h n th rh p .
perceive and pay attention to calls, noises, and murmurs. Be-
p h bl ndn r r fr ntl th n p hd f

sides, the combination of aphasi~ with deafness is exceedingly

n ." tb r f l, h v r, n t t t th r lt

f n n h p , h h ll p th r ht h lv
rare; an instance of it will be found in a case of apoplexy re-
f b th r t n f r n n blt t nd t pr h nd l tt r

ported by Banks.' This fact is striking, when we bear in mind

nd rd .

rd n th l tt r r rd d r d n t f ll p n th
the frequent simultaneous appearance of aphasia and anosmia, 2
r n n p rt n f th f ld f v n, th h p p t nt n

hemiancesthesia, s or hem-iopia.•
t n t nd r d, t n th r n t. h n th p r fr

nzn rd nd l tt r t ll p rf t, t t d t t th
Spf.eclt-blindness occurs more frequently than speech-deaf-
h p , b t th r t d ff lt. t th n fr ntl b

ness. 'Ve must be careful, however, not to mistake the results

n n t h h f th l x nd p r l x t

b r b d t th h p , nd h h t th r rl
of a genu-ine hemiopia, which usually occupies the right halves
pl t l f th blt t ppr h nd l tt r nd rd .

of both retinas for an inability to see and to comprehend letters

Th d ff lt l b n r d b th l t dp r f x

pr n. Th p t nt n p rh p t ll r d rd r
and words.
D bl n rt. R v. F br., 86 .

According as the letters or words do or do not fall upon the

* B nn f nt, B ll, d l d. d d. T. XXX. p. 8 .†TP. l , n . d.

h r. Tr n t. L . p. 26 . p r l th d rb d n h p. XX X., p. 8 ,
remaining portion of the field of vision, the hemiopic patient can
n h h th tbr f ph p n d b h ll n t n f ll.

at one time see and read, at another not. When the power of rec-
ognizing words and letters is still perfect, it is easy to detect the
h v d t l d v r l b rv t n f th rt, r p rt d b rn , P rr d,
4

nd th r .
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* nd r, l . t. F ll . B rnh rdt, B rl n, l n. h n hr. 8 2. N . 2.

hemiopia, but otherwise it is difficult. It is then frequently by

l

no means easy to say how much of the alexia and paralexia is to

rn ,l . t. F ll . .

be ascribed to the hemiopia, and how much to the more or less

pd

complete loss of the ability to apprehend letters and words.

The difficulty may also be increased by the limited power of ex-
pression. The patient can perhaps still read some word or
.h th tr t. r

1 Dublin Quart. Rev. Febr., 1865.

' Bmmajont, BulL de l'acad. de m6d. T. XXX p. 875.- W. Og~, Anosmia. Med.-
chir. Transact. LUI. p. 263. Compare also the case described in Chap. XXIX., p. 787,
in which the outbreak of aphasia was accompanied by hallucinations of smell.
3 We have detailed several observations of this sort, reported by Cfn'nii, Pernrnd,
http:

and others.
T

• Bander, loo. cit. Fall 9. Bernhardt, Berlin. klin. Woohensohr. 1872. No. 32.
l d tz d

Wernicke, loo. cit. Fall 8 u. 9.

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WORD-DEA~'NESS AND WORD-BLINDNESS. 775

n th r, b t

, pr d
nn l n

th r ll bl
r pr n

nd
n

rd . Th r
t, r, h n h tr

l t t f th
t d

another, but can no longer pronounce it, or, when he tries to do

n th n r l b nr v ll d nd t bl r th
so, produces other syllables and words. The real state of the
b
t

rn
t n h n ph n

. Th p t nt , . ., r
n , tn

d ff,
th b

hl p
rv t n r p rt d

n , th
case can then scarcely be unravelled and we stumble across the
n p n th t v rn n n th tr t, b t r n v rth l
most astonishing phenomena, as witness the observations reported
n

Th
p bl

r
fr

n z th
d n l tt r

nd v d
nd

l l tt r , b t r
rd th t

n bl t
d z .

