3. In sensory aphasia, or word-deafness (lesion at I), the patient no longer understands spoken language, but there is no disturbance of the speech-forming apparatus. The speech, however, is always impaired, because the necessary association fibers, the fasciculus uncinatus between I and II, are destroyed. The patient either misplaces his words or uses improper words to express his ideas, or the power of forming sentences is lost-paraphasia. One form of this is the so-called literal paraphasia, or stumbling over syllables, in which letters and syllables are misplaced (paralytic dementia). When the memory for words is impaired so that the patient is suddenly unable to think of a certain name of a person or object, without any impairment of the power of understanding spoken language, the condition is termed amnesial aphasia.

7. Motor aphasia occasionally, and sensory aphasia very frequently, is associated with inability to write, agraphia (destruction of V or the association fibers connecting I and II with V; see Paragraphia).

8. A person who may or may not be the subject of sensory aphasia may be unable to read, although there is no actual visual disturbance. This condition is termed alexia. The lesion is in the inferior parietal lobe (supramarginal convolution?).

If the lesion is very extensive, these phenomena may be associated and there may be total motor and sensory aphasia.

e. Mind-blindness is a condition in which a patient is unable to recognize the meaning of objects which he sees (lesion at III), or he is unable to find the right word for an object seen, although there is no motor aphasia. This condition is designated as optic aphasia (interruption of the association tracts uniting III with I and II, inferior longitudinal bundle).

Interruptions of the association tracts uniting I, III, and I produce paragraphia (similar to paraphasia), while interruptions of the tracts between I, II, and the supra

marginal convolution produce paralexia. These two conditions are seen chiefly in paralytic dementia in conjunction with defective speech (stumbling over syllables).

The term dysgraphia is applied to disturbances in the power of writing when they are of peripheral origin, analogous to dysarthria. They include tremulous writing (tremor senilis, alcoholicus, etc.) and ataxic writing (hereditary ataxia, multiple sclerosis).

Dyslexia is a functional disturbance in the power of reading, with marked loss of endurance.

The presence of these central disturbances of the speech and other functions may be determined in the following manner: The examiner engages the patient in conversation, thus: He asks him, "How long have you been ill?” If the patient fails to answer, there may be, after excluding deafness and psychosis:

(a) Deaf-mutism.-This will be at once recognized by the patient beginning to gesticulate.

(b) Total motor and sensory aphasia, which can only be determined by inquiry of a third person.

If the patient nods, and answers other questions which can be answered by "yes" or "no" in the same way, and is evidently unable to utter a word, it is usually a sign of motor aphasia. If the question makes no impression on him and he does not comply with the examiner's request to close his eyes or perform other acts of this nature, there is sensory aphasia; but if he promptly responds by doing everything that he is asked to do, sensory aphasia can be excluded with certainty.

If the patient answers every question with the same word, such as "no, no," there is monophasia. If, instead of answering correctly, he misplaces his words, syllables, or letters, there is paraphasia. It is well to apply a rigorous test by asking the patient to pronounce difficult words and phrases, such as "electricity," "third mounted artillery brigade," and similar long words or phrases. The patient is then shown various objects, such as

a match or a lead-pencil, and is asked what they are used for. If he is unable to indicate their use, either by word or gesture, sensory aphasia and peripheral visual disturbances being excluded, there is mind-blindness. If the patient understands the use of the object but is unable to give its right name when asked to do so, there is optic aphasia.

The above-mentioned disturbances having been excluded, the patient is now asked to repeat words, sentences, and numbers. If he fails to do this correctly because his recollection of the examiner's words is imperfect, there is amnesic aphasia.

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The next step in the examination consists in testing the power of writing. The patient is asked to write down words and numbers from dictation. If he does not write at all, sensory aphasia being excluded, there is agraphia, or if he is able to write only one word, such as no," there is monographia. If the writing is full of mistakes and syllables and letters are transposed or omitted, there is paragraphia. If the patient is unable to remember for more than an instant or two what has been dictated, there is amnesic agraphia. In the same way the power of spontaneous writing and copying should be tested, and if the patient is able to write, he should be examined, to determine whether he understands what he has written.

To test the power of reading the patient is asked to read written or printed words and numbers. If he is unable to do so, motor aphasia and visual disturbances being excluded, there is alexia, monolexia, or paralexia. Again, the examiner should note whether the patient understands what he reads. If there is inability to remember for any length of time the letters or numbers read, it is a sign of amnesic alexia. A more rigorous test may be made by asking the patient to form words and numbers from certain given letters and figures.

2. Testing the Memory.-The disturbances of the memory associated with the power of speaking, reading,

and writing have already been described under the head of amnesic aphasia, alexia, and agraphia.

In addition, the memory should be tested in regard to impressions acquired in early life and to more recent events, which are obtained from the history.

The examination of recent impressions includes both simple and complicated associations, single words or numbers, or rows of figures. Disturbances of the memory are designated amnesia. They occur in injuries to the skull, contusions, focal disease in the brain, and in dementia. The examination should include a rigorous test of all the various associations,-auditory, visual, tactile, etc.,—the details of which can not be given here.

3. Other Psychic Disturbances.-The examiner should determine whether there is any disturbance of consciousness (coma, somnolence, torpor), whether the intelligence is normal or impaired (dementia, idiocy), whether there is any morbid motor or sensory emotional condition (delirium, emotional disturbance with impaired consciousness, hallucinations, morbid sensory illusions of central origin, visions, morbid misapprehension of sensory impressions), and whether there are any delusions (systematized, fixed or transient flight of ideas).

The presence of melancholia (morbid depression), mania (morbid exaltation), or hypochondria must not be overlooked. The finding of these symptoms does not by any means justify the examiner in making a diagnosis of the psychosis of which these symptoms are supposed to be typical.

Diagnosis.

The diagnosis can be made only after a complete examination and careful review of the history. The examiner should satisfy himself in regard to the following questions:

1. Is there actually a disease of the nervous system, or is it merely simulated by anemia, tuberculosis, tenia, etc.?

2. Granted that there is a nervous affection, is it possible that some other bodily disease may be responsible for it (arteriosclerosis, tumors, diseases of the heart, lungs, stomach, kidneys, blood, etc., diabetes)?

3. Is the nervous disease functional or organic in character? This question can often be answered at once, but in many cases it requires much thought and a long course of observation. Thus, choked disc, degenerative muscular atrophy (RD), loss of the patellar and pupillary reflexes, are always due to an organic lesion. The mode of origin of the disease must be carefully considered.

4. Granted that the disease is organic, where is the lesion situated? (See General Symptomatology, Part IV, 3.) Is it a focal disease or a system degeneration?

5. What is the nature of the disease? The answering of this question will necessitate a careful consideration of the mode of origin of the disease, its possible connection with other diseases (infections, tumors), the site of the lesion, and the bearing of other symptoms that may be present (fever, cachexia). In many cases a single examination is not sufficient, and not rarely the course of the disease must be followed for some time before a diagnosis can be arrived at. If, as in many cases, a positive diagnosis is out of the question, the examiner must content himself with making a provisional one. It is well not to make such a diagnosis as paralytic dementia, brain-tumor, or tabes dorsalis without due deliberation, certainly never after the first examination, without very strong reasons.

5. General Remarks on the Treatment of Nervous Diseases.

The treatment of nervous diseases, more than that of any other bodily affections, demands that the attending physician should both act and think according to the dietates of psychology. Unfortunately, this part of our medical education still leaves much to be desired. But it is