ILLINOIS UNIVERSITY OF ILLINOIS AT URBANA-CHAMPA1GN PRODUCTION NOTE University of Illinois at Urbana-Champaign Library Brittle Books Project, 2014.COPYRIGHT NOTIFICATION In Public Domain. Published prior to 1923. This digital copy was made from the printed version held by the University of Illinois at Urbana-Champaign. It was made in compliance with copyright law. Prepared for the Brittle Books Project, Main Library, University of Illinois at Urbana-Champaign by Northern Micrographics Brookhaven Bindery La Crosse, Wisconsin 2014 LI BRARY OF THE U N I VERS IT Y OF ILLI NOIS 612:.78 W97d ' K f*!*&Ji< WmWTZ2THE DISORDERS OF SPEECH.A PHYSIOLOGICAL ALPHABET. I.—VOWELS. y — i e ao 11 — w These should be pronounced in the Latin manner, as ee> eh, ah, oh, oo. y and w are consonants, not vowels, but, as explained in the text, they have very close relationships to the vowels, initial y being very closely related to i, and initial w to u. II.—CONSONANTS. Voiceless Oral Voiced Oral Voiced Nasal Consonants. Consonants. Resonants. Labials. B M (1st Stop Position.) (W) W Labio-Dentals. F V Linguo-Dentals. Th1 S Th2 Z Anterior Sh Zh Linguo-Palatals. T ■ (L) JD L N {2nd Stop Position.) R Posterior K & Ng Linguo-Palatals. H or Ch Y (3rd Stop Position.) \ (R) The voiceless W and the voiceless L have been given above within brackets, the former being now almost confined to Scotland, and the latter being peculiar to Wales. The burring or uvular R is also given within brackets. ILLUSTRATIVE SENTENCES. I.—VOWELS. Even ancient elves are awed over oozing. This sentence represents only long vowels. Their short equi- valents can be represented, as shown by Mr Pitman, by attaching the letter t to each vowel, thus:— eU, it, et, at, ut, ot, <5'St. II.—CONSONANTS. Peter Brown made w//ite wax. Fine villages. Thinkest thou so, zealot P She leisurely took down nine large roses. Can Gilbert bring Loch Hourn youths?THE Disorders of Speech, BY JOHN WYLLIE, M.D., F.R.C.P. Ed., PHYSICIAN TO THE ROYAL INFIRMARY, EDINBURGH ; LECTURER ON THE PRACTICE OF MEDICINE AND ON CLINICAL MEDICINE IN THE SCHOOL OF MEDICINE, EDINBURGH. EDINBURGH: OLIVER AND BOYD, TWEEDDALE COURT. LONDON : SIMPKIN, MARSHALL, HAMILTON, KENT, AND CO., LIMITED.PRINTED BY OLIVER AND BOYD, TWEEDDALE COURT, EDINBURGH.VkU 5 PREFATORY NOTE. The text of this work has already been published as a series ^ of articles contributed to the Edinburgh Medical Journal between October 1891 and May 1894. The Appendix consists of—(A.) Notes of three illustrative cases of Speech-disorder which have been under observation too recently to be available for the text of the work; and (B.) a Eeprint of my Graduation Thesis (1865) on the Physiology of the Larynx, which was originally published in the Edinburgh Medical Journal for September 1866. I have thought it well to reprint this thesis, as its subject is intimately related to the physiology and pathology of Speech. Edinburgh, 1 Melville Street, October 1894. i I 0 13722ERRATA. Vm• " Caprolalia " at page 56, lines 4 and 14, please read " Coprolalia."CONTENTS. PART FIRST. THE FUNCTIONAL DISORDERS OF THE VOCAL MECHANISM. CHAPTEK I. PAGE On Stammering ; and on the Study of the Alphabet, - - - 1 chapter II. Physiology of Whispering. Hysterical Aphonia. Hysterical Mutism. Other Forms of Functional Paralysis of the Adductors. Functional Spasms. Bilateral Paralysis of the Abductors, - - - 33 Chapter III. The Troubles of Professional Voice-Users ; with Appendix as to Writer's Cramp, -------- 59 PART SECOND. THE DEVELOPMENT OF SPEECH; AND THE DEVELOPMENTAL DERANGEMENTS. Chapter IV. Sketch of the Development of Language in the Normal Child, - - 87 Chapter V. The Three Functions of the Voice. Speech of Idiots and Imbeciles, - 111 Chapter VI. Dumbness (Congenital Aphasia) in Persons not obviously Imbecile. Lalling on Single Consonants. Congenital Paralysis of Mouth ; and Oral Deformities. Developmental Defects of the Vocal Mechan- ism. Congenital Bradylalia and Logorrhcea. Deaf-Mutism, - 127 Chapter YII. The Development of Speech in the Human Race. Classification of Languages. Origin of Written Language. The Invention of Printing. Printing for the Blind, - - - - 149viii contents. PART THIRD. SPEECH IN ITS RELATIONS TO DISEASES OF THE NERVOUS SYSTEM. Chapter VIII. PAGE Speech in its Relations to Insanity, - - - - 182 Chapter IX. Aphasia:—Physiological Preface; with Notes upon the Leading Feat- ures of Aphasia, and upon the History and Literature of the Subject, 227 Chapter X. Aphasia in Relation to Organic Diseases of the Brain:—Prefatory Notes as to the Speech-Centres. AuditcJry7 Aphasia, - - 276 Chapter XI. Aphasia in Relation to Organic Diseases of the Brain—continued:— Motor Aphasia (Aphemia) ; Conduction Aphasia, - - - 299 Chapter XII. Aphasia in Relation to Organic Diseases of the Brain—continued:— Visual Aphasia, ------- 332 Chapter XIII. Aphasia in Relation to Organic Diseases of the Brain—continued:— Graphic-Motor Aphasia. Summary of the Leading Features of the different simple Forms of Aphasia. Additional simple Forms recognised by Lichtheim and Wernicke. Compound Forms. Method of Case-taking, ------ 354 Chapter XIV. Aphasia and other Disturbances of Speech in Relation to Evanescent Organic Affections and Functional Disorders of the Cerebral Cortex, 377 Chapter XV. Dysarthric and Anarthric Disturbances of Speech due to Lesions affecting the Motor Speech-Tracts, - - - - 411 APPENDIX. A.—Notes on Three Cases of Speech-Disturbance, - - - 449 B.—Reprint of Graduation Thesis on the Physiology of the Larynx, - 463PAET FIEST. THE FUNCTIONAL DISORDERS OF THE VOCAL MECHANISM. CHAPTER I. On Stammering; and on the Study of the Alphabet. The performance of a good player on the violin affords a beauti- ful illustration of co-ordinate movement. His two hands co-operate with each other, gracefully and easily, in the execution of their delicate task. Each hand has its own work to perform. The right, wielding the bow, is the producer of sound: in proper time, and with correct emphasis of touch, it calls forth the vibrations of the strings in rapid succession. The left hand moulds the sound into music, by its manipulation of the strings. Its fingers must not only keep pace, upon the strings, with the movements of the bow: they must touch each string, to a nicety, in the right place; otherwise the note will be out of tune. Let it be particularly noticed, as of special interest in connexion with our present sub- ject, that the two hands must act in perfect co-ordination one with the other: that is to say, that each hand, in assisting the other, must perform its part of the work exactly at the right moment—■ neither too soon nor too latesince the slightest inexactitude in this respect would be utterly destructive of the music. From the consideration of these independent and combined movements of the two hands of the violinist, one can form some conception of the wonderful facility and exactitude of execution that can be a2 THE DISORDERS OF SPEECH. acquired by the motor centres of the nervous system through the influence of education. In the production of Speech, we find a series of movements just as rapid and exact, and in like manner effected, if not by two hands, at least by Two Mechanisms, acting, like the hands of the violinist, in exact co-ordination one with the other. These two mechanisms are:— (1.) That of the Larynx, which is the producer of the vocal ele- ment in speech, and thus is comparable to the bow-hand of the violinist. (2.) The Oral Mechanism, by which the sounds of the larynx can be modified in tone or timbre, though not in pitch, as they pass through the oral cavity; and by which new sounds,produced within the mouth itself, can be added to the vocal tones of the larynx. The oral mechanism may in some respects be compared to the string-hand of the violinist. These Two Mechanisms must act together with a co-ordination as exact as that of the two hands of the violinist. Let there be a little inexactitude in this respect—only a little delay, let us say, in the .production of the vocal element,—and speech is at once inter- rupted, so as to become discordant and laborious. It will be the chief object of this paper to make it perfectly evident that the common defect of Stammering is in the great majority of cases due to delayed action of the laryngeal mechanism; though it may, apparently, in a minority of cases be caused by delayed action of the oral mechanism. A further reference to the per- formance of the violinist may help to make the matter clear. We are told by those who play the violin, that, when a player begins to learn to play from the score, his chief difficulty is with the string-hand; and that sometimes, in his anxiety to place the fingers of that hand upon exactly the right places, he is tempted to devote too much attention to it, to the neglect of the bow-hand. For a moment, he may even forget about the bow-hand altogether; and, when no sound is produced, lie may press harder upon the strings, until he discovers that the bow-hand has been neglected. So, in the common variety of stammering, the speaker neglects the laryngeal mechanism; and, when no speech is emitted, he un- wittingly throws increased force into the wrong quarter, viz., the oral mechanism, whose nerve centres thus become surcharged withSTAMMERING, AND TIIK STUDY OF THE ALPHABET. 3 energy, which may overflow into other centres and produce spas- modic complications. In explaining to a stammerer the real nature of his defect, this comparison between the violinist and the speaker will be found to be of use, as it is easily grasped and understood, even by young patients. That the defect of speech in the common variety of stammering is due to Delayed Action of the laryngeal or vocal mechanism in attacking the first syllables of words, is an old proposition; and is also to the present day maintained by the best writers on the subject. Among the first to make the proposition, was, I believe, Dr Neil Arnott, in the very interesting chapter upon stammer- ing in his work on Physics, first published in 1827. In later times, Melville Bell, in this country, and Merkel and Kuss- maul, in Germany, have taught the same doctrine; and, in drawing up recommendations for the treatment of the condition, they have all alike insisted upon the necessity of attending in a special manner to the production of the vocal element in speech. That the doctrine is true can be shown by many familiar proofs. Thus, however severely a stammerer may stammer in speech, it is seldom that he has the slightest difficulty in song. Many stammerers are excellent singers. One writer describes the case of a man who stammered very badly, but who sometimes won money by wager- ing he would sing through a long song, from beginning to end, without once stammering. In my own practice, I have had one patient, a medical student, who did stammer occasionally during his musical performances; but his songs were " nigger melodies," and contained mucli conversation. It was in the conversational parts that he had difficulty; and the difficulty did not distress him> as the audience was always under the impression that the grimaces of his blackened face were a voluntary part of the performance. This case is therefore no exception to the rule that stammerers do not stammer when they sing; and possibly some of the reported exceptions to the rule might be explained in a similar way. In like manner, stammerers rarely stammer in intoning, which is a mode of singing upon a single note. Charles Kingsley stam- mered badly in ordinary conversation all his life; but his biographer tells that he preached well, and that he had no stammer in preach- ing, because he then spoke or intoned in musical monotones. Similarly the reading of poetry, writh its musical cadences, is easier4 THE DISORDERS OF SPEECH. to the stammerer than the reading of prose. Public speaking, with its full intonations, ought, on the same principle, to be some- what easier than private conversation; but the stammerer's nervous- ness generally makes it more difficult. All this tends to show that when a primary demand for voice is made, as in song or in intoned speech, and a sufficiency of energy is thereby supplied to the laryngeal mechanism, the difficulties of a stammerer can be made, for the time, to disappear. Few stammerers would stammer at all, if they deliberately sang or intoned their conversation; but it need scarcely be said that it is hopeless to ask them to do anything so extraordinary. Yet a general injunction to the stammerer, that, in speaking, he should employ a full tone of voice, is always of use to him; as is also an injunction to practise reading aloud in a full voice for at least a few minutes every day. Melville Bell, whose experience in the treatment of the condition was very great, asserts that the success of stammer-doctors is very largely due to their almost universal practice of making their patients read aloud daily in this manner. Recognising the great value of this prescription, I have been led to ask myself if nothing further can be done to facilitate the patient's intelligent use of the voice as one of the essential ele- ments of speech. Experience has shown me that something else can be done; viz., to put, it in the power of the patient to acquire with ease an accurate knowledge of the individual letter-sounds which compose his speech. Such a knowledge will enable him, with easy decision, to throw the voice into the vowel or consonant that contains voice; and to touch off lightly, without dwelling on it, any consonant that does not contain voice, bringing the voice out immediately in the vowel or vocalized consonant that succeeds it. The desire to communicate to stammerers a knowledge of such matters has led me to construct a physio- logical alphabet, so arranged that the voiced elements are separ- ated distinctly from the voiceless, and so simply constructed as to be easily learned and remembered, even by young patients. It need scarcely be said that the construction of a physiological alphabet is no new thing. Dr Neil Arnott himself, with the very same object in view, constructed one; which will be given in the Appendix to this paper. Mention should also be made of the excellent phonetic alphabet of Mr Pitman, constructed by him inSTAMMERING', AND THE STUDY OF THE ALPHABET. 5 connexion with his phonetic method of shorthand writing;1 of the alphabetical table of Professor Max Miiller, in his well- known Lectures on the Science of Language; of the vowel and consonant tables given by Dr Bristowe in his work on Voice and Speech; of the table of consonants by Norman W. Kingsley of New York;2 of the elaborate tables of vowels and consonants appended by Dr John Hullah to his work on the Cultivation of the Speaking Voice ; of the still more elaborate vowel and consonant tables in the work entitled Pronunciation for Singers, by Alexander J, Ellis; of Melville Bell's tables in his work on Visible Speech ; and of the phonetic studies of the alphabet which have been made by the teachers of Deaf- Mutes.3 Before I proceed to draw up this alphabet, let us consider in the light of a few examples the delicately co-ordinated action which is carried on in combination by the two mechanisms, laryngeal and oral, in the production of ordinary speech. Take the word satisfy. Here the laryngeal mechanism is called upon to touch off three separate vocal sounds, each of which is evolved by the vocal cords during an instant of approximation, viz., the sounds of a, i, and y; and, between these sounds, the open glottis must permit the current of air to pass noiselessly into the mouth, where it will be utilized for the production of the voiceless conson- ants, which are made, as it were, to clothe the vowels in front and behind. Let the naked vowels, as they sound in this word, be pronounced, and then the full word itself; and the extreme delicacy and exacitude of the three separate co-aptations of the vocal cords will be realized. Let there be any delay in the pronunciation of the first vowel, and the initial s will be hissed and prolonged, ex- actly as it is by the stammerer. But the voice is not an exclusive possession of the vowels: many of the consonants are also in part made up of voice. Take the word wonder, for example. Here every letter, consonant and vowel alike, contains voice; so that the 1 See Pitman's Phonographic Teacher, p. 4, et seq. 2 Published in the Internationale Zeitschrift filr Allgemeine Sprachwissen- schaft, vol. iii. p. 246. This paper demonstrates in an ingenious way the parts of the palate, etc., with which the tongue is brought in contact during pronunciation of certain consonants. 3 See Education of Deaf-Mutes, by Thomas Arnold.6 THE DISORDERS OF SPEECH. larynx lias to maintain its vocal cords in co-aptation throughout the whole word, which may even be repeated many times in a deliber- ate and continuous hum. But add to this word the final syllable ful; and, as the word, with this addition, is being hummed over, note the moment of interruption of the hum during the production of the voiceless f. For a moment the vocal cords have been thrown apart to permit of the passage of voiceless air for the f; but they are immediately brought together again for the production of the vocal u. These examples may suffice to show what a delicate and exact work the larynx has to perform, in supplying the vocal ele- ment to the vowels and vocalised consonants, and in intermitting the voice-production when the air is required for consonants that contain no voice. Let it be noted that a stammerer experiences his difficulties only, as a rule, during the production of the first syllable of an ordinary word. The two mechanisms, laryngeal and oral, are, as it were, for the moment out of gearing, and can be put into gearing only by an effort; when this effort succeeds in educing the first syllable, the others follow, as a rule, without difficulty; and it is only after the completion of the word that the' two mechanisms again fly out of gearing. The Physiological Alphabet} Coming now to the description of the physiological alphabet, we find, on reference to the alphabetical table, that a vocal element is present not only in the vowels, but also in the majority of the consonants. It should be clearly understood, that every vocalized letter-sound is the product, not of one of the mechanisms exclu- sively, but of both combined. Even the vowels are not exclusively the products of the larynx, but owe their specific characters largely to the operation of the oral mechanism. Vowels.—A little experiment with the piano, described by Helmholtz, brings home to one very clearly the true nature of a vowel. Let the cover of the piano be lifted up so as to expose the wires, and let the dampers be raised from these by pressure of the foot on the loud pedal. Then, with the head lowered to 1 It may be of advantage to the reader to keep the Alphabetical Table of the frontispiece open before him when reading the following description of it.STAMMERING, AND THE STUDY OF THE ALPHABET. 7 within a foot or two of the sounding-board, sing one of the vowels, such as O or e, in a clear, loud tone of low pitch. The piano will not merely echo back the note in its correct pitch: it will distinctly, in its echo, pronounce the vowel, o or e, as the case may be. This is due to the fact that the different vowel-sounds consist in different combinations of the note with over-tones or harmonics. The voice, therefore, does not only excite a sympathetic vibration in that wire of the piano which represents its fundamental note and pitch: it also excites similar vibration in a number of other wires, which represent the over-tones or har- monics ; and, as these over-tones differ in the different vowels, the piano reproduces the vowels distinctly and specifically. In the production of vowels, the larynx thus furnishes the fundamental note and its over-tones; but this material is modified in passing through the oral cavity, by the action upon it of a Eesonating Chamber capable of great variation in size and shape, wherein the over-tones are individually suppressed or exaggerated; and the sound is thus moulded into the acoustic figure proper to the vowel to be produced. When the vowel is sung over the piano, this acoustic figure is represented by the grouping of the wires called into sympathetic vibration. It is chiefly to Willis,1 Wheatstone,2 and Helmholtz that we owe our knowledge of the real nature of vowels. The subject will be found fully discussed in Helmlioltz's great work on The Sensations of Tone. In English grammars, the vowels are given in the order a, e, i, O, u, and it is expected that these shall be pronounced in the English manner. But there are well-known objections to this order and pronunciation. The English i is really not a simple vowel- sound, but a compound of two vowel-sounds that may be repre- sented by the letters a i. So, also, the English u is a compound sound really representing y u. It is better, therefore, to adopt the Latin pronunciation of the vowels, which gives to each a single definite sound. Further, in arranging them, it is best to place them in an order which will represent a gradual transition from the narrowest and tightest shape of the resonating chamber—that for i (English ee),—on to the hollowest and largest shapes—those 1 Trans. of the Cambridge Philosophical Society, vol. iii. p. 231. 2 London and Westminster Review for October 1837.8 TUE DISOliDEliS OF SPEECH. for o and u (English oo). The difference in the chambers for o and for u (oo) is that in the U (oo) sound the rounded labial opening is of smaller size than that in the o sound. The order thus becomes i, e, a, o,'u. Any one, when deliberately pronouncing the vowel- sounds one after the other in this order, and using the Latin pro- nunciation, can from his own sensations realize that the resonating chamber within the mouth, very tight and narrow when the first vowel is being sounded, opens up more and more with each suc- ceeding vowel, until, with the final O and u (oo), the chamber has attained its largest dimensions. It should be carefully noted that in no one of these pure vowel sounds is there, throughout the oral cavity, any constriction sufficient to give rise to audible friction from the passing air. Let such friction be added, and in some instances the vowel will become a consonant. This is seen when the vowel sound i (ee) is pronounced with such accompanying friction of air, It then ber comes the sound of the initial y in such a word as yes. So, again, when the pure vowel-sound u (oo) is made to pass through a very small labial orifice, it becomes converted by the added friction into a w, as in the word weary. Y may therefore be described as a tight i (ee), and W as a tight u (oo). These two consonants are thus closely related to the vowels, and may be regarded as transi- tionary steps or stepping-stones between vowels and consonants. They are both obtained from vowels by the simple addition of a fricative element, due to the friction of the escaping air. ..This relationship of y and W to the vowels is described by MerkeL1. It is represented in the alphabetical table. As to the number of the vowels, it may be remarked that there are many possible shades of breadth in the pronunciation of each, and that these might fairly justify a considerable enlargement of the list by the insertion of a number of new vowel-letters to provide for them, but such shades of breadth are in the present connexion not of sufficient importance to be here described in detail. Further, it appears necessary only to refer in a word to variations in length, by reminding the reader that the same vowel may be long or short. Consonants.—Coming now to the list of Consonant-sounds, we find, on examination of the alphabetical table, that they are there 1 Physiologie der Menschlichen Sprache, p. 80.STAMMERING, AND THE STUDY OF THE ALPHABET. 9 arranged in three vertical columns, of which one column, the first, contains the voiceless consonants, whilst the second and third contain the consonants in which voice is a component element. In the sounds of the third column—Nasal Besonants,—the voice is, by the dropping of the soft palate, made to pass freely through the nose, the passage through the mouth being closed. It need scarcely be said that each consonant of this table should be pronounced as the letter is pronounced during the enunciation of a syllable containing it. Thus the letter S should be pronounced, not as ess, but as the sibilant sound at the beginning of such a word as son; and so with the others. Besides being divided vertically into columns, the consonants of the alphabet, it will be observed, are arranged hori- zontally in groups, according to the part of the mouth which is the seat of their production. The groups begin anteriorly, with the consonants which are produced at the lips—the Labials,—and pass backwards, by the Labio-Dentals, Linguo-Dentals, and Anterior Linguo-Palatals, to the group which is produced most pos- teriorly—the Posterior Linguo-Palatals. There are, in all, five groups. Of these, three are of leading importance, viz., the Labials, Anterior Linguo-Palatals, and Posterior Linguo-Palatals. These three groups are produced at the three great Stop-positions. In these three stop-positions there are greater possibilities of produc- ing a variety of consonant sounds than in the other two. It is possible at each of the three stop-positions either to stop the current of air, or to allow of its escape with fricative noise through a narrow opening; and each of these two actions can be performed with or without the addition of voice supplied by the larynx. Let us note in detail what effects can be produced at each of the Stop-positions, and also at two other positions where only fricatives can be produced. A. Taking first the Anterior or Labial Stop-position, we note that it can produce— (1.) The voiceless p, when there is complete closure of the lips, and the air is compressed behind the barrier. Occurring at the beginning of a word, this mute or voiceless consonant com- municates an Explosive character to the vocal sound which follows it in the syllable, as in the word pot. Occurring at B10 THE DISORDERS OF SPEECH. the end of a word, it gives the effect of a sudden and silent Stop, as in the word top. (2.) The Voiced Explosive b is also produced at this position. It is merely p with voice added, the air which accumulates behind the barrier being, as it were, voice-laden. The explosive and stop effects of b may be recognised in such a word as the monosyllable Bob.1 (3.) Closing the lips and sounding the voice as in b, drop the soft palate, and let the air and voice escape through the nose; and the effect will be to produce the Nasal Eesonant m. (4.) In these three consonants the labial stop-position was closed; but let it now be opened slightly, so that the air may escape by a small orifice between the lips ; and if voice be added the effect will be the production of W as in weary, this consonant, as already explained, being a Voiced Fricative made up of the 00 sound and the fricative noise produced by the passage of air through a very narrow opening. (5.) Can we here produce a simple Voiceless Fricative ? I hold that we can, and that we actually do so when we pro- nounce the initial wh, in the word which, for example, as these letters are, in words beginning with them, pronounced in Scotland. It should really be spelt hw, or more correctly ww, the first of these letters being given voicelessly, and the second with voice. In England, the voiceless letter has been dropped; and which has now been softened into wich. These are the five possibilities at the first or anterior stop-posi- 1 On careful experiment, I find that for the production of B it is not abso- lutely necessary that the air accumulating behind the barrier should be voice- laden. All that is absolutely necessary is that the voice should be emitted as soon as the air. In the pronunciation of an initial P, the air begins to escape just an instant before the voice. This can be made evident if a house-key be held before the mouth as if for whistling, and Pa and Ba be pronounced over it. And, no doubt, the same distinctions exist between T and D, and between K and G. It has been pointed out to me that the pressure of air behind the barrier is greater in the voiceless than in the voiced explosives. In the voiceless explosives the pressure of the air in the mouth is the same as in the trachea ; but in the voiced explosives the air meets with some amount of obstruction at the glottis, owing to the approximation of the vocal cords in phonation; and this obstruction in the larynx causes the air pressure to be less in the oral cavity than in the trachea.STAMMERING, AND THE STUDY OF THE ALPHABET. 11 tion. Their relations to each other are plainly shown in the Alphabetical Table.1 B. Turning now to the Second or Middle Stop-position—the Anterior Linguo-Palatal,—we find that five similar consonants are produced here also, as well as two others in addition. The com- plete stop is here effected by the apposition of the tip and edge of the tongue to the upper gum, which is the anterior part of the hard palate. T, the Voiceless Explosive, corresponds in its method of production and in its effect to p. D is simply t with voice in the air that accumulates behind the barrier. N is produced as d, except that the soft palate is lowered, and the voice allowed to escape through the nose. Sh, as in she, is the Voiceless Frica- tive of this position, produced when the stop is not complete; and zh, as in treasure, is sh with the addition of voice. (In English, zh is never spelt zh, and never occurs as an initial consonant; but in French it is common as an initial, being represented by the letters j or g, as in Jean or George.) The tip of the tongue being, above all parts of the mouth, capable of rapid and delicate movement, it is not surprising to find that in this, the middle stop-position, two Additional Fricatives are pro- duced, viz., r and 1. R is produced partly by the purring friction of the air in passing over the vibrating tip of the tongue, and partly by the voice: it is a Voiced Fricative, which can be pro- duced with different degrees of roughness. L is also a Voiced Fricative, produced by the fricative passage of air with voice over the sides of the tongue, whilst the tip is in contact with the palate at the stop-position. In English, there are no voiceless fricatives corresponding to r and 1; but in Welsh there is a voiceless 1, always succeeded by a voiced one; as in the initial 11 of Llangollen. So far as I am aware, no language has utilized the voiceless r. A curious point in the production of the letter r has been brought under my notice by my pupil Mr Thomas Macdonald, son of the late Dr Angus Macdonald. It is that the trilling motion of the 1 Babies are fond of producing at the lips a trilling noise, sometimes with- out and sometimes with voice. Some authorities have described it as a labial E, and in Germany it is called the coachman's K, because it is used for urging horses ; but, as it is not employed in European speech, I have not incorporated it in the Alphabetical Table.12 THE DISORDERS OF SPEECH. tongue is not effected by the middle of the tip, but, in most individuals, by the tip at the right side of the middle line. Is this an indication that the speech energies are not distributed with absolute equality to the two sides of the tongue, but that the tongue in speech is to some extent " right-handed " ? It would be interesting to find out, by further observation, if left-handed people trill with the left side of the tongue-tip. From the above description, it is seen that seven consonantal sounds are capable of being produced at this, the most remarkable of the stop-positions. C. Taking, lastly, the Third or Posterior Stop-position—the Posterior Linguo-Palatal,—we find that, like the first or anterior, it produces normally only five consonants. We find, further, that whilst complete stoppage is effected by the co-aptation of the back of the tongue with the palate, a considerable latitude is allowed, in this position, as to the exact spot on the palate against which the tongue may be pressed, or towards which it may be approximated. . This latitude permits of an easier transition from the consonant to the succeeding vowel. Taking, for example, the words key and coal, it will be found that in key the k sound is effected by the contact of the tongue with the hard palate pretty far forward; whereas in coal it is effected by the contact of the tongue with the soft palate pretty far back. So also with the fricatives: h in here is produced further forward than it is in home. The five con- sonants which this position is capable of producing are—(1), the voiceless explosive k, corresponding in its mode of production to p and t; (2), the voiced explosive g, as in gum ; (3), the nasal resonant ng; (4), the voiced fricative initial y, as in yes; and (5), the voiceless fricative h or ch. Much discussion has taken place as to the situation where the voiceless fricative h (the aspirate) is produced. Some hold that it may be produced anywhere in the cavity of the mouth, by the friction of the air against the walls of the oral cavity. Kussmaul, on the other hand, asserts that it is well known that the aspirate is produced by the rush of air through the widely open glottis. Like some others, I venture to dispute both of these propositions, and hold that the aspirate is the voiceless fricative of the posterior stop-position, as above stated. I also hold that the soft ch, as in the GermanSTAMMERING, AND THE STUDY OF THE ALPHABET. 13 ach or the Scotch loch, is merely the aspirate, occurring, in a somewhat pronounced form, at the end of a syllable, instead of at the beginning. The identity of the h and the ch will be recog- nised, if the two German words ich hier, or the two Scotch words Loch Hourn, be pronounced slowly and in continuity one with the other. Another consonant of a somewhat abnormal character which the posterior stop-position is capable of producing is the gut- tural or Burring R, which is characteristic of the dialect of some districts, such as the county of Northumberland, and is also otherwise a frequent peculiarity of speech. It is produced by the trilling motion of the uvula against the back of the tongue. In Paris it is said to be fashionable to use this abnormal r ; but in this country burring is regarded as a defect of speech. Besides these three great Stop-positions, there are two other positions, both of them in connexion with the upper teeth, where several fricatives, voiced and voiceless, can be produced. These are:— D. The Labio-Dental position, where f and V are produced by the passage of air between the upper teeth and the lower lip, f being voiceless, and V being f plus voice. E. The Linguo-Dental position, where the tip of the tongue, in contact with the edge of the upper teeth, allows of the production of two varieties of th—a voiceless, as in thin, and a voiced, as in thine;—and where, applied against the back of the teeth, it allows of the production of the sibilant S and its vocalized equivalent z.1 (The voiced th used, in old Anglo-Saxon, to be spelt dh.) 1 It has been pointed out to me that s can be pronounced when the tip of the tongue is applied to the lower instead of to the upper teeth. In this case, the dorsum of the tongue instead of its tip acts with the upper teeth in producing the s. On careful experiment, I find that of the whole eleven consonants which the tip of the tongue normally takes part in the formation of, viz., th1, th2, s, z, sh, zh, t, d, n, 1, and r, I can pronounce all, except one, when the tip of the tongue is held fixed behind the arch of the lower teeth; the dorsum of the tongue being employed instead of the tip in forming them. Even the th sounds can be thus produced, if the lower jaw be protruded, so as to permit of the dorsum of the tongue being brought into contact with the edges of the upper teeth. The only exception is r, which, without the agency of the tongue-tip, can only be given as the uvular or burring r. These remark-14 THE DISORDERS OF SPEECH. In the alphabetical table, each of the various groups of letters is associated with a sentence whose words begin with the letters of the group. The value of such sentences for purposes of diagnosis, and for purposes of tuition, is obvious. A well-selected stock of such sentences enables one to diagnose and analyze a case of faulty speech with ease, and without loss of time. In the tuition of young stammerers, also, the sentences afford much assistance, as they are so easily remembered. For the sentences, I have to thank my house-physicians and pupils. To sum up this part of the subject, the consonants may con- veniently be divided into the three following classes:— 1. The Typical Five of each Stop-position; viz., a voiceless and a voiced explosive or stop, a nasal resonant, and a voiceless and a voiced fricative. 2. The extra fricatives that the second and third stop-positions are capable of producing; viz., the 1 and r of the second position, and the burring r of the third. 3. The voiceless and voiced fricatives produced at the two dental positions—the Labio-Dental and Linguo-Dental,—these being six in all; viz., the voiceless f and voiced v, at the Labio-Dental, and the voiceless th and s and voiced th and z, at the Linguo- Dental. (It should be remarked that of these six the four last are formed in part by the tip of tongue. Adding these four of the Linguo-Dental position to the seven of the Anterior Linguo-Palatal, we have thus, in all, eleven consonants that the tip of the tongue takes part in the formation of. How well the dorsum of the tongue can play the part of the tip when the tip is fixed behind the lower teeth is shown in the footnote to page 13.) able capabilities of the dorsum of the tongue help to explain the similarly wonderful capabilities of the stump of the tongue after partial excision of the organ. Another very important point about the formation of s is that, whether produced by the tip or by the dorsum of the tongue, it is not neces- sarily formed at the back of the upper teeth. It can be formed almost equally well farther back, at the upper gum (2nd stop-position), where sh is formed ; but when formed here it is less sharp and hissing than when formed at the back of the teeth. It can thus be pronounced pretty well even in the absence of teeth. Some children learn to pronounce s sooner than sh, others sh sooner than s.STAMMERING, AND THE STUDY OF THE ALPHABET. 15 Comparison with the Ordinary Alphabet. It will be useful to compare the physiological alphabet above explained with the alphabet at present in general use. This will be easily done, if the ordinary alphabet be printed as below, and the letters of it which are omitted from the physiological alphabet, or are only in part represented therein, be denoted by special type thus:— abedefflrhijklm nop q rstuvwa?y z. Among the letters thus indicated in special type, c is not repre- sented in the physiological alphabet, because its value is always exactly either that of s or that of k ; q is not represented, because it is of 110 value without an attached u, while qu has the same value as kw; x, again has the same value as ks, and is therefore not in the physiological alphabet; g, in the physiological alphabet, represents the hard g as in gum, while the soft g, as in George, is not represented by any single letter, its phonetic translation being dzh ; and the same translation applies also to the English j, as in John, In French, j and soft g are pronounced without the initial d; as in Jean and George. It is very important to explain to a stammerer the phonetic meaning of the English j or soft g. Some years ago, I had sent to me at the Boyal Infirmary, by my friend Prof. Chiene, a boy of 12, who stammered so badly that he had been sent by his doctor to the Professor for surgical treatment of his organs of articulation. When he was passed on to my wTards, he wTas asked his name; but he struggled long and severely without being able to pronounce it, and at last broke down in a burst of weeping. His name was James. When it was pointed out to him that his name really began with dzh, and he was shown how to throw the voice into the initial d, he became able to pronounce the name with ease; and when, some weeks afterwards, he was shown by me to a class of post-graduates, he gave his name, and replied to several ques- tions, without the slightest difficulty. In this connexion, it may be added that the soft ch in church is phonetically tsh, and is thus the voiceless equivalent of the voiced dzh above referred to.16 THE DISORDERS OF SPEECH. The Phenomena in Stammering. The general nature of the defect of speech in stammering has already been explained, and it has been shown that the starting- point of the defect is a Want of Promptitude in the production of the vocal element in the first syllables of words. It remains to illustrate this proposition by examples from the different classes of letters, and to show in what degree the difficulty is exhibited during the pronunciation of letters belonging to each of these classes. Speaking generally, it may be said that the difficulty is least in the Vowels, which are vocals, and contain voice as their predominant element. The demand for voice in the production of initial Vowels is of so primary a nature, that the larynx usually supplies it without difficulty; just as the still greater demand for voice in song suffices, while the stammerer sings, to abolish the defect in toto. On the other hand, the Voiceless Explosives t, p, k occupy a place at the opposite extremity of the scale. They ought to be touched off lightly and easily; but when, in stammering, the succeeding vocal element in the syllable is not properly brought up to time, the stammerer, ignorant as to the cause of his difficulty, throws his energy into the wrong mechanism, and exerts a strong pressure at the stop-position, which may betray itself either in a Silent Sticking at the consonant, or in a Stuttering voiceless Repetition of its explosive effect. Instead of easily pronouncing a single small p, he produces a succession of these, or only one prolonged capital P of large size. The Voiced Explosives are only a degree less difficult than the voiceless. They are produced in the same manner and in the same variety; their radical defect in the stammerer being the absence or insufficient supply of the vocal element, which, in the case of a voiced explosive, should be thrown into the letter boldly. The other consonants, namely, the Voiceless and Voiced Fricatives and Nasal Eesonants, occupy an intermediate place between the vowels and the explo- sives, as regards the difficulty in their production. In the Voice- less Fricatives, such as S or h, the sound of the letter is prolonged whilst the speaker waits for the lagging voice-sound of the succeed- ing letter. In the Voiced Fricatives and the Nasal Eesonants, the stammerer produces the letter voicelessly, or with feeble and intermittent voice; and dwells upon it indefinitely. The voice isstammerixg, and the study of the alphabet. 17 not thrown into it boldly, as it ought to be; and the speaker there- fore feels that the proper sound has not been produced. Thus in the word mother lie emits a feeble, prolonged, and almost voice- less m; but if lie is taught to throw the voice boldly through the nose, his difficulty, in that particular instance, entirely disappears. The following list of sentences, arranged in the usual order of difficulty, will be found useful in testing the capabilities of a stammerer, and in differentiating the letters with which he may have special difficulty:— (1.) Vowels (i, e, a, o, u).—Eels ail amid ocean ooze. (2.) Voiced Fricatives {the second column minus its three Explo- sives).—We visit the Zulus, like ramblers, yearly, (zh need not be represented, as it never occurs at the beginning of a word.) (3.) Voiceless Fricatives (the first column minus its three Explosives).—Par shores seem thinly hazy. (4.) Nasal Resonants (m, n, ng).—My nephew, (ng need not be represented, as it never occurs at the beginning of a word.) (5.) Voiced Explosives (b, d, g).—Best gold dust. (6.) Voiceless Explosives (p, t, k).—Two poor comrades.1 Although the above table represents the order of difficulty in the great majority of cases of stammering—the Vowels being most easy and the Voiceless Explosives most difficult,—it does not represent the order of difficulty in all cases. I have had at least two cases in which the greatest difficulty was found in the pronunciation of the Vowels; and in not a few I have found the difficulty almost equally distributed over the whole list of sentences. When there is difficulty with the vowels, they are apt to be produced with feeble voice, and in an interrupted and tremulous manner. 1 The following additional sentences will be found of use for testing-pur-' poses :— 1. Mother make more mustard. No, no ! not now. 2. Billy Button bought a buttered biscuit. 3. Davy Doldrum dreamt he drove a dragon. 4. Gaffer Gilpin got a goose and gander. 5. Peter Piper picked a peck of pepper. 6. Tiptoe Tommy turned a Turk for twopence. 7. Kimbo Keinble kicked his kinsman's kettle. For these and many other similar sentences, see Peter Piper's Practical Principles of Plain and Perfect Pronunciation. c18 THE DISORDERS OF SPEECH. Analysis of the Phenomena. Passing now to the more detailed analysis of the phenomena of stammering as exhibited in the Vocal and Oral Mechanisms, we may begin with the Vocal Mechanism, whose want of promptitude is the primary cause of the difficulty. It should be understood that within the term Vocal Mechanism is to be included not merely the Larynx, which is the instrument of voice, but also the Lungs and Muscles of Respiration, which supply the larynx with the necessary blast of air. A. Faults in the Vocal Mechanism, due to imperfect innerva- tion. 1. Want of Promptitude in the supply of voice during the pronunciation of the initial syllable. The voice lags behind, and the energies are misdirected into the oral mechanism, as already explained. Sometimes this is the only fault in the vocal mechanism; the lagging voice being, in such cases, strong enough in tone, when it is produced. 2. The voice may be not only lagging, but also feeble in quality —the Leise Sprache of the Germans. It is low and feeble because the speaker often neglects to fill his lungs with air, and is attempt- ing to speak from a half empty chest. 3. There is often a marked sense of fatigue in the walls of the chest after the effort of speaking, due to the condition of things that has just been explained. 4. During the struggles of the stammerer, the voice may, in some cases, suddenly break from its normal baritone or bass into a piping Falsetto, the effect of which is sometimes very grotesque. This was particularly marked in one of my own cases. 5. There may be Drawback Phonation. This is the production of speech during inspiratory effort; the vocal cords being approxi- mated, and made to vibrate, when air is being drawn in between them. It is a common phenomenon among stammerers. I have notes of one striking case in which it formerly existed with, and now exists per se as the troublesome remnant of, a severe stammer of the ordinary type. The patient himself gave a very distinct account of the development of the Drawback Phonation in the course of his case. He had stammered in the usual manner up to the age of about fifteen; but at that period of life he began to make great efforts toSTAMMKlilXG, AND THE STUDY OF Tilli" ALPHABKT. 19 overcome his impediment, and found that, when in clifficulties lie could always pronounce the Word by having recourse to the "drawback" method of pronation. Practising this method voluntarily at first, he soon found that it became involuntary and habitual with him. It is now the sole remnant of his former impediment. B. lite Oral Mechanism.—Faults due to surcharge of energy. 1. The lagging of the voice, and the misdirection of energy already explained, cause the stammerer to surcharge his oral mechanism with energy, so that lie sticks or stutters at his explo- sives, and prolongs his fricatives and nasal resonants, producing those of the latter which contain voice voicelessly or with feeble vocalization. He sticks and stutters very specially upon his explosives, both voiceless and voiced. 2. From the nerve centres of oral articulation thus surcharged, an Overflow, in many cases, occurs; so that spasmodic and involun- tary movements may be excited, both within the organs of articulation, and in other parts of the face, or even of the body. Among the spasmodic movements thus produced, may be enumer- ated trembling movements and spasmodic twitchings of the lips and cheeks, working of the jaw, forcible winking of the eyes, twitching or tonic contraction of the sterno-mastoid on one or both sides, and sometimes spasmodic working of the arms. Some patients have been known even to stamp with the feet. One of the most unsightly spasms is that affecting the tongue. I had one patient, a highly educated and intelligent lady, who stammered very severely, and whose spasmodic phenomena specially affected the tongue. In the midst of her difficulties, she frequently lowered her head, turning it to one side, and at the same time protruded her tongue to its utmost extent at one side of the mouth, while she covered the unsightly protrusion with her hand. The case seemed to be merely an example of such spasmodic over- flow as more commonly displays itself in spasm of the facial muscles. The overflow probably started from a surcharged portion of the hypoglossal nerve centre, and passed into other portions of the same centre which ought not to have been stimulated at all. Kussmaul treats of this protrusion of the tongue, which he calls Aphthongia, under a separate heading, as being apart from the20 THE DISORDERS OF-SPEECH. ordinary phenomena of stammering; but the case I have referred to, besides having this protrusion of the tongue, stuttered in the ordinary way upon the explosives, and under the ordinary treat- ment showed a marked improvement. At the same time it is probable enough that - chorea, or certain local spasmodic affections of the nature of motor tic, may produce similar involuntary protru- sions of the tongue independently of stammering. C. Overflow into the TJi^per Glottis.—In a few cases the energy, imperfectly supplied to the vocal mechanism, flows excessively, not only into the organs of articulation, but also into the upper or non-vocal part of the larynx. This part consists of the structures that have the false cords for their inferior margins, and have beneath them the hollow spaces called the ventricles of Morgagni. It was my good fortune and privilege, in 1865, to demonstrate for the first time, by experiment and otherwise, the Valvular Actions of the larynx. In my graduation thesis, presented to the University of Edinburgh in 1865, and published in the Edintoirgli Medical Journal for September 1866, I showed, with reference to one of these valvular actions, that this upper part of the larynx is a true valve which renders it possible for air to be held imprisoned within the chest under strong pressure^ during such acts as those of straining and the compressive stage of coughing. My observa- tions have been fully confirmed by a careful investigation carried on conjointly by Dr Lauder Brunton and Dr Cash, who published their conclusions in the Journal of Anatomy and Physiology in 1883; and these observers have further, in a very able manner, illustrated the action by experiment on the lower animals, and by investigations into the structure of this part of the larynx in different classes of animals. To any one who reads these two papers, it must be evident that this valvular action is the real use of the false cords and of the ventricles of Morgagni. It is to be hoped that at some future time the attention of physiologists in this country will be attracted to this important subject. So far as I am aware, no adequate description of the valvular actions of the larynx has yet been incorporated in the physiological text-books. This is, however, not the place to enter further upon the discussion of the valvular actions of the larynx; and it will suffice merely to ask the reader's attention to the one of them I have mentioned,STAMMElUNG, AND THE STUDY OF THE ALPHABET. 