by Wernicke. The patients, e. g., read off, while· passing, the

p t th t th r t f r rd , r, v v r , th r d th
names upon the tavern-signs on the street, but are nevertheless
nz
rd b t

th
nn t r

rd th
d th

n th t tl
nd v d l l tt r .

f .b
p t nt r

, b t n t th rd
incapable of reading letters and words with a steady gaze.
h ll r n th t f n hb r n n .L n rd r p rh p They recognize the individual letters, but are unable to
l bl
ft n r d r n l

n t ll b pr p rl
nl f r th r

n, th r
n th t,

t
h l th f r t

nn t, nd th rd
l

put them together to form words, or, vice versa, they read the
th n t ll d t rb tr r l n rd n th th d ll d words but cannot read the individual letters. A patient recog-
p b th f r t

rn d
ll bl (B rnh rdt .

v r r r nr rd t th
nizes the word Goethe on the title of a. book, but not the word
blt t pr h nd r tt n r pr nt d h r t r .H ll d Schiller on that of a neighboring one. Long words are perhaps
tt nt n t th f

f nt ll t l
t th t th

lt v t n. Th n d
l d p nd nt p n th d

t d n, h b t
r

often read wrongly only for the reason that, while the first syl-
l ttl pr t d nr dn , n nl nd r t nd th rd r tt n lable can still be properly seen, the rest cannot, and the word
l
th th

dt h
d f th r p

lf, b
n

, f r th
h l

nd r t nd n
t r d th

f th
rtn

ht
is then filled out arbi~rarily in accordance with the idea called
,h r r th d f th nd . Th h l r up by the first syllable (Bernhardt').
l n

tr n l t n th
v r p

r tt n
, nd nd r t nd

rd nt p
t

n
nn

rd . Th f r t
th tfr t

ll
Wernicke made a very sagacious remark in regard to the
pr nt th pt f l x n dd t n t th ph th
ability to comprehend written or printed characters. He called
pr
th r

nt th
n nd r t nd

t tr n
r tt n l n

ntr tt h
, nd h

n blt t
blt t d

nd r t nd
attention to the fact that this is also dependent upon the degree
p nl n . n th th r h nd, h nh tt pt t r d qf intellectual cultivation. The uneducated man, who is but
l d, h b ph n p nt n p n .

little practised in reading, can only understand the words written

witlt tlte ald of tlte-ir spoken images ; he has to read tlte writing
n b rv t n r p rt d b v n d n b l *l v l ttl r

t d bt th t pl t t xt bl ndn x t, lth h th

p r f ht, th nt ll t, nd th p r f p h r nt t.

aloud to himself, because, for the understanding of the sight-

B rl n r l n. h n hr. 8 2. Nr. 2. p t nt th h p , h h

r n d ft r r v r fr ph , , . ., n th rd "z r h tt rt" nl
images, he requires the aid of the sound-images. The scholar
4

th f r t ll bl , "z r," d t n tl .

glances over a page, and understands its meaning without first

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B ll, d l d. d r & . b .N . 6 nd .

translating the written words into spoken words. The first will
l

present the symptom of alexia in addition to the aphasia; the

pd

other can• understand written language, and his ability to do so

presents the most striking contrast to his inability to understand
spoken language. On the other hand, when he attempts to read
aloud, he may be as aphasic as in spontaneous speaking.
.h th tr t. r

An observation reported by van den Abeele 1 leaves little room

to doubt that a complete text-blindness may exist, although the
power of sight, the intellect, and the power of speech are intact.
1
Berliner klin. Woohenschr. 1872. Nr. 32. A patient with hemiopia, which
http:

remained after recovery from aphaaia, saw, tJ. g., in the word "zerachmettert" only
T

the first syllable, "zer," distinctly.

02 08 6:26
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Bull. de l'aca.d. de mCd. beige. Nos. 6 and 7.
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776 KUSSMAUL.-DISTURBANCES OF SPEECH.

