Congenital Elevation of the Shoulder
Boston Medical and Surgical Journal
It seems probable that the fibres connecting the visual with the auditory centre were interrupted, for he found difficulty in reading aloud, and though he could recognize an object he could not recall its name. The fibres passing in the opposite direction were doubtless also interrupted, for he could not write difficult words from dictation. That the fibres passing from the auditory area to Broca's convolution were probably impaired is shown by the fact.that though he could hear and, to a
... ear and, to a certain extent, interpret from hearing, he could not talk correctly (paraphasia). To what extent these different structures were invaded it is impossible to determine. Probably the visual word centre was spared and his inability to recognize certain words when he saw them was due to the inability to reproduce the sound of the word through its sight, that is, interruption of the fibres connecting the visual with the auditory word centres. We have no reason to suppose that Broca's convolution was invaded. His speech showed not the least sign of impairment except for words whose meaning he evidently did not grasp; in other words, there was no evidence of loss of the kinesthetic speech memories, but rather lack of proper stimulus to those centres from the auditory word centre. This case tends to corroborate the views originally held by Broca and Trousseau and later sustained by Wernicke, Dejerine, Collins and many others, that there is no writing centre in the sense of a centre in which are stored up the kinesthetic memories of written words, and capable of stimulation independent of Broca's convolution. The inability to write in this case was absolutely coincident with his inability to talk. The words he could utter he could place upon paper; those which he could not, he utterly failed to write. When the auditory centre either failed to recall the memory of the sound of the word, or if remembered, to convey the stimulus properly to the kinesthetic speech centre, it failed also to communicate it to the centre for the movements of the hand. It is true that at the first trial he wrote the names of the months better than he said them, in order to do this, however, he took time, and repeatedly scanned his list. The fact that half an hour later he was able also to say them, showed that there was really littletochoosebetweenthe two defects. To one sustaining the views of Bastian, that the centre for hand movements is capable of being stimulated from the visual and auditory centres independently of Broca's convolution, it might be claimed that this case merely showed that the fibres to both the hand centre and to Broca's convolution were equally impaired. In view of the prevalence of similar cases, and in the dearth of definite cases of agraphia without aphasia 10 the prevailing opinion seems opposed to Bastian's theory. That the centres and fibres affected were not destroyed is shown by the complete recovery. The patient presented himself for examination at the neurological clinic of the Massachusetts General Hospital two months after the examination here detailed, and no defect of speech could be elicited by the most searching examination. He brought specimens of his newspaper work which showed no error, and stated that the only trouble he had recently noticed was that on one occasion he found difficulty in spelling the •wovàjeviel, and on another in recalling the word yet. This word is one of a class less readily acquired, and perhaps less readily retained, than nouns and verbs representing tangible objects and actions. It seems probable that if aphasies were systematically examined with reference to their ability to use words of this nature, defects, at least equally serious with those in the use of substantives, would be brought to light, though the simpler conjunctions and prepositions may be more firmly fixed than nouns. This is mentioned in view of the special designation (anomia) which has been used to denote inability to name objects, and which has been accorded by no less an authority than Mills, a special centre in the temporal lobe. 10 In a recent article on " Cerebral Anesthesia" contributed to Brain by the writer in conjunction with Dr. Paul, a case (seen in consultation with Dr. Phippen of Salem) was reported, which might be cited as an illustration of agraphia without aphasia. This patient (who suffered from a local cortical lesion accompanied by attacks of Jacksonian epilepsy always commencing in the hand) had no defect of speech, but could only write by tracing the let-ters slowly as if learning them anew, though she had perfect control of the movements of the fingers. She had, however, equal difficulty in sewing, or performing any movements requiring the appreciation of the feeling of objects in the hand, nor could she name such objects with the eyes closed (astereognosis). The inability to write did not demonstrate, then, lesion of a special centre for writing, but was only a single sign of the loss of the kinesthetic hand memories (active touch) resulting from lesion of the physiological group of fibres and cells presiding over the stereognostic sense. The probable seat of the stereognostic sense for the hand is not far distant from that assigned oy Bastian to the centre for writing memories, and it requires no great stretch of imagination, as was pointed out in the article mentioned, to assume that the one includes the other. The following cases are reported as illustrating the two types of the condition described as "Congenital elevation of the shoulder." In one the position was probably due entirely to the imperfect development of the muscular structures, and is analagous in every way to congenital torticollis in which the sterno-cleido mastoid muscle is imperfectly developed. It is possible and not improbable that in this condition an injury at the time of birth may be the cause of the trouble, as has been clearly demonstrated in the case of torticollis. In the other case the position of the shoulder is associated with an embryological condition, there being a distinct articulation between the upper angle of the scapula and the vertebra. Both cases have been operated upon with improvement in the appearance of the patient, and with practically normal results in regard to function.