21 namely, the valvular action of the Upper Glottis, consisting of the false cords and the ventricles of Morgagni. During Phonation, this part of the larynx remains unclosed, while the true cords below are in apposition. What would happen if, during phonation, the false cords closed over the true, and, by their valvular action, shut off the passage of air ? Exactly what does happen in a somewhat rare variety of stammering. The patient's, voicetis at once inter- rupted ; and, with open mouth and congested face, lie silently struggles, without effect, to emit the imprisoned air. During his repeated attempts to speak, the seat of impediment may be diagnosed, if one observes the peculiar sound which is made, from time to time, when the upper glottis is thus being spasmodically closed over the lower. It is a sound not unlike the k sound in huck, but produced lower down in the throat, and without contact of the back of the tongue with the palate. This variety of stain-; mering is described by Kussmaul under .the name of " Gutturo- Tetanic," and the open mouth is mentioned as one of its character- istics ; but its mechanism is not satisfactorily explained by him. The fact is, that we have here in the upper part of the larynx a fourth stop-position which is not utilized in European speech, although perhaps the true gutturals of the Arabic may be pro- duced by it. Its explosive is a cough, and its voiced fricative is a "clearing of the throat." I have had only one case iu which the Gutturo-Tetanic overflow was the chief phenomenon. Arnott made the great mistake of supposing that the difficulties of stammerers generally were due to closure of the glottis. The difficulties and troubles of a patient who stammers badly may be realized, when one studies such an analysis as the above, of the phenomena which , result from faulty distribution of energy iu the various mechanisms. Kussmaul has given a good picture of the painful struggle. Speaking of the stutterer, he says, " He closes the oral canul at one or other of the closing points, according to the nature of the letter to be articulated, and this he does as well as a man who possesses the faculty of speech could do it; instead, however, of allowing the vowel to follow without delay, he presses his lips, or his tongue and teeth, or .his tongue and palate, more firmly together than is necessary; the explosive escape of the air does not take place, the other muscles of tliQ22 THE DISORDERS OF SPEECH. face and tliose of the glottis and even the" muscles'of the neck become spasmodically affected like those of articulation, gesticu- latory movements are made, the abdomen is retracted, the head is drawn backward, and the larynx is drawn forcibly upward, until finally he works himself into a state of frightful agitation ; his heart beats forcibly, his face becomes red and blue, his body is bedewed with perspiration, and he may present the appearance of a com- plete maniac." The Causation of Stammering. The phenomena of stammering having been thus pretty fully described, a few words may now be said about its causation. It is notorious that the condition is developed much more fre- quently in the male sex than in the female. For every female case, there are probably four or five males. How this should be, it is difficult to say; but male children are, as a rule, slower in learn- ing to speak than female children; and certainly this derangement of speech is commoner among them. It would appear that some children, perfectly healthy in con- stitution and not of neuropathic diathesis, acquire the defect by simple imitation of their seniors who may happen to stammer. Stammering is, however, especially common among children of neuropathic inheritance. It is no indication of any defect of intel- lect, and may occur in children and adults who are gifted with very bright intelligence; but, nevertheless, even in the very intelligent, it may be found associated with nervousness and excitability, as well as sometimes with more distinct indications of instability of the nervous system. Occurring in a nervous subject, it is apt to aggravate his nervousness, and even to produce an unsociable and morbidly shy condition of mind. In nervous subjects, temporary conditions which aggravate the nervousness always lead to exacerbations of the stammering. Thus the presence of strangers who require to be spoken to puts a strain upon the stammerer. Often he cannot go with confidence to make purchases in a shop; and I have known a boy, going home to the country for his holidays, sit crying bitterly at a railway station because he dared 'not make the attempt to ask for his ticket. So also any depressing influence/such as exhausting work or exhaust-STAMMERING, AND THE STUDY OF THE ALPHABET. 23 ing dissipation, or a sleepless night, or any temporary disturbance of health, is apt to make the stammerer worse for the time being. Sudden and Violent Emotion, above all a severe fright, has often been known to produce stammering in children, and even in young adults. It seems certain that this and many other nervous disturbances are most frequently produced by fright when tlie constitution of the patient is essentially neuropathic or hysterical. The defect may be transmitted by Inheritance, especially in neuropathic families. No doubt, however, the apparent trans- mission is in some cases really in large part due to imitation of a parent's speech by the children. A degree of stammering more or less marked is found associated with many defects of speech that are of graver significance than itself. It is thus frequently found to be one of the elements in the deranged speech of imbeciles and idiots, in the speech charac- teristic of general paralysis of the insane, and also in the speech of patients suffering from true aphasia. Where it is thus associated with real organic disease or defective development, its treatment is always difficult and unsatisfactory; but when, as in the vast majority of cases, the intelligence is up to the average, the treat- ment may be undertaken with good hopes of a complete cure, and the certainty of at least a very marked amendment. Treatment of Stammering. Any one who has read the foregoing account of the causation and phenomena of stammering would be able, it is hoped, to draw up a scheme for the scientific treatment of the condition. My own plan is as follows:— 1. First of all, it is convenient to impress upon the patient the simile of the violin player, and to show him, as forcibly as possible, that it is his bow-hand, or rather his larynx, that is at fault ; and that he must therefore pay no attention to his mouth, but attend to his voice, and speak always in a full and resonant, though natural tone. With the view of cultivating his voice, he is recom- mended to read aloud for at least ten minutes every morning. He may begin with poetry, and afterwards, as reading improves, take to prose. If he be possessed of a musical ear, it is well for24 TIIE DISOliDEKS OF SrEECII. liim, farther, to cultivate his voice in song, and learn to read music at sight. Everything that helps to give him a ready command of voice will help to get him out of his difficulty. Arago, somewhere in his writings, tells, as to Orfila, the great medical jurist, that 011 being. severely frightened, when a boy, he was thrown into such violeut emotion that immediately afterwards he began to stammer badly; and that lie continued to do so for some years. At the recom- mendation of the family priest, he was induced to become a membey of the Church choir; and, whilst he was developing into a very excellent singer, he gradually got quit of his defect of speech. To provide for circumstances which make the patient specially nervous, it is sometimes not amiss to recommend him deliberately to intone or sing, at the ordinary conversational pitch, the first word he utters in conversation. Among my stammering patients, I had, some years ago, a boy, who, when sent by his parents to make purchases in shops, always took his little sister with him, to act as his interpreter. As he had a good musical ear, I taught him to intone his first word; and, by way of experiment, sent him to a shop to buy some oranges. He was enabled to effect his purchase without any stammer, by simply intoning the word "If," when beginning his request with, " If you please." 2. A stammerer should be taught the physiological alphabet and its sentences. With the aid of the latter, he will very soon be able to draw up the alphabet for himself, and to understand it in every part. 3. He should also be made to read and learn the additional sen- tences given in the note at page 17; and the letters that he stammers on in them must be carefully noted, in order that their proper mode of enunciation may be thoroughly explained to him. In like manner, when at his daily occupation, he must himself note carefully the words that give him difficulty in conversation, so that in the even- ing he may, by reference to the alphabet, find the key to their pro- nunciation and be able to practise upon them specially. In the com- paratively rare cases in which the patient stammers markedly upon initial vowels, it is well to confine the patient's attention for days or weeks to exercises upon vowels and words beginning with vowels. When the power of enunciating vowels readily is acquired, the patient can then proceed to practise upon the consonants. 4. In concluding the teaching of the alphabet, the teacher will doSTAMMERING,-AND THE STUDY OF THE ALPHABET. 25 well to give the pupil such a word as street, and ask him which of its letters first contains voice. If he has learned the alphabet well, he will know that the first voiced letter is r. Should this word be difficult of pronunciation, he will do well to practise first the pro- nunciation of reet, and then try street itself, touching off the St very lightly and throwing the voice boldly into the r; and so with other words with which he may have similar difficulties. With the aid of the two sets of sentences, the teaching of a young stam- merer is by no means difficult. He will soon know the alphabet very familiarly, and will be easily made to understand the all- important distinction between the letters that contain voice and those that are voiceless. 5. When there is a tendency on the part of the patient to attempt speech from an empty chest, he should be instructed to fill the chest by inspiration at suitable intervals. It is wonderful, however, how seldom much training of this kind is required, if the patient has grasped the great principle that he must speak with voice. With this principle well established in his mind, he fills his chest for voice production instinctively when a new supply erf air is needed. 6. In all cases where the patient is of nervous constitution, and apt to be depressed or put out of health by such causes as have already been enumerated, it will be well for the physician to pay special attention to the patient's health and mode of life, and, by tonics and tonic regimen, do everything in his power to raise the nervous tone and improve the general condition. 7. In cases of exceptional difficulty, it will, perhaps, be well to recommend that the patient should be placed under a tutor or specialist, who has time to devote much attention to his daily tuition. It is unfortunate that, at present, most of those who make a specialty of the treatment of stammering are persons without scientific training or knowledge. Many of them have secret methods which they bind their pupils not to divulge; and some of them teach their pupils to make exaggerated movements of the lips and face when talking. So long as the mystery and secrecy of a method is maintained, the imagination of the stammerer is worked upon; and if he has confidence in the remedy, this very confidence, and the courage it gives him, bring about, often enough, marked im- provement in his speech. But the improvement is only temporary ; D26 THE DISORDERS OF SPEECH. and the secret method always loses its efficacy, when it loses its secrecy. It would be easy to give an account of some secret methods which have had a great reputation in their day, but this would really be trespassing too much upon the reader's patience. If he is interested in their history, he will find much information about them in an article by Guillaume, which will be referred to in the Appendix to this paper. Rhythmic movement of the hand or of the head during speech has often been prescribed, as a means of diverting the patient's attention from his struggling organs of oral articulation; and good might possibly, in some cases, be done by such a prescription. But I am strongly convinced that the best and most permanent results will always be obtained from a treatment based upon an accurate scientific knowledge of the nature of the condition; and it is certain that the chief feature of such a method of treatment will be the attention it devotes to the correction of the lagging action of the vocal mechan- ism. A thorough course of vocal gymnastics could easily be ela- borated ; and here again I think there is work for the specialist. A well-educated specialist, who discarded all secret remedies, and devoted himself to the training of his pupils upon scientific principles, would do good work, and would not be without support and encouragement. At the same time, it must be remembered that many patients, especially those who are intelligent and per- severing, do not require the aid of a tutor or specialist. If they are made to understand thoroughly the nature of their defect, they can themselves, by dint of persevering and intelligent prac- tice, break their old vicious habits of speech, and acquire the new habit of speaking in a normal way. My own experience has shown me that this is often the case. As to the performance of surgical operations for the cure of stammering, I shall only say that they should never be had recourse to, under any circumstances. They were tried extensively about the beginning of this century, and there are few more melan- choly chapters in the history of Surgery than that which gives an account of them. The reader will find much information upon this subject in Guillaume's article, and in the writings of Kussmaul. The introduction into the mouth of foreign bodies, such as pebbles and tongue-bridles, is equally out of the question.STAMMEKING, AND THE STUDY OF THE ALPHABET. 27: Demosthenes, with his pebbles, has in this respect set an unfor- tunate example. Prognosis of Stammering. As regards Prognosis, it will be easily understood that the stammerer's progress will depend very largely upon his own intelligent comprehension of the principles above explained. An important factor is also the age of the patient. Perhaps the best age is between twelve and sixteen; when the patient is old enough to realize the importance of getting rid of his defect, and yet not so old as to have the defect rooted very deeply in his organs of speech by force of habit. I think that the stammerer's possession of a good musical ear is also a hopeful factor, seeing that it gives the stammerer a more definite compre- hension of tone than he would have without it. Cases with very severe spasmodic complications are generally less satisfac- tory than those not thus complicated. The habit of Overflow in the nervous mechanism of articulation wears, in time, easy channels for overflow; so that very slight surcharge may eventu- ally suffice to produce spasmodic movement of neighbouring muscles. Even in such cases, however, very great improvement may be looked for, if the patient is intelligent and persevering. When patients are defective in intelligence, or, in a marked degree, defective in self-control, the prognosis can never be so good; and improvement can be looked for only after prolonged treatment under the supervision of an intelligent tutor or specialist, who entirely understands the nature of the defect, and the means that can be employed for its removal. Bare and Exceptional Varieties of Stammering. It may now be asked if the foregoing description applies to all cases of stammering; or if, on the other hand, there are some rare cases which belong to a separate category. The doctrines just explained are, with some variations, substantially the doctrines admitted by the best scientific authors since the days of Arnott. It is, however, interesting to note that Pro-28 THE DISORDERS OF SPEECH. fessor J. Miiller, writing not many years after the publication of Arnott's conclusions, makes some very pertinent objections to the inclusion of all cases of stammering under the one simple category. In his Physiology, published about 1840, he remarks, referring to the views of Arnott and Schulthess—"This view is founded on good observations; but, though an improvement on the previous erroneous opinions, it goes further than facts justify. I knew a young man of distinguished mathematical attainments who had formerly stammered very badly, and in pronouncing his own name was apt to say i Te-Tessot' instead of ' Tessot.'" Here, Miiller's case pronounced the greater part of the first syllable, including its vowel, and hesitated only about taking the suc- ceeding consonants. He was therefore unlike a stammerer of the ordinary variety, who would have stuck or stuttered voice- lessly on the T. Some years ago, I saw a patient who stam- mered in a similar way. In pronouncing the word " resident," for example, he repeated over and over again the syllable " r§-re- re," before he was able to take the succeeding S. For a long time I regarded this as a solitary case, in my practice, of stammering due solely to want of promptitude in the oral mechanism; but, on examining the patient again quite lately, I found that, whilst the old peculiarity still to a certain extent remained, there was also a distinct difficulty of the ordinary descrip- tion, best marked during the production of the initial d, which was stuck upon because it was pronounced voicelessly. The case must therefore be regarded as one in which the want of promptitude affected both mechanisms, and displayed itself sometimes in the action of the one and sometimes in that of the other. I have not met with any case in which the want of promptitude was confined to the oral mechanism. Another exceptional variety of stammering, of which I have had experience in at least two cases, is that in which there is merely an Interrupted Utterance; the wTords being brought out, often hurriedly, in groups, between which are pauses without com- pressive or other effort in the organs of articulation. A few words are rapidly uttered, and then there is a sudden stop and a pause, whilst the patient is apparently arranging the next group of words in his mind. Then follows the next group of words, then a second pause, and so on to the completion of the sentence. In one well-markedSTAMMERING, AND THE STUDY OF THE ALPHABET. 29 case of this sort, the patient, a medical student, stated that in his boyhood he had suffered from a stammer of the ordinary kind, and that his own efforts to get rid of it had resulted in the de- velopment of this curious interrupted utterance, so suggestive of the emptying of a bottle. A very simple classification of the varieties of stammering would be:— I. The ordinary variety, in which the vocal mechanism shows want of promptitude. II. A possible variety, with the want of promptitude in the oral mechanism. III. A want of promptitude in both mechanisms. This may show itself sometimes in the one mechanism, sometimes in the other; or there may be an Interrupted Utterance, without compressive or other effort, suggestive of a want of promptitude affecting both mechanisms simultaneously and equally, and displaying itself at short intervals in every sentence. At present, however, I cannot say that the existence of the second and third classes is clearly established. I have had only one case in which there was distinctly a want of promptitude in the Oral mechanism; and in that case, as already explained, it ex- isted alongside of a similar peculiarity in the vocal mechanism. I have therefore thought it better to treat fully of the first great variety, whose peculiarities are clearly pronounced, and to say little about the others, regarding which I have as yet so limited an experience. My study of this subject was begun some years ago, at a time when I was lecturing upon those other derangements of speech that are commonly more closely studied by physicians. It occurred to me at that time that here was a derangement of speech which, as a rule, was but little understood by professional men, and which was certainly an enigma to myself. I accordingly asked my professional friends to send me as many cases as possible, as 1 wished to study the matter. Very soon I had accumulated notes of about fifty cases; and the total number of my cases has since risen to over one hundred. Studying the matter in the first in- stance exclusively from nature, I had the usual experience of those who work in this manner, of finding, when I came to look into the30 THE DISORDERS OF SPEECH. literature of the subject, that my chief conclusions had been long anticipated by others; but, knowing that the subject is still but little studied by the profession at large, I have been encouraged to write this paper by the hope that a plain statement of the facts may render it possible for practitioners generally to undertake the treatment of stammering. It is a subject of very great importance. So many stammer severely, that it is probably no exaggeration to say that the sum-total of unhappiness inflicted upon a people by this single defect is not much less than that produced by all the other derangements of speech put together. At the same time, I am not without hope that the physiological alphabet, apart from its bearing upon stammering, may be of value for educational purposes. I am sure children would learn their alphabet more easily, if it were interpreted to them from the beginning on physiological prin- ciples. And I hope particularly that the physiological alphabet may prove of value in the education of deaf-mutes. Further, I hope to go on, in future papers, to the consideration of the other derangements of speech, viz., those which are produced by defective development, and by disease of the nervous system; and, here again, I am strongly of opinion, that the very best method of entering upon the consideration of such a complicated subject is to begin at the beginning, with the study of the alphabet in the light of physiological analysis. As I have a sincere admiration for the work that Professor Kussmaul has done in connexion with the Disturbances of Speech, it has been to me a matter of regret that I have not been able to follow him in attaching quite different meanings to the words " Stammering " and " Stuttering." In this country, the two words are very closely related in meaning, " stammering " being the more general term, and " stuttering" the more specific. All of the derangements of speech described in this paper come naturally enough under the general designation of Stammering, and one of the more common phenomena is fitly enough called Stutter- ing. But Professor Kussmaul, following Schulthess, uses the word Stuttering (Stottern) as the general term for this whole class of speech derangements; and he applies the word Stammering (,Stammeln) only to certain quite different derangements of Oral Articulation, which I hope to consider by-and-by, when I come to examine the Developmental Disorders of Speech. It would beSTAMMERING, AND THE STUDY OF THE ALPHABET. 31 wresting the English word from its natural meaning, if we used the word Stammering in the same sense as Professor Kussmaul uses the German word Stammeln. In my description of the elements of the Physiological Alphabet, the reader may have been surprised to observe that I have made no use of the terms "Mediae," " Tenues," "Mutes," " Semi-mutes," "Liquids," etc. These are examples of a very venerable termin- ology, which for ages has clothed the knowledge of these matters, but which, I think, science has now outgrown. The terminology employed in this paper is much more simple, and the terms are more definite and clear in their signification. APPENDIX. The following is Dr Arnott's Alphabetical Table, referred to in the text. It may be compared with the Physiological Table of the text. TABLE OF ARTICULATION. o "aj . • !> a> o5 02 ^ T -4—3 i i_J P—t a? c3 Pc3 cSoS c "t2 . ?H CO OSh ^ .A .A O c3 S, O g s s a & ^ a 03 03 . <1 <3 £ mm p B M F y pr Labial. ... th th *.. Dental. T D N S Z E Palatal. ... L ... sh J ... With the edges of the tongue depressed. K G ng n ch H gh ghr Guttural. There can be little doubt that Arnott would have done even more than he did to solve the whole problem of stammering, had the laryngoscope been in use in his day ; but he had very false notions about the action of the glottis, and made the radical error of supposing that stammering was always produced by spasmodic closure of the glottis—a cause of stammering of only secondary importance, since it is comparatively rare. It was reserved for his successors to show that the obstruction was much more frequently at one or other, or at all, of the stop-positions. Otherwise, Arnott's conclusions were32 THE DISORDERS OF SPEECH. thoroughly rational. He taught that the encouragement of the voice was the key to the difficulty; and recommended that, at the beginning of his treatment, the stammerer should maintain the voice as continuously as possible, by interposing the vowel sound " eh " between the words of a sentence ; and that afterwards he should enable himself to dispense with this artificial aid, by studying the individual consonant sounds as shown in his table, and using the voice in their production when voice forms one of their constituent elements. As to the literature of the subject, the best works that have come under my notice are :— (1.) The Treatise of Dr Neil Arnott on Voice and Speech, beginning at p. 629 of his work on the Elements of Physics, 5th Edition. (2.) Melville Bell's little work on the Faults of Speech. (3.) Merkel's Physiologie der menschlichen Sprache, 1866. (4.) Kussmaul's great article on the " Disturbances of Speech" in Ziemssen's Cyclopaedia of Medicine, vol. xiv. (5.) The very valuable historical article by Guillaume, entitled " Begaiement," in the Dictionnaire Encyclop. des Sciences Medicales. The reader who is interested in the subject will find a full account of its bibliography in Kussmaul's article. Kussmaul truly remarks that " the literature of this impediment of speech has reached enormous dimensions ; every possessor of an establishment for the treatment of stuttering seems to have been impressed with the idea that the interests of suffering humanity necessitated his appearance as an author. Their treatises possess on the average about as much value as the current pamphlets on Balneology."physiology of whispering. 33 CHAPTER II. Physiology of Whispering. Hysterical Aphonia. Hysterical Mutism. Other forms of Functional Paralysis of the Adductors. Functional Spasms. Bilateral Paralysis of the Abductors. In the first chapter, it was shown that speech is the product of two mechanisms acting in co-ordination with each other—viz., the Vocal and the Oral Mechanisms;—and these were compared to the bow-hand and the string-hand of the violinist. It was shown, further, that Stammering is a disorder of speech which, in the great majority of cases, is due to a want of promptitude on the part of the Vocal Mechanism in attacking the first syllables of words. In the present chapter, it is proposed to consider some other nervous derangements of speech in which the Vocal Mechanism is again chiefly at fault. It will be shown, however, that, in the derangements now to be considered, the fault is not a want of promptitude, but either, on the one hand, a want of power, or, on the other hand, a spasmodic disturbance of action. Before entering upon the consideration of this group of dis- orders of the Vocal Mechanism, it may be convenient here to consider, by way of preface, the Physiology of Whispering, a subject of great importance in its relations to these derangements. Physiology of Whispering. What are the conditions necessary for the production of whispered speech? Regarding this question there is still much difference in the views of physiologists; and I may be allowed to express the opinion that the views taught by the text-books most commonly used in this country are not correct. In Foster's Physiology it is held that—" Whispering is speech without the employment of the vocal cords, and is effected chiefly by the lips and tongue. Hence, in whispering, the distinction between consonants needing, and those not needing, voice, such as e34 THE DISORDERS OF SPEECH. b and p, becomes for the most part lost."1 [In the fifth edition of Foster's Physiology (issued at about the same date as that of the first appearance of this paper in the Edin. Med. Journal) the author has rewritten the section upon the Larynx. He now holds views upon the Physiology of whispering that are the same as those advocated in this paper.] Landois and Stirling remark—"When sounds or noises are produced in the resonating chambers, the Larynx being passive, the Vox Clandestina, or Whispering, is produced. When the vocal cords, however, vibrate at the same time, audible speech is produced. (Whispering therefore is speech without voice)."2 And in the latest edition of the Encyclopedia Britannica it is said—" If the vocal cords are called into action, and the sounds thus produced are modified by the muscular movements of the tongue, cheeks, and lips, we have vocal speech; but if the glottis is widely opened and the vocal cords relaxed, the current of air may still be moulded by muscular apparatus so as to produce speech without voice, or whispering."3 The view thus expressed is as old as the time of Arnott (1827), and probably a great deal older. Arnott says—"Whispering is articulation without voice; that is to say, articulation while breath only is passing."4 In recent times, it has derived its chief support from certain experimental researches in Paris, which will be presently referred to. If this view were correct, whispering would be speech produced by the simple agency of the oral mechanism, without the co- operation of the larynx. This, if we may use again the simile of violin-playing, might be considered as equivalent to the production of melody by the agency of the string-hand alone, the bow-hand being out of employment. A very different view is held by many who have paid special attention to the subject. This view was first promulgated by Briicke in 1856,5 and is thus explained by Yon Meyer in his 1 Foster's Physiology, 4th ed., 1883, p. 661. 2 Landois and Stirling, p. 760. 3 Encyclop. Brit., articles on Stammering and Yoice, by Prof. M'Kendrick. 4 Arnott's Physics, 5th ed., p. 640. 6 Grundziige der Physiologie und Systematik der Sprachlaute (Wien, 1856). (Unfortunately now out of print, so that I have not been able to get a copy.)PHYSIOLOGY OF WHISPEKING. 35 work1 published in 1883:—" Now it is not only possible to produce all the vowels and resonants in a whisper, but also to mark the difference between the ' hard' and ' soft' consonants. Undisturbed activity must therefore be allowed to those relations by which the laryngeal tone is moulded into those sounds. Thus we find that absence of tone cannot be regarded as the characteristic of whis- pering,but that we must seek some other element which will so stand in the place of tone as to be equally affected by those modifying influences, and thus perfectly replace it as an element of speech. " This substitute for tone must have its origin in the larynx, or its subsequent fate in the air-passages would not be so entirely analogous to that of the tone produced in the larynx. Briicke takes the very probable view, that in whispering a noise is formed in the glottis instead of the tone which constitutes an element of loud speech. This noise is no other than that which has been described above as the Strepitus continuus spirans of the larynx." These views of Briicke, arrived at by observation and reasoning, without the aid of the laryngoscope, were subsequently submitted by Czermak to the test of laryngoscopic investigation, and his results were laid before the Imperial Academy of Vienna in 1866.2 Czermak entirely confirmed the conclusions of Briicke, and proved that in whispering a fricative noise is produced at the glottis by the partial closure of the vocal cords, which close and open during whispered speech very much in the same manner as they do in ordinary vocal speech. There is only this peculiarity in the action of the vocal cords, that, whereas in vocal speech the air passes the 1 "Organs of Speech," International Scientific Series, p. 273. 2 Wiener Akademische Sitzungsberichte, lii. Bd., 1866; also Czermak's Gesammelte Schriften, p. 750. It appears to me very unfortunate that, in this valuable investigation, Czermak was led to the opinion that the h sound in articulate speech is pronounced in the same manner by the larynx, as the spiritus asper of whispering. In the first chapter, I expressed the opinion that the aspirate h is the voiceless fricative of the posterior stop-position ; and this, I believe, was the view enunciated regarding it by Briicke. That it is the correct view, any one can prove for himself, by deliberately pronouncing the h sound in the word her©, and attending to his own sensations while doing so. When the tongue is pulled out for laryngoscopic examination, no true h sound can be produced so long as the parts within the larynx remain visible. If the attempt is made to pronounce h, the back part of the tongue is carried so closely up against the palate as to interfere with a view of the larynx. The spiritus asper of the larynx is, at the best, but an imitation of the true h sound36 THE DISORDERS OF SPEECH. glottis through a narrow chink between the vibrating cords, in whispering the greater part of the air is made to pass through a triangular opening in the posterior part of the glottis, between the projecting parts of the arytenoid cartilages, whose bodies remain apart, although their vocal processes are more or less closely approximated. This fricative noise plays, in whispering, exactly the same part that is played, in vocal speech, by the sonorous tones of the voice. It is the material out of which the vowels are formed, and it adds itself, as an essential element, to those consonants, which, in vocal speech, contain voice. Anyone can convince himself of the truth of this view by personal observation with the aid of the laryngoscope. The fricative noise in whispering can be made soft or loud at the will of the speaker. The carrying power of a " stage-whisper " is thus made easily intelligible. It might be objected to this view that patients have been known to whisper even after the total excision of the larynx; but there is every reason to believe that in such cases the condition of the parts was such as to permit of the production of a fricative noise at or about the level of the larynx, which could be utilized in the mouth for the production of speech.1 1 In the well known case of total excision of the larynx effected by the late Dr Foulis of Glasgow, the patient was enabled to speak, even in a loud though monotonous voice, by the insertion into the laryngeal cavity of a reed like those of a concertina. But such a reed can never permit of the elaboration of perfect speech. It would necessarily throw voice into all the consonants, even those which ought to be voiceless ; so that the first or voiceless column in our alphabet would be unrepresented. In the speech of such a patient, all his p's, for example, would be b's, and his s's, z's. It would be interesting to consider in what degree the parts at the back of the throat are capable of assuming the voice-producing functions of the Larynx, after that organ has been totally excised, or has been cut off from con- nexion with the Pharynx by stenosis of its orifice ; but that is a subject which cannot well be considered in this paper. For information regarding it, however, the reader may be referred to—(1) a paper by Professor Czermak (Gesammelte Schriften, i. 2, p. 598), in which he describes a case, where communication of the Larynx with the Pharynx had been totally cut off by disease ; (2) a case of total excision of the Larynx, recorded by Dr Hans Schmid (Archiv fiir Klinische Chirurgie, xxxviii., 1889, p. 132), in which the air passage was entirely cut off, in process of cicatrization, from the cavity of the Pharynx; (3) another case of total excision of the Larynx, reported by Dr Greville Macdonald and Mr Charters Symonds in the British Medical Journal for 1889, p. 996. In both these latter cases, curious to say, a real, though rough, voice was produced in the absence of the Larynx, by other parts at the back of the throat.PHYSIOLOGY OF WHISPERING. 37 The question about the true physiology of whispering is really an important one practically. If the larynx takes no part in whispering, then, in acute laryngitis, it would be good practice to allow the patient to whisper as much as he chooses; but if the larynx has work to do in whispered as in vocal speech, clearly the proper prescription would be to forbid even whispering, and allow the inflamed parts to have perfect rest. Further, in connexion with hysterical disablement of the vocal cords, to be presently considered, if the larynx does not work at all in whispering, its complete paralysis will not render the patient mute or speechless; but if its action is necessary even for whispering, then its complete paralysis means complete mutism. I thoroughly believe that the latter is the real state of the case. With a little practice one can allow the air to escape freely into the mouth, through the widely open glottis, while the oral mechanism is doing everything that is necessary on its part for the production of audible speech; and yet no speech will be audible, on account of the inaction of the larynx. By way of experiment, I articulated, close to the ear of my house-physician, the line " I shot an arrow into the air "; and, although he felt the breath distinctly impinging upon his ear, he could only make out clearly the fricative sound of sh, and much less distinctly that of the r's. The simile of the violinist thus holds good with regard to whispered speech, as well as with regard to speech that is vocal. Both bow-hand and string-hand are necessary for its production, but the bow-hand is producing a fricative noise, instead of a musical resonance. In the absence of a laryngeal element in speech, the only elements of our alphabet which can still be produced are those of the first or voiceless column of consonants, and, even among these, the explosives are barely audible, because there is no sound from the larynx that can have communicated to it an explosive beginning or a stop-like termination. Without the agency of the glottis, the two voiced columns of the consonants and the whole of the vowels are inaudible. In the absence of these, the patient is necessarily mute; the first or voiceless column being insufficient in itself for the purposes of speech.1 1 As regards the voiced consonants, perhaps it would be better to say that the attempt to produce them without the larynx would result in the produc- tion of their voiceless equivalents.38 THE DISORDERS OF SPEECH. We now pass to the consideration of the disorders of speech which we propose to take up in this chapter. Hysterical Aphonia. This is a condition of extremely common occurrence in hysterical patients, and, naturally, it is most frequently met with in those of the female sex. Like the other manifestations of hysteria, it may be developed at any period of life; but, in the majority of cases, it occurs either during the earlier years of womanhood, or in the later years, at or about the climacteric period. The exciting cause is very frequently some emotional disturbance; and thus again it is like the other phenomena of hysteria. In many cases, on the other hand, the patient being of hysterical con- stitution, it owes its beginning to the mere catching of a cold, with attendant hoarseness. The difference between such a patient and an ordinary person with cold is, that, in the former, the aphonia remains for a long period, it may be for months, after the actual catarrh has passed off, whereas in the latter the voice returns at once when the catarrh is recovered from. It may thus begin more or less gradually with a cold, or appear suddenly after emotional excitement. Occasionally it is produced by some hysterical seizure, such as a fit, the aphonia remaining after the fit has passed off. Lastly, in not a few instances, it appears in hysterical subjects spontaneously, without any apparent exciting cause. Patients who have once had hysterical aphonia are more or less liable to a recurrence of it. As a rule, it admits of immediate cure by suitable treatment; but there are cases which prove exceedingly obstinate, in spite of any treatment that can be employed. Such cases are cited, for example, by Sir Morell Mackenzie.1 I have myself met with one case of this kind. I saw the patient for the first time twenty years ago, in consultation with the late Dr Matthews Duncan; and, for the second time, four or five years ago. During the whole of this period, the lady had remained aphonic, although perseveringly treated by several specialists. Laryngoscopic examination of a case of hysterical aphonia shows that the adductor muscles of the arytenoids and vocal cords are in a state of paresis, though not of complete paralysis. They are 1 Manual of Diseases of Throat and Nose, vol. i.HYSTERICAL APHONIA. 39 strong enough to bring the arytenoids and cords into close enough approximation for the production of the spiritus asper of whispering, but they are not strong enough to bring the parts sufficiently together for the production of vocal tone. In the great majority of cases the chink of the glottis is straight or linear in its edges, its only fault being that it is too wide; and one may therefore conclude that all the adductor muscles are equally involved in the paresis. But there are exceptional cases, well figured by Mackenzie and others, in which individual adductors are specially at fault. In some of these the Eima Glottidis presents the form which it assumes in normal whispering, the greatest opening being a trian- gular one at the posterior part of the glottis, between the projecting parts of the arytenoid cartilages; so that the weak muscle is here evidently the inter-arytenoideus, which ought to have brought the bodies of the cartilages into close apposition. In others an ellip- tical slit, widest at its middle, is left between the vocal cords, owing to the weakness of the thyro-arytenoidei muscles, which lie alongside of the cords, and ought by their contraction to support and keep them in apposition during phonation. Or the vocal processes of the arytenoid cartilages are too wide apart for phonation, owing to the weakness of the crico-arytenoidei laterales. Or, again, the Eima Glottidis, instead of forming a straight line, presents a sinuous aspect, owing to the weakness of the crico-thyroid muscles, which stretch the cords during phona- tion. All of these latter appearances, however, are exceptional; the common condition being the one of general paresis of the adductors first described. Hysterical paralysis is essentially bilateral. Some hold that it is invariably so, but others admit the possibility of a few cases being unilateral. Although the voice proper is thus absent in hysterical aphonia, it can, in a great many cases, be evoked during the act of coughing ; and its retention of normal characteristics during a cough, together with the absence of any laryngeal pain or irritation, may sometimes help to lead one to a correct diagnosis, without the aid of the laryngoscope. In severe cases, however, the voice is sometimes absent even in coughing; though the cough rarely or never assumes that husky or laryngeal character which is suggestive of intra- laryngeal disease. In treatment, it is well, at the outset, to inspire the patient with40 THE DISORDERS OF SPEECH. a confident hope of immediate cure: and witli tliat view, she may be asked to cough loudly; so that, if the cougli be vocal, her atten- tion may be directed to the vocal element in it. In a very great number of cases, the only further treatment that is necessary for the immediate restoration of the voice is to assure the patient that you are about to bring it back, and, allowing her to believe that you are performing something of the nature of a curative operation, to introduce the laryngoscopic mirror into the mouth in the usual way, and to ask her, in a commanding manner, to say or sing ah. Two or three commands of this sort very generally suffice to bring back the voice. The voice remains with the patient after the operation is over; and she often shows great astonishment at finding herself thus at once able to speak quite freely in a perfectly natural tone. When this simple procedure does not .suffice, other means must be tried. Dr Olliver of Boston recom- mends that the physician should compress the larynx slightly between his fingers, pressing the alae of the thyroid cartilage inwards towards each other. This gives additional support to the vocal cords within the larynx. It is a means which I have employed in some cases with success. Another, and very efficacious method of treatment, is the use of the Faradic Battery. This can be employed either externally, the electrodes being placed one on either side of the box of the larynx, or internally, by means of the very valuable intra-laryngeal rheophore, invented by Sir Morell Mackenzie. In using this instrument, one electrode is fixed by means of a fillet to the box of the larynx externally, whilst the other—the rheophore—is introduced into the larynx itself by the mouth. When its extremity is in contact with the vocal cords, the circuit is closed by the pressure of the operator's finger upon a spring. A point to be borne in mind in using this instrument is, that the shock communicated through the delicate mucous membrane will be much stronger than the shock of the same current transmitted through the resisting cuticle of the operator's hand. The operator will therefore do well to bear in mind the golden rule of electro-therapeutics, and try the current upon his own person, before he subjects the patient to it. He can easily do this, by applying the outside electrode to the outside of his throat and the rheophore to the surface of his tongue. I have had one case at the Royal Infirmary, occurring in the person of an apparentlyHYSTERICAL APHONIA. 41 robust young man, which resisted all other means of treatment, but was at once cured by the use of Mackenzie's intra-laryngeal rheophore; and the same treatment also cured the patient at once a second time, when, after a year or two, the condition recurred. Still another method of treatment which deserves attention is one also recommended by Mackenzie, viz., the inhalation of a stimu- lating vapour, such as that of ammonia. Some years ago, I had a patient, a young lady sent to me by my friend Dr Berry Hart, who resisted the laryngoscopic cure, being by that means only got to produce one note, and to read in a monotone; but who was subse- quently cured, without my aid, on inhaling the vapour of the so-called ainmoniaphone—an instrument which, at that time, was being much advertised in this city. A few drops of Liq. ammonise, sprinkled upon a piece of cotton wool, would probably have been equally efficacious. The element of faith is all-important in the treatment of these hysterical conditions. It need scarcely be added, that, in all such cases, it is desirable to attend to the patient's general health, and to prescribe such general tonic treatment and regimen as are appropriate in combating a constitu- tional tendency to hysterical manifestations. Hysterical Mutism. This is a subject which has, of late, been attracting much atten- tion on the Continent. I do not know that much lias been written about it, as yet, in English; but several cases have been recorded by Dr Wilks, in his Diseases of the Nervous System, and others by Wells, Bright, Willis, and Johnson.1 It is a very striking condition, occurring for the most part in patients who are obviously hysterical, but occasionally met with as a symptom existing per se, without any of the usual hysterical accompaniments or stigmata. It is very closely related to hysterical aphonia, both in its causation and in its tendency to ultimate recovery. Like aphonia, it often appears suddenly as a result of violent emotional excitement, such as fright, or as a result of a convulsive seizure. It frequently disappears with a suddenness equal to that of its onset; and, curious to say, the cause of its disappearance may be an emotional excitement or a fit, such as 1 See collections of cases by Cartaz and others, to be presently referred to. F42 THK DISORDERS OF SPEECH. might originally have produced it. The difference between a case of Hysterical Aphonia and one of Hysterical Mutism is, that the aphonic patient, though the voice is lost, can still speak in a whisper, whereas the subject of hysterical mutism cannot speak at all, not even in a whisper; yet the intelligence and all the other faculties are maintained equally well in both cases, and the mute patient, if educated, can still, with the utmost fluency, give expres- sion to thought in writing. I have, in my own practice, met with only one well-marked case of hysterical mutism. The patient was a young gentleman, who was brought to me some years ago by my friend Dr Sibbald, one of the Commissioners in Lunacy for Scotland. As this case presented the features of the condition most charac- teristically, I may be allowed here to insert, from my notes, a short abstract regarding it. Mr X., aged 29, seen by me on the 15th of October 1886, was a tall, fair-haired, well-developed man, with a full, light brown beard ; but was rather pale, and was somewhat excitable in manner. His history was shortly as follows:— Five years before his visit to me, he had been working very hard, in preparation for the examinations required for his entry into the service of one of the public departments. During this period he sought recreation, from time to time, in boating; but it was thought by his friends that he exerted himself too much in that way. He was also, unfortunately, at the same time, subjected to a good deal of emotional excitement, owing to circumstances of a personal nature. It was when suffering from the exhaustion and disturb- ance produced by these various causes, that he first began to be affected with seizures, which his medical attendant believed to be of the nature of catalepsy. These attacks began with a dropping of the jaw, and produced a loss of all muscular power for several hours, without any loss of consciousness. They continued to afflict the patient from time to time, at intervals of two or three months, up to the date of his visit to me. From the first, the attacks always deprived the patient of the power of speech during their continuance ; and gradually these periods of mutism became more prolonged, until, about a year after their first occurrence, the mutism became permanent. The fits had changed in their character some months before I saw him: instead of being passive during their existence, the patient had become the subject ofHYSTERICAL MUTISM. 