L.†D T RB N F P H.

n, f rt f v r f , tr th p pl x hl n th nj

A woman, forty·five years of age, was struck with apoplexy while in the enjoy-
nt f th t bl n h lth. ft r h r n n r t rn d, b t

h p r l z d p n th r ht d , nd h d p n v r th l ft h r nt ll
ment of the most blooming •health. After some hours consciousness returned, but
n h t d ll, th r , th p h fr . x l t r, th ~;he was paralyzed upon tho right side, and had pain over the lP.ft eye; her intelli-
p r l nd th n f r nd nt ll n h d l td pp r d.

gence was somewhat dull, tho memory weak, the speech free. Six weeks later, the
paralysis and the weakness of memory and intelligence had almost disappeared.
T nth ft r th tt h d v r d th t h ld n l n rr d pr nt n

nd rtn . h th t xt, d t n h d th f r f th l tt r , nd ld

v n p th t xt, b t n p bl f tr n l t n th rd nt p n rd
Two months arter the attack she discovered that she could no longer read printing
nd th ht . h ld pr h nd p t r , nd d ph r r b h nd r
and writing. Sh~ saw the text, distinguished the forms of the letters, nud could
t d n ntl d r ph r pr nt t n , b t n t rtn ." h nv nd n

even copy the text, but was incapable of translating the words into spoken words
b l p bl h d th b rv t n, th p t nt h d lr d r n d th p rt

r d rd f n nd t ll bl .
and thoughts. She could comprehend pictures, and decipher a rebus; she under-
Br db nt n t n l r r bl b rv t n. stood consequently ideographic representations, but not writing. When van den
v r nt ll nt nd n r t n, ft r ff r n fr r br l pt

Abeele published this observation, the patient had already regained the power to
(h d h ,v tn ,d lr ,l t nt r l th p rt r d pr nt n nd rt

read some words of one and two syllables.

n .H

nd rr
th t xt, b t d d n t nd r t nd t, lth

tl b th fr d t t n nd p nt n l .H
hh

nv r
ld t ll

t n
rt

d
l

•
nd h v b l r v r l r ,b t n ll th n f tr t ,p r n , nd
Broadbent 1 communicates a no less remarkable observation.
th n f l dh h n t bl t n nd nd th pl t nd t

f l r bj t h h r h ld p b f r h . H d d fr n xt n v h A very intelligent and energetic man, after suffering from cerebral symptoms
rrh nt th l ft t p r ll b , th r pt r nt th v ntr l . T ld

(headache, vomiting, delirium), lost entirely the power to read printing and writ-
ing. He saw the text, but did not understand it, although he could still write easily
h rrh r f nd, n n th l r b rd r nv l t n f th l b th

th r nd l r r n , h h h d pr d d ft n n f th n hb r n r

br l b t n , l t d n th r nb t n th l r nd f th f r f
and correctly both from dictation and spontaneously. His conversation was good
lv nd th v ntr l t th p nt h r th d nd n h rn v n ff.
and his vocabulary very large, but occasionally the names of streets, persons, and
n th , th r f r , th nd t n f th rd

things failed him ; he was not able to name on demnnd the simplest and most
t th t r ntr f rd n t n f r rtn t ll p r

f t, h l th t xt ld n l n rb pr h nd d.
familiar objects which were held up before him. He died from an extensive hem-
n n l n, t r h r f r v r tr n b orrhage into the left temporal lobe, with rupture into the ventricle. Two old
rv t n r rd d b tph l.2

hemorrhages were found, one in the lower border-convolution of this lobe; the
H xh b t d t th tn f th t f r nthr p l , r tr d t r,

h ,b d h pl , pr nt d th ph n n f n n pl t ph .H
other and larger one, which had produced a sortening of the neighboring cere-
nt ll nt, b t h r f rp l rn d b h rt p r d. H p
bral substance, was located in the region between the lower end of the fissure of
fl ntl , b t h ld n t f nd nd d d n t nd r t nd f rd . H ld rt
Sylviusand the ventricle at the point where the descending hom was given off.
v r ll fr d t t n, b t h rtl ft r n bl t r d th rd h h d

In this case, therefore, the conduction of the word-images

r tt n, nd h ff r d n n r l fr pl t l x .B n f tr t
4

,h v r, h h lf v r l rl xpl n d, h d d nr d n th

to the motor centre of co-ordination for writing was still per-

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rd h h d r tt n fr d t t n p n th t bl t H p dh fn r v r
l

*Z t
L . t.

hr. f. thn l
8.

