Cases of organic brain disease with lesions involving the speech areas and therefore presenting symptoms of aphasia require a special method of examination. An outline for guidance in such examinations was prepared by Professor Adolf Meyer some time ago for use in the New York state hospital service. It is here reproduced without essential change.
The examination presupposes a knowledge of the previous educational level of the patient and a complete neurological status, especially accurate tests of hearing, vision, and other senses. Never omit the question whether the patient is right or left handed. Give a general description of the mental condition of the patient and his attitude toward his needs and the surroundings, the extent of attention and spontaneity, his general appreciation of the condition and of the purpose of the examination.
Reaction to words heard: Does the patient understand his own or others' names, simple or complicated words, orders (button the vest, open the mouth, show the tongue, touch your nose, open the window, hold up three fingers)? Can he compose words spelled to him? Does he pay attention? Does he depend upon gestures? How does he react? (By repeating the words; by forming the question; by adequate answers in words or gestures? Or are the reactions inadequate, paraphasic, mere action, irrelevant productions, or gibberish?) Are there circumlocutions? Evasions of difficult words, or sticking to words? Does the patient pick out and handle correctly objects named?
Reactions to things heard: Does the patient understand such sounds as the mewing of a cat, barking, ticking of watch, jingling of keys (tests being made with his eyes shut)? Is the intonation of question, scolding, etc., understood?
Repetition of words and sentences: Is the meaning understood at once or only after repetition, or not understood notwithstanding repetition? Is there automatic echolalia?
Spontaneous speech: (a) Have the patient give an account of the onset of the trouble, of his admission to the hospital, and of his present condition. Note to what extent he volunteers speech, opens or continues conversation, and sum up the defects of speech shown during these and subsequent tests. What is the extent of his vocabulary? If possible secure a stenographic example. (6) Reciting the alphabet, days of the week, months of the year, counting from one to twenty, forward and backward, with or without help, (c) Calculations, (d) Reciting the Lord's prayer, a poem, (e) Spelling words, counting words and syllables. (f) Foreign languages.
Reaction to things seen: Can the patient name coins, key, ring, knife, button, thread, bottle; wool, cotton, and silk in various colors; a book; geometrical figures; the meaning, forms, and colors of pictures? Does he understand the meaning of movements such as fiddling, shooting, gestures of threat and beckoning? Is the mimic appreciation disturbed (see also intonation)?
Reaction to things smelted: Can the patient notice and name odors and identify them (wintergreen, clove, peppermint), or point to the name on a list, or when mentioned?
Reaction to things tasted: Sugar, salt, quinine, noticed, named, or picked out from a list, or when mentioned?
Reaction to things felt (with eyes shut): Recognition and naming of objects (right and left hand); writing on the skin (hand and forehead, geometrical figures, numbers, words). Writing movements with the flaccid hand.
Reaction to words seen, reading: (a) Printed letters, short and long words, newspaper headings, paragraphs; does the patient spell them, read them in syllables, or as a whole? Does he pronounce correctly and does he understand? (6) Abbreviations (W. C. T. U., Y. M. C. A., G. A. R., U. S. A.). (c) Written cards (orders, questions); numerals (Arabic, Roman, fractions, multiplication), (d) The patient's own writing; name, etc.
Is the sense grasped without speaking what is read, or only from reading it aloud? Does the patient fumble with his hands? Speak without grasping the sense? Are the helps of any use, such as tracing the letter with a pencil or finger, or by extensive movements of the hands and arms? Is there much clinging to previously spoken words? Is there any improvement by repetition and by helping along?
Writing: (a) Spontaneous, a letter to a friend with signature, or a statement concerning present condition. Describe the effort. (6) Writing from dictation: name, sentences, numerals, abbreviations (Y. M. C. A., etc.). Calculations in writing, (d) Copying written or printed words and sentences. Does the patient understand what he copies? Copying unfamiliar characters, such as Greek or Hebrew.
Drawing: Triangle, circle, tree, automobile; copying.
Music: Is singing and playing understood? Can a tone be taken correctly? Can the patient play or sing? Sing a tune with the words? Speak the words without the tune? Can he read notes? Write notes (from memory or copy)?
Mimic and gestures: To what extent understood and used?
Internal language: Is the memory of places and topography motor or visual? Are forms remembered by motion or visually? Can the patient sound words mentally? Remember the faces of friends? Color of things, visually or only by word association? As a rule conclusions must be drawn from the general composure, adaptability, attention; the indications of the number of letters or syllables in a word; playing with cards, counting out every sixth card, etc. Does the patient reason?
Apraxia: Use of objects, etc.
Analysis of paraphasic symptoms: Is the patient aware of the difficulty? Is he apathetic or indifferent, or making efforts to correct himself, or to substitute?