43 violent hysteroid movements, throwing his limbs about, clenching his hands, and striking his head forcibly if allowed to do so. The mutism had existed continuously for about four years before his visit to me. When, five years before I saw him, the patient had thus broken down, he abandoned the intention of taking service in the public department, and emigrated to one of the colonies. Here he obtained employment in an office, and lived in comparative comfort, though mute and still subject to recurring attacks of the hysteroid seizures. He remained in the colony four years. About a year before I saw him, he had met with a melancholy accident, when sailing with a companion on an inlet of the sea. His boat had been capsized, and his companion had been drowned. During the period of violent excitement which naturally attended upon this accident, the patient had cried for help; but on being rescued he had become mute as before. These cries for help were the only words he had uttered for years. During the whole period of his mutism, he was reported to be rest- less at night, and to groan, and even to cry out, in his sleep ; but it was remarked that he never, even then, uttered any articulate words. When I saw him, three months after his return to this country, he was evidently quick and intelligent; and he was very prompt in replying to questions by means of pencil and note-book which he carried for the purpose. When asked to pronounce a word or utter a vowel sound, he could emit no laryngeal sound, not even a whisper. He only made grimaces with his mouth. (Unfortunately I did not make a note of the specific character of the labial move- ments.) Persevering attempts were made to get the patient to pronounce some words, or at least to emit some vowel sounds from the larynx, but without result. Dr Sibbald afterwards informed me that the patient was much exhausted by the examination, so that on going home he had an exceptionally prolonged succession of his hysteroid seizures. He was brought to me a second time a few days after his first visit, but the examination on this occasion was not so exacting. At this visit, it was found that when the patient coughed the ordinary vocal element was present in the cough, and presented its normal characteristics. This observation was made use of, and the patient was made to cough in imitation of coughs made by44 THE DISORDERS OF SPEECFT. myself; each succeeding cough having added to it a more and more prolonged vocal element, until the cough ended with a prolonged sound like " ah." The patient imitated thus far faithfully; but when asked to sing out the " ah " sound without the initiatory cough, he became as mute as before. He was asked to note well the fact that his larynx could still produce natural voice in coughing, and he was assured that in course of time he would completely, and perhaps suddenly, recover his voice for the purposes of speech. The subsequent history of this case is instructive. Some months after I had seen the patient, when he was living quietly at home in the country, he went out one evening to dine with a friend in the neighbourhood. At first the conversation was, no doubt, carried 011 on his part in writing, as usual; but when the evening was somewhat advanced, a change occurred, and the patient, to the delight of himself and his friend, began to express himself with perfect freedom by word of mouth. The sitting seems to have been somewhat prolonged, but the patient continued to retain his powers of speech; so that when, at a late hour, he returned to his. own home, he greatly surprised his friends by his powers of expres- sion. Next morning, however, he was as* mute as ever, and had once more to have recourse to writing. Some months after this incident, the patient returned to the colony where he had formerly resided; and soon after his arrival he suddenly regained his power of speech. One Sunday, upon meeting his sister when she was walking home from church, he suddenly found himself able to converse in an ordinary way. He had thus been mute almost continuously for about five years. Since his recovery there has been no recurrence of the mutism. Although it is only a few years since the title Hysterical Mutism was invented, cases of the condition were described under various titles as long ago as the middle of last century. Later, about thirty years ago, a number of cases were put upon record under the title of Functional Aphasia. Among others, several were published in 1874 by Kussmaul1 under this title. The title Hysterical Mutism was first given to the condition in 1883 by Professor Revilliod of Geneva, who wrote a paper on the subject that attracted much attention. In 1886, Professor Charcot began 1 Kussmaul's article on Speech, Ziemssen's Cyclopedia, vol. xiv.HYSTERICAL MUTISM. 45 to make the condition widely known to the profession by means of his clinical lectures. In the same year, his assistant, M. Cartaz,1 published twenty cases collected by him from various sources. This paper contains also an excellent account of the literature of the subject. In the same year, 1886, a similar collec- tion of cases was published by Dr H. Bock2 of Berlin, who lias the merit of first showing that Hysterical Mutism, unlike Hysterical Aphonia, occurs with equal frequency in both sexes. Later, in 1888, Dr Marcel Natier3 of Bordeaux, published the largest col- lection of cases that has yet been made. He confirmed Bock's conclusion, that the condition was as common in the male sex as in the female. As this is the latest and largest collection of cases, it will be specially referred to presently. The cases put upon record by Charcot are very illustrative. In his Legons sur les Maladies du Systeme Nerveux, vol. iii. p. 422, he devotes the twenty-sixth lesson to Hysterical Mutism; contrasting a well-marked case of it with one of that partial mutism which results from glosso-labio-laryngeal paralysis. In his Legons du Mardi for 1888-89, he returns at p. 247 to the subject, devoting his twelfth lesson to the description of a very interesting case of hysterical mutism, which, along with other grave hysterical mani- festations, had resulted from hypnotism, practised upon the patient by a professional " magnetiser." In the first of these lessons, M. Charcot not only, in his peculiarly vivid manner, describes the symptoms, but also devotes some space to the consideration of the nature and causation of the condition. He shows that there are many features shared in common by hysterical aphonia and hysterical mutism. They occur in the same type of patients, are produced by similar exciting causes, and are not unfrequently found to alternate with each other in the same patient, the aphonia in some cases passing into mutism, and the mutism in other cases passing into aphonia. Obviously the mutism is the more severe condition of the two. It implies absence even of the power of whispering as well as of that of speaking aloud. 1 Progres MJdical, 1886 ; and Appendix to Charcot's Legons sur les Maladies du Systeme Nerveux. 2 Deutsche Medizinal-Zeitung, Dec. 1886. 3 Revue mensuelle de Laryngologie d'Oiologie et de Rhinologie, Nos 4 5 8 and 9, 1888. ' ' '46 THE DISORDERS OF SPEECH. I think it unfortunate that Charcot has been led to adopt the view of those physiologists who regard whispered speech as the product of the oral mechanism alone, without any participation of the laryngeal. He says, in the first lecture referred to,"Whispering, gentlemen, is nothing else than a language spoken and articulated. This phenomenon—remark it well—is absolutely independent of laryngeal voice: this fact has been demonstrated experimentally in the most conclusive manner, in the laboratory of M. Marey in .1876, and also by M. Boudet of Paris in 1879. These authors have, by means of the graphic method, conclusively proved that in whispering the larynx takes no part, the vocal cords not entering into vibration. The air then traverses the larynx as it traverses the trachea: it traverses an inert tube. That is all." According to this conclusion, M. Charcot must regard the larynx as inert alike in aphonia and in mutism, and he has to search else- where than in the larynx for the cause of the dumbness which distinguishes the latter from the former condition. He has to suppose that in every case of mutism the oral articulative mechanism is also disabled. He accordingly looks to the higher motor centres for speech, and he believes that in mutism there is a cortical disablement that is not present in aphonia. He con- cludes, page 427,—" There is here then, in short, a motor aphasia, and, I add, purely motor: a variety rare, very rare, in the domain of the common organic aphasise, with which there are found most frequently associated in diverse proportions other troubles of interior language, such as word-blindness, or word-deafness, or, again, agraphia." With great respect for the opinion of an authority so eminent, I must be allowed to express the belief that this explanation does not cover the whole ground: in particular it fails to explain in any way the very close connexion that is known to exist between Aphonia and Mutism. It appears to me that, on this subject, M. Charcot has been misled to some extent by the erroneous conclu- sions of the physiologists whose views he cites regarding the nature of whispering. As already explained, I thoroughly agree with those physiologists who hold that the participation of the larynx is as necessary for whispered as for ordinary speech. It is a point upon which the reader may arrive at a conclusion by observation of the process of whispering when practised by himself.HYSTERICAL MUTISM. 47 Let him whisper in a "stage whisper," which is merely the ordinary whisper exaggerated, and I am mistaken if he will have the least inclination to regard whispering as an act which can be carried 011 without the participation of the larynx. Or, still better, let him sing in a whisper; which, after a little practice, he will be able to do, in tune, and yet entirely without voice. Holding, as I do, that there can be 110 speech without the co-operation of both mechanisms, I believe that the disable- ment of either the one mechanism or the other may produce mutism. I believe that in the majority of cases it is the vocal mechanism that is at fault, and that in such cases the condition of hysterical mutism is essentially the same as that of hysterical aphonia, only more advanced. This view explains at once the transitions from the one to the other already referred to, and the existence of so many features which are common to both. These transitions and common features are well illustrated by the twenty cases collected by M. Cartaz, and appended to the third volume of the Legons already quoted from. M. Cartaz, however, holds the same physiological views, and has the same theories as M. Charcot. Quite recently the subject has been considered by another dis- tinguished pupil of M. Charcot—namely, Professor A. Pitres of Bordeaux—in his recent work on Hysteria.1 He describes a very interesting case, and cites the treatise of M. Natier, who has col- lected from various sources a great many cases of this condition. But M. Pitres unfortunately does not enter into any discussion 011 the exact relationships of mutism and aphonia. The paper by M. Natier is an important one. He has col- lected, in all, seventy-one cases. Although the views expressed by him regarding the nature and etiology of the condition are not in any way different from those held by Professor Charcot, I think a careful study of the cases makes it evident that they can be grouped into several classes. It seems clear to me—(1) that, in a number of the cases, the mutism may be explained by the simple disablement of the Yocal Mechanism ; (2) that, in others, the mutism has resulted from a disablement of the mechanism of Oral Articulation, the vocal mechanism being intact; (3) that, in a few, Both Mechanisms are involved; and, lastly, that, in some 1 Legons Gliniques sur VHystdrie, 1891.48 THE DISORDERS OF SPEECH. cases, there are important Complications which deserve to be specially mentioned. Class 1.—As an example of the first class, in which there is simple disablement of the Vocal Mechanism, I would cite from the paper, Obs. IX.,—" A woman, 21 years of age, of nervous temperament. In consequence of a sore throat, which lasted eight days, she re- mained completely aphonic. All treatment was without result. When patient was seen a year afterwards, the voice was completely abolished ; in spite of the greatest efforts, the patient could articu- late no sound nor produce the least intonation or cry." After eight months of further treatment without effect, the patient was cured by the use of endo-laryngeal electrization, which caused her to have a prolonged hysterical fit, after which, on waking next morning, the voice reappeared. Obs. III., V., VI., XVIII., and XXII. seem to belong to the same class. Class 2, in w7hich the mechanism of Oral Articulation is dis- abled, is well represented by Obs. II., communicated to M. Natier by M. Pitres. Patient was a young woman of twTenty-one. With- out entering into details, it may be said that she could emit clearly only one sound, viz., the vowel-sound a, the pronunciation of the other vowels being very defective. The emission of this vocal sound shows that her laryngeal mechanism was unaffected. She could not at first articulate a single consonant, but, after per- severing attempts, she was got to pronounce the consonants b, f, 1, p, and t; and, with great hesitation, the syllables (pronounced in the French manner) bas, fa, la, pas, tas. " After a quarter of an hour of repetition of these five words, she is shown (by analyzing the movements) the articulation of the other consonants, and, after about half an hour of exercise, she can pronounce all the consonants of the alphabet followed by an a. It is in vain that one tries to make her pronounce the same consonant followed by another vowel. It is well to remark that she was nevertheless in full possession of her intelligence." From this time the patient progressed favourably, and was soon able to pronounce easy words, such as " Bonjour, Monsieur, Madame," etc. She soon began to speak and to make herself understood, although with much difficulty, the tongue appearing embarrassed in its movements. Next day she spoke very well, without any hesitation and without a shade of difficulty.HYSTERICAL MUTISM. 49 Class 3, in which Both Mechanisms seem to be involved, is illustrated by Obs. LV. The patient, a woman aged 43 years, lost her voice in October 1884, so that she could only speak in a whisper, and felt much fatigue in doing so. During the summer of 1886 the voice disappeared completely, so that she was not only affected with aphonia, but with a veritable mutism. The voice was restored when the patient was under treatment with hypnotism. The physician caused the patient, when in this condition, to cough, and to clear the throat sonorously. He first made these sounds himself, and then caused the patient to imitate them; afterwards he got her to produce them of herself at com- mand. He then passed to the pronunciation of vowels, and soon obtained e and a, a little later O, and with great difficulty i (ee), and then U, pronounced ou. Later still, he combined the vowels with the easiest consonants—the labials, in em, am, pa, po, etc.,—as one does for children who are being taught to read. Gradually in this manner the speech was restored, and eventually became perfect. Obs. LXXI. is also a good example of this 3rd class. Among the Complications mentioned are,—(1.) Agraphia, in Obs. LXX., a case recorded by Charcot in 1888. There was, in this case, no word-blindness nor word-deafness. The case is described as one of Hysterical Apoplexy, which produced unconsciousness for five or six hours, and resulted in paralysis of the right arm, and paresis of the right leg. As patients with hysterical mutism, when educated, almost always write with perfect ease, the presence of agraphia must render the diagnosis exceptionally difficult. (2.) Temporary Deafness, exhibited in Obs. LVIII. This renders the patient for the time being a deaf-mute, but questions are understood if put in writing. (3.) Temporary Blindness has been observed in some cases. I believe that the study of M. Nader's collection of cases thoroughly justifies the above classification. It will be observed that it is the same classification that I have already proposed for the varieties of stammering, with this difference, that the mechanism involved is not affected by a mere want of promptitude, but by a want of power, or, to express it in another word, by paralysis. If the view regarding the physiology of whispering which I have advocated is accepted by the reader, he can have no difficulty in G50 THE DISORDERS OF SPEECH. accepting also this classification of the varieties of hysterical mutism ; but if he takes the other view of whispering, and regards it as an act of the oral mechanism alone, without co-operation of the larynx, he will not be able to accept the classification, but must refer all varieties of mutism to disablement of the Oral Articulative Mechanism. Whatever view be entertained regarding the Physiology of whis- pering, I think there can be no doubt that Hysterical Aphonia and Mutism alike must be referred, not to a mere peripheral disable- ment of the mechanisms of speech, but to a disablement of one or other or both of the cortical centres from which they are innervated. Many believe that the will itself is enfeebled, and that sudden cures are effected merely by the strengthening of the power of the will, through the influence of faith in the physician, and the tonic effects produced by a restoration of confidence. If hysterical mutism of the first class and hysterical aphonia are essentially identical, the treatment already explained as suitable for aphonia would be equally appropriate for this variety of mutism : it ought to include both the employment of the local measures that have been described and the use of tonic remedies and regimen suitable to the constitutional state. For cases of the second class, it would seem rational to apply electricity and other local treatment to the organs of oral articulation, such as the Tongue and Lips, instead of to the Larynx; and in cases of the third class the local treatment of both mechanisms would seem to be indicated. For the examination of a case of hysterical mutism, with a view to determine the class to which it belongs, I would propose that atten- tion should first be paid to the Laryngeal functions, and that, with the view of testing these, the patient should be asked to make some laryngeal sound, such as a. If no such sound can be pro- duced, even in a whisper, the laryngeal function is obviously dis- abled. If the patient can produce a vocal sound at command, the function is probably intact. Secondly, in testing the Oral mechan- ism, the physician should ask the patient to try the pronunciation of the voiceless consonants of the first column of our alphabet, viz., those which are represented by the initials of the sentences, " Far shores seem thinly hazy," and "Two poor comrades." In the normal condition, the vocal cords take no part in producing these voicelessIIYSTEItlCAL MUTISM. 51 consonants; so that when mutism is due to the larynx alone, the patient ought still to be able to produce these voiceless consonants. On the other hand, if the oral articulative mechanism be disabled, it will be impossible for him to produce even these. Gf course the production of voiceless consonants alone would not enable him to speak. There may be other obvious signs of disablement in the oral mechanism, such as slowness in the movements of the tongue; and, among Natier's cases, some are mentioned in which the patients complained of a feeling of weight or heaviness in the tongue. When the patient requires to be taught the positions of the lips, tongue, etc., in the pronunciation of the various consonants, the oral mechanism is obviously at fault. Other Forms of Paralysis affecting the Adductors. Aphonia without mutism, the patient being able to speak in a whisper, results, frequently enough, from the operation of various conditions other than hysteria, such as Blood-poisoning, Fatigue, etc. (A.) The most important are those connected with various kinds of blood-poisoning. It is now the belief of many authorities that paralysis in such cases is due to Peripheral Neuritis. If that is so, they ought properly to be classed as due to organic rather than to functional causes. As, however, the toxic paralyses are, in their curability and in their symptoms, allied to the paralyses of Hysterical origin, it may here be convenient to make a note of them. Paralysis following upon Diphtheria has been known to affect the muscles of the Larynx in some cases.1 Other forms of paralysis are notoriously more common after diphtheria than paralysis of the laryngeal muscles, but the laryngeal paralysis is sometimes met with. It may present varieties, as regards the muscles involved, similar to those of hysterical paralysis; but it is said that paralysis of the muscles supplied by the superior laryngeal nerves, and more especially paralysis of the crico-tliyroid muscles, occurs in a greater proportion of the diph- theritic than of the hysterical cases. In such cases, as the Superior Laryngeal is the sensory nerve of the Larynx, there 1 Morell Mackenzie, Diseases of the Throat and Nose, vol. i. p. 145 ; also p. 434.52 THE DISORDERS OF SPEECH. may be anaesthesia of the mucous membrane. It should also be noted that, after diphtheria, although the paralysis is sometimes bilateral, it is more frequently unilateral than that due to hysteria. The other toxic conditions which are capable of producing aphonia from paralysis of the adductors are, more especially, chronic arsenical poisoning, chronic plumbism, and rheumatism; and here, again, the paralysis is more frequently unilateral than that due to hysteria, although, as in the other conditions, it appears to be oftenest bilateral. The existence of peripheral neuritis in one of the motor nerves would satisfactorily account for the limitation of the paralysis, in some of these cases, to one side or to one muscle. In the treatment of these toxic varieties of paralysis, the local employment of electricity is again of great value. The constitu- tional state must, of course, be treated with appropriate remedies. (B.) Still more closely allied to hysterical aphonia is the loss of voice which sometimes attends upon conditions of constitutional or Nervous Depression. Such huskiness of voice, or complete aphonia, is common enough in chlorosis and other forms of anaemia, being, no doubt, in such cases due to the mal-nutrition of the nervous system. It is also, in both sexes, a common accom- paniment of constitutional neurasthenia, and of the depression of health and spirits which may be produced by mental trouble. It should be kept well in mind that the voice is in close sympathy with the mind, and especially with the emotions: its sound is cheerful or sad in close correspondence with the mental state for the time being. At times of profound emotion, it may become hoarse or husky; and, if the emotion be prolonged, it may be reduced even to a whisper. The reader will probably remember the striking picture, by Mr Archibald Forbes, of General Skobeleff, as he appeared upon his emergence from that scene of carnage, the final attempt to storm the redoubts of Plevna:—"He was in a fearful state of excitement and fury, his uniform was covered with mud and filth; his sword broken, his cross of St George twisted round on his shoulders; his face black with powder and smoke; his eyes haggard and bloodshot; and his voice quite gone. He spoke in a hoarse whisper. I never before saw such a picture of battle as lie presented. I saw him again in his tent at night; he was quite calm and collected." (C.) Paresis of the adductors may be produced by Fatigue of theHYSTERICAL STAMMERING. 53 larynx, caused by public speaking or singing; but I shall reserve the consideration of this and other troubles of professional voice- users" for my next paper. Hysterical Stammering. If the doctrines regarding the nature of stammering explained in the first chapter are remembered by the reader, he will not be surprised to learn, that, in several of the recorded cases of hysterical mutism, the patient has stammered markedly in recovery from the mutism. Evidently the voice, in returning, was pro- duced with difficulty, and therefore did not, in the first syllables of words, come up to time. The case of mutism recorded by Professor Pitres illustrates this point. The patient in that case seems to have stammered in the ordinary way when he attempted to speak, and even to have had spasmodic phenomena, from overflow of energy, in his jaw, neck, and eyelids. It was further characteristic of ordinary stammering, that when the patient sang the stammer entirely disappeared. This case of mutism resulted from a fright; and Professor Pitres draws atten- tion to the fact that fright is often the cause of stammering as well as of mutism, especially when the patient is of hysterical constitution. The same writer also refers to a case recorded by Professor Trousseau in his Clinique Medicate, in which the patient repeated many times, in echo-like fashion, the last syllable of the words she uttered. He speaks of this also as an example of hysterical stammering; but perhaps it should more properly be classed under the heading of Echolalia, which I hope to consider later, in connexion with aphasia and other conditions. Rhythmic Spasms of the Vocal and Respiratory Mechanisms, of Hysterical Origin. These rhythmic spasms are perhaps more intimately connected with the function of respiration than with that of phonation. It may here therefore suffice to make only a brief reference to them. They form a most interesting class of the rhythmic spasms which may affect almost any part of the body in the graver varieties of hysteria. In some cases the patient barks rhythmic-54 THE DISORDERS OF SPEECH. ally; in others she coughs rhythmically; in others she sneezes; in others she snorts; in others she sniffs with the nose; in others she hiccoughs ; in others she yawns ; and in others she screams. These various rhythmic spasms have certain features that are common to all of them. They are frequently associated with the ordinary stigmata of hysteria, but in not a few cases they may exist by themselves, as the sole manifestations of that condition. They are all alike apt to be produced by violent emotion, hysterical seizures, nervous shocks, or physical injuries. They may last but a short time—a few hours or days. But, in other cases, they may continue for months, or even for years. Often they occur with intervals of complete cessation. Each seizure may last for some hours; the spasm being, in different cases, repeated with very different frequency— occasionally over a hundred times per minute. Sometimes, on the other hand, it may continue to trouble the patient all day long, while she remains awake; and may even keep her awake during the night. It is a feature common to all the varieties, that the spasm entirely ceases when the patient falls asleep. As already said, I do not intend to give any detailed account of these spasms. I may say that the reader will find them excellently described and classified in the recent work of Professor Pitres, which has already been referred to. I am tempted, however, to make the briefest possible reference to two cases of this descrip- tion which have been under my own care. One of these was a case of Hysterical Barking, which was admitted to my wards in the Boyal Infirmary, 011 the 15th January 1889. She was brought to me by my friend Dr Penman of Hawick. I remember well the first arrival of the patient. Dr Penman had previously come to my side-room, and was describing the case, when of a sudden he paused, and said, " Listen, that is the patient." We listened, and in the distance, along the corridor of the Infirmary, we heard a sound like the quick barking of a small terrier dog; and this sound gradually became louder, until, on the patient's arrival, she proved to be herself the source of it. It was a quick, high-pitched bark, repeated at the rate of about 120 times per minute, and maintained for several hours at each seizure. There was, along with it, 110 appearance of dyspnoea, and no disturbance of intelligence. Like the bark of a dog, the sound was destitute of the sudden valvular beginning which is characteristic of a true cough. The patientrhythmic spasms of vocal and respiratory mechanisms. 55 was admitted to the side-room of the female ward ; but she did not sleep much during the first night after arrival, and barked so much that one of the patients in the large ward asked the night- nurse, "When will that dog stop barking?" Under anti- hysterical treatment, this patient made an almost complete recovery. The other case that I should like to mention was one of Hysterical Sneezing. The patient was a young gentleman, aged 21, of delicate appearance, whom I saw on the 15th September 1884. The sneezing had existed for about eight months, and had troubled the patient for several hours nearly every morning. It began immediately when he awoke, at 7 o'clock, and continued without intermission until about 10 a.m:. It made the patient's nose run as in severe catarrh, and always left him with a severe headache and considerably exhausted. In this case an immediate cure was effected by very simple means. The patient was got to place under his pillow a small bottle full of crystals of carbonate of ammonium, and, immediately on waking in the morning, to put this smelling-bottle to his nose, and inhale from it as much as he could conveniently bear. He also took at the same time a full dose of tincture of assafoetida. From the date of the first employment of the smelling-bottle, the sneezing practically disappeared. Hysterical coughing and hiccough are commoner than barking or sneezing. They cannot here be described in detail. In general feat- ures, however, the whole of this group of rhythmic spasms have characters which are closely similar. It may be added that instead of a long rhythmic succession of barks or coughs, sometimes a single harsh bark or cough may trouble the patient from time to time; and it is so also with the other varieties that have been enumerated. The treatment of these conditions is that of the hysterical state. A measure of great efficacy is sometimes the morning shower- bath. The use of electricity, also, often cuts short an attack. In the case of hiccough, the poles of the Faradic battery may either be applied at each side of the chest, opposite the attachments of the diaphragm, or, one pole being applied over the epigastrium, the other may be placed over the phrenic nerve where it crosses the scalenus anticus at the root of the neck. In the latter case, only comparatively weak currents should be used.56 THE DISORDERS OF SPEECH. Other Nervous Spasms, not necessarily Hysterical, of the Vocal Mechanism. (A.) A curious variety of spasm is that in which the patient from time to time involuntarily ejaculates some word or syllable (Logospasmus Choreiformis). Occasionally the words ejaculated are of a disreputable character (Caprolalia). In that case, the ejaculations are often associated with a simultaneous convulsive tic, or spasm, of the upper extremity, or of some other part of the body. Prof. Charcot discusses this subject in the first lesson of his Lemons du Mardi for 1888-89. He suggests that these verbal ejaculations ought to be referred to a spasmodic disturbance of the higher functions of the brain, those of ideation; and he shows that they are often associated with other indications of mental enfeeble- ment, such as a striking loss of decision in the performance of the ordinary business of life. He records a case of a little boy affected witli caprolalia and convulsive tic, who got into trouble by involuntarily shouting his bad words to other boys. Not understanding the nature of his case, they thrashed him for his supposed impudence. (B.) Another spasm of the vocal organs which must not be omitted, is that tonic spasm of the adductor muscles of the larynx, which closes the glottis and produces the well-known Laryngismus Stridulus of infants, with its agony of dyspnoea. The causation and treatment of this serious condition cannot here be con- sidered. The reader may, however, be reminded that an exactly similar condition occasionally occurs in adults as a symptom of hysteria, and that sometimes tracheotomy has even been performed in such cases for the relief of the dyspnoea. I can recall one such Case, seen many years ago. It occurred in the person of a young woman, and produced such alarming and prolonged dyspnoea, with laryngeal stridor, that, had the patient's hysterical antecedents not been well known, the operation of tracheotomy would probably have been performed. When the case is really a hysterical one, tracheotomy is rarely or never required. The inhalation of a little chloroform and the administration of an antispasmodic, such as assafoetida, usually effect a speedy cure.PARALYSIS OF THE ABDUCTOK MUSCLES OF THE LARYNX. 57 Bilateral Paralysis of the Abductor Muscles of the Larynx, viz., the Crico-Arytenoidei Postici. This is a somewhat rare condition, and a very dangerous one. Its causation varies in different cases: generally it is due to disease of the nerves or nerve-roots ; but in a few cases no organic cause can be detected. It has been known to succeed epilepti- form fits. It has no distinct relationship to hysteria, is as common in the male as in the female, and is most common at a somewhat advanced period of life. It does not interfere with the voice. It produces stridor during inspiration, expira- tion being performed without noise. This inspiratory stridor is alarmingly loud when the patient sleeps. The condition is frequently the cause of death by suffocation. In the treatment of it tracheotomy is generally advisable. Sir Morell Mackenzie records a number of cases of this condition, in his work on Diseases of the Larynx. I have seen only one case, the patient being a man of about 60 years of age, who was brought to me many years ago by my friend the late Dr Angus Macdonald. The rough stridulous noise produced by this patient during in- spiration strongly reminded me of the noisy breathing of a " roaring" horse; and 011 referring to one of the authorities on veterinary medicine, I found it stated that one of the possible causes of uroaring" in the horse is this paralysis of the abductor muscles of the vocal cords. Having thus endeavoured to give a brief account of the leading paralytic and spasmodic affections produced by functional causes, I have now only to add that paralysis and spasm of the larynx may also result from organic disease of the laryngeal nerve centres or nerve trunks. I hope at a future time to take up the considera- tion of these organic causes of paralysis and spasm. They will naturally fall to be considered when we come to treat of the relations of organic disease of the nervous system to the function of speech. Meantime it may be remarked,—(1), that functional paralysis and spasm have a much more favourable prognosis than their organic equivalents; (2), that Functional Paralyses are essentially bilateral, and specially affect the ad- ductors; whereas the Organic are in most instances unilateral, H58 TIIE DISORDERS OF SPEECH. and affect the abductors at least as mucli as tlie adductors; (3), that Bilateral Paralysis of the Abductors is much rarer than Bilateral Paralysis of the Adductors. It usually results from organic disease affecting the nerve-centres or nerve-trunks. Some hold that is never produced by functional causes in any case; but an organic cause cannot always be detected.the troubles of professional voice-users. 59 CHAPTER III. The Troubles of Professional Voice-users; with Appendix as to Writer's Cramp. In this chapter, we propose to consider the disturbances of phonation that are most apt to appear among those who require, in the daily business of life, to use their voices professionally. Preachers, lecturers, teachers, advocates, officers, singers, actors, auctioneers, and costermongers are examples of persons who follow such occupations; and the list might be greatly enlarged. People in general use their vocal organs, in speech and occasionally in song, in their daily life; but there is an important difference between the speech or song of private life and the speech or song required in a public oration or vocal performance. The public performances put a strain upon the vocal organs that they are seldom subjected to in the course of private life. Under strain these may break down. In this chapter, an attempt, will be made to describe the various ways in which a break- down may occur; to explain the curative measures that may be used in the treatment of such cases; and to give some rules for the general management and hygiene of the vocal organs. The systematic study of the troubles of professional voice-users has of late years been pursued by a number of good observers. But, although much progress has been made, it cannot be said that scientific knowledge regarding such affections is yet in a very advanced condition. Much, however, that is important has been learned ; and the subject is well worthy of careful study, seeing that so many persons, in all civilized communities, depend upon the voice for a livelihood. In such persons, a break down of the vocal organs may be most disastrous to themselves and their families.60 THE DISORDERS OF SPEECH. Points in the Physiology of Voice Production. By way of preface, the reader may be reminded of a few physio- logical points that bear upon the subject. Briefly, it may be said that song differs from speech in that it contains Music as its predominant element; but that it resembles speech in that it gives articulate expression to thought in words. Public speaking occupies, in this respect, an intermediate position between song and ordinary speech. It contains less music than song, but more than ordinary speech, since its tones must be fuller, rounder, and louder, if they are meant to travel to a distance. Dr John Hullah, in referring to the necessity for musical utterance in public speech, street cries, etc., makes, in his admirable little book on the Speaking Voice, the following remarks:—" The first person who ever attempted to address a very large assembly must have discovered, by the time he had uttered a dozen words, that, if what he had to say was to be made not only audible but intelligible, to any but those immediately about him, his utterance must be partially musical; and that the more numerous his audience, and the larger his auditorium, the more musical must that utterance be. .....Every factory, every ship, and (more familiar instance) every street, will furnish us with examples of accentus and even concentus, of partially or even of perfectly musical utterance." Of course the musical element in public speaking may be overdone: it is only the good public speaker who will be able to supply it abundantly in his tones without allowing them to assume the characters of " sing-song " or of monotonous intonation. Dr Hullah also very neatly describes the differences between the varying Pitch and Intonation of speech and those of song. " In speech," he says, " the voice glides up and down what, by an allowable figure, may be called an inclined plane; in song it makes steps, the proportions of which to one another are ascertained. .....The variations of pitch in speech may be compared to the effect produced by sliding the finger up and down a vibrating string; those in song to that produced by stopping such a string at certain intervals and at no others." He further shows that the range of pitch in the gliding tones of speech is small, being con- fined, as a rule, to the musical interval of one-fourth, whereas the range of pitch in song is, of course, very much more extensive.POINTS IN THE PHYSIOLOGY OF VOICE PRODUCTION. 61 Tlie Carrying or Travelling power of speech depends almost entirely upon the predominance of its vocal element. A shout would be no shout without an emphatic production of voice, and a public speaker will be well heard in a large hall only when he makes a sonorous use of his voice in speaking. We find, in like manner, that the letters of the Physiological Alphabet which carry best to a distance are those which contain most of the vocal element in their composition. Thus the vowels carry best of all; next them the nasal resonants; next these the voiced fricatives; next these the voiced explosives; and after these the voiceless explosives and fricatives, which carry worst of all. Helmlioltz has made some remarks upon this subject. He says, "It is interesting in calm weather to listen to the voices of men who are descending from high hills to the plains. Words can no longer be recognised, or at most such as are composed of m, n, and vowels, as ' Mama/ 4 no/ But the vowels contained in the spoken words are easily distinguished. They form a strange series of alterations of quality and singular inflexions of tone, wanting the thread which connects them into words and sentences."1 Sitting in my room late one night, when working at this subject, I listened to a singer with a good voice, as he passed along the street on his way home. When he was under my window, I could make out distinctly every word of his song, but he immediately turned a corner of the street, and the words became unintelligible, most of the consonants having been lost on the way to my ear. Still, for some time, I could distinctly make out the vowels in the words he was singing; until, when he was farther in the distance, the vowels reached my ear shorn of the harmonics to which they owe their specific characters, so that I could no longer distinguish one vowel from another. Yet the fundamental note, with its pitch derived from the larynfc, enabled me to follow the melody until it finally died away.v Musicians tell us that the four chief properties of voice are, Intensity, Compass, Flexibility, and Timbre; and that the last of these, which may be translated " quality," is the most essential of all, if the voice is to give pleasure in song. Training has great power in enhancing all of these, especially when Nature has pro- vided an originally good organ, and a good musical ear. By 1 Helmlioltz, Sensations of Tone, p. 111.62 THE DISORDERS OF SPEECH. training, the Intensity or Power of the voice may be increased; the energy of the muscles of the chest and larynx being increased by daily and systematic exercise. In like manner, training can increase the Flexibility and the Compass of the voice. Above all, training can communicate to the voice a precision in attacking musical notes that is seldom or never met with in the singing of an untrained musician. In the trained singer, the moment the air begins to act upon the vocal cords the note is emitted in perfectly correct tune, and sometimes, when desirable, with a sudden explosive effect, which has been called the "shock of the glottis," or "Coup de Glotte." This "shock of the glottis" is a subject about which much has been written by Mandl,1 Lunn,2 Lennox-Browne and Behnke,8 and others who have written upon voice-production. The manner in which training communi- cates this precision to the vocal organs is a subject worthy of very careful consideration, although in this treatise only a few words can be said about it. We must remember that singing is, after all, the result of muscular action, carried on in obedience to impulses proceeding from certain cerebral nerve centres. It seems to me that more attention might, with advantage, be paid to the action of these centres. Writers upon the voice fully recognise the influence of training in strengthening the muscles, and in making them prompt to obey influences proceeding from the nerve centres; but perhaps they do not sufficiently recognise that its influence 1 Hygiene de la Voix, par le Dr L. Mandl, 1876. 2 The Philosophy of Voice, by Charles Limn, 1874. After the publication of my paper in 1866, Mr Lunn was one of the first to rccognise that the valve- actions described in it are important functions of the Larynx. Unfortunately his consideration of the subject led him to think that the false cords and ventricles of Morgagni are concerned in the production of the " Shock of the Glottis." This I think is a mistake. I believe that the Ventricles of Morgagni have little or nothing to do with the function of voice. During phonation the false cords are widely separated, and the Ventricles of Morgagni are, I believe, collapsed and empty. I admit, however, that it is difficult or impossible to prove that the ventricles are collapsed. The " Shock of the Glottis," I believe, owes its almost explosive character to the force and precision given by training to the muscles that are called into play. The note is struck at once, in perfect tune, and it may be struck with great power: " as," says Dr Hullah, "the sound of the violin reaches the ear the instant the bow of the skilful violinist touches the string, so should that of the voice at the instant expiration—the bowing of the violinist—begins." 3 Voice, Song, and Speech, 1883.POINTS IN THE PHYSIOLOGY OF VOICE PRODUCTION. 63 upon the Nerve Centres is more important still, inasmuch as the power of directing any finely co-ordinated muscular act can be acquired by such centres only after careful practice. That it is acquired, is apparently due, not only to the fact that the frequent repetition of the act habituates the nerve-cells to the discharge, and the nerve-fibres to the conduction, of the nerve-force required, but also to the fact that the muscular sense and the other senses excited by the performance of the act engrave, in the regulating centres, a perfect motor picture of the act,—this picture being copied and imprinted afresh each time the act is repeated.1 This view helps us to understand the long and laborious training neces- sary for the development of a fine singer. The training lias been exercising, not only his muscles and nerves, but also his nerve- centres, which have been acquiring motor memories or pictures, so well defined, that, by force of habit, they can be utilized in the production of song, without any strain of attention on the part of the singer using them. The Timbre or Quality of the voice probably depends more upon the condition and management of the Pharynx, and other accessory parts such as the Oral cavity, than upon the condition or management of the larynx itself. Any disease or derangement of the Pharynx is apt to tell injuriously upon the quality of the voice. It will be well, however, to reserve the discussion of the vocal relationships of the Pharynx until we come to consider an affection of that part which is of common occurrence in public speakers, viz., Follicular Pharyngitis, the producer of Dysphonia Clerieorum, or Clergyman's sore throat. Meantime, let us consider those troubles of professional voice- users that are more immediately connected with the functions of the Larynx itself. Laryngeal Troubles in Professional Voice-users. A. Reference to the effects of ordinary Laryngeal Disorders.—Like other people, those who use the voice professionally are apt to suffer from Laryngeal Catarrh, an affection which produces hoarse- ness as one of its symptoms. This affection is specially serious to 1 The formation of such motor memories or pictures of co-ordinated move- ments is discussed by M. Victor Horsley in a very interesting manner in one of his recent papers.64 THE DISORDERS OF SPEECH. the professional voice-user* because it disables him more or less for professional work, and because* if he continue such work while suffering from it, the inflammation may be aggravated* and its duration prolonged indefinitely. The catarrh may even be originally excited by over-straining of the Larynx, as in coster- mongers or others who have to shout a great deal So, in like manner, Nervous causes of disablement, such as the Hysterical* Neurasthenic, or Toxic conditions enumerated in the last chapter* may affect speakers and singers, just as they affect others* and may be specially important in them only because of the special importance to them of the organ affected* Further, the larynx of a professional voice-user may be disabled by any one of the many varieties of Organic disease, such as tubercular or specific disease, or new growths. All that need be here said about these diseases is that a very slight organic change, such as might be of little importance to those who do not use their voice professionally, is often disastrous to the professional voice-user, and more especially to the pro- fessional singer. Although slight, it may be sufficient to destroy the purity of his vocal tones. B. Fatigue Neuroses of the Larynx, -—These and the other Neuroses of the Larynx will be found described* with special ful- ness and care, by Gottstein, in his work on Diseases of the Larynx.1 One of the other contributions to the subject is a very interest- ing paper by Professor B. Frankel of Berlin.2 As Frankel's paper describes the three leading forms of Fatigue Neurosis with admirable clearness, I shall begin my account of the Fatigue Neuroses by giving a summary of its contents. Taking writer's cramp of the hand as the most typical example of a Professional Fatigue Neurosis, Frankel reminds his readers that that affection occurs in three different forms, viz., (1) the, Spasmodic, (2) the Tremulous, and (3) the Paralytic. Comparing these varieties of writer's cramp with the Fatigue Neuroses of the Larynx that are met with in professional voice-users, he finds all three varieties represented. 1 Die Krankheiten des Kehlhopfes, 3rd edition, 1890. Unfortunately the former edition, translated into English by Dr M'Bride, does not contain the section on the Laryngeal Neuroses. 2 Deutsche Medicinische IVochenschrift, Feb. 1837. He uses " Mogiplionia" as a general term for these Fatigue Neuroses of the Larynx.LARYNGEAL TROUBLES IN PROFESSIONAL VOICE-USERS. 65 Thus the Spasmodic Variety is represented by cases of Phonetic Spasm of the Glottis, many of which have already been put on record by observers on the Continent and in this country. The leading characteristic of this variety is the sudden Stop, during public speech or song, from involuntary closure of the glottis. This closure may be complete; and then the patient emits no sound, although he may move his lips as if still speak- ing, and may give evidence, in his expression and congested face, of making a great effort. On the other hand, the closure may be incomplete; and then, in his efforts to speak, the patient emits sounds of suppressed vocal character, such as are so often produced in other conditions of straining. Frankel makes no attempt to describe the appearances presented by the larynx during such involuntary closure. Other writers, however, who have recorded cases, have attempted to describe the appearances on laryngoscopic examination. They say that the true cords are seen to be in the closest apposition throughout their whole length; and this they consider to be the cause of the obstruction. I venture to express the strongest doubt as to the accuracy of this observation. I have already, in the first chapter, referred to the valvular closure of the false cords over the true, during any effort of straining. I may here add that, in the investigation therein referred to, I proved that the construction of the True cords is such as makes them as badly fitted as they could possibly be to offer an effective resist- ance to the Exit of air under strong pressure. When they are in apposition, the air-space below them is wedge-shaped, so that the column of air, pressing up from the trachea, can, as it were, wedge itself between them. In so doing, it will escape with a sound that is more or less vocal. Complete closure, with effective resistance to the exit of air, can be brought about only by the co- operation of the False cords and the ventricles of Morgagni, which act in the valvular manner already explained. I have never myself seen a case of this Spasmodic variety of laryngeal fatigue neurosis; but, from the description of its symptoms in recorded cases, I have no doubt that this is the correct explanation of its mechanism. A complete closure of the false cords over the true will cause the appearance of silent effort, as in the gutturo-tetanic variety of stammering; an incomplete, will permit of the escape of air, and the air in passing, will throw the true cords into vibration. In 166 THE DISORDERS OF SPEECH. the latter case, one will hear those straining vocal noises (half smothered owing to the almost complete apposition of the false cords) that are so characteristic of the act of straining. In doubting the accuracy of the observations above referred to, I have the less hesitation, inasmuch as I recognise that, in order that the state of the glottis during the spasm should be displayed, it would be necessary for the patient to speak or sing while the mirror is in his throat, and also at the same time to have a true involuntary spasm—not merely make, voluntarily, what he might consider an imitation of one. The condition appears to me to be one in which the whole glottis, true and false cords alike, is seized with involuntary spasm, and is closed up, com- pletely or incompletely, as it normally is during any act of straining. The Tremulous Variety of writer's cramp is thought by Frankel to be represented in the larynx by certain forms of involuntary and irrepressible Tremolo in the emission of notes; but he thinks the subject is as yet imperfectly understood, and does not enter further upon the discussion of it. To the third or Paralytic Variety, Frankel devotes special atten- tion. He has had, in all, six patients who suffered from it: four public singers (three female and one male), one female teacher, and one preacher. He describes, as those of a perfectly typical case, the symptoms as they presented themselves in one of the lady singers. She was young, and apparently in excellent health; and she suffered from no trouble in the larynx except when she sang. When requested to sing, she began in a beautiful, strong soprano, clear as a bell; but, after a certain time, the voice became weak, and one could see that it was becoming more and more difficult for her to bring out tone as she had done at the beginning. " Finally she stopped, with tears in her eyes, in the middle of the song. When asked why she did not go on, she answered, * I cannot. In the first place it gives me pain in the throat. That, however, I should not care for. But I am not able to sing any more: my voice is gone/ Although in giving this reply she spoke in a perfectly clear voice, it was impossible for her to sing again. The attempt to do so only produced a noise that scarcely deserved to be called tone." Laryngoscopic examination showed nothing distinct, although Frankel was inclined to think that the vocalLARYNGEAL TROUBLES IN PROFESSIONAL VOICE-USEKS. 