.
fect, while the text-images could no longer be comprehended.
In conclusion, we must make room here for a very ~trange ob-
pd

servation recorded by Westphal. 2

He exhibited at the meeting of the Society for Anthropology, a retired actor,
who, besides hemiplegia, presented the phenomena of an incomplete aphasia. He
.h th tr t. r

was intelligent, but his memory for pieces learned by heart was impaired. He spoke
fluently, but be could not find and did not understand a few words. He could write
very well from dictation, but shortly after was unable to read the words he bad
written, and he suffered in general from complete alexia. By means of a strata-
gem, however, as he himself very clearly explained, be succeeded in rending the
word he b~ written from dictation upon the tablet. He passed his finger over
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T
02 08 6:26

'Loc. cit. Ca.se 8. Zeitschr. f. Ethnologic.

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WORD-DEAFNESS AND WORD-BLINDNESS. 777

h l tt r f th r tt n rd fh r rtn t n nd r d t hl

d n . H th n d rt f l l t n, nd nt d ff th f th p r t
each letter of the written word 1\.8 if be were writing it again and read it while so
l tt r .
doing. He then made a sort of calculation, and counted off the sum of the separate
xpl n th ph n n n b th th r th t th n

letters.
t ll nt n n h t tr n p th v nt f

We explain this phenomenon by the theory that the in-

th r tt n t tt r nt t nd , nd h t

b n th nt t rd . Th t pr v ,

p r l , th t th r n t nl p th l dn
telligent man knew lww to t1·anspose tlte movement-images of
tlte written letters into acoustic sound-images, and how to com-
fr th t ntr f rd t th t r ntr f r

r tt n rd , b t l n fr th l tt r t th f r r. t

th t th tr n th n th th r f th x t n
bine these into acoustic word-images. rrhe case seems to prove,
as Spamer also assumes, that there is not only a path leading
f v nt , h h p n th pr d t n f rd

b th t n f th l r pp r t .

r n r ll d tt nt n t th f t th t n ph ,
from the acoustic centre of word-images to the motor centre for
h nr t dt t

th r p rt, . ., th n
h p rt n f th b d , t

n t d f th r, th
h n t

tb n
d

written words, but also one from the latter to the former. At
r f th t .H rb d tt nf nd n f th
the same time the case strengthens the theory of the existence
f th
v nt , b t t

rd h rd,
r

v.
rr

dd n th
tt rb

ht. Th r
tt nf

t n
nd n

of movement-images, which accompany the production of words

h r f t t f nf n n th p r pt v nd n t n th x
by the action of the muscular apparatus.
pr v tr t.

J t th nd r t nd n f r r tt n rd nb l t,

Griesinger called attention to the fact that many aphasics,

when requested to touclt some portion of the body, touclt instead
n th t f r f r . n nt nt r d ff th 66 f r

f rf r ,b th ddn t n h t th f r nt b f r

th t 6 (Tr . n th r ph , n th th r h nd, l

some other part, e. g., the nose instead of the ear, without being
th hh ld n l n r nt n rd , ld dd nd b

tr t n p p r, nd v n lt pl nd d v d pr tt ll
aware of the mistake. He ascribed it to a confounding of the
(Pr t.N

movements, but it is more correct to ascribe it to a confounding

h v lr d p n f p t nt h h dl t th nd r

t nd n f r ln t , lth hh t ll bl t pl
of the words heard, as v. Gudden' thought. There is question
ll b r (F n lnb r . nv r l ,L n

here of a state of confusion in the perceptive and not in the ex-

th pl t ph nd r ph , h ld r dl td n

nn t n l d h hh h rd. n th r p t nt f Pr t
pressive tract. ·
rr p nd nzbl tt f lr h z. rzt . Bd. ., b d rD n b rd nV r

tr B r r .
· Just as the understanding for written words can be lost, so
n Pr t, l . t, p. 0.

can that for figures. An accountant read ·off the sum 766 figure
4

for figure, but he did not know what the figure 7 meant before
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l

the two 6 (Trousseau). Another aphasic, on the other hand, al-

though he could no longer count in words, could add and sub-
pd

tract on paper, and even multiply and divide pretty well

(Proust). -,
We have already spoken of a patient who had lost the under-
standing for musical notes, although he was still able to play
.h th tr t. r

well by ear (Finkelnburg). Inversely, Lasegue 2 saw a musician

with complete aphasia and agraphia, who could readily set down
in notes any melody which he heard. Another patient of Proust's
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1
Correspondenzbla.tt fiir Schweiz. Aerzte. Bd. L, bei der Discussion fiber den Vor·
T

trag Biermer's.
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t In Proust, loc. cit., p. 310.

