point is not rarely in the external or middle ear. Irritation of the auditory centers and nerve, however, is sometimes the cause.

Involvement of the labyrinth or of its nerves is marked usually by vertigo, and in extreme cases by forced movements in a given direction, which, as in Ménière's disease, may furnish attacks of great suddenness, throwing the patient to the ground. The space sense with equilibration is disturbed.

Finally, in no case of obscure brain symptoms should the possibility of extension of infection from suppuration in the middle ear and mastoid be forgotten,-a condition that specular examination and local searching should reveal.

Smell. The sense of smell may be reduced or obliterated in one or both nostrils. It is necessary to test them separately, closing firmly the opposite anterior naris. The inspiratory efforts should not be too vigorous, as thereby the test odor may reach both nasal spaces through the pharynx. In selecting the test-material, pungent odors or irritants, such as ammonia or tobacco-snuff, should not be employed. In hysteria anesthesia of the mucosa may be associated with absence of the sense of smell, so that the strongest irritation gives rise to no response; otherwise, when the olfactory nerve is completely destroyed, stimulants and irritants have their usual effect. It is also well to choose an odor with which the patient is familiar, and to recollect that people vary greatly in keenness of scent. The sense of smell is greatly impaired by nasal catarrhal trouble, and is often practically lost during a severe cold in the head. Degeneration of the fifth nerve, which supplies common sensation to the nasal mucous membrane, also lessens its

acuteness.

Occasionally the sense of smell is greatly intensified. Hallucinations of smell are rare, and in several cases have been found to depend upon disease in the temporosphenoidal lobe.

Taste. Pure taste sensations are the recognition of bitter, sweet, sour, and salt. When a taste is associated with an odor, we speak of a flavor, and it requires the participation of the olfactory nerve, usually stimulated by way of the posterior nares. Flavors, in consequence, are lost with the loss of smell, and not with the loss of taste. The margin and tip of the tongue are more sensitive to sours and salts, while the base and pharyngeal pillars best recognize bitter and sweet. The entire gustatory area, which includes the dorsum of the epiglottis and even a portion of the rima glottidis, as well as much of the pharyngeal wall, distinguishes all tastes more or less readily.

For the purpose of testing taste, solutions of sugar, quinin, citric acid, and salt, or the powdered substances, answer. The tongue should be protruded and the test-substance applied to a small area. Some moments are usually required before the taste is perceived. The galvanic electric current furnishes a simple and reliable agent. Two probe-pointed metallic electrodes a few millimeters apart are placed on the portion of the tongue to be tested, and a non-painful current from one or two cells, of a few milliamperes' volume, is used. A metallic taste is elicited.

Taste is lost from the tip of the tongue in lesions of the facial nerve

involving the chorda tympani, and from the rest of the gustatory area in lesions of the fifth nerve involving its lower division close to Gasser's ganglion. Hemiplegic states rarely show a one-sided loss of taste, while the hemianesthesia of hysteria, when pronounced, is usually marked by ageusia on the same side.

Perversions of taste-parageusia-and increased sensitivenesshypergeusia—are sometimes encountered in neurotics and hysterics. Subjective taste sensations are also rare, but may furnish the aura of an epileptic attack or be dependent upon local irritation of the trunks of the nerves of taste, as in ear disease affecting the chorda and facial nerve.

CHAPTER VIII.

SPEECH.

THERE are as many kinds of speech as there are avenues to consciousness and routes therefrom. We have spoken language, written and printed speech, gestures and emotional attitudes that portray ideas and serve as media for the communication of ideas. Consequently, speech may be modified by disease in innumerable ways as the successive levels of the nervous system are invaded, and every variety of speech may be disturbed either in its perceptive or emissive channel.

The emission of vocal speech requires mechanically the coördinate action of the mouth parts, the larynx, and the chest-muscles of respiration. Malformations of the nose, throat, mouth, and larynx are attended with difficulty in shaping the resonant chamber for the precise modifications of vocal sounds in the production of spoken language. Cleft-palate, closed nasal spaces, and tied-tongue are not uncommon conditions of this variety. They cause difficulty mainly in the pronunciation of the consonant sounds. If we are familiar with the physiology and mechanism of consonant production, we have the key to diagnosis.

For this purpose the accompanying chart, slightly modified from

Wyllie, is of great importance. He divides consonants into voiceless and vocal, as their pronunciation is or is not devoid of laryngeal sound. By having the patient pronounce these letters, or phrases containing them, the seat of the difficulty is at once recognized. For instance, in the palatal palsy of diphtheria the posterior linguopalatals and the nasal resonants, especially Ng, which depend on the separation of the nasal spaces from the pharynx by the soft palate, are slurred or lost.

Stammering, or stuttering, is a speech defect attended by difficulty in attacking properly the enunciation of words beginning with certain consonants. These consonants are reiterated with more or less spasmodic respiratory effort, and finally the word either drops out or is explosively spoken. There is always more or less incoördination in the needed muscular combinations.