67 cords were no longer approximated quite so closely as they had been before the patient sang. In all the other cases the symptoms were closely similar to the above. The teacher, for example, after speaking for about an hour and a half, found that her voice became fatigued, and that she could not proceed further. The . preacher found that his voice failed and disappeared in the course of the service. Like the other patients, he had a painful feeling of fatigue in the throat, followed by progressive failure of his voice, so that more and more effort was required to bring it out; and at length, bathed in perspiration from his exertions, he was obliged to bring the service to a close. In all other respects, the patients were in good health, and had no trouble, even with the larynx, except when they were using it professionally. Frankel devotes some space to the consideration of the treatment of such cases. He shows that hitherto the treatment of confirmed cases has been very disappointing; and he reminds his readers that the same may be said regarding the treatment of con- firmed Writer's Cramp. As, however, in recent years, considerable success has been obtained in the treatment of Writer's Cramp by the use of Massage, lie has, in one case, tried this treatment for fatigue neurosis of the larynx. The result he regards as encouraging. Anointing the throat of the patient with Lanoline, he stroked with the fingers the skin 011 each side of the larynx, along the anterior borders of the Sterno-mastoids, from the angles of the jaw downwards. At each sitting he made forty or fifty of such downward strokings; and, at the same sitting, ten or fifteen transverse strokings over the Hyoid bone. Improvement followed in a few days; and, although the lapse of time was not sufficient to enable him to say that a permanent cure had been effected, the patient had become able to sing for half an hour or more. These cases of Fraukel's may be regarded as typical of the variety of fatigue neurosis which corresponds to the Paralytic Variety of Writer's Cramp. As has already been remarked, the larynx, in these cases, always performed its functions normally except when called upon to do professional work. There are other cases, however, in which a break-down occurring during professional exertion produces a hoarseness or aphonia that remains for weeks or months, showing itself even in ordinary conversation. Sir Morell Mackenzie records several interesting cases of this de-68 THE DISORDERS OF SPEECH. scription. In the British Medical Journal for 1863, vol. ii., p. 313, lie describes the case of a clergyman, in whom aphonia came on suddenly one evening when he was preaching in a large London church. " While in the middle of a sermon, he felt a sudden pain in the throat, and was obliged to finish in a whisper. He had, oil two previous occasions, lost his voice in a similar manner, but on this occasion the aphonia persisted for about two months. Examination of the throat showed no trace of disease either in the larynx or in the pharynx." In the same paper, he also describes the case of a fish-hawker, in whom aphonia came on suddenly after he had been making great efforts one Saturday evening. . The patient partially recovered his voice, but the weakness subsequently increased, so that, for four months, he was obliged to give up his vocation. Laryngoscopic examina- tion showed nothing but imperfect approximation of the Cords during the attempt at vocalization. In both of these cases, a speedy cure was effected by the employment of Intra-laryngeal Electrisation. Michel, in a paper to be presently referred to, says that when, in a public singer, a break-down resulting from over-exertion is succeeded by persistent hoarseness, one should be very cautious about making an altogether favourable prognosis. He thinks that, in the greater number of such cases, a loss to the voice in metal, in polish, and in fulness of tone, remains ever afterwards ; and that the voice may never regain its former staying-power. Many other phenomena have been observed to occur in the vocal organism, when it is thus overstrained and made to break down. The Kespiratory part of the Mechanism, apart from the larynx, may suffer during the disturbance, and may show the symptoms of failure of nerve power, or those of inco-ordinate action, or those of overflow into centres which normally should not be stimulated during speech or song. Two cases that have come under my own observation presented phenomena of this nature. The first case was seen by me in December 1881. The patient was a young Scotch clergyman, of good physique, and apparently in good health, who for a year had been troubled, when preaching, with a "quick, catching cough, and a feeling as if his throat flapped together." This trouble first occurred after the patient had preached eight sermons on seven consecutive days, and was feelingLARYNGEAL TROUBLES IN PROFESSIONAL VOICE-USERS. 69 fagged by the exertion. It afterwards recurred more or less severely every Sunday, so that he became nervous about it when- ever he was called upon to preach. He thought that his nervous- ness aggravated the condition. The attacks were especially apt to come on if he felt tired. They always produced a quick succession of short, sharp coughs, which gave him much annoyance, and excited great sympathy for him among the congregation. He had had several holidays of some weeks' duration, but the cough had always returned when he resumed his service in church. He was recommended by me to try the effect of a dose of Bromide of Potassium half an hour before beginning the service; and, during service to take, from time to time, if threatened with the cough, a dose of a mixture containing Aromatic Spirit of Ammonia, Spirit of Chloroform, and Camphor Water. The case seemed one of spasmodic irritation of the coughing centre, produced by overflow of energy from the surcharged centre for phonation. The second case, which I saw on the 10th of July 1888, was somewhat more complicated in its symptoms. The patient was a young English clergyman, engaged in Cathedral service. He, also, was of healthy appearance; but he informed me that during the previous winter he had been out of health, from a rather severe attack of diarrhcea, which lasted more than a week, and pulled him down a good deal. The first symptom that troubled him when speaking was a feeling of want of breath at the end of a sentence, and an inability to draw breath for the next sentence. Entering upon that sentence with scarcely any breath, he got "quite pumped"; but, when in this condition, lie found that the power of inspiration returned to him spontaneously. He had a sensation " as if the tube were inclined to close;" and sometimes he had difficulty in getting breath out, as well as in getting it in. There was no pain. Sometimes, in reading, he had difficulty in pro- nouncing individual letters, such as g, and found it especially difficult to pronounce o without aspirating it. He found that he had more difficulty in reading in the low monotone required for the daily service in the Lady Chapel, than in reading in the high monotone required for the service in the Cathedral. His troubles caused a little gasping, with long pauses. Sometimes, when exhausted, he would end a sentence with a quaver. He always felt the services to be a heavy strain upon him, and was especially70 THE DISORDERS OF SPEECH. nervous when about to read. Preaching was easier to him; as he could then change the pitch of his voice, or pause, as he pleased. He was given a nervine tonic, and recommended to try the effect of a little Bromide of Potassium before beginning the service. This case is rather complicated ; but its chief feature seems to have been a failure of power, and of co-ordination, in the Respiratory portion of the vocal mechanism. The difficulty of articulating certain consonants and vowels seems to indicate that the innerva- tion of the Oral Articulative Mechanism was also to some extent disturbed. In connexion with the most typical and common form of fatigue neurosis, viz., writer's cramp, it is now well ascertained that persons who are subjects of neurasthenia are more frequently and easily affected by the condition than persons of strong con- stitution. It is also known that temporary nervousness, such as might be produced by the presence of an onlooker, aggravates the condition for the time being. Reasoning from this analogy, we may believe that Neurasthenia and nervousness may also act as predisposing causes of the Laryngeal Fatigue Neuroses. The two cases last described seem to confirm this conclusion, as both patients asserted that their nervousness aggravated their symptoms. In the treatment of all such cases of Fatigue Neurosis, prolonged rest from professional work is undoubtedly the leading indication ; and this rest should be taken early, before the habit of break-down has become confirmed by frequent repetition. When professional duty is resumed, the greatest care should be taken to avoid over- strain ; and the method of delivery should be most carefully attended to. Something more will be said about these matters presently. In some cases, the use of massage and electricity has been attended with good effects. When the patient is young, and as yet so little accustomed to clerical duties as to be agitated and nervous during their performance, I think it is reasonable to prescribe for him a little Bromide of Potassium, of which a single dose may be taken half an hour before service begins. Pharyngeal Troubles of Professionctl Voice-users. We now come to consider an affection that is believed to be peculiarly ommon among clergymen—so much so, indeed, that itPHARYNGEAL TROUBLES OF PROFESSIONAL VOICE-USERS. 71 has received, in this country, the name of Dysphonia Clericorum, or Clergyman's sore throat. Curious to say, it is an affection of the Pharynx rather than of the Larynx. In well-marked cases, it develops into the disease known as Follicular Pharyngitis; but in slighter cases there may be only Catarrhal Irritation with Kelaxa- tion and Congestion of the Pharynx, without special hypertrophy of its follicles. The common occurrence of this condition among public speakers illustrates the fact that the Pharynx plays a most important part in the production of voice. Public orators, when speaking, have generally on the table beside them a glass of water, or of some special beverage, with which they refresh the throat if it begins to feel dry, or if the voice begins to be a little husky. Mandl, in his book upon the voice, devotes much attention to this subject, and gives us details about the practice of many well-known actors and singers as to it. He takes us behind the scenes: and tells how one celebrated artiste refreshes the throat, during the entr'actes, with soda water; another with beer; another with porter; and so on. How do these fluids act? Clearly they can never reach the larynx, but can only moisten the cavities of the mouth and pharynx. The necessity for them illustrates the great importance of the pharynx in voice-production. As a part of the vocal tube1 or resonating chamber, the Pharynx helps to give volume and timbre to the voice: without it the notes of the finest larynx would be destitute of agreeable quality and of carrying- power. The views of Michel2 on this subject are thus summarized by Schech3:—"The wall of the Pharynx forms the most important reflector for the sound-waves streaming out of the Larynx. : Here, and against the Velum Palati, they first strike. If this wall is not smooth, but knotty and uneven, from granulations and hyper- trophies, 'sound shadows' must be formed; just as an uneven 1 The expression "vocal tube" is used in one of the best pamphlets 011 the Physiology of the Larynx that I am acquainted with, namely, that entitled Experimental Researches into the Physiology of the Human Voice : a Memoir, by John Bishop, M.R.C.S., etc., 1836. 2 Die Krankheiten der Nasenhohle und des Nasenrachenraumesf 1876. 3 Die Krankheiten der Mundhohle, des Rachens, und der Nase. 3rd Edition, 1890.72 THE DISORDERS OF SPEECH. mirror surface can give only a distorted image of a body placed before it. Owing to the faulty reflection, the tone thus suffers loss: it is weakened; it does not carry far; or, what is the same thing, it loses its metal." Further, the Velum Palati and the Pharyngeal wall, in acting as reflectors of the sound-'waves, are not passive and inert. Both in speech and in song, they are constantly in a state of great muscular activity. In speech, the Pharynx shares with the Oral cavity the duty of shaping the Kesonating Chambers for the vowels; and in song the Pharyngeal cavity is contracted or enlarged, shortened or elongated, in sympathy with the pitch of the notes,—being in the highest notes shortened and contracted, and in the lowest elongated and enlarged, to a remarkable degree. This constant activity may help to explain its known liability to inflammatory irritation when overworked by public speaking. Even dryness of the Pharynx tells unfavourably on the voice; and, naturally, disease has still more marked effects. Schech1 gives a very detailed account of the present state of knowledge as to the causation, symptoms, and treatment of Folli- cular Pharyngitis; and the subject will also be found ably discussed in Sir Morell Mackenzie's work on the Diseases of the Throat and Nose. It appears, as the result of recent observation, that the affection is, in its slighter degrees, exceedingly common. Schech goes so far as to say that there is scarcely a grown man who is quite free from some amount of granular change in the pharyngeal mucous membrane. Children, up to the age of twelve, are gene- rally free from it; and the female sex also enjoys comparative immunity. Among the predisposing causes, are certain constitutional states, such as Scrofula, Heart disease, and the state of constitutional weakness that sometimes follows an attack of one or other of the acute infectious diseases. It is common among persons engaged in occupations that expose them to the respiration of a dusty or impure atmosphere. It is common, also, in those who exercise their voices professionally; more especially in clergymen and in military officers—being in the latter produced by straining of the voice in shouting commands. It may thus either be originally 1 Op. citp. 122, et seq.PHARYNGEAL TROUBLES OF PROFESSIONAL VOICE-USERS. 73 produced by overstraining of the voice, or, having been produced otherwise, be aggravated in this way. Other causes, which seem capable of exciting or aggravating the affection, are the habitual use of tobacco in smoking or snuffing, and the use of hot spices or condi- ments with the food, or of irritating drinks such as alcohol. It will here be unnecessary to give a detailed description of the appear- ances in Follicular Pharyngitis, but it may be said briefly that three forms of the affection have been distinguished, viz., (1) the Simple Hypertrophic, (2) the Hypertrophic with excessive Secretion, (3) an Atrophic form, which seems to be the outcome of the Hyper- trophic ones. In the Hypertrophic forms, rounded granulations, or elongated elevations, or extensive patches of thickening are visible on inspection ; and these, on microscopic examination, are found to be made up of hypertrophied mucous glands, with surrounding infiltration of lymphoid tissue. In the areas of hypertrophy, the orifices of the mucous ducts are often observed to be widely open; and, from these openings, in the form of the affection that is attended with increased secretion, whitish masses or shreds of secretion may depend. In the Atrophic form, the mucous mem- brane in the atrophied parts is thin, smooth, and dry. When the condition is well marked, the patient complains of a constant irritation at the back of the throat, as if some foreign body or irritating particle were lodged there. He is constantly hawking or clearing his throat to get rid of this irritation; and he may be rendered so miserable by it as to become hypochondriacal, or even, sometimes, suicidal. Cough is also frequently excited ; and, as the inflamed surface may bleed, Ha}moptysis may occur. Besides cough, another result of reflex irritation is spasm of the glottis; which; however, is met with only in a very small proportion of the cases. To the professional voice-user, one of the most serious of the symptoms is the Hoarseness that attends upon this affection. This may exist without direct involvement of the Larynx in the inflam- matory change, as has already been explained; but there is no doubt that in some cases the disease extends into the Larynx; and that in others the constant coughing and clearing of the throat overstrain the Larynx, and, by exciting congestion and catarrh in it, tend materially to aggravate the hoarseness. In treatment, the general health should be attended to. The use K74 THE DISORDERS OF SPEECH. of tobacco and of stimulating foods and drinks should be forbidden. Prolonged rest should be given to the vocal organs, and the inflamed parts should be treated locally. For the local treatment of slight cases, sprays have been found of great service. A two per cent, solution of Bicarbonate of Soda, or Bicarbonate of Potash, or a solution of Chlorate of Soda may be used in this way; or, with the view of soothing irritation, a four per cent, solution of Bromide of Potassium. For more severe cases, Schech speaks highly of Mandl's Iodine solution, which is made up of Iodine, Iodide of Potassium, Glycerine, and Oil of Mint. If a good result be not obtained from these measures, the granulations may be destroyed individually by means of escharotic paste, or by the actual cautery. Mackenzie prefers to apply to them the escharotic London Paste, by means of a wooden spatula. Schech and others cauterize them with the galvano-cautery. Sajous1 prefers to use, for this purpose, the end of a thick wire, heated to redness over a spirit lamp. Of course such energetic treatment should be undertaken only by a skilled surgical specialist. All the authorities are agreed as to the efficacy of such energetic local treatment in cases that without it would be incurable. The atrophic form, Pharyngitis Sicca, is not so amenable to treat- ment as the hypertrophic one. All that can be done is to keep the parts clean and moist, by means of nasal douches and oral sprays: the sprays that are preferred being those of warm milk, mucilaginous decoctions, one per cent, solution of common salt, sulphur waters, etc. The nasal cavities often require special attention in such cases, as the disease is apt to involve the walls of the Naso-pharynx. Michel2 has lately written an interesting paper as to certain slight morbid conditions that are apt to damage the Singing Voice, by interfering either with the free movement of the Velum Palati, or with the contractions of the Palato-pharyngeal muscles, contained within the Posterior Pillars of the Fauces. He holds that anything interfering with the free elevation of the Velum Palati tells injuri- ously upon the voice by interfering with the action of that part in its function as a Eesonator. He also holds that the Palato-pharyngeal muscles, acting in association with the Thyro-hyoid, Sterno-hyoid, Crico-thyroid, and others, assist in shaping the Rinia Glottidis for 1 Diseases of the Nose and Throat, by Chas. E. Sajous, M.D., 1888. 2 Dr C. Michel of Cologne, Deut. Med. WochMay 1889.PHARYNGEAL TROUBLES OF PROFESSIONAL VOICE-USERS. 75 the production of high notes; and that anything interfering with their free contraction will therefore have a damaging effect upon the power and purity of the voice. Among the slight conditions that interfere with the action of the Palato-pharyngeal muscles, he enumerates a Paretic condition of the Soft Palate, adhesions of the Tonsil to the Posterior Pillar of the Pharynx, the growth of Tonsillar Tissue in the substance of the Posterior Pillar, and the presence of follicular granulations upon the surface of the Posterior Pillar. In treatment, he divides adhesions of the tonsil and removes tonsillar growths and follicular granulations by means of the galvano-cautery, and endeavours to restore the muscular power of the Yelum by gymnastic exercises of it. Besides paresis of the soft palate, he mentions Hypertrophy of the Naso-pharyngeal Tonsil, as another condition which may interfere with the upward movement of the Velum. He recommends removal of the hyper- trophied texture. A question that has engaged the attention of many writers on Voice-Production is—How is it that, of all professional voice-users, clergymen are the most affected by Follicular Pharyngitis ? The answer given by these writers almost always is, that in preaching, more than in other forms of public speaking, the voice is apt to be used in a strained and more or less unnatural manner. Dr Hullah teaches that the public speaker should find what is the most natural and easy pitch for his speaking voice, and that he should use this pitch in his public speaking. Macready, also, the English tragedian, has left us his opinion upon this subject.1 He says, "Relaxed throat is usually caused, not so much by using the organ, as by the kind of exercise,—that is, not so much by long or loud speaking, as by speaking in a feigned voice. I am not sure that I shall be understood in this statement, but there is not one person in, I may say, ten thousand, who, in addressing a body of people, does so in his natural voice; and this habit is especially observable in the pulpit. I believe that relaxation of the throat results from violent efforts in these affected tones, and that severe irritation and often ulceration is the consequence. The labour of a whole day's duty in a church is nothing, in point of labour, compared with the performance of one of Shakespeare's leading 1 See letter to Dr Mackness, printed in the latter's Treatise on Dysphonia Clericorum.76 THE DISORDERS OF SPEECH. jcharacters, nor, I should suppose, with any of the very great displays made by our leading statesmen in the Houses of Parlia- ment. I am confident as to the first, and feel very certain that the disorder which you designate as the clergyman's sore throat is attributable to the mode of speaking, and not to the length of time or violence of effort that may be employed. I have known several of my former contemporaries on the stage suffer from sore throat, but I do not think that among those eminent in their art it could be regarded as a prevalent disease." We are told by Mandl of the care that another actor took to use his voice at its natural pitch. He tells us, as to Talma, the great French actor, that immediately before going on the stage he used to ask some bystander, "What time is it ?" and, on getting a reply, to say, "Merci, Monsieur." On passing to the stage, he kept in recollection the pitch of these everyday words of his own, and was careful to use it in his first words to the audience. Much that is interesting and important upon this subject will be found in the work of Dr Hullah. But we need not dwell upon it. It is sufficient to say that when a clergyman begins to be troubled with sore throat, he should look well to his method of enunciation; and that, if the method be faulty, he should correct it without delay. In doing so, he may be encouraged by the example of Cicero himself, as to whom, in Middleton's Life of Cicero (quoted by Dr Mackness), there is the following passage :— " Cicero says of himself,4 My body at this time was exceedingly weak and emaciated, my neck long and small, which is a habit thought liable to great risk of life if engaged in any fatigue or labour of the lungs; and it gave the greater alarm to those who had regard for me, that I used to speak without any remission or variation, with the utmost stretch of my voice, and great agitation of my body. When my friends, therefore, and physicians advised me no more to meddle with causes, I resolved to run any hazard rather than quit the hopes of glory which I proposed to myself from pleading*; but when I considered that, by managing my voice and changing my way of speaking, I might both avoid all danger and speak with more ease, I took a resolution of travelling to Asia, merely for an opportunity of correcting my manner of speaking.'" Other points to be attended to are:—(1.) The posture in reading- should be such as to let the speaker stand upright; the readingPHARYNGEAL TROUBLES OF PROFESSIONAL VOICE USERS. 77 desk being raised enough to let him follow the print easily with- out stooping over it. (2.) The speaker must take care to correct any tendency to speak from a chest insufficiently filled with air. Cases are reported in which great relief was got by careful atten- tion to taking breath at suitable intervals. (3.) Dr Hullah points out that the liability of clergymen to sore throat may also, in some degree, be due to the long intervals of rest between the weekly occasions of effort; and he suggests that clergymen, besides attend- ing carefully to their mode of enunciation on Sundays, should exercise the voice in reading aloud, etc., on week days. These recommendations appear to me to include all that is really essential as to measures of prevention. When the mischief is done, rest is the chief indication ; and the medical treatment should include both such general tonics and regimen as may be required by the state of health and such local treatment as has already been described. The habit of smoking should, in cases of Follicular Pharyngitis, be strictly forbidden. I saw, on the 10th of October 1891, a case in which the local appearances spoke eloquently as to the affec- tion being due to the habit of smoking. Along with much con- gestion of the soft palate and pharynx, increased secretion of mucus in the pharynx, and enlargement of several follicles on its posterior wall, there was, in the buccal cavity, a most peculiar condition: over the whole of the roof of the mouth, as far back as the junction of the hard with the soft palate, the mucous membrane was thickened and whitened; and everywhere the whitened surface was dotted abundantly with little black spots, like the black tops of comedones on the nose. The black spots were the openings of dilated mucous ducts, blackened by tobacco smoke. Many professional voice-users believe that some of the watering places, especially those with sulphur springs, are of value in the treatment of Follicular Pharyngitis. Further, it may be added that, as the voice answers so sensitively to conditions of the health and nervous system, the professional voice-user should try to keep himself in good health and good spirits. No special rules can be laid down for him in this respect. The general rule that will be most valuable to him, as it is to us all, is that, in living, he should do his best, in every way, to pay respect, and yield obedience to the ordinary laws of health.78 THE DISORDERS OF SPEECH. WRITER'S CRAMP. As public speakers often become tlie subjects of Writer's Cramp, a few notes upon that affection, appended to this chapter, may not be out of place. Public speakers are liable to become the subjects of it, because so many of them require, in preparing their orations, to commit them in the first place to writing. Much writing brings about fatigue in the hand, and induces this condition, which is the commonest and most typical example of a Fatigue Neurosis. Excellent accounts of the affection are so easily accessible, that it is here unnecessary to enter into any great detail regarding it. One of the standard papers on the subject, that by Dr G. V. Poore, is in the Med. Ckir. Transactions, vol. lxi., 1878; and, more recently, Dr Poore has given an abstract of his views in the form of a short article contributed to Quain's Dictionary of Medicine. Further, a full and able account of the Professional Fatigue Neuroses in general, written by Dr Morris J. Lewis, will be found in the fifth volume of Pepper's System of Practical Medicine. In Ziemssen's Cyclopaedia, also, there is the well-known article by Erb; and in Eulenberg's Encyclopcedie, 1885, there is a full and instructive article by Prof. Berger of Breslau. In this chapter, it will suffice to remind the reader of the leading features of the affection, and to note the means which have been used with most success in its treatment. In speaking of the Fatigue Neuroses of the Larynx, the three chief varieties were noted to be,—(1) the spasmodic, (2) the tremulous, and (3) the paralytic, and it was remarked that, in presenting these varieties, the Fatigue Neuroses of the Larynx resembled the Fatigue Neurosis of the Hand called Writer's Cramp. Although the title "Writer's Cramp" seems to imply the existence of spasm as an invariable symptom, this is by no means actually the case. It is only in the Spasmodic variety that true cramp or spasm is the leading symptom; and in pure examples of the Tremulous and Paralytic varieties spasm is not met with. There are, however, many cases of a mixed character in which spasm is associated with tremulousness, or with paralysis, or with both. " Scrivener's Palsy " is another name for the affec- tion almost as familiarly known as " Writer's Cramp."writer's champ. 79 As to the comparative frequency of each of the three forms, Prof. Berger, in the article above referred to, states that, of 64 cases which came under his own observation, 24 belonged to the purely Spasmodic Variety, 10 were cases of Writer's Palsy, and 8 were cases of Writer's Trembling. The remaining 22 were examples of com- binations of two or all three of the above forms. Including some of the combined cases, it was found that spasm exhibited itself more or less in 34 of the 64 cases. A few words may be said about each of the leading varieties. I. The Spasmodic Form.—When the patient is engaged in writ- ing, spasm sets in in one or several of the muscles that are being used. Sometimes it is the Flexors that are affected, and then the pen is involuntarily grasped with great force between the thumb and fingers, or the thumb is bent strongly inwards upon the palm. Sometimes it is the Extensors, and then the index finger or thumb is straightened out and carried apart, so that the pen may drop from the hand. The spasms thus affecting the Flexors or Extensors may be either tonic or clonic: in the latter case the fingers, hand, or even whole arm, become affected with involuntary jerking movement. It may be said, however, that tonic cramp is far more common than clonic jerking, which is met with only now and again. II. The Tremulous Form.—This variety, which is the most rare of the three, is constituted by the occurrence of trembling of the hand, and more especially of the fore-finger, whenever the patient attempts to write. At first, it is not so utterly destructive of the writing-power as is either of the two other forms; but, as it advances, it makes the handwriting more and more tremulous and wavy, until at last it makes it quite illegible. Lewis notes that the fore-finger may, in some cases, remain more or less tremulous, even when the patient is not writing and the hand is at rest. III. The Paralytic Form.—The leading feature of this form is simple want of motor power, exhibited by the hand when the patient is engaged in writing. For all other manipulations, the motor powers of the hand may be unimpaired ; but, in a severe case, no sooner has the patient taken pen in hand, and made a few strokes with it, than he finds the motor power of his hand ebbing fast away, so that presently it may be almost impossible for him, even with the greatest effort, to write a single letter. Accompanying this progressive loss of motor power, there is an increasing and80 THE DISORDERS OF SPEECH. very distressing sense of fatigue in the hand and arm : the arm is sometimes described by the patient as feeling as heavy as lead, and as being at the same time quite sore with fatigue. Efforts to continue work with the disabled hand induce also a sense of pro- found general fatigue; and the exhausted patient, if he persevere, may, from his exertions, become bathed in perspiration. In rare cases, Vaso-motor changes are developed, the hand becoming turgid with blood and even slightly cyanosed. And, also in rare cases, shooting pains, of neuralgic character, may occur. The common troubles of sensation, however, are the sense of sore fatigue and the feeling of heavyweight; and these sensations may extend from the hand up even to the shoulder. Something of the feeling of sore fatigue and weight may be present even in the Spasmodic and Tremulous varieties, but it is most constantly developed, and most severe, in the Paralytic one. Other points in the Symptomatology of Writer's Cramp, brought out especially by Dr Poore's careful examination of cases, are:— (1.) The occasional presence of neuritis in one or other of the nerves supplying the hand. This occurs most frequently in the trunk of the Ulnar Nerve, but is also met with occasionally in the Median, or in the branches of the Musculo-Spiral. It betrays itself by exciting Sensory disturbances, such as tingling and hyperasthesia over the cutaneous area of distribution; and by producing, in the muscles sup- plied, a paretic weakness, which may be associated with perceptible wasting, with fibrillar movements, and with more or less diminution of response to the Faradic current. There may also be more or less tenderness to pressure over the trunk of the nerve. The occurrence of Neuritis in the Ulnar Nerve was well exemplified in a case of the Paralytic variety seen by me, for the first time, in October 1889. In this case, there was, along with a little tender- ness over the nerve trunk, tingling sensation over the ring and little fingers, and very slight but perceptible wasting in the muscles of the Hypothenar Eminence. (2.) Alteration of Electrical Re- actions in individual muscles. Dr Poore believes that the disable- ment of any one of the many muscles employed in writing may throw the whole process into disorder, by impairing a link in the chain of co-ordination. He examines the muscles individually with the electric current; and he states that, in a very large number of his cases, it was possible distinctly to make out, in the affected"WRITEU S CRAMP. 81 limb, that one or several of the muscles presented an alteration of electrical reaction. Usually this alteration was only of a quanti- tative character, being, in slight cases, a quantitative Increase, and, in severer cases, a quantitative Decrease, of excitability to the elec- trical current. That such quantitative alteration existed, was made evident when the reactions of the muscles of the hand affected were carefully compared with those of the corresponding muscles of the other hand. Only in a few cases did he find, in muscles already wasting, the qualitative alterations known as the Eeactions of Degeneration. As to the Pathology of Writer's Cramp, much has still to be learned. It is unquestionably the result of over-fatigue, and is brought about by the continual repetition, hour by hour, and day by day, of the muscular movements required in the operation of writing. The mechanism of these movements is nervous as well as muscular, and the nervous impulses call forth the activity of many nerve-cells and nerve-fibres, from the starting points of these impulses in the Cortex of the Brain, down, through the Spinal Cord, to their ultimate expenditure in the muscles. All of these cells and fibres being exercised, it seems reasonable to suppose that any one of them may become fatigued. Many will have it that Writer's Cramp is always peripheral, and due to local change in the muscles or in the nerves at or near their muscular distribution. Some, on the other hand, point to certain resemblances between Progressive Muscular Atrophy and Writer's Cramp, and teach that the latter is essen- tially a spinal affection, due to fatigue of the large motor cells in the Anterior Cornua. A third opinion, at present very powerfully supported, is that Writer's Cramp is essentially a Cerebral affec- tion, due to exhaustion of that part of the Cerebral Cortex that is the primary source of nerve-energy for the muscular movements of writing. Although the subject is involved in great obscurity, there is pretty good ground for supposing that there is truth in each of the three hypotheses represented by these several views. Most authorities now think so. That the symptoms may spring out of exhaustion of the cortical centres seems to be rendered almost certain by the circumstance, already alluded to, that Writer's Cramp is most easily induced, and occurs most frequently, in those who, by inheritance, dissipation, worry, or overwork, are subjects of Neurasthenia or Hypochondriasis. In L82 THE DISOKDERS OF SPEECH. Neurasthenia, the supply of energy is below par, so . that the motor cortex gets easily exhausted, and a Fatigue Neurosis is readily developed. It has also been observed that Nervousness, such as may be excited in the patient by the presence of an onlooker, aggravates the affection for the ctime being. Further, Dr Lewis has, in his observations upon the allied Telegraphist's Fatigue Neurosis, noted that, in some cases, when the patient feels the inability to perform with his hand the simple manipulations required in using the Morse instrument, he at the same time ex- periences an inability to form in his mind a proper conception of the dots and strokes required for representation of the letters. I saw last August a patient, now suffering from marked symptoms of Neurasthenia, who, when speaking in public, has of late observed a want of power in the tones of his voice. Five years before, he had consulted me on account of a very distinct threatening of Writer's Cramp, produced by over-fatigue in writing. In this case, Neur- asthenia seems to have been the predisposing cause of weakness both in the hand and in the Larynx. But, while thus fully recognising the importance of nervous exhaustion as a predisposing cause of Writer's Cramp, we yet cannot exclude the probability that many cases are of local or peripheral causation. It seems certain that, among professional scriveners, the simple fatigue of the muscles by work specially hard and long continued is of itself sufficient to induce the affection, even where the constitution is quite robust. In these cases, peripheral changes in the nerves or muscles may be expected to occur with special frequency. As to the possibility of Writer's Cramp having sometimes its origin in over-fatigue of the Spinal part of the motor tract, Dr Poore, in his chief paper, points out that several of the leading affections of the Spinal Cord may begin to betray themselves first of all in the hand, during the act of writing. Progressive Muscular Atrophy shows itself in this way more frequently than any of the others; but Dr Poore also records a case of Locomotor Ataxia that began with inco-ordinate movement of the hand in writing, and that developed to a marked degree in the upper, before it affected the lower extremities. Dr Poore supposes that in such cases there existed, in the first instance, a strong predisposition to the form of disease ultimately developed, and that the fatigue ofwriter's cramp. 83 writing merely acted as the accidental exciting cause that deter- mined the locality for the first appearance of the symptoms. Quite lately, Dr Fer6 of Paris1 has recorded a case of Jacksonian Epilepsy that first set in with tonic spasm of the fingers during the act of writing. He is disposed to think that there was in that case a predisposition to Epilepsy, and that the locality of the first con- vulsions was determined by the fatigue of the act of writing. He refers to the experiments of Scliiff, who shows that when a muscular act involving the contraction of only a limited group of muscles is so oft repeated as to induce fatigue, there is produced in the corresponding area of the Motor Cortex a condition of over-excitement that tends to invade the whole hemisphere of the same side, and ultimately even to spread to the other hemisphere. He thinks that this process may account for the generalization of the spasm that occurred in some of the attacks exhibited by his patient. Fully admitting, however, the possi- bility that an affection of the Spinal Cord or Brain to which there already exists in the patient a strong predisposition may thus have the locality of its first symptoms determined by prolonged fatigue in writing, we may reasonably ask whether it be not possible, even in the absence of such predisposition, that Progressive Muscular Atrophy may in some cases be excited by reckless endeavours of the patient to continue the work of writing after a Fatigue Neurosis in the hand has become fully developed. Onimus showed, in 1876,2 that in artisans, such as blacksmiths, prolonged fatigue was capable of producing what he called a Professional Muscular Atrophy, an affection that he regarded as distinct from Progressive Muscular Atrophy. It seems, however, questionable whether a dis- tinct line of demarcation can properly be drawn between the two affections; and some of the best authorities upon Muscular Atrophy do not recognise the distinction.3 I have notes of two cases in which very striking and extensive atrophy of muscles began in the hand, and was attributed by the patients, in both cases, to over- 1 Comptes rendus des seances de la Society de Biologic, Jan. 10th, 1891. 2 Lancet, 1876. 3 As to the frequency with which Progressive Muscular Atrophy results from fatigue in special groups of muscles habitually and excessively used in certain occupations, see article by Eulenburg in Ziemssen's Gyclopcedia, vol. xiv., p. 114 : also article in Eulenburg's Real-encyclopadie, vol. xiii., p. 595.84 THE DISORDERS OF SPEECH. fatigue. In the first of these, a clerk, aged 27, admitted into my Ward May 1st, 1886, the symptoms set in with a prickling sensation and numbness in the right hand and arm, when the hand was fatigued by writing. This was speedily followed by increasing loss of power and wasting in the muscles, so that lie was soon obliged, in writing, to use the left hand. Presently, symptoms of the same kind appeared also in the left hand; and subsequently, year by year, the wasting increased, extending gradually to the arms and trunk. He had been the subject of these symptoms for about nine years before I saw him. When in Hospital, he pre- sented extensive wasting of the muscles of the upper extremities and trunk, and was evidently the subject of an advanced Progressive Muscular Atrophy. His symptoms included well-marked fibrillar movements in the muscles affected. The second case was that of a blacksmith, aged 51, who was admitted into my Ward on Jan. 14th, 1888. His symptoms had set in eighteen months before, at a time when he was much overworked. One morning, in using the small hammer, the fingers of the right hand were seized with cramp. This continued to recur several times daily, and he soon noticed that the ball of his thumb was getting wasted, and that his fingers were getting weak, so that his grasp was too feeble to hold the hammer, which sometimes flew out of his hand. Wasting extended pretty rapidly both to the right arm and to the left hand and arm. When he came under my care, the hands and fore-arms were extremely wasted, the Extensor muscles of the elbow joints markedly so, and the Trapezius, Pectorals, Latissimus Dorsi, and Scapular Muscles, to a considerable degree. In this case, no fibrillar movements could be detected in the wasted muscles. It may be that in these cases there was a marked predisposition to Progressive Muscular Atrophy, and that the fatigue of certain groups of muscles merely played the role of an exciting cause. Nevertheless these two cases have suggested to my mind the possibility that there may be a form of Writer's Cramp in which the fatigued and exhausted portion of the motor tract is that part of the Anterior Cornu in the Spinal Cord that gives origin to the nerves for the hand; and that, in this form, a reckless persistence in the attempt to continue writing may lead, quite naturally, and without the co-operation of any marked predisposition, to the development of Progressive Muscular Atrophy.writer's cramp. 85 As to the treatment of Writer's Cramp, complete abstinence from writing for a lengthened period is the measure urgently called for, whenever the development of the affection is distinctly threatened. Too much attention need not be paid to an occasional feeling of fatigue in the hand, or even to occasional cramp-like closure of the fingers upon the pen, if these.symptoms occur only after very pro- longed exertion in writing. It is probable that every one who has written much has had occasional experiences of this kind. But when these symptoms begin to trouble a patient whenever he writes a little, it is time for him for a while to give up writing altogether, if he can possibly afford to do so. If he must go on, then he should, if possible, use a pencil or stylographic pen; or, if this is not allowable, take care to use a penholder that is large and thick. Thick cork penholders are now sold, and a substitute for these can be easily made by fitting a cork upon an ordinary penholder. If the symptoms should still persist, it will be highly advisable that the patient should for a long period give up writing altogether. He might with advantage learn to use the American type-writer, which calls a different set of muscles into action; or, still better, employ an amanuensis. For cases in which the affection is distinctly threatened, as well as for those in which it is confirmed, the use of the Constant Current has been found of value, the anode being applied to the affected muscles and the kathode placed over some neutral part of the body. Of still greater value is the method of treatment by Massage and Gymnastics. This method has been systematized and developed more especially by Wolff of Frankfort (formerly a teacher of writing), and by Dr Schott of Nauheim. These specialists have obtained very remark- able results, which are testified to by many eminent Continental physicians and surgeons, such as Billroth, Charcot, and Bam- berger. Lewis, who has had personal communication with Wolff, thus summarizes his method :—" It consists of a combined employ- ment of gymnastics and massage ; the gymnastics are of two kinds : 1st, the active, in which the patient moves the fingers, hands, fore- arms, and arms in all directions possible, each muscle being made to contract from six to twelve times with considerable force, and with a pause after each movement, the whole exercise not exceed- ing thirty minutes, and repeated two or three times daily; 2nd, passive, in which the same movements are made as in the former,86 THE DISORDERS OF SPEECH. except that eacli one is arrested by another person in a steady and regular manner; this may be repeated as often as the active exercise. Massage is practised daily for about twenty minutes, beginning at the periphery; percussion of the muscles is considered an essential part of the massage. Combined with this are peculiar lessons in pen-prehension and writing." A fuller account of this method, by Dr Theodore Stein of Frankfort, with a record of ten cases successfully treated by it, will be found in the Berliner Klinische Wochenschrift for 1882, p. 527. There seems to be no doubt that this method constitutes a decided advance in the therapeutics of Writer's Cramp. There are however, many cases,—especially, it would seem, those of Cerebral origin,—in which even this method is of no avail. On the whole, therefore, Writer's Cramp, when of long duration and thoroughly confirmed, must still be regarded as an affection that is apt, in a large number of instances, to prove persistent and incurable.EXPRESSIVE INARTICULATE SOUNDS. AUTOMATIC EXERCISES OF THE SPEECH ORGANS, LANGUAGE OF FACIAL EXPRESSION & GESTURE. INTELLIGENT SPEECH, FIRST YEAR SECOND Mi par YEAR THIRD YEAR " <PART SECOND. THE DEVELOPMENT OF SPEECH; AND THE DEVELOPMENTAL DERANGEMENTS. CHAPTEE IV. Sketch of the Development of Language in the Normal Child. Before entering upon the consideration of those derangements of speech which are due to arrested development, it is very desirable that we should have clear ideas as to the development of speech in the normal child. There are so many children in the world, and so many parents with full opportunities of observing them, that the various steps in the development of speech ought, one would think, to be very familiarly known. This, however, is far from being the case. Nature's processes in this development are so gradually completed as to exhibit no very striking steps that might serve as landmarks to the ordinary observer. Even a medical parent, however accustomed to accurate observation, would be able to give but a very poor account of the phenomena presented in the course of the development of speech in his own child, if he trusted entirely to memory. A full understanding of the process of development of speech can be obtained only by systematic observation of the child's progress from day to day, and by noting down in writing, day by day, the observations made. This is a tedious process, requiring much self-denial and patience. It is a kind of work many are willing enough to begin, but few are capable of carrying to a88 THE DISORDERS OF SPEECH. successful conclusion. Among those who have been most suc- cessful in recording the progress of their own children in speech, are Charles Darwin,1 from whose valuable observations a selection will presently be given ; and W. Preyer,2 Professor of Physiology in Jena, whose book upon the Mind of the Child ought probably to be regarded as the standard work on the subject. Other well- known writers 011 this subject are Berthold Sigismund,3 Taine,4 Y. Pollock,5 Perez,6 and Dr G-. J. Romanes.7 The book of Professor Preyer, which is in two volumes, has been translated into English by Mr H. W. Brown, teacher in the State Normal School, Worcester, Mass., U.S.A. Besides treating of the development of the senses and the will in the child, and of the intellect generally, this work contains, in its second volume, a series of very detailed notes regarding the development of speech in the Professor s own son, during the three first years of his life. I11 the Appendix, also, the author has brought together summaries of the conclusions of 110 fewer than thirteen or fourteen other observers (including some of those above mentioned) who have watched the development of speech in their children in a similar fashion. Professor Preyer has thus done invaluable service, both in recording his own observations and in bringing together a very considerable mass of observations made by others; and the reader will find, on perusal of his work, that these observations are classi- fied and considered in a very interesting and instructive manner. For a brief sketch, however, we must adopt a plan different from that of Professor Preyer, and arrange the facts in a different manner. Preyer's method is essentially a chronological one; the progress of his boy in all particulars being noted down day by day. In a short paper like this, it will enable us to deal with the matter more clearly and succinctly, if, instead of a chronologicalj 1 C. Darwin, Expression of Emotions; and Biographical Sketch of a Child, Mind, vol. ii., 1877. 