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L.†D T RB N P H.
778 KUSSMAUL.-DISTURBANCES 01<' SPEECH.
bl t rt nn t , nd v n t p , nd

nd r t d l n l d h hh h rd, b t n bl t was able to write music in notes, and even to compose, and
pl fr

t
n t .

p t nt p dr n , lth h th
understood also any melody which he heard, but was unable to
nn t pr d th p nt n l . h th r r n t th r play from notes.
v r

n ph
r r

r n l n
n bl t

r bl t d t n
.

h rt nt
Sometimes we see patients copy drawings, although they
p f n th f r t th nv nt n l lf r , nd cannot produce them spontaneously. Whether or not the re-
th r l

nd f r , nd tr t
t

t
nd

p
n th

th th l tt r. n th l
v n nf nd th

t
p n

verse occurs we are unable to say.

th ph bn d th pr x †th r f r th :Many aphasics are no longer able to distinguish or to count
b
f th n

h h th th n
l t

r
ll

xpr
th nd r t nd n f r th

d. Th f r r nd t n
n

t
pieces .o f money; they forget the conventional social forms, and
n tb nf nd d th ph , h hh t d l nl th
the religious customs and signs ; they even confound the spoon
th

b n
n b h h th

tt d h v r.
d r

h v
xpr d. Th

n th t th nt ll
t h

t
and fork, and try to eat soup with the latter. In the last case
b p rf tl pr rv d n f ph , b t th n v r th
the aphasia is combined with apraxia-tiLe memory for the
n pr x .

H PT R XXV .
uses of th-i ngs is lost as ·w ell as the 'U nderstanding for the s-igns
h t D r f th ntr nd Tr f p h.
by wk'ich tlw things are expressed. The former condition must
N th t h v rr v d t th p nt, h hp r t t

not be confo~nded with aphasia, which has to deal only with

rv th ntr nd tr f p h fr th t ndp nt f

ln lf t , h h r f r v l nt t n xp r
the signs by which the ideas are expressed. This mistake has
nt l r lt , th n th t h t ll tr t b

been committed however. We have seen that the intellect may

n f h t d r th n pt n h h h v

f r d nr rd t th r nn t n .
be perfectly preserved in cases of aphasia, but this is never the
B n , rn (l . t. , nd p r (l . t. h v

case in apraxia.
pr d d n th tt pt t f r h h t dr n .

Th d r fB n n rr tf rt r n : t

nn rl t bl h p l ntr f r th r , nd

dr tl nn t th ntr f n pt n n t nl th th CHAPTER XXVIII.

ntr f r rd , h h rr t, b t l th th t r

ntr f rd n t n, h h b l v t b n rr t.
&hematic Diagram of the Centres and Tracks of Speech.
rn d th t fl t n th ntr np r

B rl n r l n. h n hr. 8 .N . 6 nd .

Now that we have arrived at this point, which permits us to

4

survey the centres and tracks of speech from the standpoint of

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clinical facts, which are for us equivalent to as many expei·i-

l

mental results, we think the time has come to illustrate by

pd

means of a schematic diagram the conceptions which we have

formed in regard to their connections.
Baginsliy,• Wernicke (loc. cit.), and Spamer (loc. cit.) have
preceded us in the attempt to form such schematic drawings.
.h th tr t. r

The diagram of Baginsky is incorrect for two reasons: it

unnecessarily establishes special centres for the memory, aml
directly connects the centre of conceptions not only with the
centre for word-images, which is correct, but also with the motor
centre of co-ordination, which we believe to be incorrect.
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Wernicke made the mistake of locating the centres in par-

T
02 08 6:28
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1 Berliner klin. Wochenschr. 1871. Nos. 36 and 37.

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