Speech in idiots and infants often consists of the iteration of a syllable or single sound (lalling) or the repetition of the final word or phrase overheard by them, without reference to its meaning,-echolalia. In multiple sclerosis the speech becomes deliberate and each syllable is pronounced with the distinctness of scanning. In general paresis the words are jumbled. The patient catches in the middle of words, repeats syllables, slurs sounds, and omits terminals or even important words. This is called syllable stumbling. In hereditary ataxia the speech shows the incoördinate control of the musculature of vocalization and is usually slow, monotonous, and unmodulated. In cerebral palsies with athetosis speech may be characteristically modified by the spasmodic actions of the muscles of the tongue, throat, and chest. It is explosive, sputtering, now slow, now fast, and the tone qualities are uncontrolled. In hysteria persistent aphonia is a frequent symptom, a whispering voice only remaining. Complete mutism may also develop slowly or suddenly in this malady, but voice sounds, as in coughing or sneezing, usually remain to show the neurotic character of the disturbance. In progressive bulbar palsy the paralysis of the tongue is early marked by indistinctness of speech and a loss of the lingual consonant sounds. If the lips are weakened, the labials can not be produced, and, finally, through paralysis of the tongue and larynx, vocal speech is reduced to inarticulate noises.

In diseases marked by tremor, as in alcoholism, Graves' disease, and paralysis agitans, the voice is also tremulous. Depression, excitement, and the emotions generally are manifest in the timbre and modulation of the voice. The deaf are inclined to speak in a monotonous, high, or more often low, tone that is quite peculiar to them.

Aphasia. Organic disease of the brain, throwing out of operation the various cortical centers related to speech or breaking up their connecting channels, produces peculiarly interesting phenomena that require very careful examination. Any of the qualities or varieties of speech may be affected, or almost any combination of defects may be present in a given case. Practically we have to investigate both spoken and written speech and to determine first how they are received and apprehended, and, second, how conceived and expressed. In other words, we try to

1 "Disorders of Speech," Edinburgh, 1894.

determine whether the difficulty lies in the entrance-channel or the receptive center on the one hand, or in the formulating center and the emissive route on the other.

Take, first, the reception of spoken speech. Is the hearing good, tested by watch, tuning-fork, voice, and various sounds? If so, does the patient understand the words used; or is he word-deaf-that is, while hearing words does he fail to appreciate their meaning? Test this by directing him to execute certain movements to shut his eyes, clap his hands, etc.

Second, how does he produce spoken speech? Is it reduced to a single expletive or phrase, or is he completely dumb? Does he forget names of common objects (amnesia verbalis), stammer, slur, stumble, or reiterate? Does he miscall objects with which he is familiar (paraphrasia), and is he aware of his mistakes? Is his speech a jargon of meaningless sounds or words strung together like beads? If dumb, can he write his answers? and if he can not write, can he indicate with his fingers the number of syllables in the names of objects pointed out to him? Finally, can he repeat or echo what is said to him, or is he inclined to echo his own words or expressions? does he understand his repeated words?

Written Speech. If vision is good, does the patient understand written or printed questions? This can best be determined by writing simple commands, as, stand up! sit down! give me your hand! and not by questions that can be answered by a nod. Proper responses show comprehension. If the written questions or commands are only partially understood, we must attempt, by repeated tests, to decipher the limitations of his alexia. Secondly, does he write? If agraphia is not present, does he use wrong nouns (paragraphia), repeat letters or words, or make serious omissions? Can he write from dictation and from copy, and does he then understand what he thus writes?

When other speech avenues of the mind are blocked or only partly obstructed, the recognition of gestures, their use and repetition, should be noted. Some patients do not recognize gestures (amimia), or employ wrong gestures in attempting to explain themselves (paramimia).

To some patients objects have lost their meaning, so that familiar things and intimate friends are not recognized,-a condition called mindblindness. The sense of touch may still furnish information to the mind that has lost its recognition of visual impressions, so that a piece of money or familiar object may be correctly named when placed in the hand, though unrecognized by sight.

The handwriting, especially with the pen, in many cases furnishes diagnostic evidence of great value, as well as a means of studying the progress of the disease. A hand-magnifier will often bring out peculiarities that are not readily seen by unaided vision, and for the same purpose photographic enlargement may be used. When abnormalities are slight or only suspected, a specimen from something written several months or years previously will serve as a proper basis for comparison. Appropriate allowances for youthful growth or the decrepitude of age

must be made. The education, habitude of writing, and physical condition at the time are also to be considered. As a rule, in health the down strokes are made with more strength, precision, and rapidity than the other written lines. If they show inequalities, tremor, waves, or marked angularities, the significance is greater than the appearance of these anomalies in the upward lines or connecting curves. The signing of the patient's name, for those who write it frequently, becomes quite automatic, and often fails to fairly show the character of the disturbance. It is well to dictate some ordinary sentence, to have the patient copy a paragraph from a newspaper, or write a little account of his illness. Many times it is only after writing a few minutes that the difficulty manifests itself. This is particularly true in writers' cramp. In general paresis the first of a letter page may be well, firmly, and coherently written, the latter part showing tremor, inequalities, omitted words, and incoherence. Blots, spatters, and wavering lines demonstrate the ataxia of the patient. The aphasic shows his cerebral lacunæ by using wrong words, by writing jargon, and by the repetition of letters, syllables, and words or phrases when not intended.

Mirror-writing is a variety in which the letters are formed backward, like printers' type, and appear properly when viewed in a reflecting surface. Left-handed children often write thus naturally, and it has been noticed in hysterics and degenerates. Rare cases of mirrorspeech have been recorded, in which words were inverted by syllables or literally.

Varieties of handwriting are given in the description of the various diseases which present such peculiarities.

Finally, photography furnishes a most valuable adjunct to case-taking when any peculiarity of conformation, attitude, gait, or facial expression is observed. Serial photographs vividly present the course of the disThe use of a case-book, properly prepared, is of the utmost value to systematize the examination and secure a full but concise record. The following form may serve as an outline, requiring to be properly spaced for actual use:

ease.