2 The Mind of the Child. International Educational Series, 1890. 3 Kind und Welt, 1856 ; see Preyer's Appendix. The book itself seems to be now out of print. 4 Acquisition of Language by Children ; contributed originally to the Revue Fhilosophique ; translated into English for Mind, vol. ii., 1877. 5 An Infant's Progress in Language, Mind, vol. iii., 1878. 6 The First Three Years of Childhood, 1889. 7 Mental Evolution of Man, 1888.development of. language in the normal child. 89 we adopt an analytic method, and treat of each factor fully before proceeding to take up the next factor. This arrangement will, in the case of each factor under consideration, help us to bring together without confusion, as occasion may require, the observations that have been made on it by the various writers that have paid special attention to it. The plan of this chapter will be quite clear to the reader if he will, before reading it, examine with care the accompanying Diagram. It is hoped that the Diagram will be found to be so easily under- stood as not to require description. The only point that requires to be specially stated is that the various factors of the Diagram will, in this chapter, be taken up from left to right, in the order of the Diagram, Crying being first considered, and the Production of Intelligent Speech last. Independently of speech properly so-called, there are other means by which the child can give expression to its emotions and states of feeling. Such are Crying and Laughing, Crowing, and the Language of Facial Expression and Gesticulation. The development of these methods of expression is intimately related to the development of speech proper. There is a language in the very tones of the child's voice, and in the expression of its face— a language inherited rather than acquired—which is understood by mothers and nurses from a very early period of the child's life. The same language of vocal tone, facial expression, and gesticulation, used by the parents, is understood from a wonderfully early period by the child. It forms, indeed, the first means of com- munication between the minds of parent and child; and, later, it plays an extremely important part in the education of the child to the understanding of speech properly so called. I propose in the following brief sketch to say, in the first place, a few words about each of these inarticulate methods that Nature has provided for communicating information to others regarding states of thought and feeling. Expressive Inarticulate Sounds. A. Crying.—Naturally, the first Expressive Inarticulate Sound that claims our attention is Crying. It is by crying that the child announces its arrival in the world; and for months after- m90 THIS DISORDERS OF SPEECH. wards it occupies itself much in crying while awake, partly perhaps for exercise, and frequently as an indication of hunger or wetness, or some other form of discomfort. Both Preyer and Darwin make some valuable observations about crying. Preyer says that, in crying, certain vowel-sounds can be more or less clearly distinguished, viz., those of ua, ua, which maybe represented in English by the sounds of oo eh, oo eh. These are repeated, with untiring uniformity, for many months; only a few other sounds being added to them, viz., the syllables ma, nei nei, which in his child made their appearance in crying on the 64th and 65th days. He observes that even within the first five weeks, notwithstanding the uniformity of the vowel-sounds, the tones of the voice are so varied, that it may be told with certainty from these alone whether the child feels hunger or pain. There is screaming, with eyes firmly closed, in hunger; whimpering in slight indisposition, etc. During the 18th month, he notes still greater precision in the expression of the various moods by these inarticulate tones; and states that by screaming, wailing, whimpering, and weeping, moods of grief, desire, hunger, wilful- ness, and fear, are made easily recognisable. Darwin, in his work on the Expression of the Emotions, says (p. 160) that infants, when young, do not shed Tears when crying, although tears may be caused to flow by reflex irritation of the conjunctivae. On one occasion he accidentally brushed the open eye of his child with the cuff of his coat, and noticed that, although the irritated eye watered and the child screamed violently, the other eye remained dry. In this child, his first observation of the free effusion of tears during screaming was when the child was at the age of 139 days : they rolled down the cheeks. He states that in other children he has found the period at which the eyes become slightly suffused with tears during crying to be very variable, being in one child as early as the age of twenty days, and in another at sixty-two days. In one instance he was positively assured that tears ran down at the unusually early age of forty-two days. Preyer thinks Darwin mistaken in placing the date for the shedding of tears so late as he does. He believes that in German children pain causes the shedding of tears almost from the first, and states that in them it is not weeping, but sobbing, that first comes so late.expressive inarticulate sounds. 91 Darwin directs attention to the closure of the eyes daring screaming, and to the square shape of the open mouth. He quotes with approval the description by Mrs Gaskell of a baby crying. She says, " It made its mouth like a square, and let the porridge run out at all four corners." Darwin also directs attention to the contraction of the corrugators and the firm closure of the eyelids that are associated with screaming. B. Laughing.—Darwin makes some interesting remarks regard- ing the Physiology of laughter. At p. 220, op. cit} he says that whether laughter should be regarded as the full development of a smile, or a smile as the last trace of a laugh, we can follow, in infants, the gradual passing of the one into the other. Eecognising how difficult it is to be sure when the motions about an infant's mouth ought to be interpreted as a smile, he carefully watched the phenomena in his own infants. He found in one of them a pretty distinct smile at the age of forty-five days; and eight days later, the smile was unmistakable—the eyes becoming bright and the nose transversely wrinkled. There was at the same time a little bleating noise which perhaps represented a laugh. At the age of 113 days this noise became more broken and interrupted, as in sobbing; and he then regarded it as certainly incipient laughter. In two other children, smiling appeared at about the same date as in the first child. Preyer's boy seems to have smiled rather sooner than Darwin's children. Quoting Pliny's remark that no child laughs before the fortieth day, Preyer says, " I observed an audible and visible laugh, accompanied by a gleam of the eye, in my child for the first time on the twenty-third day. He was pleased with a bright rose-coloured curtain that was hanging above him; and he made peculiar sounds of satisfaction, which first led me to pay attention to him." The child afterwards laughed as a sign of joy, on looking at his mother's face, from the sixth to the ninth week; and by the sixth month his laugh had become merry, being accompanied by rapid raisings and droppings of the arms as a sign of the utmost pleasure. It first became persistently loud, in play with his mother, in the eighth month; so that every one could then at once recognise it as a laugh without looking in that direction. At such times, " the child made a peculiar impression of gaiety upon every one who saw him." The father notes that towards the92 the disorders of speech. close of the first year the laugh became different, being more conscious, and indicative of more understanding than before. Preyer notes that the child could by tickling be made to laugh even as early as the second month. Later, this reflex laughter was found to bear a close resemblance to that produced by the imitation of laughter in others. It did not seem to be fully possessed of the merry ring of^ the spontaneous expressive laughter. Darwin says that in the gradual acquirement by infants of the power of laughing we have a case in some degree analogous to that of weeping: practice is necessary before the child can either laugh or weep; just as it is necessary before he can walk. The art of screaming, on the other hand, from being of service to very young infants, is finely developed from the earliest days. He holds that children probably laugh and cry by inherited instinct, and that they understand by instinct these actions in others. He says (p. 379) that one of his own children at the age of four months understood a smile, and responded to it by another ; and that the same child, when a few days over six months' old, was brought by sympathy to the point of weeping, when his nurse pretended to cry. Darwin remarks upon the retention of weeping throughout life by savages as a means of expressing emotion; and quotes from Sir John Lubbock the case of a New Zealand chief " who cried like a child because the sailors spoiled his favourite cloak by powdering it with flour." He thinks that laughter is primarily the expression of mere joy and happiness; as we clearly see in children at play, who are almost incessantly laughing. He once heard a child a little under four years old, when asked what was meant by being in good spirits, answer, " It is laughing, talking, and kissing." C. Grunting.—This is an inarticulate sound of a more or less expressive character, which may be placed alongside of crying and laughing. Preyer noted it within the first three months, as an announcement of completed digestion, or of wetness; and says that for the first of these states it was retained by the child into the seventeenth month. It was generally associated with " abdominal pressure," and with lively movements of the arms.language of facial expression and gesture. 93 Language of Facial Expression and Gesture. A. Facial Expression. (a) Frowning.—Darwin, carefully observing his own infants from under the age of one week to that of two or three months, found that " when a screaming fit came on gradually, the first sign was the contraction of the corrugators, which produced a slight frown, quickly followed by the contraction of the other muscles round the eyes." He states that, when an infant is uncomfortable or unwell, little frowns may be seen to pass like shadows over the face, and that these are sometimes followed by a crying fit. He notes a steady little frown on the face of an infant seven or eight weeks old who was sucking some milk which was cold and therefore displeasing to him. (b.) Rage.—Darwin says that in one of his own infants under four months old he repeatedly observed that the first symptom of an approaching passion was the rushing of blood into the bare scalp. He says that " every one who has had much to do with young children must have seen how naturally they take to biting when in a passion. It seems as instinctive to them as in young crocodiles, who snap their little jaws as soon as they emerge from the egg." Preyer, referring to children about the age of seventeen months, observes that when no response is made to a persistently expressed desire they may be seized with a regular fit of rage, throw themselves on the floor, strike out when taken hold of, and scream furiously and most angrily; but he notes that it may also happen that disappointments of this sort produce tears of sorrow instead of fits of rage. Frowning, flushing, and screaming are noted as among the common indications of anger in children. (c.) Disgust.—Darwin (p. 273) says that he never saw disgust more plainly expressed than 011 the face of one of his infants at the age of five months, when, on one occasion, some cold water, and on a subsequent occasion, a piece of ripe cherry, was put into his month. This was shown by the lips and whole mouth assuming a shape which allowed the contents to run or fall quickly out; the tongue being at the same time protruded. He remarks that the protrusion of the tongue in letting a nasty object94 THE DISORDERS OF SPEECH. fall out of the mouth may explain how it is that lolling out of the tongue universally serves as a sign of contempt and hatred. (d.) Sulkiness.—Darwin (p. 242) shows that sulkiness in young children is shown by pouting, or, as it is sometimes called, " making a snout." " When the corners of the mouth are much depressed, the lower lip is a little everted and protruded, and this is likewise called a pout. Bat the pouting here referred to consists in the protrusion of both lips into a tubular form, sometimes to such an extent as to project as far as the end of the nose, if this be short. Pouting is generally accompanied by frowning, and sometimes by the utterance of a booing or whooing noise. This expression is remarkable as almost the sole one, as far as I know, which is exhibited more plainly during childhood, at least with Europeans, than during maturity. There is, however, some tendency to the protrusion of the lips with the adults of all races under the influence of great rage. Some children pout when they are shy, and they can hardly then be called sulky." (e.) Guilty Expression.—Darwin (p. 275) notes that he observed a guilty expression without a shade of fear in some of his own children at a very early age. " In one instance the expression was unmistakably clear in a child two years and seven months old, and led to the detection of his little crime—the taking of pounded sugar which he had been told not to take. It was shown, as I record in my notes made at the time, by an unnatural brightness of the eyes and by an odd affected manner impossible to describe. As he had never been in any way punished, his odd manner was certainly not due to fear, and I suppose it was pleasurable excite- ment struggling with conscience." (/.) Surprise.—Both Darwin and Preyer remark on the elevated eyebrows and open mouth as indications of surprise; and Darwin tells an anecdote which shows that children at a distance can interpret the lifting up of the hands, with fingers extended and spread apart, as an indication of astonishment. (g.) Fear.—Preyer (vol. ii., p. 132) notes screaming as a sign of fear, which in his child was most markedly produced by anticipa- tion of the cold bath; and he observes (p. 131) that fear is one of the moods of mind which the child makes easily recognisable by the character of its screaming. Darwin, as is well known, has very fully described the indications of fear in man and in the lowerLANGUAGE OF FACIAL EXPRESSION AND GESTURE. 95 animals; but he says nothing regarding it that applies in any special way to children. (h.) Blushing.—About the phenomenon of blushing, Darwin has a great deal that is interesting to say. He distinguishes it from the flushing of rage, which is common to man and some of the lower animals; and holds that blushing is the most strictly human of all expressions; that it cannot be produced by any physical means; and that the psychical condition which seems neces- sary for its production is self-consciousness and sensitiveness to the opinions of other people regarding personal appearance, conduct, etc. He shows that idiots do not blush, and that blushing never occurs in very early infancy. Excessive blushing is frequently an inherited peculiarity. When the tendency is strongly developed, it may appear at the age of two or three years. He has notes of two little girls blushing at the age, of between two and three years, and of another sensitive child a year older, blushing when reproved for a fault; and he states that many children, at a somewhat more advanced age, blush in a strongly marked manner. Young people always blush more freely than the old. He has a good deal to say about Shyness as a cause of blushing. He says, " with young children it is difficult to distinguish between fear and shyness, but this latter feeling with them has often seemed to me to partake of the character of the wildness of an untamed animal." In one of his own children he noticed a trace of shyness at the age of two years and three months. It was shown, not by a blush, but by the eyes being for a few minutes slightly turned aside. He thinks that shyness, and shamefacedness, and real shame, are sometimes exhibited in the eyes of young children before they have acquired the power of blushing. He holds that, as shyness apparently depends on self- attention, " we can perceive how right are those who maintain that reprehending children for shyness, instead of doing them good, does much harm, as it calls their attention still more closely to themselves/' Remarking on the absence of self-consciousness in children at a very early age, he says that " it is one of their chief charms that they think nothing about what others think of them. At this early age they will stare at a stranger with a fixed gaze and unblinking eyes, as on an inanimate object, in a manner which we elders cannot imitate."96 the disorders of speech. B. Gestures. (a.) Negation and Affirmation.—One of the gestures which is soonest acquired by children is the moving of the head from side to side as an indication of negation. Darwin thinks that this movement, as well as the companion movement of nodding for affirmation, may have originated in connexion with the feeding of children. When the child is willing to take its food, it bends the head forward, but, if unwilling, it turns the head to one side. In the latter case, if the food be pressed upon it, it may turn its head alternately to the one side and to the other. Later, the child is easily trained to employ these movements as indications of affirma- tion or negation. Preyer states that his child first shook the head from side to side when any one said "No, no," to him in the thirteenth month, but that he did not learn the affirmative nod till the fifteenth month. (b.) Pointing with the Hand or Finger.—This is a very important gesture, much used by young children. Preyer states that it is already employed with perfect correctness before the first attempts at expression in words. He refers to a little girl of eleven months, who, not yet able to speak at all, answered such questions as "Where is Papa?" "Where is Nanny?" correctly, without a single mistake, by movements of the eyes, and by indicating direction with the finger. He states that later this pointing is used as an expression of a wish. One of Darwin's children, for example, at the thirteenth month, picked up a piece of paper and gave it to his father, pointing to the fire, because he wished to have the pleasure of seeing it burn. Many other gestures might be described, such as the stretching out of the hands and grasping with the fingers when something is wanted; such movements being developed from a very early period. Shrugging of the shoulders, as indicative of helplessness, is frequently developed, by inheritance or imitation, in the children of French and German parents; but is rare in English children. Sometimes the child's Actions are full of expression,—for example, those of Preyer's child of twenty-two months when he wished to sit at the table. "~No one listening to his entreaty, he goes into the corner of the room, tries with a great effort to get a heavylanguage of facial expression and gesture. 97 chair, does not rest till he has placed it at the table, strikes with the flat of his hand on the seat of the chair, thus expressing plainly without words what he wants, and exults when he has been put up on the chair." Preyer thus concludes his consideration of this subject:—" The variety in the expression of the countenance, when, in the second and third years, the separate passions gradually awake, is inde- scribable; and, on account of the transitoriness of the phenomena, is hardly to be reproduced pictorially. Jealousy, pride, pugnacity, covetousness, lend to the childish countenance a no less character- istic look than do generosity, obedience, ambition. These states could not be recognised by the expression of countenance unless each of them had its own expressional movements; and, in fact, these movements appear in greater purity in the child, who does not dissemble, than they do in later life." As to the power of the passion of jealousy in children, Perez1 has some interesting remarks. He says, for example, " One of my nephews at the age of three years used continually to talk of the little brother he was soon to have. ' I shall love him so much,' he would say every instant. But when he saw the baby taken up on his mother's lap, and kisses and caresses, and his father's care and attention, he expressed his annoyance loudly. He even said to his mother, 4 Won't little Ferdinand soon die ?' When the baby began to walk and talk, the elder child would torment him in hundreds of naughty ways; beating him, dragging him out of his chair in order to take his place, shouting in his ears, calling him naughty and ugly, taking away his toys, and mimicking his way of talking and walking.'7 Automatic Exercises of the Speech Organs. A. Babbling.—This is a most interesting phenomenon, exhibited by all healthy children from a very early age. It is the Automatic and Unconscious Exercise of the organs, which at a future time will become the agents of Speech. Just as the child, before he can walk, must exercise his limbs in kicking and sprawling, so, before he can even begin to speak, he must exercise 1 Of. cit.y p. 71, et seq. n98 THE DISORDERS OF SPEECH. his organs of Speech in a similar inco-ordinate fashion. In crying and laughing, as already shown, the organs of Phonation are abundantly exercised. In Crying, the Oral Mechanism has been observed to take a slight part, sufficient for the imperfect pro- duction of a few vowel sounds, and one or two consonants. But, in Babbling or Prattling, we have something altogether different: something more nearly akin to the movements of articulate speech, inasmuch as the Oral Mechanism takes part in it almost as actively as the Yocal. In babbling or prattling, vowels are produced in much greater variety, and with much greater distinctness than in crying, and consonants are for the first time produced abundantly, their variety being, indeed, astonishing. From the very detailed notes of Professor Preyer, we may make a few illustrative extracts showing the progress of his child in the production of vowel and consonant sounds during this process of babbling. On the forty-third day, Preyer heard the first consonant. " The child in a most comfortable posture, uttering all sorts of obscure sounds, said once distinctly, am-ma. Of vowels, a O was like- wise heard on that day. But on the following day the child surprised me and others by the syllables, spoken with perfect distinctness, ta-hu, ta-hu. " On the forty-sixth day, in the otherwise unintelligible babble of the infant, I heard, once each, go (o nearly like i in bird), oro; and five days later, ara. " In the eighth and ninth weeks, the two utterances orro and arra became frequent; the O and a being pure, and the r uvular. It has already been noted that ma and nei-nei were produced, in crying, on the sixty-fourth and sixty-fifth days. On the sixty-fifth day, a-omb was produced, in babbling. " On the day after, distinctly, once each, la, grei, aho; and, besides, ma, again. " On the sixty-ninth day, the child when hungry uttered repeatedly, and very distinctly, momm and ngo. " In the tenth week, of the syllables earlier spoken, only orro is distinctly repeated. On the seventy-first day, the child being in the most comfortable condition, there comes the new combination ra-a-ao; and five days later, in a hungry and uncomfortable mood, na and nai-n.automatic exkkcises of the speech organs. 99 "On the seventy-eiglitli day, the manifest sign of contentment habu was very distinct; and likewise in the twelfth week, a-i and uao, as well as a-o-a, alternating with a-a-a and o-a-o. " It now became more and more difficult to represent by letters the sounds already more varied, and even to distinguish the vowels and repeat them accurately." The above may be taken as an example of Preyer's detailed observations. But it will not be necessary for us to follow his description further in full detail. It may suffice to say that, within the first seven months, all the vowel and consonant sounds, with a few exceptions, had been recognised in the babble of the infant. The exceptions were w, which appeared in the twelfth month; s, in the fourteenth; Z, in the fifteenth; f, in the six- teenth ; and sh, which did not appear until the twenty-fouyth month, when the child had already acquired some amount of actual speech power. One of the chief occupations of a healthy child is this babbling or prattling, and he is most apt to practise it when he is feeling happy and comfortable. B. Croaving.—When he is specially happy he frequently prac- tises Crowing, which appears to be little else than a loud and joy- ous production of sounds of the same nature as those of babbling. Preyer notes that, on the seventy-eighth day, the manifest signs of contentment were habu, ai, uao, etc. About the fifth month, began the amusing crowing of the child, an unmistakable expres- sion of pleasure; the child pronouncing the strong aspirate sound ha with the labial r in brrr-ha, as well as other sounds, such as aja (j like y in English). About the thirteenth month, the joy- ous crowing sound had become stronger and higher; the child crying out, on seeing his mother in the distance, a sound which might be represented by the letters ahija. The habit of babbling and crowing is retained by the child even after he has begun to acquire the power of Speech. Preyer's child in the thirty-fifth month is reported to have been found repeating all sorts of meaningless syllables again and again, much as in the period of infancy, only more distinctly; "but, just as at that time, they cannot all be represented on paper, or even be correctly reproduced by adults." C. Mimic Eeading.—A further development of babbling is100 the disorders of speech. the child's Mimic Reading of books and newspapers. This was first noticed by Preyer during the fifteenth and sixteenth months. He says, " The child likes to take a newspaper or a book in his hands and hold the print before his face, babbling a-e, a-e, a-e, evidently in imitation of the reading aloud which he has often observed. By giving the command, ' Read,' it was easy to get this performance repeated." It was again observed in the nineteenth month, when the child, spreading a newspaper on the floor, " read" over it for a long time in a monotonous voice, e-ja-e-e-ja nanana ana-na-na atta-ana aje-jd sa. It was kept up in the same manner in the twentieth month. In the twenty-first month, the reading became still more frequent; but, singularly enough, the sounds, from the eighty-ninth week on, became different, the consonants becoming more prominent than they had hitherto been. In the twenty-seventh month, it is noted that babbling monologues are becoming less frequent. D. Echolalia.—This curious phenomenon seems, in the progress of development, gradually to take the place, to a considerable extent, of the babbling monologues above described. The child may begin to practise it even before he has acquired the power of pronouncing any actual words, spontaneously or at command; the pronunciation of words by Echolalia seems at first to cost him much less effort than the pronunciation of words at command; and the words produced by Echolalia are, in the first instance at least, produced in a parrot fashion, without the slightest inkling of their meaning, and with- out any apparent effort on the part of the child to understand them. They are mere sound-imitations, and for the most part are repetitions of the last words in sentences that the child has just heard spoken in his vicinity. The child repeats the last word again and again mechanically. No doubt this mechanical repeti- tion plays an important part, as a preliminary exercise, in the development of actual speech. The words will by-and-by be produced intelligently with all the greater ease, if their pronuncia- tion has already been practised mechanically. Preyer, in the fourteenth month, first noted this parrot-like repetition; the first examples of it being given in the repetition of syllables that the child had in the first instance uttered of his own accord, and that his father, Preyer himself, had immediately afterwards pronouncedintelligent speech. 101 to him. " Thus attai, tai, atta, were often easily and correctly repeated in this way; but, strangely enough, frequently, in a whisper." In the twenty-third month, it is noted that if the child hears some one speak he often repeats the last syllable of the sen- tence just finished, if the accent be 011 it; as in 4 What said the manV when he says man; or in 'Who is there V when he says there. Once the name Willy was called; and immediately the child called iiile, with the accent on the last syllable; and repeated the word many times. In the twenty-fourth month, Ecliolalia is still further developed: the child after hearing shouted the German word ' Herein !' (' Come in !'), repeated it as arein, arrein, ha-arein; at first as a sound, but afterwards with more intelligence, looking at the door. In the twenty-seventh month, articulation being further developed, the child is able to repeat by Ecliolalia little sentences which he has just heard pronounced ; and some of these, at subsequent times, he would occasionally reproduce from memory without understanding them, to the great amusement of the family; for example, Um Gottes willen (for God's sake), and Da hastn (there you have him). He also imitated all sorts of noises, such as the whistle of the locomotive, and the voices of animals. Intelligent Speech. A. The Understanding of Spoken Wokds.—How early the awakening intelligence of the child begins to interpret the lan- guage of gesture, tone of voice, and facial expression, has already been illustrated by the case of one of Darwin's infants, who at four months smiled in response to a smile, and at six months was brought to the point of crying when the nurse pretended to cry. The Understanding of Spoken Words dawns upon the child con- siderably later. In learning to understand words and to speak, girls are, as a rule, earlier than boys. The case of one little girl has already been cited, who at eleven months correctly answered the questions, "Where is Papa?" "Where is Nanny?" etc., by pointing with the fingers, though not yet able to speak a word. In a process of development, it seems natural that words should be understood before they can be intelligently produced; and it is the fact that, throughout the process of learning to speak, the102 THE DISORDERS OF SPEECH. understanding of what is spoken keeps far ahead of the power of independently producing spoken words. In most children, the understanding of certain words in very familiar use, such as papa and mama, seems to dawn upon the child towards the end of the first year, or about the beginning of the second. Preyer notes that, in the twelfth month there was for the first time developed in his boy an ability to discriminate words heard. " The child turns round when his name is spoken in a loud voice: he does this, it is true, at other loud sounds also, but then with a different expression. In the thirteenth month, the word mama, which formerly had often been used by the child in his babbling, is now for the first time referred to his mother." Preyer remarks that in this month, the first of the second year, the most important advance consisted in the now awakened understanding of spoken words. <£ The ability to learn, or the capability of being trained, has emerged almost as if it had come in a night. The child is now easily taught to hold up his arms, when the question is asked, 'How tall is this child ?' and to hand prettily an ivory ring to his father, when asked, 4 Where is the ring?' If, when he is holding a biscuit to his mouth, he is asked to give, he holds the biscuit to the lips of the person who asks him." In the fourteenth month, the understanding of words heard is found to have still further advanced. He knows where the clothes-press is; and turns his head in the right direction when asked, " Where is papa—mama—the light ?" When asked to play the piano, he beats his hands on the table. If anyone speaks to him of the nose, lie snorts. When 'No, no,' is said to him, lie shakes his head from side to side. Yet, with all this rapidly advancing understanding of spoken words, there is, at this time, no power of producing speech properly so called. The child can- not even repeat ' Pa' or ' Ma' or ' o' or ' e,' and the only word which he employs with a definite meaning is one of his own invention, viz., atta, which with him signifies away or gone. In the fifteenth month, when coughing is spoken of he coughs; when blowing, he blows; when kicking, lie stretches out his legs; and when the moon, the clock, the eye, or the nose is mentioned, he raises an arm, spreads the fingers, and looks in the proper direction. He also gives his hand when asked to do so.intelligent speech. 103 In the sixteenth month, he can point out the features of his own face, and knows where 4 the other eye' and 4 the other ear' are. In the eighteenth month, a number of additional words are understood; such as finger, glass, door, sofa, thermometer, stove, watering-pot, and biscuit. Still, as yet, the repeating of syllables spoken for him is rare; even the word Mama being responded to by ' ta.' In the nineteenth month, Pa is at last correctly pronounced in imitation; and in the twentieth he can say Papa. From this time forward, the vocabulary of words that are under- stood rapidly increases; and it continues to keep ahead of the vocabulary of words which can be pronounced by the child. But it will not be necessary for us further to follow the progress of the child from month to month. B. Words of Child's Own Invention.—A few remarks may now be made about the specific word-sounds of their Own Invention which some children from a comparatively early period employ in making known their wants, or in giving expression to their emotions. Both Darwin and Preyer have noted some of these. Darwin says that one of his children, in the twelfth month, when he wanted food, began to say mum, instead of beginning to cry as formerly. At a later time, shu-mum was used for sugar, and still later, black shu-mum for black sugar, these words being pronounced with a very marked tone of longing. Preyer says that his boy frequently in crying said momm when hungry; that this was noticed even so early as the tenth week; and that a child observed by Frau Schultze of Dresden used to say mam-am in the same circumstances. Mimi was a word used by Preyer's boy as a general designation for food. It was supposed to be derived by the child from the word Milch, which he was in way of hearing frequently. It appeared first in the twenty-first month, and was often uttered with indescribable longing. Hay-uh was a begging sound associated with stretching out of the arms and forward inclination of the bodj^, which began to be used during the first three months of the second year. Atta, as already indicated, was a word employed, for a considerable period, with the meaning of away, when anything disappeared or a light went out. It first began to be used in the fourteenth month.104 THE DISORDERS OF SPEECH. Preyer thinks it a mistake to designate these words as " words of the child's own invention." He regards them as probably obscure imitations of words that the child has been in the habit of hearing: Mimi, for example, being probably derived from Milch. Cases, however, are recorded by others, in which a copious vocabu- lary of such words, each word with its definite signification, was employed by the child for a lengthened period before any serious attempt was made to employ words of the mother-tongue. Komanes1 records two remarkable cases of this description. In the first case, two twin boys, remarkably alike in personal appearance, invented, at the age when speech is usually first developed, a language of their own; and for several years 110 pains could induce them to speak anything else. Even the usual first words 'papa, mama/ they refused to use. They had their own names for their parents and for their aunt; and, talking in their own speech, they played together with all the liveliness and volubility of common children. Their word for carriage was ' ni-si-boo-aand when a carriage was heard in the street, they would shout this word, and run to the window to see it. The second case was that of a girl, aged four-and-a-half years, sprightly, intelligent, and in good health. At two years, she had been backward in speaking, and used only the words Papa and Mama. After this, she began to use words of her own invention, and, though she readily understood what was said, never used the words used by others. Gradually she accumulated a consider- able vocabulary of her own words. She had a brother, eighteen months younger than herself, who learned her language. When the two were together, they could converse with great rapidity and fluency. It is curious that in this case, although the parents were American and spoke English, and no French-speaking people lived in the house, some of the words employed were in sound closely allied to French. Thus feu meant 'fire, light, cigar, sun;' too (Fr. ' tout') meant ' all, everything;' and nepa (Fr. ' ne—pas') meant4 not/ Petee-petee (an apparent equivalent of the Frencli 'petit') was the name given by the girl to her little brother; and ma (Fr. 'moi') meant 'me' or '1/ The word mea signified both cat and furs; but this is almost the only trace, in the language, of words suggested by the imitation of sounds. A considerable list of other 1 Op. citp. 138, et. seq.intelligent speech. 105 words is given from the vocabulary of this curious case. Migno- migno signified ' water, wash, bath;' go-go, delicacies; gar, 'horse'; deer, money of any kind; beer, literature, books, etc.; peer, ' ball'; and so on. It will not be necessary to give the case in full detail: the specimens of words already given will suffice to show that the designation " words of the child's own invention " is probably the best that could be used for the words thus occasion- ally formed and used by children. In most cases, there is nothing in them to suggest, even remotely, imitation of the mother tongue.1 C. Intelligent Speech Pkoduction-.—In following the progress of Preyer's boy as he began to accumulate a vocabulary of words which he understood but could not pronounce, we found that about the nineteenth month the vocabulary was already considerable. It presented a remarkable contrast to the small number of words with definite meaning that he was as yet able to use for the purposes of speech. These consisted merely of his old self- invented word atta and the words pa and papa. During the progress of that month, however, he made many efforts to imitate other words that were pronounced to him : thus, for 4 bitte' (please) he said bis, bits ; etc. For 'Fleisch' (meat) he said daisch. In the twentieth month, he correctly reproduces several words of two syllables, such as Papa, Mama, bebe, baba, and neinei; but 'trocken' yields tokke, and ' warm' and ' weich' become wai. For ' adieu' he gives ade; and he declines to try4 Gute Nacht,' though he holds out his hand when one says it to him. In the twenty-first month, the father notes that words of unlike syllables are not repeated at all : not even ' bitte' (please). In place of ' danke' he gives dank-kee —at an earlier time it had been dakku. When asked, " Do you want milk ?" he replied Neinein; and, on another occasion, when asked, "Does it taste good?" he answered Jaja. In the twenty- second month, he is remarked to obey orders with surprising accuracy. In the twenty-third month, the first spoken judgment is noted: he said heiss (hot), when he found milk too hot in 1 The first of these two cases was originally published by Mr Horatio Hale, in the Proceedings of the American Association for the Advancement of Science, vol. xxxv., 1886. The second case was originally published by Dr E. R. Hun, in the Monthly Journal of Psychological Medicinet 1868. 0106 THE DISORDERS OF SPEECH. drinking it; and in the same week, looking at the stove, he suddenly said with decision heiss (30 weeks previously he had reproduced heiss by Echolalia without understanding it). 4 Wasser' is now pronounced as Watja; and Mimi means milk and food in general. His grandparents lie designates as E-papa and E-mama. A great many words can now be imitated more or less correctly; ' Ohr' being given as Oa,4 Haus' as Hausesess, 4 Hand' as Hann,' Finger' as Pinge, 4 Karl' as Kara,' Butter' as Buoto. (Echolalia is about this time noted as being very active.) Spontaneously the child says Ab (off), when he wants a neck-ribbon loosened. Tor "Guten Morgen" he says Moigen, and for "Gute Nacht" he says Na. In the twenty-fifth month, progress is noted as extraordinary. It is observed that the vowels give the boy no difficulty, with the exception of u (oo) and i (ee), which he does not yet produce perfectly. Among the consonants, sch (sli) is still omitted; as also are many double consonant-sounds, such as cht. He now gives in his own fashion the names of many things when they are pointed to, saying, for example, Nana for ' Nase' (nose); Ba for ' Backe' (cheek); Tenn for ' Kinn' (chin); Ann for ' Hand.' In the twenty-sixth month, sch (sli) now appears for the first time, in the word Handschuh (glove), but not in other words. He now for the first time begins to use verbs, but always in the infinitive, as, Mama auch tommen (Mama come too); and he makes new infinitives out of nouns, saying, for example, messen from 'Messer' (knife), when he wishes to have an apple pared. He now in his own way expresses his feelings by words; exhibiting, for example, much sympathy when dolls are being cut out of paper, being afraid that the head (Topf) may be taken off; and crying "arme Holz" (poor wood), when a stick of wood is thrown into the stove. In the twenty-eighth month, besides other indications of great progress, he asks his first question, viz., " Where is Mima ?" It is noted that, in his articulation, he still misses s and sch frequently. In the twenty-ninth month, he uses the first personal pronoun for the first time, saying " Bitte gib mir Brod" (please give me bread). He had formerly designated himself by his Christian name, Axel. In the thirty-second month, he uses this pronoun in the nominative case, saying, " Ich komme gleich " (I am coming immediately). In the thirty-third month he has progressed so far as to use sentences of some length; thus,INTELLIGENT SfEECH. 107 pointing to the picture of a cock, he says, " Das ist der Hahn —kommt immer—das ganze Stuck fortnehmt—von der Hand—und laiift fort" (That is the cock—keeps coming— takes away the whole piece—out of the hand—and runs off). This refers to his previous feeding of fowls, at which a cock had actually behaved as described. During this month, he for the first time uses the second personal pronoun, remarking, " What a pretty coat you have." It is about this time remarked that a feeling of self-hood is becoming strongly developed, so that the boy wishes to do everything for himself, without help. When asked where he learned such and such an expression, he replies that he learned it " himself alone." In the thirty-fifth month, a feeling of causality begins to be expressed in language. Questions are now asked till it reaches the point of weariness: " Why is the wood cut ?" " Why does Frederick clean the flower-pots ? " and so on, ad infinitum. The father says that it seems remarkable that he did not once hear the child say " When ?" until the close of the third year. "The sense of space is but little developed at this time, but the sense of time still less." It is remarked that the articulation is being speedily perfected, so that of German sounds the sch alone is seldom correct, being represented by s. It did not finally replace the S until the forty-six month. In the thirty-sixth month, grammatical errors are becoming much more rare, and long sentences are formed correctly, though slowly and with pauses. The father remarks that the child's manner of speaking, now that he was three years old, approximated more and more rapidly to that of the family, through continued listening to them and imitation of them. He therefore, at the conclusion of the thirty-sixth month, gave up taking notes. The above are but examples of the very detailed observations recorded by Professor Preyer regarding the progress of his boy. Many details have been omitted; but the work itself is easily accessible, and is worthy of careful perusal. It appears to me that one of the most striking facts brought out by this valuable record is the marked difficulty which a child experiences in his first attempts Ho pronounce syllables or words by a definite effort of the will, either spontaneously exercised or made at request. This difficulty becomes all the more striking when one considers108 THE DISORDERS OF SPEECH. the apparent ease with which, for months previously, consonants and vowels have been produced in automatic babbling, and words, and even phrases, have been reproduced by the process of Echolalia. The first efforts at intelligent speech call into action the higher and more conscious functions of tbe Cerebrum, which, as yet, have had little or no concern with the processes of articulation. Everything goes to show that the higher centres can learn their own duties with regard to speech, and train the lower speech-centres to prompt and perfect obedience, only after a period of persevering effort. All such effort involves the exercise of intelligence and attention. In our next chapter, we shall find that the chief Developmental Derangements of speech are to be met with in children who are feeble minded, and therefore defective in intelligence and the power of attention. These children are incapable of making the sustained effort required for the training of the nervous mechanism. Even in Preyer's boy, great difficulty, sometimes betrayed by efforts of straining, was observed in the production of syllables at command for the first time. But another case, reported by M. W. Humphreys, Professor of Greek in Yanderbilt University, Nashville, and referred to by Preyer in his Appendix (p. 257), exhibits the transition from automatic and mechanical Babbling and Echolalia to Intelligent Speech-production in an even more striking manner. This child, a girl, when only four months old, began in her babbling a curious mimicry of the tones of ordinary conversation. It is reported that, when she was six months old, the articulation in these babbling conversations was singularly distinct. When she was eight months old, it was found that she knew by name every person in the house, as well as a great many of the objects around her. At the eleventh month, she could imitate with accuracy any sound given her; and she indulged in monologues, in which she used a great many real or imaginary words without reference to meaning. But now came the transition step. " After the first year, her facility of utterance seems to have been lost; so that she watched the mouths of others closely when they were talking, and laboured painfully after the sounds. Finally, she dropped her mimicry of language, and, at first very slowly, acquired words with the ordinary infant pronunciation; showing a preference for labials (p, b, m), and linguals (t, d, n, but not 1)." This case is no doubt exceptional, and Preyer regards it as, up toINTELLIGENT SPEECH. 109 this time, unique ; but it is extremely instructive, as showing, in a very striking and exceptional way, how different is the action of the Cerebrum in babbling and echolalia, from its action in the production of voluntary and intelligent speech. A subject upon which a few wrords may still be said, is the order in which the vowels and consonants are produced for the first time, during the earliest efforts at voluntary speech. This order certainly seems to differ from that observed in the production of the babbling sounds. In the latter, it would appear that the vowels and consonants are from the first produced almost indiffer- ently, and with equal ease; only a few—viz., w, S, z, f, and sh —being, in the case of Preyer's boy, for some months delayed. In voluntary speech, on the other hand, there is certainly an order of difficulty; though to make out this order in detail many cases would have to be recorded and compared. At present, we can only say :—(1.) As to the vowels, that i (ee) and u (oo) are the only ones not pronounced with ease from an early period; (2.) As to the consonants,that the three pronounced during closure of the Labial,or first stop-position—viz., p, b, and m—and the corresponding three pronounced during closure of the Anterior Linguo-Palatal, or second stop-position—viz., t, d, and n—seem to be the easiest for the child, and generally the first employed. Everybody knows that the sylla- bles pa, ba, ma, ta, da, na, rank among the first which can be reproduced by the child. The consonants produced during closure of the third stop-position—viz., k, g, and ng—are later in appearing as parts of voluntary speech; and sometimes their appearance is delayed for months, or even for years. Among the fricatives, those which most frequently present difficulties to the child are probably r and 1, and, in a less degree, sh, s, ch, and y. Preyer's boy had special difficulty with the sh sound as compared with the s; but the reverse of this sometimes happens, as is shown by the case of a child observed by Gustav Lindner (see Appendix to Preyer's second volume), who for months used the sh sound in- stead of the s. Another point well worth noting is the " Smudging " or Scamp- ing of the syllables in baby speech. The child omits the consonants difficult to him; sometimes putting nothing in their stead, and some- times substituting for them others that he can pronounce without effort. He also converts double consonants into single ones. Often110 THE DISORDERS OF SPEECH. he reduces a syllable to such simplicity that the listener can guess at its intention only from the sound of the vowel. In our next chapter, we shall see these and other features of baby-speech repro- duced in the c lalling' of weak-minded children. As to the developmental relationship between walking and speaking, much information will be found in Preyer's work. He shows that some children walk as early as the ninth month, and others not until they are a year and a half, or even two years old. He thinks that much depends upon the surroundings. He is of opinion that" children in sound condition mostly walk before they speak, and understand what is said long before they walk." In this chapter, I have endeavoured to separate the various phenomena from each other, and to consider each by itself; although, as the reader will understand, the processes described are for the most part going on simultaneously during the child's development. Perhaps the Diagram may in some degree serve to keep before the mind of the reader the correlations of the various processes in point of time. Although I have adopted this method of presentation, which is different from that of Professor Preyer, I trust that this chapter will suffice to bring before the reader the general conclusions arrived at by Darwin and Preyer regarding the development of speech in the child. Many important facts and much detail have been omitted, but I trust that none of their observations have been mis-stated; and I hope that this brief statement of their views may be useful to the reader, as an introduction to the study of the developmental derangements of speech that I propose to treat of in my next chapter.the three functions of the voice. Ill CHAPTER V. The Three Functions of the Voice. Speech of Idiots and Imbeciles. It will probably contribute to clearness of description if, before entering upon the consideration of the Developmental Disorders of Speech, I make, in the first instance, an endeavour to lay before the reader, in brief, some of the main facts regarding the Normal Development of Speech that were discussed, at some length, in the last chapter. This, I think, may be done most simply, if we concentrate attention specially upon the production of Voice, and try to realize the various functions that are, one after another, assumed by the Voice in the course of development. The Three Functions of the Voice. 1. An Exercise for the Lungs and Respiratory Muscles.