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some element in the blood which has a deleterious effect upon the cerebral circulation.
It will be observed that there is no abolition of a faculty in such cases as the above, but simply an obstacle to the manifestation of such faculty. The faculty of language is present, but one of the processes is wanting by which it is brought into communication with the external world.
LEFT HEMIPLEGIA WITH APHASIA; NO DISEASE OF FRONTAL CONVOLUTIONS ; EXTENSIVE DISEASE OF RIGHT HEMISPHERE; VEGETATIONS ON
AORTIC AND MITRAL VALVES; FIBRINOUS BLOCKS IN THE SPLEEN.
William Lemon, a gasfitter, æt. 40, was admitted into the Norfolk and Norwich Hospital on January 4, 1868, with the following antecedent history ;-He had been ailing more or less since Midsummer, but had been able to continue his work till early in November. A fortnight later, he was suddenly seized with left hemiplegia, and considerable embarrassment of speech, to such an extent that a stranger could not understand him at all. His power of speech gradually improved, and at the end of a fortnight he could speak nearly as well as usual.
Condition on admission.—There is complete motor paralysis of left leg and arm ; anæsthesia only partial, if any.
He has no pain or abnormal sensation in the head, and the organs
of special sense are unimpaired, and there now remains but very slight embarrassment in his speech. Urine
sp. gr. 1023, freely acid, slightly albuminous, and loaded with lithates. There is a well-marked double bruit heard nearly all oyer the anterior part of the chest, but at its maximum intensity at the apex, the diastolic murmur being the most marked. Pulse 84, quite steady and regular, but very hard, sharp, and almost dicrotic.
January 18th.— This patient continued much the same as on admission up to 6 p.m. yesterday, when the nurse, on taking him his tea, noticed he had lost the power of articulation, although he seemed to know all that was going on; a few minutes before the power of speech was lost he spoke a few words, implying that he saw imaginary beings around his bed. The power of articulation was never recovered, and he soon became comatose, and died early this morning.
Autopsy.—Heart: weight 19 oz.; right ventricle contained coloured and decolorised clots extending just beyond the pulmonary valves; right auriculo-ventricular orifice admitted four fingers and a thumb; tricuspid valves healthy; walls of left ventricle immensely hypertrophied; dilatation of left auriculoventricular orifice; the mitral and aortic valves were both covered with fibrinous vegetations, apparently recent; there was commencing atheroma to the extent of an inch and three quarters at the origin of the aorta. Liver: weight 4lbs. 2 oz., healthy. Kidneys; the right weighed 11 oz., the left 8 oz., both in a state of intense congestion. Spleen: very soft and friable, contained several fibrinous blocks. Brain : stripped of dura mater, it weighed 3lbs. 31 oz.; there was no abnormal vascularity or other morbid appearance, either on its convex surface or at the base. There was a general flattening of the superior surface of the right hemisphere, which was somewhat less developed than the left, and its convolutions were shrunk. The brain was carefully sliced, and no abnormal appearance disclosed until opening the lateral ventricles, when a yellow stain was
seen on the upper portion of the right corpus striatum; on a level with this body, but behind, and external to it at about the middle third of the hemisphere—was a softened portion of about the size and shape of a large walıut; there was also slight softening of the thalamus at its posterior part. On cutting into the corpus striatum it was seen that the posterior two-thirds had undergone the softening process, being of a yellowish hue, and waxy consistency. Antero-posterior slices were made in both anterior lobes, but no morbid change revealed; the frontal convolutions were examined with great care, ad the right and left convolutions compared, but they seemed perfectly healthy; but as the softening of the right hemisphere approached so near the surface of the right sidecertainly within half an inch of the third frontal convolutionit is quite possible that some slight alteration of the posterior part of the frontal convolutions may have existed, not patent to our means of investigation. The vertebral and basilar arteries were healthy, as also the termination of the carotids. There
was no obstruction of the middle cerebral arteries, but that on the right side, when traced along the fissure of Sylvius, presented at the point of its first bifurcation a milky appearance, to the extent of about a quarter of an inch in length. The olivary bodies were specially examined, and were quite healthy, as were also the medulla oblongata, cerebellum, pons, and crura cerebri.
Microscopic Examination.—A separate examination was made of the corpus striatum, and also of the softened hemisphere. In the corpus striatum there was no proper brain structure ; an absence of vessels and nerve fibres; an abundance of granular matter. In the portion taken from the hemisphere there was an absence of nerve fibres, and the vessels were coloured with fawnish pigment; there was an abundance of granular matter, with here and there a fat globule.
The above case is extremely interesting from several points of view. In the first place, I would observe that the cardiac disease was doubtless the primary cause of the softening of the cerebral tissue ; and it is extremely probable that some vegetations, similar to those observed on the aortic and mitral valves, had become detached, and thus had been carried into one or more of the cerebral vessels, although no positive evidence of obstruction existed after death.
The condition of the spleen is confirmatory of this view, as the fibrinous blocks found in that organ undoubtedly betokened an obstruction to the splenic circulation similar to that which had probably produced the cerebral symptoms. It would seem that these fibrinous deposits in the spleen have been frequently observed in the autopsies of aphasic patients. In four of Dr. Wm. Ogle's cases this condition of spleen was observed ; and in each case-as in that of Lemon—there was also disease of the heart.
It will be observed that the lesion of speech was
associated with paralysis of the left side. This coincidence of aphasia with left hemiplegia is, I believe, much more common than is generally supposed. I have at the present time an instance of it under my care at the Norwich Hospital, and I have already, in the preceding pages, mentioned cases where this combination of symptoms was observed. Dr. Crichton Browne has informed me that he has collected six cases of left hemiplegia with aphasia, which I trust he may be induced to place on record.
If the above observation is in direct antagonism to M. Dax's theory of the localisation of speech in the left hemisphere, it is a fortiori opposed to that of Professor Broca; for although the softening was suspiciously near the third frontal convolution of the right side, the left frontal convolutions, as indeed the entire left hemisphere, presented no trace of disease whatever.
I could mention several other most interesting cases which have lately fallen under my own observation, where loss or lesion of the faculty of articulate language was a prominent symptom, but this part of my essay has already far exceeded its original limits, and I trust that the observations I have recorded may have been sufficiently varied to illustrate the clinical history of aphasia. I shall, therefore, now proceed to the consideration of certain abstract points suggested by an analytical study of the cases mentioned in the preceding pages, and for the accomplishment of this task I shall have to avail myself of the assistance of the sister sciences-Physiology and Comparative Anatomy.
In the preceding pages I have endeavoured to review what is at present known of the clinical history of aphasia; having first ventured critically to analyse a certain number of cases recorded by independent observers in various parts of the world, I have then minutely detailed several cases which I have myself had the opportunity of personally watching.
It will be observed that the observations which I have recorded in illustration of my subject have been of the most varied character—from the typical case where the loss of speech was complete, to that where the loquelar defect was only a slight or even occasional symptom, believing that it is only by the careful study of cases illustrative of the various forms and degrees in which derangement of the faculty of speech is observed, that we can hope to throw any light upon this much disputed question—the localisation of the Faculty of Speech.
I shall now proceed to dwell upon certain abstract points suggested by the consideration of the 72 cases to which I have referred in the former parts of this essay In the first place, it may be said that it is