—The crying of a new-born child cannot properly be described as its method of expressing emotion. At this early period of its exist- ence, there is probably no emotion to be expressed. The nerve force which first calls the crying muscles into action, has, in all probability, been furnished, not by the brain at all, but by the Spinal Cord, or, to be more precise, by the Medulla Oblongata. Even anencephalous children, if alive, will cry at birth, although they may be possessed of no trace of brain texture. The purposes of Nature, in thus calling the Vocal Mechanism into action so early in life, seem capable of easy explanation. It seems certain that the increased air-pressure put upon the lungs by the strain of crying must, immediately after birth, play a very important part in opening up the air vesicles for the entrance of air. At the same time, there can be no doubt that the act of crying affords a112 THE DISORDERS OF SPEECH. means of exercising, in a beneficial way, all the muscles of the Eespiratory System. It must tend to strengthen these muscles, much in the same way as, in after years, the muscles of the limbs will be strengthened by exercise or by gymnastics. Crying, laughing, singing, shouting and talking, practised freely by young children, are generally believed to be good tonics for the lungs; and it is entirely in harmony with this belief to find that deaf- mutes, who cannot talk, and who otherwise use their voices much less than normal children, are believed by many to have weak chests, and to be specially prone to chest affections. It would appear, further, in regard to deaf-mutes, that they derive benefit to their general health, and especially to their Eespiratory Organs, from being taught to speak by the modem " oral method," which calls their vocal organs and respiratory muscles into play in the ordinary way, as in the speech of others. This tonic function of vocalization, especially important as it is to the health of the child during the first days and weeks of its life, when crying is its leading form of exercise, probably retains something of the same kind of tonic influence on the Eespiratory Organs in after years, when vocalization is practised in other ways. The free use of the voice is probably an important tonic to the whole Eespiratory System throughout the years of growth and development; and even in later years something of the same utility cannot reasonably be denied it. Thus we may conclude that, before the voice is used at all as a means of expressing either emotion or thought, it is used automatically as a means of exercising the lungs and the muscles of respiration; and that, even after the voice has become the chief expressive instrument of the mind, its exercise still continues, throughout life, to have something of its old tonic effect upon the Eespiratory System generally. 2. A Means of Expressing Emotion.—Very soon, however,—even so early as a few days or weeks after birth,—the function of voice- production begins to fall more and more under the sway of the Cerebrum. The Sensorium has, in the meantime, been receiving- many forms of stimulation from without, and is beginning to awake. It has been receiving impressions of many kinds, which have been poured in upon it through the organs of special sense and cutaneous sensibility. Light has begun to form images on the Eetina; sounds have been falling upon the ear; the other organsTHE THREE FUNCTIONS OF THE VOICE. 113 of special sense have been transmitting their various forms of sensation; the cutaneous sensibility lias become more and more developed; and visceral sensations have been experienced, in connexion with the condition of the digestive and other internal organs. It is one of the far-reaching laws of Nature, that the child soon experiences pleasure or pain from the various sensa- tions thus produced; and, further, that the sensations which give it pleasure are for the most part produced by causes favourable to health, whereas those giving pain are for the most part produced by causes that are really hurtful. These sensations of pleasure and of pain may be regarded as the first- developed and the most rudimentary forms of emotion. It has been appointed by Nature, that the child is no sooner capable of experiencing them than it is capable also of expressing them to others. They find their natural expression in the language of vocal tone, facial expression, and bodily gesture. Here then is a Second Function that is subserved by voice-production : the func- tion of Expressing Emotion. How early the voice assumes this function, and how rapidly it acquires power in the performance of it, has been illustrated in the last chapter. Crying soon becomes wonderfully expressive: the shedding of tears converts it into pathetic weeping; and soon, as Preyer points out, " by screaming, wailing, whimpering, and weeping, moods of grief, desire, hunger, wilfulness and fear are made easily intelligible." Crying thus gives expression to emotions of a more or less painful character; and with crying are closely associated the equally expressive movements of the features that form almost an integral part of the act. The pleasurable emotions find no less eloquent expression in the vocal cachinnations of laughter, and in the facial expression which is united with these. Crying and laughter are as strongly contrasted in their sounds as they are in the emotions they so efficiently express: no two sounds could be more different than the wailing cadences of weeping, and the merry, ringing, broken notes of laughter. Grunting, as shown in the last chapter, is another mode of inarticulate expression that is sometimes used by children. Sighing, groaning, and sobbing, are also sounds of a highly expres- sive character that are partly vocal. Further, in Ordinary Speech and in Public Speaking, the " emotional colour/' as we term it, depends very largely upon the p114 THE DISORDERS OF SPEECH. tones of the voice,—emphasized as these are by associated facial expression and bodily gesture. The mind of the listener gathers something from the words uttered, and something from the tone and manner of their utterance. A child can interpret the tone and manner, long before he is able to understand the meaning, of the words addressed to him. We have seen, in the last chapter, how early children respond to smiling utterances, and how they may be brought to the point of weeping when others pretend to weep in their presence. Many of the domestic animals share with man this power of using and interpreting the language of vocal tone, facial expression, etc. The dog, for example, is a master of an inarti- culate language of tone and gesture, which is closely allied to that of man himself; and though he may be able to interpret but few of the words addressed to him by his master, he is always most keenly alive to the interpretation of the vocal tone in which they are uttered, and of the expression and gestures that are associated with them. Whilst the expressive power of vocal tone is constantly exhibited even in the ordinary conversation of every-day life, we must observe its effect in the public speaking of a powerful orator, if we wish to estimate to the full the power of expression that can be embodied in the tones of the human voice. We all know with what burning effect the words of such an orator can be made to penetrate the minds of the audience, and with what wonderful power he can sway their emotions at his will. Lastly, what shall we say of song ? It is another form of expressive and highly emotional vocalization, not second in its power even to oratory; and it may therefore be placed in the same category. Yet there is something special in song which entitles it to be placed apart from all other forms of expressional vocalization. For its exercise, and even for its enjoyment, it demands the possession of a special faculty, which we call "a musical ear;" whose most essential feature seems to be the power of discriminating, to a nicety, the pitch of musical notes. The development of this special faculty seems to bear no intimate relationship to the development of the other faculties of the mind. It is known that many men of genius have been utterly destitute of musical ear: and it is further known that in idiots and imbeciles the musical faculty is often well developed; the pro- portion of individuals with musical ear being among imbecilesTHE THREE FUNCTIONS OF THE VOICE, 115 almost the same as it is among the general population. That imbeciles should so often possess a good faculty for music along- side of other faculties so poorly developed, is a very striking fact, which I hope to illustrate further in the course of this chapter. Thus, in many ways, this Second Function of the voice, that of expressing emotion, is exhibited throughout life. The power and variety of its expressiveness gradually increase during the^years of growth and development, from the very early period when the voice first begins to express emotion in the acts of crying and laughing. Even ordinary individuals, in the ordinary course [of development, attain to great efficiency in expressing their emotions. In a few exceptional cases, the highest levels of expressiveness are attained: when art and native genius combine to confer upon individuals the gift of song or of telling oratory. 3. Acting with Oral Articulation, it forms Words.—In the course of development, the Third Function assumed by the Voice" is to take part with the Oral Articulative Mechanism in the pro- duction of those complicated and varied sounds that we know as Articulate Words; and thus become the instrument of Thought. How the two mechanisms, Vocal and Oral Articulative, work together in producing Articulate Words, has been pretty fully illus- trated in the former chapters of this work. In the first chapter, in connexion with the study of stammering, it was shown how delicately the two mechanisms are co-ordinated one with the other in the production of speech; and in the second chapter, in con- nexion with the study of Hysterical Mutism, it was shown how complete dumbness may result from the paralysis of either the one mechanism or the other. The vocal element of Speech is supplied in short tones, broken up almost as much as the cachinnations of laughter, but differing from these in their much less regular dura- tion and much more varied pitch and intonation. How these vocal tones of the larynx are, in speech, fitted or dovetailed into the other sounds that are produced within the mouth by the Oral Articula- tive Mechanism, and how the two mechanisms co-operate like the two hands of the violinist, has already been fully explained. As regards the specific value of the products of each of the two mechanisms, it is here important to remark, that whilst Emotion can, as we have seen, be expressed, in many ways, inarticulately, Thought can find its full expression only in articulate words. In116 THE DISORDERS OF SPEECH. the formation of these articulate words, the Oral Articulative Mechanism takes a part no less important than that taken by the Mechanism of the Voice. Farther, all experience goes to show that the development of functional power in the Oral Articulative Mechanism bears, in the child, a most important relationship to the development of the intellectual faculties. The intellectual faculties form, as it were, a superstructure, built, in the course of development, upon a foundation that is made up of the primitive instincts and emotions. So it is also with the expression of thought in articulate speech. It is a new function, added to the previously existing emotional function of the voice ; and it is a function which the Yocal Mechanism can assume only when it is brought into the most intimate co-ordinate relationship with the mechanism of Oral Articulation. The intellect of the child may fairly be said to be budding, when it begins, for the first time, to understand the meaning of a few spoken words; and it may be said to be gradually expanding, when this vocabulary of words that can be understood is observed to be growing from day to day and week to week. The next step is for the child himself to produce articulate words. We have seen, in the last chapter, how, in the course of natural development, this step is led up to, by the instinctive and automatic exercises of the mechanisms of speech in the processes of Babbling, Crowing, and Mimic Reading. These .preliminary exercises remind one of the automatic exercise of the voice before it has assumed its function of expressing emotion. Begun instinctively, and practised automatically from a very early period of life, it is curious to observe how these articulative exercises tend to assume an imitative character, and to develop into Echolalia. The child begins to catch up sounds of words that have just been uttered by others, and to repeat these mechanically, as mere sound imitations, without in the least attempting to decipher their meaning. It is about this time that the great step in advance is taken. The child has already learned to understand the meaning of a few words, and perhaps has reproduced some of these by echolalia; but now for the first time he begins to produce these words not as mere echoes of sounds, but as words with definite signification; or, being asked to pronounce a certain word, he attempts to do so by a distinct effort of his will. These are the real beginnings of speech-production. The words hitherto pro-THE THREE FUNCTIONS OF THE VOICE. 117 duced by echolalia have been evolved with almost no exercise of attention or effort of the will. But now the leading feature of word-production is that the requisite movements of articulation are produced under careful supervision of the attention, and by a distinct effort of the will. A new agent, namely, the higher Intellectual Consciousness, is thus beginning to interfere with the operations of the Speech-centres. Ultimately this new agent will take almost entire command of Speech-production. At this early stage, however, it has not yet acquired complete command; and it can get the Speech-producing centres to produce the simplest words only after many futile attempts and much persevering- practice. I hope, at a future time, in connexion especially with Aphasia, to discuss at greater length the mutual relationships of the speech-centres and the higher consciousness. At present, I shall ask the reader's attention only to two facts:—(1.) That the speech- mechanisms are formed upon the Keflex Plan, with a sensory or receptive, and a motor or productive side, between which there are connecting fibres, by which influences can travel forwards from the sensory to the motor centres, so that sounds heard by means of the receptive centre may, in echolalia, be imitated mechanically by the motor. (2.) That with the development of the ruling faculties of the nervous system—namely, the intelligence and the will, — command is taken by these faculties of the reflex mechanism of Speech. Sounds formerly meaningless to the child are now interpreted as words with definite meaning; and soon, with ever increasing success, the productive side- of the mechanism is compelled to reproduce these words by effort of the will. Somethinghas already,in the last chapter,been said as to the order of difficulty experienced by the child in the voluntary production of the various vowels and consonants. It may here be repeated that the vowels are more easily produced than the consonants. The middle vowels, such as o and a, are the easiest of all; and the vowels at the two extremities of the list, viz., i (ee) and u (oo) are somewhat more difficult, apparently because their production involves a little more muscular effort. Of the consonants, it has already been shown that the three produced during complete closure of the first stop-position, viz., p, b, and m, are generally the first to be learned; but that almost as early as these in making118 THE DISORDERS OF SPEECH. their appearance are the corresponding three consonants produced during the closure of the second stop-position, viz., t, d, and n. Thus the syllables pa, ba, and ma, ta, da, and na, are usually the first that the child learns to pronounce. The consonants produced during closure of the third stop-position, viz., k, g, and ng, are later in appearing; and their appearance may be delayed for months, or even for years. As to the fricative consonants, it has already, in the last chapter, been pointed out that " those which most frequently present difficulties to the child are probably r and 1, and, in a less degree, sh, s, ch, and y." Another matter which was commented upon in the last chapter was the "Smudging" or Scamping of the syllables in baby-speech. " The child simply omits the consonants difficult to him, sometimes putting nothing in their stead, and sometimes substituting for them others that he can pronounce without effort. He thus converts double consonants into single ones. Often he reduces a syllable to such simplicity that the listener can only guess at its intention from the sound of the vowel." When this Scamping articulation is but slightly marked, it is perhaps best described by the term Slurring or Thickness of Speech. A single consonant perhaps is omitted, or is imperfectly produced during the pronunciation of a difficult syllable. The most typical example of such slurring is perhaps met with, not in baby-speech, but in the slovenly articulation of a person somewhat inebriated, who, as is known, is apt to pronounce " British Constitution " as " Brizh Conshishushon " A. child who lalled slightly might possibly pronounce the words in a somewhat similar way ; but if lalling were strongly pronounced, he would be more likely to give them as "Bitte I'ontitu" and this would be ail example of scamping rather than of slurring.1 These various forms of imperfect articulation, existing together, go to make up the variety of imperfect speech known as Lalling, a very useful term which has been applied to the imperfect utterances of baby- speech. Lalling is natural in every child at a certain period of 1 We speak of a man "Scamping" his work when he performs it in a slovenly way, and takes as little trouble with it as possible. By some authors babies are said to " truncate " their words; and this is true enough : but they may omit consonants at the beginning and middle as well as at the end of a word ; so that I think " Scamping " is preferable, as the descriptive term. Perhaps it is something of a " slang " word, but it is the most expressive I can think of.THE THREE FUNCTIONS OF THE VOICE. 119 its life. Bub in healthy children it passes away as the child, by efforts of attention and intelligent practice, gradually masters its difficulties of articulation. Lalling is, I think, much the best term for these imperfect performances of the Oral Articulative Mechanism; and when the above defects exist in combination, as they always do at a certain stage of baby-speech, the term is very specially appropriate. I also think it is justifiable to use it as a general term that may be applied even to cases where the above defects exist singly; and in this chapter I propose so to use it. In Germany, these defects of Oral Articulation have been treated of under the general term Stammering (Stamtneln).1 I have already, iu the first chapter, protested against the use of the English word Stammering in this sense. In this country, the word thus used would be altogether misapplied; since, when we speak of Stam- mering, we always think of an element of hesitancy in the Speech. In these Oral Articulative defects, however, there is not necessarily any hesitancy: the words may be emitted with apparent ease, although the syllabic articulation is so imperfectly performed. It should, at the same time, be remembered that in its first efforts to speak the utterances of the child are often emitted very deliberately, and with much apparent effort. It should be noted also, that true Stammering, with Stuttering, very frequently appears, as a passing phenomenon, even in normal children. It is, further, most important to make note of the fact that in imbecile children this true Stammering or Stuttering, due to want of promptitude in the Vocal Mechanism, is often found associated with Lalling, due, as we have just seen, not to want of promptitude, but to want of precision in the performance of the Oral Articu- lative Mechanism. Lastly, the reader will remember that " Words of its own Invention " are employed, more or less, by almost every normal child, when true speech-production begins to be developed. In normal children, these words are, with the further growth of Speech-power, soon disused and forgotten. We shall find that in imbeciles similar words are often invented, but that, in them, they 1 In Germany, the term lalling (lallen) is apparently applied to the imperfect utterances of baby-speech only when these are so inarticulate as to be almost or altogether unintelligible; Lalling being described as an extreme development of "Stammering" (Stammeln). See article "Stottern," by E. Arndt, in Eulenburg's Real Encyclopalie, vol. xix., p. 173.120 THE DISORDERS OF SPEECH. are not speedily forgotten,—being retained as elements of Speech throughout life. These then are the three functions that are fulfilled by the exercise of the Voice: (1.) It is a healthy exercise for the Kespira- tory Organs; (2.) In association with facial expression and gesture, it is an instrument for the expression of emotion; (3.) In close association with Oral Articulation, it is the chief instrument for the expression of thought. Defects of Speech in Idiots and Imbeciles. " Idiocy," says Pr Ireland,1 " in its mental manifestations at least, may be viewed as a fixed infantile condition. Idiots remain all their lives children in intellect, often so in their feelings and desires. Of course there is always this difference between an idiot and another child, that, although at a given time the potential intellect of the one is no greater than that of the other, the idiot has the benefit of a larger experience." In estimat- ing the degree of mental imbecility, and thus forming a practical classification of idiots and imbeciles according to the depth of their imbecility, many great authorities are agreed in thinking that there can be no better guide than an examination of the patient with special reference to the function of Speech. Griesinger2 says,—"The relations of Speech are so interwoven with the whole process of mental development, and so necessary to education and intellectual advancement, that the classification of idiots according to their capability of speaking (generally into three degrees), is one of the best that can be established." Esquirol3 has divided idiots and imbeciles into five classes, of which the lowest is utterly mindless and speechless, and the highest has a free and easy utterance, though a defective power of reasoning. I propose to give presently short notes of a series of cases which represent such a gradation of intellect and of Speech-power as is indicated by Esquirol; and I hope that these cases will bring very prominently before the reader's mind the permanent infancy, alike of the imbecile intellect and of the imbecile speech. We shall 1 On Idiocy and Imbecility, by William W. Ireland, M.D., 1877, p. 264. 2 Mental Pathology and Therapeutics, New Sydenham Society, 1867, p. 370. 3 Traite des malad. ment, t. ii. p. 288.defects of speech in idiots and imbeciles. 121 find iii these notes all the peculiarities of infantile speech reproduced; and the cases will represent stages in the development of a normal child, mounting upwards from that total absence of faculty which is proper to the child newly born, to a level not far removed from the intellectual capacity and speech-power of an ordinary adult. Some of the cases to be described were seen by me at the Morningside Asylum. For opportunities of studying these, I have to thank Dr Clouston. In making notes of them, I was kindly aided by one of his assistants, Dr Middlemas, formerly my own house-physician. Some of the other cases were studied by me at the National Institution for Imbecile Children at Larbert; and for the privilege of making notes of these, I have to thank Dr Leslie of Falkirk, the Visiting Physician, and Mr Skene, the Eesident Superintendent. My former house-physician, Dr A. S. Duncan, assisted me in taking notes of the Larbert cases. In all, I have before me notes of about twenty selected cases, all of which present points of special interest; but considerations of space forbid me to insert more than a limited number of the cases. Unfortunately I have, among them, no example of the very lowest depth of idiocy. To supply this defect, I shall give, as the first case, a brief note as to such a patient extracted from the valuable work of Dr Ireland. The rest of the cases will be from my own notes. Case I.—(Dr Ireland> p. 267.) Intelligence and Speech nil.— " I have seen an idiot seven years old who only swallowed food when placed 011 the back of the tongue within reach of the reflex actions of the Pharynx. He was kept tied in a chair, for, although unable to design any motion, he would sometimes make involuntary bounds, which would throw him on the floor." Case II.—(.Larbert Institution.) Only one word understood. Bab- Ming.—A lad of eighteen, slender and rather short; constantly walking about in shambling fashion with head much bent for- wards; always smiling and laughing quietly to himself and to others. Never cries nor sheds tears; never blushes; good-natured and affectionate, but very stupid utterly helpless as to evacuations and as to dressing himself. When his chair is set at table, knows to sit down upon it, and can use a spoon at meals. Understands Q122 the disorders of speech. no word but his own name, "Johnnie," which he answers to by coming when called. He, however, responds readily to smiles and kindness. Often amuses himself by " babbling " the single syllable mamamama for a long time. Produces no single intelligent word. Nurse says that he has a good ear, seems to like music, and sometimes hums over a polka he has often heard played. Case III.—(.Larbert Institution.) Responds to his own name, and calls out name of cat. No other language. Echolalia well marked. Grunting.—A boy, aged twelve; short, but not deformed; vacant, sometimes puzzled, expression; very stupid ; sometimes inattentive as to evacuations ; cannot dress himself, but can feed himself at table. Is affectionate, responding readily to smiles and kind- ness; gets excited when petted, grinning and working arms up and down ; cries sometimes, and sheds tears; has " roaring tempers," during which he tears his collars; has turns of laughing aloud. Grunts to himself a good deal; shows marked Echolalia, repeating " Lizzie," when he hears any one call for the nurse, and repeating in similar fashion the name of any boy when it is shouted by another. Understands nothing but his own name ; and the only intelligible word employed by him is, " pussy, pussy," which he addresses to the cat. Has no musical ear, and never sings. Case IV.—(Larbert Institution.) Understands only his name. No other words understood ; no words produced except in Echolalia and in Song.—Boy, aged thirteen ; subject to fits; well-made; walks quite well; is very restless. Has fits of laughing, also of passionate roaring; is sensitive, and easily made to cry and shed tears ; responds readily to smiles and kindness. Understands no word but his own name; and can produce no words except by Echolalia, or in song. Eepeats by Echolalia any name that is called out in the Day-room. Nurse states that he has an excellent musical ear, and that he often sings hymns to himself when in bed, or sitting in the Day-room, the words being—though this seems almost incredible—pronounced quite correctly. Case V.—(Larbert Institution.) Patient able to understand much of what is said, but not able to produce any speech whatever.— A girl, aged sixteen; short stature, rickety legs, large head.defects of speech in idiots and imbeciles. 123 prominent forehead. Bemarkably silent and sedentary; occupies herself chiefly in scraping up wood fibre of her chair with her nails. Does not play with other children, and when among them is apt to pinch them severely. Is very cleanly as to evacuations. Feeds herself at table with knife, fork, and spoon; but cannot dress her- self. Nurse says that she understands almost everything that is said to her. Never utters a single word; seldom makes any gesture, or shows emotion; but on one occasion, when nurse hurt her finger, patient suddenly showed sympathy by kissing her and crying. The only sound she gives vent to is an occasional broken cry. Case VI.—{Larbert Institution.) Understands speech vjell, and can speak a little, but in speaking lolls very markedly.—A boy, aged eight; small and bandy-legged; head very narrow in front and broad behind. Is very active, restless, and mischievous ; is fond of catching insects, especially " dockers." Smiling, impish expression of countenance. Talks a good deal, especially to him- self; but articulation so imperfect that scarcely anything he says can be made out. The following is his pronunciation of the numerals, when he is made to repeat them to dictation one after the other. "One, foo, chree, four, fia, hik, seggen, eight, nine, ten, evven." Understands not only gestures, etc., but also spoken words; bringing chairs, etc., when asked to do so. Case VII. — (Larbert Institution.) Well-marked Echolalia. Understands Spoken Language. Speaks a good deal> but lalls. Has a special talent.—A girl, aged thirteen; good figure; pleasant face, though rather dreamy expression. Imbecility dates from occurrence of Meningitis at three. When first brought to Institution, showed marked Echolalia; repeating several times " Maggie, Maggie," when her name was called out. If any- one said "Maggie, sit down," she would repeat the whole sentence several times over. Is very cleanly, and is able to dress and feed herself, but puts everything to her nose and smells it before putting it to her mouth. Used to be destructive of her dress, but on being beautifully dressed took a pleasure in her appearance, and gave up tearing her dress. Understands all that is said to her; bringing chairs, etc., to order. Is very124 the disorders of speech. affectionate, and responds readily to smiles and kindness. In speaking, drawls her syllables, and pronounces them with marked lalling:—thus, for the numerals dictated to her one by one, she gives, "One, two,free, four,fie, six, sim, eight, nine, ten, ewen, el." Is remarkably neat handed, her sewing being really beautiful. No musical ear. case viil—{Morningside Asylum.) Uuderstcinds a little Speech. Uses a few ivords, some of them being " Words of her own Invention." Language of Facial Expression and Gesture very well marked.— A young woman, aged twenty-three; fairly well grown; rather lively expression, though obviously silly. Cries sometimes, shedding tears when hurt. Laughs and smiles readily. When pleased, grunts to herself in a characteristic way. Exhibits rage, fear, etc., well in facial expression. When sulky, pouts, making a true "snout" with her lips. Never blushes. Uses gestures, largely indicating her wishes in this way. Understands simple directions quite readily, and does what she is told. The following is a list of the words which she makes use of; and it will be observed that some of these are Words of her own Invention:—Aye for yes. When wanting to attract attention she often repeats Aye several times. No for negation, though she often shakes her head for this. Tucka—tucka is her name for herself. Pia she uses when she wants anything, and wishes to attract the nurse's attention. Papia when she wishes to go to the bath-room. M-m-m-mia when she wants food, or wants her hat to go out. Puttyka is for pussy cat. Yahoo is an apparently meaningless expression, often uttered when she is pleased. Beh when she is playing with something, and is pleased—she still plays with dolls. Cannot be got to repeat the numerals to dictation. Sometimes sings to her- self part of a dance tune, the notes being given pretty correctly. Case IX.—(Morningside Asylum.) Understands Speech fairly ivell; but in speaking lalls, lisps, and stammers.—A young woman, aged about twenty; paralyzed 011 right side. Intelli- gence so good that in most respects she behaves like a grown- up person. Laughs readily, but seldom or never cries. I11 speaking, sometimes uses T for K, D for G, Th for S or Sh, and 1) for Z or Zh. She stammers over the explosives, and whendefects of speech in idiots and imbeciles. 125 words begin with explosives she often tries to overcome the difficulty by means of " drawback phonation." Gives the numerals as:—E-one, T-oo, Theree, Four, Five, Ishish, Theven, Eight, Nine, Ten. Case X.—(Larbert Institution.) Intelligence considerable. Un- derstands Speech. No babbling, Echolaliay or pronounced lalling; but slurs slightly.—Boy, aged eleven; well made; rather small; good head and face. Is cleanly, and is able to dress himself. No fits of crying unless when meddled with; but is hot-tempered. Laughs freely; blushes occasionally. No babbling or Echolalia. Understands Speech, obeying commands readily. Gives the numerals himself continuously, but omits 17 and 18 in naming them up to 20. Says 2 + 2 = 3. Slight slurring when he speaks; but no pronounced lalling. Sings in correct tune; but words are mixed up. Case XL—(.Larbert Institution.) Intelligence now almost normal; Speech very good; excellent musical ear; sings admirably.—A girl, aged twelve; rather short, but well made; pretty face, fine eyes and teeth, but deformed palate. Expression dreamy. Very affectionate ; is of happy disposition and pleasant manners. Likes to work and help the nurse. Talks exceedingly well, and has good memory for words, repeating each test sentence as a whole when it is spoken to her. Sings remarkably well, having a good voice and ear. In singing the song called "The Cobbler," performs appropriate actions with much vivacity. Is the leader of the other children when they sing together. This girl has improved remarkably since she was brought to the Institution eight years ago. She then spoke incoherently, and was passionate and mischievous. The only thing about her at present, indicative to a stranger, of anything unusual in her mental constitution is her decidedly dreamy expression. One of the most memorable incidents connected with the pleasant and instructive day which I spent, some months ago, in the Larbert Institution, was the singing of the children, under the leadership of the patient whose case has been last described. The Superintendent having kindly asked them to sing to us, they sang126 THE DISORDERS OF SPEECH. a number of hymns, very tastefully and tunefully. In visiting this beautiful and admirable Institution, one could not help feeling how much happier and healthier the children evidently are, carefully tended and educated, and living partly in the society of others like themselves, than they could, in most cases, possibly have been in private homes, where, if they are among other children, there is often so much to vex and humble them, and where they cannot have the advantage of being educated by teachers experienced in the education of children of weak intellect. The above eleven cases have, as far as possible, been given in an ascending scale, from mental zero up to a level of intelligence and speech-capacity little removed from that of a normal indi- vidual. It is hoped that the cases bring out with sufficient clearness—(1), that Lalling is the leading defect in the speech of imbeciles; (2), that stammering is occasionally associated with it; (3), that in the lower grades of imbecility, babbling, grunting, echolalia, and the use of "Words of their own Invention," are met with in association with conditions of mental development closely corresponding to the conditions with which they are associated in the development of normal children. Thus Dr Ireland's axiom, that " Idiocy, in its mental manifestations at least, may be viewed as a fixed infantile condition," is illustrated at every point, when one examines into the powers of interpreting and of producing speech presented by any well-marked case of mental imbecility. Dr Ireland, who was formerly Physician of the Larbert Institu- tion, informs us (p. 263) that for purposes of education he used to divide the pupils in the Institution into five grades. " I. Comprising those who can neither speak nor understand speech. " II. Those who can understand a few easy words. " III. Those who can speak, and can be taught to work. " IV. Those who can be taught to read and write. " V. Those who can read books for themselves." He found that " most cases can be put under one or other of these classes. Where there is difficulty it is generally with the third class, for some can speak who cannot be taught to work, though very few."dumbness ok defective spekcii. 127 CHAPTER VI. Dumbness (Congenital Aphasia) in Persons not obviously Imbecile. Lalling on Single Consonants. Congenital Paralysis of Mouth; and Oral Deformities. Develop- mental Defects of the Yocal Mechanism. Congenital Bradylalia and Logorrhcea. Deaf-Mutism. Dumbness or Defective Speech {Congenital Aphasia) in Persons not obviously Imbecile. This is a subject which has of late been attracting a good deal of attention. Sir William Wilde, in his well-known book on Aural Surgery, published in 1853, was one of the first to direct attention to the existence of dumbness in individuals who are neither deaf nor the subjects of a pronounced degree of mental imbecility. The returns obtained in the Irish Census of 1851 brought out clearly that not a few individuals were dumb though they wrere not deaf, this being the condition reported to exist in 334 of 4485 mutes residing in Ireland. Of these, 115 were reported to be imbeciles, 45 to be paralysed, 43 to be both paralysed and imbecile, and 131 to be dumb only, without being either paralysed or imbecile. Inquiring into the circumstances of many of this last class, Sir William Wilde found that in a few the dumbness resulted from local paralysis of the tongue and other organs of articulation. To these cases, further reference will be made presently. In seven other cases, of each of which he has given a special account, there was no such local paralysis; the patients could hear well, could understand what was said, and dis- played generally a pretty fair amount of intelligence; only they could not speak. A careful examination of these seven cases, however, shows, in all of them, the existence of peculiarities128 THE DISORDERS OF SPEECH. indicative of some mental defect. They are noted to be restless or mischievous, or to display other indications of want of mental power. To my mind, the records of these cases are distinctly suggestive of the existence of a defective intelligence, strong enough to have acquired the power of interpreting words, but too weak to train the motor side of the Speech-centres to their production. Dr Broadbent1 has recorded an interesting case which he thinks may be fairly regarded as one of Congenital Aphasia. The boy, who had not yet learned to speak, was, at the age of six years, run over, and hurt on the left side of the head. When under Dr Broadbent's care at the age of eleven, he was bright and intelligent, could run errands, and saw that he got the proper change if told beforehand how much it should be. He was, however, irritable and passionate with younger children. For "father" and "mother," he said fave and move; said no and yes indistinctly; and dunno for " don't know." These were all the words that could be got from him at the first visit. To most questions, he answered keeger-kruger. He wrote his name pretty well, and could copy several words, but could not write "yes" or "no" when asked to do so. At a subsequent visit, he showed some improvement. On being, for example, asked the time, which was 2.45, he said free o'clock; and when told that lie was not quite right, said indistinctly, about half-past two. Dr Hartman discusses the subject at some length in his work 011 Deaf-Mutism.2 He says that apart from cases " in which Dumbness is produced by functional disturbance, or a malformation of the organs of articulation, he has succeeded in finding in the literature of the subject only one case, described by Waldenburg,3 in which dumbness seems to have existed, although the hearing was normal. and the intellect good. This refers to a boy whose mother was affected, in the third month of pregnancy, with total paralysis of the right side, and with complete loss of speech. From birth, the right half of the boy's body was not so well developed as the left, and he did not learn to speak, although his intellect proved to be well developed, and he could hear. Even when Waldenburg 1 Medico-Chirurgical Transactions, vol. lxxv., 1872, p. 155. 2 Deaf-Mutkm, translated by Dr Cassels, 1881, p. 24 et seq. 3 "A Case of Congenital Aphasia," Berlin. Klin. Wochenschrift, 1873, p. 8.DUMBNESS OR DEFECTIVE SPEECH. 129 whispered behind the boy's back, the latter understood him, and did what he was asked—' Open your mouth*; ' Give me your hand/ This is the only case in which a complete Congenital Dumbness seems to have been ascertained where the power of hearing existed. Unfortunately Waldenburg was only able to examine the case once." Dr Ireland, in discussing the subject (p. 275), says that among imbeciles " there is a certain class who may be styled Idiotic Aphasics, who remain obstinately mute, though it is clear that they have more intelligence than other children who talk volubly. Sometimes, indeed, they have so much intelligence that people doubt whether they are imbecile at all. I have seen three or four such cases," he says: " they all appear to me to be imbecile children." He records (p. 27G) the case of a boy, who used a great many " Words of his own Invention." Dr Y. Uchermann1 of Christiania has described three cases of Aphasia (two Congenital, and one caused by fright at the age of 2\ years). One of these cases was complicated with stuttering, and another with some degree of deafness. They were treated with some success at deaf-mute institutions, by the u Oral Method" of instruction. Dr W. B. Hadden2 has recently recorded three very interesting cases—boys, aged respectively seven, eleven, and four,—in which, although the intelligence seemed to be fairly good, speech was very defective, the characteristic features of Lalling being very strongly pronounced. The cases are especially valuable, inasmuch as the education of them, when under Dr Hadden's care in St Thomas's Hospital, by the " Oral Method" employed for the edu- cation of deaf-mutes, was attended with excellent results. Dr Frederick Taylor3 has recorded a very interesting case in which the patient, a boy aged 8J years, who had been to school, could read little words, write in a child's hand to dictation, and copy words from a book, was yet very backward in speech. Along with the defects of articulation which I have classed under the term " lalling," this patient presented the interesting peculiarity that he was in the habit of adding to most of his imperfectly articulated words the superfluous syllables da, eeda, or ida. Thus 1 Archives of Otology, October 1891 ; translated by Dr J. M. Mills, New York. 2 Journal of Mental Science, Jan. 1891. 3 Meet Ghir, Trans., vol, lxxiv, B130 the disorders of speech. lie rendered the words "Our Father which art in heaven" as Ouarda Fararda id arda a haaida. In commenting upon the case, Dr Taylor says that this peculiarity reminds him of a childish trick sometimes practised by school-boys. Kussmaul (p. 814), referring to this youthful practice, states that in Germany it is exhibited among children in what is known as the " Erbsen speech" game, in playing which the child attaches the superfluous syllables "erbsen" to all monosyllabic words. He refers to two aphasic cases who in like manner attached meaningless syllables to their words. So far as I know, Dr Taylors is the only case in which this curious feature has been recorded as met with in association with Lalling. I have myself met, in hospital and private practice, with about ten cases of children whose speech was very defective, and who yet did not present any very pronounced features of imbecility. From among these I select three, about which I here insert a few brief notes. Case I.—Intelligence not very obviously defective. Dumbness almost absolute. Sudden swearing under Emotion.—A girl, aged seven, recommended to me by my friend Dr John Thomson, and at present under treatment in the Royal Infirmary. This patient was shy and apparently stupid on admission, but soon got accus- tomed to residence in the Hospital, and became very lively. She is now bright and merry, though rather mischievous. The ex- pression of the eyes is bright and affectionate, and only now and again shows a little of the restless vacancy so common in imbeciles. Her manners, however, are a little peculiar. When at home in the country, she was in the habit of playing very much with dogs; and now, on rushing up to clasp one's hand, she opens her mouth, which is decidedly large, as if she would like to bite playfully in dog-like fashion. Understands orders quite well, bringing any article when requested to do so. She is almost totally dumb. The only words she is known to have pronounced before admission are Bob (the name of a brother) and Jean (the name of a sister). Ba is her own name for herself. She is much in the habit of biting her lower lip; and when asked to pronounce such a syllable as pa or ma, she bites her lip in this fashion, and, opening the mouth, emits the vowel without the consonant. The staff-nurse has succeededdumbness or defective speech. 131 in training her to pronounce pa, ba, ma, ta, da, na; but as yet she cannot muster courage to pronounce these syllables to the doctors. She is sometimes mischievous: making inarticulate noises during prayers in the wards, and occasionally waking up, too early in the morning, patients who are friendly to her. On these occasions she has once or twice cried, f< Get up, Ba." The most surprising inci- dent in connexion with this case occurred a few days ago. It was the sudden pronunciation of two bad words, when the patient, in the bath-room, had some water thrown over her by another girl. The words were, "You d-d b-"!! Daring the last few days, this patient has been heard practising, for her own amuse- ment, the pronunciation of the first of these two bad words; and on one or two occasions, when slightly annoyed, she has emitted both of them again. She has also once, from the opposite side of the ward, called to the nurse, " Here—come here." Her sister, aged eleven, who is also a patient in this ward, and who is possessed of good intelligence, states that the patient was never, at home, heard to utter either the words " Come here" or the expression before- mentioned. She is now acquiring other new words. To-day she said, " Go hame;" and she repeated the word hame to me quite distinctly. Dr Charlton Bastian1 records a case in some respects similar to this. Patient was a boy who was subject to fits in childhood, till about the end of the second year. When nearly five years old, he had not spoken a single word, and physicians had been consulted as to his dumbness. But some months afterwards, " on the occa- sion of an accident happening to one of his favourite toys, he exclaimed ' What a pity/ though he had never previously spoken a single word. The same words could not be repeated, nor were others spoken, notwithstanding all entreaties, for a period of two weeks. Thereafter the boy progressed rapidly, and speedily became talkative." When, at the age of eleven, he was seen by Dr Bastian, he spoke in an ordinary manner, without the least sign of impedi- ment or defect. This case recalled to Dr Bastian's mind the old story of the dumb son of Croesus, who, when at the siege of Sardis his father was threatened by a Persian soldier, is reported by Herodotus to have cried out suddenly, " Oh, man, do not kill Croesus;" also the story told by Aulus Gellius of the Samian 1 The Brain as an Organ of Mind, International Scientific Series, p. 606.132 the disorders of speech. athlete, previously dumb, who, on detecting foul play when casting lots for a contest, suddenly spoke, calling attention to the guilty party and to his act. Gellius adds that he spoke quite freely and clearly ever afterwards. Dr Bastian's observations upon the case are very interesting. He thinks that Speech has been practised by so many generations of men that the power of speech is now inherited by each succeeding generation almost as if the act of speech were an instinctive and automatic one ; and that in the normal condi- tion of things, including a normal condition of hearing and the mental faculties, the productive speech-centres easily learn to call forth the requisite movements, whenever the requisite level of structural development has been reached. The young swallow leaves its nest and flies automatically, when it is mature enough to do so. The young child, if it be normal in structure and development, presents something of the same automatic facility, in acquiring, at the proper time, the movements of speech. When a slight abnormality interferes with the action of the speech-centres, it may, Dr Bastian thinks, in some cases be overcome by the stimulus of strong emotion, which may break down a barrier that the weaker volitional stimulus has failed to penetrate. Case II.—(Private Case.) Intelligence fair, but speech extremely defective. Lalling very prominent.—Boy, aged eight, fairly well grown, does not look imbecile. Father states that he began speaking at the usual time, but made little progress. His intelligence is considered by the father to be not quite so bright as that of the other children. The boy, however, attends school with the others, and can learn his lessons; being able to understand what he reads in books quite well, although not able to pronounce the words. The test sentences of the Physio- logical Alphabet show that he can pronounce p, b, and m, and t, d, and n quite well; but that he cannot pronounce k, g, or ng. Of the Fricatives, he can pronounce sh and zh, f (sometimes), 1 (sometimes), h, ch, and y. He cannot pronounce W, V, th (x) th (2), s, or z. He gives the numerals as—un, two, he, hoa, hi, hit, hoten, eight, nine, ten, eatten, tel, hirteen. The father was given a copy of the Physiological Alphabet, which was ex- plained to him; and he was shown how7 to teach patient the pro- nunciation of the defective consonants.dumbness or defective speech. 133 Case III.—(Case seen at the Institution for Deaf ancl Dumb, Hen- derson Row, Edinburgh.) Speech now almost perfect, though patient was at one time dumb.—This patient, a lad of about eighteen, happened to call upon Mr Illingworth, the head teacher, when I was visiting the Institution. He is nowr engaged, as a_ tailor in the country. He gives one the impression of being perhaps a little weak in intellect; but, thanks to Mr Illingworth's careful tuition, is able to express himself in Speech quite easily, and in a natural way. Mr Illingworth has kindly furnished me with the following note of his case:—" The boy, H. B., entered this Institution at the age of seven years. His hearing was almost normal, but he had 110 power of speech, and did not attempt to articulate a single word. His general intelligence was below the average. After he had been at school for four years, an attempt was made to teach him to speak by the Oral Method (previous to this he had always communicated by signs and the Manual Alphabet). Exactly the same means were adopted as with a totally deaf child, and the difficulties in obtaining the correct sounds were almost as great. After four years' instruction by the Oral Method, H. II. was able to speak very distinctly, but with slight hesitation, which, however, was daily wearing off; and when he left school, a year ago, he gave promise of becoming (with encouragement and practice) a very good, free speaker." A careful consideration of cases in which Dumbness or LaUim? o Speech exists without pronounced Imbecility or Deafness, leads one, I think, to the conclusion that in the great majority of such cases there is an element of weakness of mind. We all know that some normal minds are specially strong in their receptive qualities, being able to accumulate much information, and yet able them- selves to originate but little that is valuable; whereas other minds, not so apt to acquire information, are strikingly original and productive. I11 imbecile minds, there are probably the same varieties; and one can find it likely that in the development of Speech, which is so closely allied to the development of Thought, the receptive faculties sometimes display a normal activity, while the productive are sluggish, and tardy in their develop- ment. Great variation in this respect is met with, as we have seen, even among pronounced imbeciles. In cases of slight imbe-isi TIlE DISORDERS OF St^kcH. cility, the weakness may exist almost exclusively in the productive faculties, and the backwardness of Speech-production may be thus accounted for. There may be a want of the active energy required for the training of the Speech-centres, which is in all children a more or less laborious process. At the same time, it may be admitted that there may be cases in which, along with a good general development of both brain and mind, there is a local defect in the productive Speech-centre, due either to arrest of development in utero or to injury at or after birth. A very few of the recorded cases are suggestive of this explanation; but the great majority must, I think, be referred to an original defect of the mental faculties. Another lesson which, I think, we may gather from a con- sideration of the foregoing cases, is that the proper method of treatment is to place them under the care of a teacher who can instruct them in articulation by the Oral Method now used for the teaching of deaf-mutes. Dr Hadden's cases illustrate the value of this method; and it is still more forcibly demonstrated by the case of which Mr Illingworth has furnished the record. Probably the best measure to take is to place the patient in an institution for the deaf and dumb. That is what I propose to recommend for Case I., the little girl at present in the Infirmary. Inability to Articulate some Single Consonant. I do not think it would be stretching the meaning of the term too much to include the faults of articulation now to be mentioned under the general term of Lalling, and to describe them as cases of Lalling upon some single consonant. In most cases, such an isolated difficulty with a single consonant seems to be but a lingering trace of those natural difficulties which the individual experienced in childhood with many or all of the consonants. With all the others, the difficulty lias sooner or later been over- come, but with this particular one it still remains as a peculiarity of articulation. Kussmaul has given a full account of these condi- tions, and it will not, in this paper, be necessary to do more than enumerate some of the more common and important of them. (1.) R is the consonant which in most of these cases proves the stumbling-block. Sometimes the Uvular R is substituted for theINABILITY TO ARTICULATE SOME SINGLE CONSONANT. 135 Anterior Linguo-palatal (Burring). Sometimes L is substituted; a patient of my own, for example, giving, " Lound the lugged lock," for " Round the rugged rock." Sometimes W takes the place of E; in which case the name of the father of medicine would be pro- nounced as Hippocwates." In rarer cases, E has been converted into two Ts, or into G or Ng, or been prefaced by an initial S, Ds, or Z (see Kussmaul). There seems to be no doubt that Burring is sometimes due to shortness of the Frenum Linguae; which prevents the tip of the tongue being elevated sufficiently for the production of a proper R. Burring has been termed Rhota- cismus: when other letters are substituted for R, the conditign has been termed Pararhotacisnms. (2.) L frequently presents similar difficulties. When the letter is omitted or defectively pronounced, the condition is called Zambdacismus: when other letters are substituted for it, Para- lambdacismus. The letter substituted may be T, D, S, Zh, N, Ng, or R (8.) Difficulties with S (Sigmatismus and Parasigmatismus). It may be pronounced with unpleasant sharpness, or letters may be substituted, especially Th (Lisping), and Sh as in Mozhesh. A curious case of my own substituted Ch (tsh) for S, and instead of saying " Sarah sat sorrowful," said " Charah chat chorrowful." (4.) So, in like manner, there may be difficulties with the Sh sound, for which S, or L, or the softened French Gn; is sometimes substituted. (5.) A very common and important difficulty, persisting especially in children who have been slow in learning to speak, is inability to pronounce K or G (Gammacismus and Paragam- macismus), the place of these letters being frequently taken by TandD. The E and G are sometimes not mastered for years after the articulation of all the other consonants has become quite easy. Other difficulties occur with other consonants, but the diffi- culties already enumerated are the most common and important. It is worthy of note at this point, that Lalling upon a single con- sonant is not entitled to be regarded as any indication of defective intellect, although, as we have seen, persistent Lalling upon many consonants is always very strongly suggestive of such a defect. Lisping, and the substitution of W for R, are sometimes affected by dandies. The Greek dandies used to substitute 1 for r—■136 THE DISORDERS OF SPEECH. Alcibiacles, for example, pronouncing the word corax, a raven, as colax;-—but this at the present day is too suggestive of mere childishness. Defective Articulation owing to Congenital Paralysis of the Tongue, etc., and to gross Oral Deformities. (1.) Congenital Paralysis of the Muscles of the Mouth.—A case of this kind has been recorded by Sir William Wilde.1 Patient, a female aged forty, " can hear perfectly well, but has no power over the muscles of her mouth, so that she cannot drink without throwing back her head, neither was she able to suck when an infant,.....cannot protrude the tongue beyond the lips, nor elevate the palate. Can only say, 'No.'" Another case has been recorded by Hartmann.2 Patient, a coachman, had remained dumb ever after a passing attack of paresis of left arm and leg during childhood. Examination showed that the motions of the tongue were very sluggish and imperfect. He could not elevate the tip, nor protrude it normally; had marked Lalling in the pronunciation of the few words that he attempted. Kussmaul observes that congenital or acquired Hypertrophy of the tongue sometimes renders speech impossible, and sometimes merely causes " Stammering " (Lalling). (2.) As to Gross Oral Deformities, the most common and im- portant are Hare-lip and Split-palate. The former, which neces- sarily interferes with the labials, can be remedied by Surgical operation. The latter, which produces, even in slight cases, a very disagreeable Nasal Snuffling during speech, and* which in severe cases may render speech quite unintelligible, can be treated either by Surgical operation or by the insertion into the hiatus of an artificial Obturator or Velum. For full information regarding this latter method of treatment, the . reader is referred to the very able work on Oral Deformities by Norman W. Kingsley, late Dean of the New York College of Dentistry. This author states that far more perfect speech can be obtained from the employment of suit- able Obturators and Yela than has ever been obtained from Surgical operation. * Aural Surgery, p, 466, Op. cit., p. 26.DEVELOPMENTAL DEFECTS OF THE VOCAL MECHANISM. 137 Developmental Defects of the Vocal Mechanism, as Displayed in Speech (1.) There may be so great a defect of development in the Vocal Mechanism that Voice-production, even in the crying of infancy, is impossible. If, in such cases, the larynx is not even able to act with sufficient vigour to produce the spiritics asper of Whispering, the patient will necessarily be dumb. One of Sir William Wilde's cases seems to have belonged to this category, but to have presented, at the same time, malformation, and some degree of congenital paralysis, of the Oral Articulative organs. The case was that of an intelligent, well-formed, agricultural labourer, aged twenty, who was completely dumb, and " seemingly not capable of giving expression to even inarticulate sounds. His hearing was acute and correct, and he had no cerebral disease." (2.) The Voice may retain during life that disagreeable "crack" which in the normal condition is its peculiarity only during the period of puberty. This is stated1 to be a frequent peculiarity of the voice in adult idiots. (3.) The voice may fail to undergo the usual change at puberty, and may retain throughout life much of the puerile character and pitch. (4.) The great developmental Neurosis, in connexion with the Vocal Mechanism, is Stammering; which usually appears when the child first begins to speak, or very soon thereafter. The nature and phenomena of stammering have, in the first chapter, already been explained ; but it is here well to remember that it is one of the most important, perhaps the most important, of all the Develop- mental Disorders of Speech. In the great majority of cases, as already explained, stammering is a fault of the Vocal Mechanism, and the essence of the fault is want of promptitude in attacking the first syllables of words. It may here be useful to contrast it with the almost equally important disorder of Speech which we have called Lalling, using this word in very much the same sense as the Germans use the word "Stammering" (Stam- 1 Eulenburg's Real-Encyclopadie, edition 1881, vol. vii., article "Idiotie" by Dr W. Sander, p. 109,138 THE DISORDERS OF SPEECH. meln). Lalling, as has been shown, is due to want of pre- cision and want of cleverness in the action of the Oral Articulative Mechanism; and this want of precision, when persistent, and displayed in the enunciation of many of the consonants, is, in the great majority of cases, as has been shown, the result of imperfect education of the Speech-centres, owing to defective intelligence and power of attention. Apart from those cases in which defective articulation is displayed only in connexion with one consonant, and those other cases where local paralysis or deformity is sufficient to account for it, Lalling articulation, in the great majority of cases, means imbecility of mind. It is veiy different with Stammering (Stottern). Stammering, associated with Lalling, is indeed often enough found in imbeciles; but in the great majority of cases Stammering exists by itself, and is in no way indicative of deficient intelligence. It is, however, very frequently connected with the Neuropathic diathesis; being more especially apt to be associated with Nervousness, and instability of the Emotional nature. The frequent association of this defect of the vocal mechanism with a certain Weakness of Inhibition in the emotional nature,recalls to one's mind the physiological relationships of the voice as a means of expressing emotion. In like manner, the equally intimate connexion of Lalling with Imbecility, recalls the connexion which has been shown to exist between the development of Oral Articulation and the development of the Intellect. Some of the German authors1 have described Stammering (Stottern) as a Dysarthria Syllabaris (a difficulty of articulating syllables), and Lalling as a Dysarthria Literalis (difficulty of articulating letter sounds), but I regard this as an erroneous method of classification. When a patient stutters on a voiced consonant, such as m or d for example, because he does not throw the voice into it, he stutters upon a letter, not upon a syllable. The above definition of Stammering (Stottern) is therefore founded upon a false basis. The true physiological basis upon which to found distinctions between the two defects, is the analysis of Speech into its two component elements, viz., the Yocal and the Oral Articulative. The common variety of Stammering (Stottern) is due to want of promptitude in the action of the Vocal Mechanism; and the faulty articulation 1 See Kussmaul, op. cit., p. 633. Also article Stottern, by Arndt, in Eulen- burg's Real-Encyclopadie? vol. xix. p. 173,developmental bradylalia and logorrhcea. 139 of Lalling (Stammeln) is due to want of precision in the action of the Oral Articulative Mechanism. In the normal child, this want of precision must be attributed to insufficient practice; in the imbecile adult, to want of the intelligence required for the education of the Speech-centres. For the examination of a case of Stammering the test sentences given in page 17, and in the footnote to that page, will be found to be useful. For the examination of a case of Lalling, the test- sentences attached to the Physiological Alphabet of the frontispiece are the most suitable. It is also well, in testing a case of Lalling, to take the consonants of the alphabet one by one, and to observe how each is pronounced, not only as ail initial, but when occurring at the middle or the end of a word. Thus with the letter P let the patient pronounce Pa, then ap} and then appa ; and so with the others. The reader may have remarked that I have frequently made use of the numerals as test words in recording the pro- nunciation of lalling patients. Developmental Bradylalia and Logorrhma. Bradylalia (slowness of Speech) is a condition which displays itself normally, to a greater or less extent, in every healthy child, during the earlier stages of its progress in Speech-production. Speech is as yet difficult, and the difficulty betrays itself in a certain deliberation of utterance. The same deliberation is displayed permanently in the speech of a certain number of imbeciles. Even some adults who are not imbecile, but whose mental operations are habitually performed with exceptional de- liberation, display it. Speech in these is slow and often scanty. They are " men of few words," and these few are always deliber- ately emitted. The opposite condition, that of Logorrhcea, is also frequently met with in those of weak mind, or at least of weak mental inhibition. These are the chatterers, who say, in very many words, little that is worth listening to. When the words crowd upon each other so much as to interfere with their distinct articulation, the condition has sometimes been called " Cluttering.'' In his admirable work on The Neuroses of Development, recently published, Dr Clouston describes a case of this kind. The patient,140 THE DISORDERS OF SPEECtl. an imbecile man of middle life, expressed liis feeble thoughts so volubly, that, although " articulation is normal when slowly per- formed, the moment ordinary speech begins, the mental co-ordina- tion is lost, and we have a torrent of half-articulated words, follow- ing each other like peas running out of a spout." The defects displayed in developmental Bradylalia and Logorrhoea are thus to be regarded as indicative rather of mental peculiarities, than of defects in the action of the Speech-Mechanisms. The Language of Deaf-Mates. When a child of three or four years is brought by its parents for examination, because it has not yet begun to speak, and they are getting alarmed about its dumbness, the physician is called upon to decide as to the cause of the dumbness. At this early age, the case is not necessarily one of much gravity. If the child is found, 011 examination, to have good hearing; and is reported to show, in its play and in its general conduct, that it interests itself in matters that interest children; to be cleanly as to evacua- tions ; and to be, in disposition, moderately affectionate and manage- able ; the case may be one in which the development of Speech, though tardy, will in the long run be satisfactory. All that the physician need do, in such a case, is to recommend patience, and the encouragement of the child in its attempts to speak. It will be well, at the same time, to examine the mouth, in order to see if there be any peculiarities about the Oral Structures that may be interfering with articulation; although it must be remembered, that, apart from Hare-lip and Split-palate, peculiarities of this kind are by no means common. In every case of dumbness in a child, the two most important questions that the physician will be called upon to decide, are:— (1.) Is the child imbecile ? (2.) Is it deaf ? In many cases, un- fortunately, the indications of imbecility will be only too evident. The child may have a vacant expression, in some cases torpid and passive, in others restless and yet purposeless; often it will be reported that the child is passionate and unmanageable; the parents may have been forced to observe its inability to interest itself so much as other children in toys and play; and it may also be heedless as to evacuations.me Language of deaf-mutes. 141 If the case be one of Deafness, and the child be otherwise normally constituted, its whole expression and conduct will be very different from those of an imbecile child. Already, even at this early age, there may be a certain wistfulness in the expression of the eyes, indicative of the child's instinctive employment of the sense of sight with a diligence that may in some measure com- pensate for the absence of hearing. The hearing should be specially tested. Some one should stand behind the child and clap the hands, or call his name, both aloud and in a whisper; and note should be taken of what response the child makes to such stimuli. It should be remembered that even partial deafness may cause dumbness. In such a case, it will be found that the child responds to loud sounds, but makes no response when his name is whispered or when other slight sounds are made close behind him. For the future training of the child, it is most important to ascertain whether the loss of hearing is very marked or comparatively slight. The majority of deaf-mutes are not absolutely deaf to very loud sounds. About the various forms of language that may, for the purposes of expression, be employed by Deaf-Mutes, I should like to say a few words. I. The Language of Natural Signs.—This is a most interesting subject, regarding which the reader will find full information in any of the works upon Deaf-Mutism, but perhaps nowhere a more striking account than in the second and third chapters of E. B. Tylor's well-known work on the Early History of Manhind. Without entering into any detail about the Natural Language of Signs, I may say that essentially it is merely a development of that language of facial expression and gesture that is employed by every child and adult, more or less. In the deaf-mute, it lacks the aid which is given to it, in the natural child, by the expressive tones of the voice,—the voice of a deaf-mute being harsh and dis- cordant, and of very little expressive power. But, on the other hand, in the deaf-mute, gestures and signs attain to a development far ahead of that displayed in the normal individual. It is the only language which the uneducated deaf-mute can employ for purposes of expression, and Nature herself teaches him to employ it with wonderful power and expressiveness. The basis of the language is essentially Pictorial Bepresentation of things and142 THE DISORDERS 03? SPEECH. actions. A red tent can be represented by making the outline of its shape in the air with the hands and touching the lip to show that it is red. Cowering or crouching may be used as the indication of fear; crossing the arms and shivering as that of extreme cold. " To put the forefinger against the closed lips is 'silence'; but the finger put into the mouth means a'child/" In the Berlin Deaf-and-Dumb Institution, " to pull up a piece of skin on the back of one's hand is ' flesh or meat/ Make the steam curling up from it with the forefinger, and it becomes c roast meat.' Make a bird's bill with two fingers in front of one's lips and flap with the arms, and that means ' goose;' put the first sign and those together, and we have f roast goose.' .... To express the pronouns I, thou, and he, I push my forefinger against the pit of my stomach for ' I'; push it towards the person addressed for ' thou ' ; point with my thumb over my right shoulder for ' he '; and so on." This Language of Natural Signs is the mother-tongue of the deaf and dumb. "Without multiplying examples of it, I may add that its syntax is different from that of ordinary speech, in so far as it invariably follows the rule of putting the most important element of the sentence first in order. Thus, " I am hungry, give me bread," is expressed as " Hungry me, bread give "; and " Bring a black hat" becomes " Hat black bring." In every community of deaf-mutes, certain arbitrary or conventional signs are always added to the signs suggested by Nature; and the language is thus made fuller and more efficient. Thus we are informed by Mr Tylor that one of the teachers at the Berlin Institution was indicated among the boys by a sign suggesting the loss of an arm, not because he wanted an arm, but because he came from Spandau, and one of the boys who had been to Spandau had there seen a man who had lost an arm. This Natural-Sign Language of deaf-mutes has called forth the admiration of many who have had opportunities of studying it. The reader will find in Mr Tylor's work an eloquent description of the religious service conducted by one of the teachers of the Berlin Institution for the benefit of the uneducated deaf-mutes of the city. Mr Tylor says,—"No one could see the parable of the man who left the ninety-nine sheep in the wilderness, and went after that which was lost, or of the woman who lost the one piece of silver, per- formed in expressive pantomime by a master of the art, withoutTHE LANGUAGE OF DEAF-MUTES. 143 acknowledging that for telling a simple story and making simple comments on it, spoken language stands far behind acting." It must, however, be admitted that this language is, after all, little fitted to impart to a deaf-mute any high degree of intellectual culture. " Its poverty is obvious .... it is calculated for the expression only of the ordinary emotions and tangible tilings.1" II. Taking the above Language of Natural Signs as a basis, the Abbe de l'Epee and his successor the Abbe Sicard added to it a vast number of conventional or arbitrary signs, to represent a great variety of words, including many prepositions, con- junctions, etc. They perfected their system to such a degree, that they could, in this language of natural and artificial signs, dictate to their pupils whole sentences of words, which the pupils could correctly transfer to writing. They supplemented this system by teaching their pupils to write and draw, and to spell words upon the fingers by means of the bimanual alphabet. These methods have been largely followed in many other countries throughout the world, but the artificial signs have, as a rule, not been so much adopted as the other parts of the system. III. In some schools, the pupils are taught to express them- selves by writing only, or by writing and the Manual Alphabet. Written words are directly associated with objects, and the mental images of these words are eventually made to play, in the pro- cesses of thinking, the same part that, in persons not deaf, is played by the sound images, or memories, of audible words. IV. In many of the best schools, Oral Speech is taught; arti- ficially, by means of articulation and lip-reading. The pupils are at the same time taught to write. V. In many schools, the best parts of the Oral and Sign Systems are combined; only the most intelligent pupils being fully in- structed in Oral Articulation and " Lip-Keading."2 At the present time, it may be said that, for conducting ordinary conversation, the chief rivalry is that between the practice of the Manual Alphabet, by means of which an educated deaf-mute can express himself almost as quickly as an ordinary person can by word 1 Degerando, quoted by Arnold, in Education of Deaf-Mutes, p. 132. 2 For a fuller description of these methods see Arnold's Education of Deaf- Mutes,144 THE DISORDERS OF SPEECH. of mouth, and the practice of Oral Articulation and "Lip-Beading," which, when successfully acquired, enables the deaf-mute to express himself by word of mouth like an ordinary person, though his tones are apt to be more or less harsh and unmusical. The latter practice involves a difficult process of education, and the exercise by the patient of the closest attention and observation. But, when successfully mastered, it has the great advantage of enabling the patient to understand what is said to him by any- one, and make himself understood.by anyone he may speak to. It thus enables him to mix in ordinary society, and to converse with people who cannot use the Manual Alphabet. This Oral Method, which was first systematically taught in a school, in the last century, by Samuel Heinicke, a Saxon schoolmaster,1 has always, since his day,been much cultivated in Germany; a.nd, at the present time, is beginning to find much favour everywhere, throughout Europe and in America. How successful it is some- times, is illustrated by an anecdote told by Kussmaul regarding a conversation with one of his hospital patients. He had for some time been freely conversing with this patient; and, having observed nothing unusual in his manner of expressing himself, was afterwards much surprised to learn that he had been conversing with a deaf 1 " It is hardly just to call Heinicke the founder of the German method. He only gave a more logical application to tlie principles taught by Bonet, Wallis, and Amman, but he clearly perceived that there could be no compromise between speech and signs as fundamental in teaching language." Arnold's Education of Deaf Mutes, p. 85.—Heinicke began teaching in Dresden in 1V5 4. In 1760, Thomas Braidwood founded a school in Edinburgh, and taught " lip- reading " very successfully. He was visited by Dr Johnson, and is referred to in laudatory terms in the latter's famous account of his tour to the Hebrides. Braidwood afterwards, in 1783, removed to London, where he was soon the first head-master of the first public institution established in England for the education of deaf-mutes. The school founded by him in Edinburgh has been kept up ever since, and now occupies excellent premises in Henderson Bow. Edinburgh also has, in Donaldson's Hospital, a splendid Institution which is partly devoted to the education of Deaf-Mutes. A century before the time of Heinicke and Braidwood, " Lip-Reading " was successfully taught in Spain by Pedro Ponce de Leon, a Spaniard of illustrious birth, and his successor Juan Pablo Bonet, a capable man of business, employed in official services. It was in Spain, also, that the one-handed alphabet was invented. The two-handed alphabet, used generally in this country, was invented, at a later date, in France,THE LANGUAGE OF DEAF-MUTES. 145 man, who had understood all his remarks by the method of lip- reading. In this country, many eases have already been successfully taught by this method; but it is universally admitted that success has hitherto not been so great as it has been in Germany. The reason alleged is that the English language is not so well fitted for " lip- reading " as the German is. There can be 110 doubt that the chief difficulty in regard to English is, not that the sounds of the words are more difficult of pronunciation, but that the spelling of the words has departed so widely'from their sounds. The spelling, in English, is now far from being strictly phonetic, whereas in German it still continues to be almost strictly so. The deaf-mute can thus read a German word correctly if he has mastered the phonetic values of the component letters. Knowing the letter- sounds well, he can even practise reading aloud by himself with- out much danger of falling into errors of pronunciation. It is very different with the English deaf-mute. Even a person not deaf (say a foreigner), in learning English, finds the spelling of the words no sure guide to their pronunciation. What then must be the difficulties of a deaf-mute, who cannot always have a tutor at his elbow, to show him, by "lip-reading," how each word is pro- nounced? In America, this difficulty has been grappled with in a special way. It appears that, in some of the American insti- tutions, Melville Bell's system of "visible speech" has been adopted, this system having an alphabet (altogether different from the ordinary one) in which each letter has a definite phonetic significa- tion. In this country attempts are made to get over the difficulty by phonetic spelling. But I do not think that phonetic spelling has been made so accurate and easy of comprehension as it might be made. In particular, I think it would probably be of great advantage to deaf-mutes to have a phonetic alphabet in which the relationships of one vowel to another, and of one consonant to another, are clearly displayed. If such a Physiological Alphabet as I have given in the first paper were adopted for the teach- ing of deaf-mutes, each letter would have a definite phonetic signification, so that words spelt phonetically by it might be read with ease by the deaf-mute, if only he had previously mastered the individual letter-sounds. In order to adapt this Physiological Alphabet to the teaching of deaf-mutes, it would be necessary to write the vowel-sounds in such a way as to enable the deaf-mute T146 THE BlSOHDEtlS OF SmCtf* clearly to distinguish one from the other. No change would be required in the alphabet of consonants: they might be written ex- actly as they are in the alphabet of the first chapter. In making the following attempt to improve the manner of writing the vowels, I have taken a hint from Dr Hullah's method of indicating the varying breadth of vowel-sounds. I have also added to the English vowels several foreign vowels, and a few diphthongs. For the alphabet of consonants, the reader is referred to the Physiological Alphabet of the first chapter. I. Long Voivels, as in the sentence:— Even ancient elves are awed over oozing. e a e aa aa 5 55 II. Equivalent Short Vowels ;— eet it et at ut ot out III. Foreign Vowels:— German ii, as in uber; French u} as in user;1 German o, as in olig? IY. Diphthongs:— (1.) English u as in pi^re eu. (2.) i as in pile ai. (3.) „ oi as in boil oi. (4) „ au as in hovj au. By way of example, take this sentence, spelt phonetically in accordance with the foregoing :— Speetsh Iz laik kloth ov Arras, oplnd and poot abra&d, wharbai 2 1 12 thi imadzherl doth apper in figur; wharaz In tha^lts tha lai but az in paks.3 1 I print the French u in italics merely to distinguish it from the other varieties of u. 2 For the German ii, the Resonating chamber within the mouth is shaped as for e in even; for the French u, it is shaped as for e in elves; for the German o, it is shaped as for aa in are. In all three, the lips are brought into very much the same position as they are for the pronunciation of oo in ooze. The German o might be used to represent the vowel sound in some English words, such as bird. 3 Plutarch, Life of Themistocles*THE LANGUAGE OF DEAF-MUTES. 147 If I were a teacher of deaf-mutes, I should, I think, have the first series of lessons printed entirely in such a phonetic alphabet. The next lessons I should have printed in double lines, of which one would be phonetic and the other in the ordinary spelling. Later, the two spellings might be given on opposite pages. Still later, only a few of the more difficult words might be repeated in phonetic spelling, after the ordinary spelling; and finally, the lessons might be printed entirely in the ordinary spelling. I submit this sugges- tion, respectfully, for the consideration of those who may be specially interested in the education of deaf-mutes. Perhaps I may not be considered too bold in offering it, since I have, of late years, been a good deal occupied with the study of the Physio- logical Alphabet. The system of " Lip-Reading " is rapidly gaining ground every- where. It has no rival in its capability of enabling deaf-mutes to mingle in ordinary society. It is also claimed for it, by its advocates, that it is a better aid to thinking than any of the other methods. Although, as has been truly said, the uneducated deaf- mute is a standing refutation of the opinion that there can be no rational thinking without words, it is nevertheless the case that his thinking can never attain to a high level until he has been educated to the use of words. In order to think in words, he must first be able to call up their images in his mind. No process of training will ever enable him to call up their sound-images. For him, sound has no existence. But, in the absence of sound, he can, when educated, store up the visual images of written words; and he can use these in the processes of thinking, in place of the sound- images employed by others. If trained to Oral Articulation and Lip-Reading, he can employ other word-images or word- memories, of a kind more closely allied to sound-images. He can then employ the memories of production that are imprinted by the muscular sense of the motor mechanism and by the tactile sense of the mucous surfaces used in speech. To these, in forming his concepts of words, he can add the sense of vibration produced by the voice, and also the visual memories of the movements observed in others when he is practising " lip-reading " of their speech. It seems that the memories or concepts of words thus obtained are the best working substitutes for the sound-memories which ordinary people employ in the processes of thinking. Even in148 THE DISORDERS OF SPEECH. France, where the sign systems were formerly so much in vogue, the system of Lip-Beading is now rapidly coming to the front. Of recent works on the subject, one of the best is by a professor at the National Institute for Deaf-Mutes in Paris.1 In this country also, rapid progress is being made; and many persons have been most successfully trained in Lip-Reading. Nevertheless, great diffi- culties are met with in the training of large numbers; and success is much more probable when a teacher devotes himself almost entirely to one or two pupils. The language is partly accountable for this, and especially, I think, the spelling of the language. I think it is reasonable to believe that the difficulty would be materially lessened, if phonetic spelling were rendered accurate and easy of comprehension. 1 Comment on fait parler les Sonrds-Muets, par L. Goquillot, 1889.the development of speech in the human race, 149 CHAPTER VII. The Development of Speech in the Human Eace. Classifica- tion of Languages. Origin of Written Language. The Invention of Printing. Printing for the Blind. Any account of the Development of Speech would be most incomplete if it were content merely to treat of the subject in its relations to the individual Child, and made no attempt to indicate the views that are current regarding it in its relations to the Human Eace. This consideration has weighed with me, and has led me to write the following chapter. Although the relations of the subject to practical medicine are somewhat remote, the facts brought out in the study of it are of great scientific value. They throw light upon the nature of speech and upon its relations to thought. Fortunately, in this country, the subject has been treated by a number of writers remarkable alike for eloquence and for learning. Any notes that I can make in this chapter, from the works of these authors, must of necessity be brief and frag- mentary ; but I shall try to make a statement of their chief conclusions, and, when possible, shall give these conclusions in their own words. The Development of Speech in the Human Eace. *" In examining the history of mankind," says Dugald Stewart, " as well as in examining the phenomena of the material world, when we cannot trace the process by which an event has been produced, it is often of importance to be able to show how it may have been produced by natural causes. Thus, although it is impos- sible to determine with certainty what the steps were by which any particular language was formed, yet if we can show, from the150 THE DISORDERS OF SPEECH. known principles of human nature, how all its various parts might gradually have arisen, the mind is not only to a certain degree satisfied, but a check is given to that indolent philosophy which refers to a miracle whatever appearances both in the natural and moral worlds it is unable to explain." 1 These words of the eminent Edinburgh Professor were written about the end of last century, when the science of Philology was yet in its infancy. Since those days, that noble science has been pursued by many eminent scholars with brilliant success. Their investigations have thrown a flood of light upon the real nature of human speech. Tliey have shown how the languages of mankind can be classified, according to their affinities, into a number of great groups; all the members of each group having evidently sprung from a common parentage. Even between the great groups, they have shown the existence of certain affinities, not it is true of a very pronounced or intimate character, but yet sufficient to render it probable, even on strictly scientific grounds, that the human race possessed at least the rudiments of speech before it was scattered abroad in the various parts of the world. The method pursued by modern philologists has been to a very marked extent an analytic one. They have studied in detail a vast number of languages, ancient and modern, and, according to the affinities discovered among them, have grouped them as above indicated. The chief ground for such a grouping has been the discovery that among the members of each group the "roots" of the words are possessed in common ; that in certain of the groups these " roots " are welded together in a characteristic manner; and that among the members of each group there is in grammar and syntax much that betrays a common parentage. Something will presently be said about the characteristics of each of the great groups thus differentiated. In the meantime, perhaps an example or two will best illustrate the manner in which a community of " roots " can be shown to exist among the members of a great group. I shall take these examples from the pages of Prof. Max Miiller, the leading exponent of philological science in this country. In deal- ing with the great Aryan group of languages, this author uses among many other illustrations the root "ar." This he finds in the later Sanscrit in the word arya, a tiller of the soil. With the 1 Quoted hy Max Miiller, Lectures on the Science of Language, vol. i. p. 391,THE DEVELOPMENT OF SPEECH IN THE HUMAN RAC)E. 151 meaning of " to plough," he finds it in the Latin ar-are; the Greek ar-oun; the Irish ar; the Lithuanian ar-ti; the Eussian or-ati; the Gothic ar-jan; the Anglo-Saxon er-jan; and in the modern English to ear. Shakespeare says (Eichard II., iii. 2), "to ear the land that has some hope to grow." And in Deut. xxi. 4 we read, "A rough valley which is neither eared nor sown." He further traces this root into the words signifying the plough, or the instrument of earing; such as the Latin ara-trum; the Cornish aradar; the Welsh arad; and many other derivatives. "Even the word earth, the Gothic airtha, the Anglo-Saxon eorthe, must have been taken originally in the sense of ploughed or cultivated land." Taking again the word respectable, he separates from it its root " spac/' to look or see, and demonstrates the presence of this root in a vast number of words of the various languages, ancient and modern, which constitute the great Aryan group. These are but two of the numerous examples of roots in the Aryan languages which are given by Professor Miiller. He shows that after the most careful analysis of any one of the more highly developed languages of mankind, four or five hundred of such roots are what remain in the crucible; and that from these the thousands of words composing the language are essentially formed. He is very emphatic in his assertion that these roots are predicative, and the signs of general ideas :—Thus the root "m&" in Sanscrit means to measure, from which is derived moon, the measurer; " man," a derivative root, means to think, and as a noun it therefore means the thinker; the sun is the begetter; the root " g& " means going; " sth&," standing; " sad," sitting; " da," giving; " mar," dying; " 7EECtt clear that, according to the manner in which roots are put together, we may expect to find three kinds of languages, or three stages in the gradual formation of speech:—(1.) Eoots may be used as words, each root preserving its full independence. (2.) Two roots may be joined together to form words, and in these compounds one root may lose its independence. (3.) Two roots may be joined together to form words, and in these compounds both roots may lose their independence. " What applies to two roots applies to three or four or more." 1 (1.) Radical Stage.—Chinese is the interesting example of a language in which each root is a monosyllabic word, preserving its full independence, and having its own substantial meaning. The expression " With a stick" would in Latin be expressed by the single word baculo, but in Chinese by the two words y cang: y having the meaning "employ"; so that the expression means literally "employ stick." The expression "at home"—in Latin domi—is, in Chinese, 0.0-li: uo meaning " house," and li originally " inside." There is no trace of grammar in ancient Chinese: the genitive case, for instance, is represented simply by placing the word that is in the genitive first in order,—"a man of the king- dom" being given as koue kingdom, jin man (the kingdom's man). The parts of speech are determined by the position of the words in the sentence:—thus ngd ta ni means " I beat thee "; but ni ta ngd would mean " thou beatest me." The adjective has the force of an adjective because placed before a noun. The same word placed before a verb would have the force of an adverb. "In Chinese," says Prof. Miiller, "no analysis of any kind is required for the discovery of its component parts. It is a language in which no coalescence of roots has taken place. Every word is a root, and every root is a word. It is, in fact, the most primitive stage in which we can suppose human language to have existed. It is language comme it fant; it is what we should naturally have expected all languages to be." (2.) The Agglutinative Stage.—In the second great group of languages, the Turanian, we have the group to which, according to Professor Miiller, by far the largest number of languages belong. It, in fact, comprises all the languages spoken in Asia and Europe, except those that belong to the Aryan and Semitic families. It 1 Max Miiller, vol. i. p. 330.CLASSIFICATION OF LANGUAGES. 163 is the type particularly characteristic of the races which have been at one time, or are even at the present day, of nomadic habits. In it, two roots may be joined together; and in these compounds one root may lose its independence. Its parts of speech have been considerably elaborated; the nouns having declensions and cases, and the verbs conjugations and tenses. The verbs are said to be particularly elaborate. Turkish is one of the best examples of the group. In Turkish—to take one or two examples,—the general idea of loving in the abstract is expressed by the root sev. Whatever additions be made to this root by agglutination of other syllables, it always remains itself unchanged, and is never modi- fied, as the English fall is, in fell; or take is, in took. It becomes the participle loving, or the noun lover, by the addition of er,—sev + er;—and in this form it is used as the verb, sever-im being I love, sever-sen thou lovest, and so on. Sev-mek is to love; sev-ish-mek is to love one another; sev- in-mek is to love oneself, or rather, to rejoice and be happy.1 In illustrating the nature of this agglutinative group of lan- guages, Dr Komanes uses the English word un-cost-li-ness, in which each syllable represents a root,—although in some of them, as in the syllable li (like), the root has suffered serious deterioration. Strung together into one word, the syllables have yet distinct meanings which can still be recognised, though in some cases with difficulty. He says, " If all our words had been formed on the type of this example * uncostliness/ English would have been an agglutinative language." Prof. Max Miiller says, " The agglutina- tive languages preserve the consciousness of their roots, and there- fore do not allow them to be affected by phonetic corruption; and though they have lost the consciousness of the original mean- ing of their terminations, they feel distinctly the difference between the significative root and the modifying elements." (3.) The Inflectional Stage.—The third great group of languages, that in which two or more roots, joined together to form words, may, in these compounds, all lose their independence, is that of the Inflectional languages, of which there are two families, viz., the Semitic and the Aryan. It is curious that the higher civilisa- tion of the world has been, to a most remarkable extent, owing to 1 For the above, and many other, examples of Chinese and Turkish, see Max Miiller, vol. i.164 THE DISORDERS OF SPEECH. the races of mankind who have spoken or continue to speak these lan- guages. Hebrew, Chaldee,and Arabic, may be instanced as examples of the Semitic family; Sanskrit, Persian, Latin, Greek, the Teutonic languages, the Celtic, and the Slavic, as representatives of the Aryan. In this great Inflectional group, the roots have been welded together into a closer relationship than in the Agglutinative languages. To use the simile of Professor Miiller, they represent a mosaic in which the elements are so closely applied to each other that the joinings cannot be discovered, whereas in the Agglutinative languages each separate element is still distinctly definable among the rest. In the Inflectional languages, " the various elements which enter into the composition of words may become so welded together, and suffer so much from phonetic corruption, that none but the educated would be aware of an original distinction between root and termination, and none but the comparative grammarian able to discover the seams that separate the component parts.''1 Thus the English word lord would be nothing but an empty title " unless its original form and meaning had been discovered in the Anglo-Saxon hlaf-ord, meaning the source of bread, from hlaf, a loaf, and ord, place." The word lady is similarly derived from hlaf, loaf, and dige, from digan, to care for or help. " Hence lady means one who helps or serves bread to the family." In like manner it would be impossible to know how the terminal letter in the word loved puts the verb in the past tense, were we not assured by philologists that the expression was originally I love did (I did love), and that the did has been attenuated to the single letter d. When the union of roots has thus become more intimate, the structure " can be manipulated in a variety of ways without involv- ing its disintegration so that the languages of this type admit of more artistic employment than those of any other. Romanes gives the following formula (from Hovelacque) regard- ing these three great groups of languages. R representing a root, a sentence in a language of the radical or isolating type (Chinese) might be represented thus,—R + R + R, each root maintaining its complete independence. In the agglutinative type, the chief roots still maintain their independence, but the subordinate roots undergo some modification, though still remaining distinctly recog- 1 Max Miiller, op> citvol. ii. p. 370.CLASSIFICATION OF LANGUAGES. 165 nisable as roots. The formula given for these is Er, Err, rE, or rEr. In the inflectional type, either the chief roots or the sub- ordinates may undergo inflectional change so as to become irrecog- nisable as roots, except to the learned, who can trace out the history and affinities of the word; and this inflectional change is, in the formula, denoted by attaching the letter x to the root changed. As either the chief root or the subordinates may undergo such in- flection, the formula is, Erx, Exr, Errx. Professor Miiller (p. 372) is of opinion that every language can be classified as a member of one or other of these three great groups,—the Eadical, the Agglutinative, and the Inflectional. He thinks that the second of these was developed from the first, and the third from the second. At page 378, he says—"As far as the formal part of the language is concerned, we can- not resist the conclusion that what is now inflectional was formerly agglutinative, and what is now agglutinative was at first radical." Analogy between the Species of Languages and the Species of Plants and Animals.—Darwin has made some very interesting remarks about the obvious parallelism that exists between the development of different languages and the development of different species of plants and animals. He says—" The formation of different lan- guages and of different species, and the proofs that both have been developed through a gradual process, are curiously parallel. But we can trace the formation of many words further back than that of species, for we can perceive how they actually arose from the imitation of various sounds. We find in distinct languages, striking homologies due to community of descent, and analogies due to a similar process of formation. The manner in which certain letters or sounds change when others change, is very like correlated growth. We have in both cases the reduplication of parts, the effects of long- continued use, and so forth. The frequent presence of rudiments both in language and in species is still more remarkable. The letter m in the word am means I, so that, in the expression I am, a superfluous and useless rudiment has been retained. In the spell- ing, also, of words, letters often remain as the rudiments of ancient forms of pronunciation. Languages, like organic beings, can be classed in groups under groups; and they can be classed, either naturally, according to descent, or artificially by other characters.166 THE DISORDERS OF SPEECH. Dominant languages and dialects spread widely and lead to the gradual extinction of other tongues. A language like a species, once extinct, never, as Sir C. Lyell remarks,' reappears.' The same language never has two birthplaces. Distinct languages can be crossed or blended together. We see variability in every tongue, and new words are continually cropping up; but, as there is a limit to the powers of the memory, single words, like whole languages, gradually become extinct. As Max Miiller has well remarked :— ' A struggle for life is constantly going on amongst the words and grammatical forms in each language. The better, the shorter, the easier forms are constantly gaining the upper hand, and they owe their success to their own inherent virtue/ To these most im- portant causes of the survival of certain words, mere novelty and fashion may be added; for there is in the mind of man a strong love for slight changes in all things. The survival or preservation of certain favoured words in the struggle for existence is natural selection/'1 Phonetic Decay and Dialectic Regeneration—By the processes of Phonetic Decay and Dialective Regeneration, curious changes have been brought about in the words of every language. Abundant illustrations of such changes may be found, for example, in any language belonging to the Inflectional group. If we take French, which is one of the direct descendants of Latin, we find, as Professor Miiller points out, that many of the Latin terminations are substantially retained in the spelling of words, though, having become mute, they have disappeared from pro- nunciation. " Thus, j'aime is ego amo; tu aimes, tu amas; il aime, ille amat. There was originally a final t in the French il aime, and it comes out again in such phrases as aime-t-il ?" In the future of the same verb, the process of Dialectic Regeneration is exhibited. The old Latin is amabo, but the French is j'aimerai. "How did the termination rai bud forth like a blossom in Spring? . . . The Latin future was destroyed by means of phonetic corruption. When the final letters lost their distinct pro- nunciation, it became impossible to keep the imperfect amabam separate from the future amabo. The future was then replaced by dialectical regeneration, for the use of habeo with an infinitive is found in Latin, in such expressions as habeo dicere, I 1 Descent of Man, p. 90.CLASSIFICATION OF LANGUAGES. 167 have to say, which would imperceptibly glide into, I shall say." The future j'aimerai is, literally translated, I have to love. In English, the effects of phonetic decay are as strikingly exhibited as in French, and dialectic regeneration has in English been brought about to an extent perhaps without parallel in any other language. In the ancient languages of Teutonic type from which English has descended, it was at one time the practice to place the pronoun after the verb, the word am, for example, being, as already in- dicated, complete in itself, with the meaning of " I am," the terminal m having originally the signification of " I." So, in like manner, art was originally complete in itself, the final t repre- senting the second personal pronoun. In Latin and Greek, all verbs exhibit these personal terminations, but in English the verb to be is one of the few that still retains some of them. Long ago, these terminations became so decayed as 110 longer distinctly to indicate personal pronouns, and, by process of dialectic regeneration, new personal pronouns were placed before the verb. In these circum- stances, the genius of the English language had, in most cases, the good sense to drop the useless terminations altogether, retaining them neither in the spelling nor in the pronunciation. The gram- mar of English has thus been reduced to the greatest simplicity, so much so, indeed, that some authorities will have it that English, like Chinese, has no grammar at all;—for " What is grammar," says MaxMiiller, " but conjugation and declension ?" and conjuga- tion and declension have in English been reduced to a simplicity that contrasts remarkably with their condition in the other lan- guages of the same group. Among a people speaking the same language, the processes of phonetic decay and dialectical regeneration always bring about the development of different dialects in different districts of the country. The accent differs in different districts; certain words are pro- nounced differently; words and expressions are retained in some districts, though they have become obsolete in others; and even the pronunciation of certain letters may be such as to be charac- teristic of the district,—as is the use of the burring E in North- umberland, and the substitution of Z for S in Somerset. The different dialects struggle with each other for predominance, until at last the contest is decided by one dialect becoming the literary dialect of the country, and the spoken dialect of all educated people168 THE DISORDERS OF SPEECH. in it. A standard of good taste is thus established, and any marked departure from it, if the articulative powers are normal, comes to be branded as either an affectation or a vulgarism. It would be easy to give abundant examples of Affectations, but it may suffice to remind the reader of the affectations practised in the substitution of th for s (lisping) and in the substitution of W for r ;—which, however, are affectations only when they are practised voluntarily. A new affectation, which seems to be gaining ground at present, is the substitution of n for the terminal ng in words ending with ing. The most striking Vulgarism in English is the omission of h where it ought to be pronounced, and the insertion of it where it ought not. Omitted in one place, it takes its revenge by cropping up where it has no right to be. Tt is much the same with the letter r. Even in polite English, the r sound has, when occurring after a vowel, been so softened as to be effaced. It takes its revenge by appearing where it has no right to be. In southern English we hear it in such expressions as " Isabellar of Spain." This obtrusive r, Dr Hullah regards as unpardonable; but it is so common even among highly educated people that it is beginning to acquire a respectable position in society. The unpardonable errors are those connected with the letter H. These are the Shibboleths of modern English society. The reader will remember the passage about this word Shibboleth, the sh sound of which was in one of the dialects of the Hebrews given as S:— " And it was so, that when those Ephraimites which were escaped said, Let me go over; that the men of Gilead said unto him, Art thou an Ephraimite ? If he said, Nay; then said they unto him, Say now Shibboleth: and he said Sibboleth: for he could not frame to pronounce it right. Then they took him, and slew him." The English Language.—When a language of the Inflectional type has dropped its useless terminations, and thereby greatly simplified its structure and grammar, it is said, by some authorities, to have passed into the Analytical stage. As already indicated, the English language has more than any other language passed into this condition. It is, in fact, the chief representative of what has been called the analytical modification of the Inflectional type. It is well known that Grimm, one of the illustrious founders of Modern Philology, has paid a remarkable compliment to the English lan-CLASSIFICATION OF LANGUAGES. 169 guage. He says,—" The English language possesses a power which probably never stood at the command of any other nation. This singularly happy development and condition has been the result of an intimate union of two of the noblest languages, the Teutonic and the Eomance ; the former supplying the material groundwork, the latter, the spiritual conceptions. In truth, the English lan- guage. which, by no mere accident, has produced and upborne the greatest and most predominant poet of modern times (I can, of course, only mean Shakespeare), may, with all right,be called a world- language, and, like the English people, appears destined hereafter to prevail with a sway more extensive than its present one over all portions of the globe. For in wealth, good sense, and close- ness of structure, no other of the languages at this day spoken deserves to be compared with it,—not even our own German, which is torn even as we are torn, and must rid itself of its defects before it can enter into the lists as a competitor with English." 1 The total number of words in the English language has been variously estimated, one dictionary of repute giving 43,566, another 58,000, and a third 70,000. It is said that a perfect dictionary would include as many as 100,000. Professor Miiller says,—" The Hebrew Testament says all that it has to say with 5642 words, Milton's works are built up with 8000, and Shakespeare, who probably displayed a greater variety of expression than any writer in any language, produced all his plays with about 15,000 words/'2 The same authority states that a well-educated person in England seldom uses more than about 3000 or 4000 in actual conversation; and he quotes an observation made by an English clergyman, Mr D'Orsey, in his Study of the English Language, that some of the labourers in his parish had not 300 words in their vocabulary. This observation, Mr Farrar informs us,3 has been widely disputed; but he seems himself, from his own observations, inclined to accept it as substantially correct. Alphabetical Letter-sounds used in Different Languages.4—No lan- guage uses more than a comparatively small number of the sounds 1 Quoted by Lennox Browne & Behnke, Voice, Song, and Speech, p. 37. 2 Max Miiller, op. citp. 309. 3 Chapters on Language, p. 52. 4 This subject is discussed at considerable length by Kussmaul, who gives many other examples. Y170 THE DISORDERS OF SPEECH. wliich the organs of articulation are capable of producing. Each language makes its own selection of these sounds. Even among European nations employing the same alphabet, there are differ- ences in the sounds given to some of the letters. Thus the English th sound is peculiar to English, and is with difficulty acquired by foreigners. Terminal n's have only a half-nasal pronunciation in French. In German, s is pronounced like the English z, and z like the English ts. Still more striking peculiari- ties are exhibited among non-European peoples. The Chinese, for example, have no E in their language, and say " Yamelika" for " Americathe Japanese have no L, and say "Horrand" for " Hollandand the Mohawks have no labials or labio-dentals, and therefore have in their language no p, b, f, v, w, or m. The Arabs have their true gutturals, pronounced deep in the throat, about the upper part of the larynx. The Hottentots make much use of clicking noises, of which some are made by the tongue, and others by the lips. Song.—Among those who hold the view that Speech developed itself gradually out of a previously existing language of vocal tone, facial expression, and gesture, an interesting difference of opinion has arisen as to the period at which Song was probably developed. Herbert Spencer, in his Essays, holds that song was late in coming, and that it probably developed itself out of the cadences of impas- sioned speech. Darwin, on the other hand, has advocated the opposite view, and holds that song in all probability preceded speech. He says,1—"As we have every reason to suppose that articulate speech is one of the latest, as it certainly is the highest, of the arts acquired by man, and as the instinctive power of pro- ducing musical notes and rhythms is developed low down in the animal series, it would be altogether opposed to the principle of evolution, if we were to admit that man's musical capacity has been developed from the tones used in impassioned speech. We must suppose that the rhythms and cadences of oratory are derived from previously developed musical powers. We can thus under- stand how it is that music, dancing, song, and poetry, are such very ancient arts. We may go even further than this, and, as remarked in a former chapter, believe that musical sounds afforded one of the bases for the development of language." 1 Descent of Man, p. 570.ORIGIN OF WRITTEN LANGUAGE. 171 Origin of Written Language. The language of Gesture employed by deaf-mutes, savages, and others, has been described as substantially a picture-language, by means of which objects are, as it were, pictured in the air. As already indicated, it is held by many that this language of pictures in the air must have played an important part in preparing the way for the language of Spoken Words. This, however, cannot be proved to be a fact: it is only a proposition, with much to be said in its favour. It is very different in regard to the origin of Written language. Here ~the evidence is conclusive. All authorities are agreed that there can be no possible doubt about the fact that picture-writing preceded word-writing, and that out of picture- writing, word-writing was slowly evolved. From the writings of Mr E. B. Tylor, I shall endeavour to extract a few of the most illustrative facts bearing upon the question. The various tribes of North American Indians have made, on rocks and tombstones and blazed pine-trees, many excellent examples of the most primitive type of picture-writing. They practise such picture-writing to the present day. Everything indicated is rudely but clearly drawn. In the record of a hunting expedition, for example, two comparatively large figures, those of a bear and a cat-fish, indicate the clan names or totems of the chiefs who took part in it; and a number of smaller figures, those of six cat-fish and one bear, indicate the spoil of the expedition. A warlike expedition, in like manner, is rendered by the figure of the chief on horseback; the totem of his principal ally, a king- fisher; six canoes, with upright lines in them to indicate the number of men in each; a tortoise, apparently to indicate that the expedition got to land; and three discs under a vault, to indicate that there were three suns under heaven, that is, that the voyage took three days. Among the semi-civilized Aztecs of Mexico, the Indian picture- writing made some steps in advance. Pictures, better drawn than those of the ruder Indians, continued to be used in writing, as the representatives of the things pictured, but already, long before the conquest of the country by the Spaniards, a new element had been added to the writing. It was the employment of a large number172 THE DISORDERS OF SPEECH. of pictures to represent, not the things pictured, but syllabic sounds identical with the spoken name of the thing pictured, or at least with the first syllable of that name. Thus & phonetic system of signs for syllables added itself to the older pictorial representa- tions of things. "The device," says Mr Tylor, "is perfectly familiar to us in what is called a i rebus,' as where Prior Burton's name is sculptured in St Saviour's Church as a cask with a thistle on it,4 burr-tun.'" It is known that by this compound picture- writing the Aztecs made known to their king at the capital the first arrival of the Spaniards on their coast. Chinese writing, though at the present day its characters have little in them that is suggestive of pictures, is really the direct descendant of a picture-writing of the ordinary type. As the ancient picture characters have been preserved, the whole history of this development can be traced. In the ancient characters, the sun was a disc, the moon a crescent; and a fish, a dog, a mountain, and a tree were represented by conventionalized sketches of these objects. Gradually these pictures underwent change, by a process equivalent to the phonetic decay of spoken words; so that eventu- ally they became, to all appearance, merely conventional signs for the objects indicated. At the same time, Combinations of the signs were constantly invented. By these combinations Ideas or Concepts were represented; so that the title Ideographic has been given to this type of writing. The adjective bright is thus repre- sented by the combined signs of the sun and the moon, and the verb to divide by the combination of the sign for a knife and that for the number eight. As in the case of the Aztec writing, one step was made towards the formation of a phonetic alphabet; and it was made in the same way. Many of the signs became phonetic syllable signs, like Prior Burton's " rebus." But here a difficulty, inherent in the " poverty-stricken" Chinese language, had to be encountered. In Chinese, the same spoken word has in very many cases a great variety of meanings, and in speech the specific meaning is generally made intelligible merely by accent. or intonation. But accent and intonation could not be faithfully represented in the characters, and therefore another device had to be adopted. The word chow in Chinese means many things. Among others it means " ship." Therefore a ship stands for the sound chow. But the same sound means a "ripple." ToORIGIN OF WRITTEN LANGUAGE. 173 make this clear, when ripple is indicated, the sign for water is added to that for ship. In like manner, as the sound chow may mean loquacity, the sign for speech is added to that for ship when loquacity has to be indicated. Thus " the great mass of characters at present in use are double, consisting of two signs, one for sound and the other for sense."1 " Egyptian Hieroglyphic Inscriptions consist of figures of objects, animate and inanimate, men and animals, and parts of them, plants, and heavenly bodies, and an immense number of different weapons, tools, and articles of the most miscellaneous character. These figures are arranged in upright columns or horizontal bands, and are to be used in succession, but they are not all intended to act upon the mind in the same way. When an ordinary inscrip- tion is taken to pieces, it is found that the figures composing it fall into two great classes. Part of them are to be read and under- stood as pictures, a drawing of a horse for 'horse,' a branch for ' wood/ etc., upon the same principle as in any savage picture- writing. The other part of the figures are phonetic. Thus, the figure of a strap, the name of which is m — s becomes a phonetic sign to write the sound m — S with. (The — stands for some vowel, which is represented by ou in the Coptic form of the word, mous.) "2 Here then we have represented the " rebus " or syllabic stage of phonetic writing, as it is met with in"Aztec and Chinese writing. But the hieroglyphics went further than this. Along with the two sets of characters above indicated, there is a third set, which, by most authorities, is held to represent simple con- sonant sounds without attached vowels. Thus it appears that the figure of a mouth is often used with the simple signification of the letter r—the Egyptian word for mouth being ro;—and there are many other signs which apparently stand for simple consonants. In the same inscription, all three stages in the development of written characters may thus be found to be represented: (1.) Pure picture-writing; (2.) The " rebus " stage of syllable phonetic writ- ing ; and (3.) Alphabetical phonetic writing. In ancient Egyptian, as in Chinese, the poverty of the language displayed itself in the employment of the same spoken word in a great variety of senses. To indicate the specific meaning to be attached to the word, the same device was employed in the Hiero- 1 E. B. Tylor, op. citp. 400. 2 Ibid., p. 98.174 THE DISORDERS OF SPEECH, glyphics as in the Chinese. After the phonetic symbol, came the " determinative sign," in the shape of a picture to be read as a picture. Thus, the signs for " the letters k k followed by the pic- ture of a star hanging from heaven mean 'darkness' (Coptic kake)."1 Mr Tylor says that had there been none of these determinative signs in the inscriptions, the deciphering of them in modern times " could hardly have gone a step beyond the first stage, the reading of the kings' names." The third element in the hieroglyphics is believed, by most authorities, to have furnished the first suggestion to the Phoenicians for the construction of a complete phonetic alphabet, in which each letter would represent a single consonant or a single vowel. This is the final step in the development of written speech. Obviously, it reduces the written characters to a number exceedingly small, as compared with the number required for syllabic sounds, or the still greater number required for pictorial representations. Learn- ing to read and write becomes a comparatively easy matter when words are thus represented by signs of their component letter- sounds. If the Phoenicians were, as is generally believed, the first to construct such an alphabet, the world owes them a debt of gratitude. Whether some sage among them, taking hints from the hieroglyphics, evolved the whole alphabet as it is found in their literature, or whether it was developed gradually, by a process of gradual improvement, is now, I suppose, impossible to determine. In whatever way it was elaborated, there can be no doubt that the Phoenician alphabet was the parent of the Greek and Roman, and therefore of the alphabet which we use at the present day. The Invention of Printing. A full and instructive article on Typography has been contri- buted to the last edition of the Encyclopaedia Britannica.2 I shall avail myself of it in making here a few brief notes as to the development of printing. Before the invention of printing, books were of course published in manuscript, and all figures or pictures in them were drawn with the pen or painted with a brush. " In the thirteenth century there 1 E. B. Tylor, op. citp. 99. 2 By J. H. Hessells and John Southward.THE INVENTION OF PRINTING. 175 already existed a kind of book trade. The organisation of universities, as well as that of large ecclesiastical establishments, was at that time incomplete, especially in Italy, France, and Germany, without a staff of scribes and transcribers, illuminators, lenders, sellers, and custodians of books, and persons who prepared and sold the vellum or parchment required for books and documents." It was when the production of manuscripts had thus attained to its greatest development, that the art of Block-printing or Xylo- graphy first made its appearance. This was, in fact, nothing more than wood engraving. On a single block of wood, a picture was engraved, and, along with it, were engraved the words explanatory of the subject. At a later time, upon a single block a whole page of reading was engraved. Whole books were thus printed from engraved blocks, each page from its own block. Many of these " block-books " have been preserved to the present day. This art of block-printing seems to have been practised as early as the 12tli Century, and it is certain that about 1400 it was known all over Germany, Flanders, and Holland. With such blocks of engraved words in their hands, it must have required no great exercise of the imagination, on the part of the engravers, to see that if the letters of the alphabet were engraved on a block in this fashion, and then cut apart from each other so as to form movable " types " of the individual letters, an immense saving of labour would be effected. It would no longer be neces- sary to engrave the letters anew for every new book. It would be possible to use the same types over and over again for the printing of a multitude of books,—their re-arrangement for each being all that would be required. The carrying of this idea into effect con- stituted the great and beneficent invention of printing, which, in these last centuries, has contributed so enormously to the advance of civilisation. The types were first cut in wood, but in a very few years it was found to be much more convenient to have them cast in metal. Who was it that first cut out the movable wooden types and printed from them? About this question there has been a controversy for about four hundred years. In the article alluded to, the reader will find the facts of the case very fully stated. The Dutch claim the invention for their countryman, Lourens Janszoon Coster, who worked at Haarlem. The Germans, on the other hand, hold that the inventor was Johann Gansfleisch, commonly known176 THE DISORDERS OF SPEECH. as Gutenberg, who worked at Mainz. After a most elaborate examination of the evidence, the authors of the article conclude thus:—"As the case stands at present, therefore, we have no choice but to say that the invention of printing with movable metal types took place at Haarlem, about the year 1445, by Lourens Janszoon Coster." Gutenberg and the other printers, established a few years after this date at Mainz, seem to have improved the art and made it more artistic.1 By means of the primitive hand-press, very beautiful printing was done by the old printers; but the work was slowly executed. In recent times, great improvements have been effected in rapidity of execution. The use of steam-power; the valuable invention of " stereotyping" (taking metal casts of the types after they have been set up; so that the printing surfaces can be multiplied indefinitely); and the exercise of great mechanical ingenuity in the construction of printing machines; have all contributed to make printing, in these latter days, a process which can be carried out with the most wonderful rapidity. The celebrated Walter machine, for example, employed at present by most of the leading newspapers, when working at its average speed, is capable of turn- ing out in an hour 12,000 copies of a large newspaper, printed on both sides. Printing for the Blind. Within recent times, several valuable inventions have been made by modifying the letter-signs of the alphabet so as to make them available for special purposes. Among these may be mentioned the representation of the letters by the combined dots and dashes employed in the Morse system of telegraphy; also the lines and dots used for phonetic shorthand writing. It will here not be necessary to say anything about either of these valuable inventions. N"or will it be necessary to describe the signs used for musical notation; nor the symbols that have been invented, from of old, for arithmetical, algebraic, and astronomical purposes. But with regard to some of the last mentioned I may quote an 1 It should be noted that the arts of Block-printing and of Printing from Movable Types were both practised in China and Japan for centuries before they arose in Europe.POINTING FOR THE BLIND. 177 interesting remark made by Mr Tylor. He says, "' © before clock 4 min,' and ' j) rises at 8 h. 35 m./ survive to show that even in the midst of the highest European civilisation, the spirit of the earliest and rudest form of writing is not yet quite .extinct." I should like, however, to say a few words about the Raised Letters that have been invented for the benefit of the Blind. Full infor- mation on the subject may be found in the work by Dr T. E. Armitage, Hon. Secretary to the British and Foreign Blind Asso- ciation.1 The inventor of raised characters for the blind was M. Valentin Hauy, the founder of the Institution des Jeunes Aveagles in Paris. He invented raised characters in 1784; using, for the purpose, the Italic or written form of the Roman letter. This system was introduced into this country in 1834, but it was soon super- seded. Mr Gall, of Edinburgh, in 1834, printed the Gospel of St John in a modified Roman letter, using serrated lines and replacing curves by angles. Mr Alston, of Glasgow, adopting the idea of Dr Fry, the type- founder, used ordinary Roman capitals,—a method still used in some of the English and American asylums. The system of Lucas, introduced about 1838, is a stenographic shorthand; and the characters are altogether arbitrary, consisting mainly of lines with or without a dot at one end. It is used by the London Society for teaching the blind to read, and in several of the provincial asylums. The Braille system was invented in 1829, by M. Louis Braille, a blind pupil of the Institution des Jeunes Aveugles in Paris. It has been recommended for adoption by every European Congress of educators of the blind since 1878. "Its signs are purely arbi- trary, and consist of varying combinations of six points, placed in an oblong, of which the vertical side contains three, and the horizontal two points.'' There are sixty-two possible combinations of these six points, "so that after the modest requirements of the English alphabet have been supplied, there remain a sufficient number of signs for punctuation, contractions, etc." For the letter A, only one of the six dots—the uppermost of the left vertical side—is raised ; for B, this same dot and the one below it; for C, 1 The Education and Employment of the Blind. Second edition, 1886. Z178 T-HB DISORDERS OF SPEECH. the upper dot of each vertical side; for D, the same two and the second of the right vertical side; and so on. These raised dots are found to be more clearly perceptible to the touch than any kind of lines. In the Braille type, not only words, but also music has been extensively printed. In the Edinburgh Asylum, the Braille type has been in use for the last twelve years, and gives great satisfaction. With the aid of simple apparatus, the pupils print' letters for themselves. They also stereotype the characters upon metal plates, from which copies can be taken with a printing-press. In this way, they have themselves printed many volumes. Among the other systems that have competed in this country for adoption, may be mentioned those of Frere, Moon, and Carter; but it will not be necessary to describe them. As the human mind is, in the natural condition of things, prim- arily educated to speech through the " ear-gate," a person born blind is as to speech undoubtedly in a less unfortunate condition than is a congenital deaf-mute. The blind child learns to speak and to understand audible speech like other children. Though he cannot appreciate expressive gestures and facial expressions, he can fully appreciate expressive tones, and has the enormous advantage of being educated to speech early, and in the normal way. Still, even as regards speech, he is in a very unfortunate position. It has been said that in the case of most educated persons a full half of the new thoughts that daily reach the mind reach it through the medium of the eye, from printed and written characters. No invention can put the blind in a position to read the words of ordinary print or writing. The learned blind—and there have been many such—have employed others to read aloud for them. Still, the invention of raised characters has been of immense service to the blind, as has also been the education to various kinds of work that is given them in the Asylums for the Blind now established in every great city. By the education of the unfortunate blind, and the still more unfortunate deaf-mute, humanity has, during the last hundred years, done itself great honour. In the foregoing notes, I have tried to indicate the chief facts in the development of speech, audible and visible. These facts, IPRINTING FOR THE BLIND. 179 think, are well calculated to illustrate the relationships between speech and thought. This, however, is a difficult metaphysical subject which, for the present at least, I cannot do more than glance at.1 I shall therefore only say a few words about the rela- tions of nouns to percepts. The facts before us show very clearly that the human mind forms images of things, which it can recall in imagination at will. These images are memories of sense impressions. There are sight- images and sound-images ; and there are also images or memories of taste, touch, and smell. By combining these sense impressions, the mind forms percepts of objects. A percept thus represents a knowledge of the sensible properties of the object, so far as, in any given case, these have been ascertained. As all intelligent minds form such percepts in the same way, and hold them in the memory ready to be revived, no elaborate description is needed to revivify, in the mind of another person, a percept already familiar to him. A mere hint is sufficient. The deaf-mute thus suggests a familiar percept to the mind of another person by his imitative gesture or picture in the air. The early inventors of picture-writing, in like manner, suggested familiar percepts by making actual drawings of the objects, as visible to the eye. Audible speech fulfils its function largely by calling up percepts in the mind. And it does so much more efficiently than either gestures or pictures. The wonderful law of association in the human mind permits of the linking together of a certain sound and a certain percept, and this word-sound represents not merely one of the sensible properties of the object, such as its external form,— it is equivalent to the whole percept,—it is its symbol or equiva- lent. Thus, to call up in the mind of another person the percept, say, of a horse, the horse need not be described: a single word is sufficient. Something has already been said as to the specula- tions regarding the manner in which these word-symbols first came to be developed. It has been shown that according to one opinion the first words were voluntary imitations of natural sounds, and that according to another the " roots " of languages, which may be regarded as in some measure representative of the primitive words, ought to be regarded as " ultimate facts " in Philology, ad- 1 The subject will be found to be fully discussed both by Farrar and by Romanes, op. cit.180 THE DISORDERS OF SPEECH. mitting of no explanation. Whatever may have been the primi- tive origin of words, they are, in their essential nature, symbols. They are suggestive of percepts, in virtue of the law of associa- tion; and they are so subtly suggestive that a long train of thought expounded by a speaker can be called up to the minds of his hearers in instantaneous response, while he is in the act of speaking. These word-symbols are so superior to all others in their power of calling up percepts, that, in the development of written characters, the final triumph was attained only when the sounds of speech were at last analysed into their component letter-elements, and a written character was given to each of these. The visible writing then for the first time accurately suggested to the mind the audible sound, in virtue of the wonderful law of association. Written words are thus the visible symbols of sound symbols. In this respect they are so efficient that, when we read the words upon a written or printed page, they almost seem, to the imagina- tion, to sound audibly in our ears. So efficiently has language linked itself to thought, that many have difficulty in conceiving of thought as capable of existing at all without at least a mental embodiment of it in language. Prof. Max Miiller even goes so far as to say, "There is no thought without words, as little as there are words without thought."1 "What a strange -definition," says Darwin, "must here be given of the word thought." It seems pretty clear that if the disputants upon this question agreed to attach the sapie meanings to the terms employed in their argu- ments, they would soon come near to a general agreement. Many eminent authorities, as we have seen, hold that speech itself was invented by thought; and truly a man must be a master of words before his best thoughts can be expressed in language that is worthy of them. Some hold that thought can never be adequately expressed, but can only be suggested. Thus, according to Du Ponceau,2 "Thought is vast as the air; it embraces far more than languages can express, or rather languages express nothing; — they only make our thoughts leap out in electric sparks from the speaker to the listener. A single word suggests a crowd of ideas which the 1 Quoted by Darwin, Descent of Man, note to p. 89. 2 Quoted by Farrar, op. cit., p. 263.PRINTING FOR THE BLIND. 181 spirit combines and collects with the rapidity of lightning." The truth probably lies, as usual, between the two extreme views. Words are wonderfully suggestive, but they are so closely equiva- lent to percepts as to be at the same time wonderfully expressive. They are naturally most expressive with those who have best learned how to use them.PART THIRD. SPEECH IN ITS RELATIONS TO DISEASES OF THE NERVOUS SYSTEM. CHAPTEE VIII. Speech in its Belations to Insanity. As the peculiarities of speech in Congenital Imbeciles have been already pretty fully discussed, that subject need not be included in the present chapter. It is the other class of insane persons that I now wish to treat of: persons who at one period of their lives have been sane, and in the full possession of the faculty of intelligent speech; but who are now insane, their minds having, in one way or another, become disordered or degenerate. I think it desirable at the outset that we should, as clearly as we can, distinguish between the faculty of Thought and that of Language. They are so closely and intimately bound together that it is difficult or impossible to draw between them a strict line of demarcation. Damage done to the one tells in most cases more or less unfavourably upon the other. The union, indeed, is so intimate, that, as we have already seen, there are philosophers who would have us believe that there can be no thought without speech and no speech without thought. That view, however, is not one that seems to me to derive any support from the study of the language of imbeciles, deaf-mutes, apliasics, and insane persons. The study of such cases, on the contrary, seems dis- tinctly to strengthen the more generally accepted view, viz., that,SPEECH IN ITS RELATIONS TO INSANITY. 183 however natural it may be for thought to embody itself in speech and in the other forms of expressional language, and however difficult it may be to draw a line of demarcation between the one and the other, they are yet in their essence distinct. Thought, intelligence, mind, are terms which we use synonymously to indicate the highest endowment of the brain. Language, though so wonderful in itself, must take a lower place. It is the instrument of thought, the magic mirror in which a man may look and read the thoughts of another person, or into which he may cast his own thoughts for another's information. It was by the mind's own efforts that the mirror was originally polished and made efficient; and it is only by the mind's constant attention that it can be kept in good order for daily use. When the mind is damaged, the mirror truthfully reflects a damaged and distorted image. When the mirror is damaged, the reflected image of the mind is not a good and true one; it is blurred, if not distorted, owing to fault in the reflecting power of the mirror. There are facts, however, in the relationships of the two that this familiar metaphor gives us no help in understanding. Such, for example, are the Morbid Activities that are assumed, in certain cases, by the Cerebral Organs of Speech, independently of the will, and sometimes in spite of any inhibitory power that can be brought to bear upon them. When the strong correcting and controlling influence of a healthy mind is no longer exercised upon the organs of speech, a variety of Speech Hallucinations may be developed. Voices may be heard, or Writings may be seen upon the wall; or Motor Hallucinations may be developed in the motor centres; and these last may become Impulsions, and compel the patient to ejaculate words or phrases involuntarily, or even in spite of every effort to suppress them. It is further to be noted, that, in conditions of Dementia (loss of mental power) the function of thought seems often to decay more rapidly than the function of articulate speech; so that even when thought has been reduced almost to zero, the speech organs may yet retain their articulative power, and be able to produce, automatically, words and phrases that had been stored up within them in happier times. Here, again, the disorder of speech does not quite keep step with the advancing disorder of the mind.184 THE DISOKDERS OF SPEECH. But these semi-independent actions and changes in the speech organs, though important in themselves, play, on the whole, but a secondary part. In the majority of cases of mental disease they are not prominently exhibited. The function of language, in the majority of cases, shows little independent activity of this sort. Its activities are, for the most part, in strict correspondence with those of the mind, whose disorder it mirrors with striking fidelity. Still, these independent or semi-independent activities of the speech-organs deserve to be carefully studied, as they are not only important but extremely interesting. They, however, render the subject that we have now to consider more complicated than it would otherwise be. On their account chiefly it will be expedient for us^to look at the Speech of the Insane from several different points of view. I propose therefore:— (1.) To make the Mind our first standpoint, and to give a few illustrations of the faithful manner in which the disorder of the mind is mirrored in the speech of the patient. (2.) To treat of Speech-Hallucinations and other disorders of action that are met with in insanity in connexion with dis- turbances of the cortical speech-centres. (3.) To treat separately of the affections of speech in Dementia ; showing how, in such cases, the decay of speech is slower than the decay of thought; and how, in some of them, the disease of the mental cortex spreads downwards into those cells of the cortex that form the executive motor centres for articulation, thus causing the appearance of an ominous paralytic element in articu- lation, that is of the greatest significance both diagnostically and prognostically. Illustrations of the manner in which Language Mirrors the Condition of the Mind. "Observation," says Griesinger,1 "shows that the immense majority of mental diseases commence with a state of profound emotional perversion, of a depressing and sorrowful character. Guislain was the first to elucidate this highly interesting fact, and make it at all serviceable. Of its general correctness, there can be no doubt; and we can have no hesitation in speaking of 1 Mental Pathology and Therapeutics (New Syd. Soc.), p. 210.manner in which language mirrors condition of mind. 185 a stadium melancholicum as the initiatory period of mental disease. Of course, there are exceptions. Thus in senile dementia, in periodic mania, in meningitis, in the mental diseases consecutive to typhus fever, pneumonia, cholera, sunstroke, etc., the outbreak of mania is generally observed without being preceded by melancholia; but the cases are much more frequent in which the stadium melancholicum only appears to be absent, because it was less intense, and was not then recognised as a stage of mental disease." Probably many persons have had experience of. the stadium melancholicum,—the debatable land between sanity and insanity— who yet have never passed over the border into the state of pro-; nounced insanity. When the disastrous passage is made, the patient may either, on the one hand, sink deep into the depres- sion of true Melancholia, or, on the other hand, pass into the condition of Mania, and become unnaturally exalted in his thoughts and emotions. In some cases, again, there is a rotation, which presents alternately the conditions of melancholia and mania, the Folie Circulairs. In others the mind goes wrong only in some limited and partial way: there may be Moral Insanity, for example, in which deterioration is exhibited chiefly or solely in the sense of right and wrong; or there may be Monomania, in which a single delusion on some particular subject alone betrays the insanity. A. Melancholia.—In true melancholia all forms of outward expression exhibit the profound mental suffering of the patient. The condition has been aptly described as one of mental pain, and in acute cases the suffering may be most pathetically expressed. " The patient/' says Griesinger, " bewails himself, heaves deep sighs, and is engaged in prayers and supplications, but always on the same subject."1 Often there is much motor excitement. "The patients," says Dr Clouston, in speaking of excited (motor) melancholia, "rush about, are violent to those about them, wander ceaselessly, walking up and down like tigers in a cage; or roll on the floor, or wring their hands, or shout or groan, or tear their clothes, or in their cries, attitudes, and motions express loudly their mental pain. In short, the muscular expression of the 1 Op. citp. 227. 2 a186 THE DISORDERS OF SPEECH. prevailing emotion is strong, and uncontrollable by volition."1 In chronic cases, the same features may be presented, although their manifestations are less violent. The patients may continue to bewail their condition for years. In the Eoyal Edinburgh Asylum I was lately shown a case of this kind, the patient being a middle-aged woman with prematurely gray hair. Her constant cry is to be taken to jail, where she may expiate, by suffering imprisonment, the fearful crimes she imagines herself to have committed. The tones of her voice are curiously deep and strong, —so much so, that when I first heard them from a neighbouring ward I could not tell whether it was the voice of a man or of a woman. They have evidently been deepened by their habitual expression of painful and sombre emotion. But there are many varieties of phenomena exhibited by different cases of melancholia, according to its degree of intensity, and to the various kinds of delusion and hallucination that are associated with it. These varieties of type I shall not attempt to enumerate, but I think it may be well to make note of one special type that in its expressional manifestations contrasts remarkably with the violence and excitement of ordinary acute melancholia. I mean the variety of melancholia known as " Melancholia with Stupor;" a condition that sometimes supervenes upon the acutely violent type, and sometimes is developed primarily. In this variety the sufferer is the picture of silent despair. He seems lost in a fearful dream, and sits silent and immobile, perhaps listening to the internal utterances of the evil spirits by which he often imagines himself to be possessed. He* may not utter a single word even for years. If he do reply to questions, it may be slowly, and often in a whisper. There is often a pause before his reply, owing to the feebleness and slowness of all mental action that is not devoted to the delusional ideas with which the mind is possessed. Sometimes the enfeebled will is not capable of produc- ing even a whisper, though in the attempt to speak the lips may slightly and silently move. Often there is no response at all, not even this slight movement of the lips. The attention cannot be roused from without; it is wholly concentrated within, upon the mental suffering, or upon delusions or hallucinations. Such a 1 Clinical Lectures on Mental Diseases, p. 90.MANNER IN WHICH LANGUAGE MIRRORS CONDITION OF MIND. 187 case, on superficial examination, might be mistaken for one of dementia; " but the glance of such a patient," says Griesinger, " does not indicate the nullity proper to dementia; it expresses a painful emotion—sadness, or anxiety, or concentrated astonish- ment." 1 I saw lately, in the Royal Edinburgh Asylum, a female patient suffering from this variety of melancholia. She was silent, but her eye was not vacant of expression. I was informed that if the nurses left the patient for a moment she would immediately attempt to commit suicide. She had many times been caught in the act of making such attempts. Melancholia with stupor may gradually pass into the condition of true and permanent Dementia. All classes of melancholia are peculiarly apt to be troubled with speech hallucinations. They may hear voices, or they are con- scious of being prompted internally by thoughts which seem to them to be articulated within some part of their own body. I shall have something more to say about those hallucinations in the second part of this chapter. The Facial Expression in cases of melancholia varies according to the variety of melancholia that is presented, but it is always faithfully indicative of mental suffering. In acute cases the features are expressive of violent excitement and mental agony; in melancholia with stupor, they denote the condition of dull despair. Darwin has treated fully of facial expression in condi- tions of grief and despair; but as we do not require detailed descriptions in order to be able to recognise such expressions on the human countenance, it will not be necessary here to enter upon any description of them. I shall only make a note of one point of special interest. It is that according to Sir James Cricliton Browne, who contributed some observations on the point to Darwin's work on the Expression of the Emotions, the "grief muscles" are especially often seen to be in a state of contrac- tion in patients with melancholia who have hypochondriacal delusions about the condition of their internal viscera.2 These " grief muscles," as Darwin has called them, are the corrugators of the eyebrows, and their elevator, the occipito-frontalis. When these muscles act together, they form a horse-shoe wrinkle on the 1 Op. cit.y p. 247. 2 See Darwin, Expression of the Emotions, p. 193.188 the disorders of speech. middle of the forehead, the convexity of which is upwards. In long-continued cases of melancholia the expression of mental suffering gets stereotyped on the countenance, and the lines expressive of it often get deepened to a marked degree. B. Mania.—In Acute Mania the excitement is often extreme. Loud speech and violent motion of the body may be incessant. Hurry, excitement, incoherence, and incessant noise are the charac- teristics of acute mania. The characters of the speech are well summed up by Esquirol. He says, " Speech, given to man to express his thoughts and affections, betrays the disorder of the intelligence of the maniac. His thoughts present themselves in crowds to his mind, press upon each other, push each other aside pile mile. Thus words and phrases escape from his lips without connexion, without consecutive order, and with an extreme volu- bility." This may be taken as the usual state of matters in the most acute cases. Referring to cases less acute, the same authority goes on to say, " Some maniacs, full of confidence in themselves, speak and write with facility, and make themselves remarkable by the eclat of their expressions, by the profundity of their thoughts, and by the most ingenious association of ideas. They pass, with the greatest rapidity, from expressions the most affectionate to insults and to threats; they pronounce words and incoherent phrases that have no agreement with their ideas and actions; sometimes they repeat for several hours together the same word, the same phrase, the same passage of music, without appearing to attach to it the least meaning. There are some who create for themselves a language quite peculiar; others, in speaking of them- selves, never do so except in the third person. Sometimes the maniac takes a tone of bombast and vanity, and holds himself at a distance. Nothing being able to fix his attention, he yields to the fugitive desire of the moment, and directs himself towards an O ' object that he may not be able to reach. Diverted in his course, though it be rapid and precipitate, he suddenly arrests himself, dreaming and pensive, and seems to be preoccupied with some plan. He escapes from this state of mind immediately, runs with speed, sings and cries; then he stops himself, his physiognomy takes an expression of joy, he weeps, he laughs, he dances, he speaks in a whisper, in a loud voice; in this unconquerable activity hismanner in which language mirrors condition of mind. 189 movements are lively, sudden, uncertain. The movements and the gestures of maniacs, which appear every one more meaningless than another, are but the expression of the exaltation and disorder of the ideas and emotions of these patients/'1 In Simple Mania the same characteristics are exhibited as in Acute Mania, but they are greatly toned down. There is inco- herence of speech and inconsistency of conduct, with comparatively mild exaltation and excitement. Here is what I got taken down from the mild delirium of a middle-aged woman in the Eoyal Edinburgh Asylum, who sat talking to herself quietly, and laughing occasionally :—"You're not dead yet. I'll not get you. When I was in York Lane why did you not take the candidate I had then ? When you was in Seafield you would not say that to Eobert. That beautiful face of thine. When I forget Spittal Street I'll shine. If I'm no religious, can you lift it up in Spittal Street ?" If the amount of thought that presumably suggested these sentences were put into the balance, it would evidently weigh as nothing in com- parison with the amount of speech produced. This suggests a very important question, viz., the question whether in such cases the speech centres are not to a large extent displaying restless activities of their own that are almost independent of the normal stimulus of thought. I shall refer again to this question in the next part of this chapter. It is generally admitted that the condition of mania is more perilous to the mind than that of melancholia. Mania, more fre- quently than melancholia, causes the mind to sink into a stupor which is apt to be prolonged into permanent Dementia. Even in cases where there is apparent recovery, the patient has not often completely restored to him his former power of mind and fineness of sensibility. The edge has generally been taken off his intellect, and his affections also have been blunted. C. Monomania, Moral Insanity, etc.—I do not think it will be necessary to treat in this chapter of the speech of patients suffer- ing from Monomania, Moral Insanity, or the other special forms of mental derangement. In fact, nothing could be said about the speech of such patients except that, as in melancholia and mania, 1 Esquirol, Maladies Mentales, vol. ii. p. 151.190 THE DISORDERS OF SPEECH. it faithfully mirrors the mental condition of the patient. But it does so rather in the meaning of what is said than in the manner of saying it. There is one curious form of monomania, however, of special interest in connexion with speech, that I may be allowed to say a few words about. It is that in which the patient is under the delusion that, for some special reason, it is necessary that he should be absolutely and permanently taciturn. Such an indi- vidual, though generally insane, is not necessarily so. He may be under a religious vow never to utter a word. Thus we know that the Carthusian monks, in their monastery, keep silence, and converse with each other solely by gestures and in writing, except on Sundays and festivals. In other cases the reason for the taciturnity cannot be discovered. Thus Kussmaul tells of a pedlar in Switzerland who, for at least 15 years, carried on his business entirely by means of signs. " For some unaccountable reason he had condemned him- self to absolute dumbness." Such cases, however, must be rare. In general, when an individual condemns himself to dumbness, he does so in obedience to some insane delusion. Dr Clouston has recorded a good case of the kind. He says,—" I have a man in the Asylum, D. T. K, who for ten years has never spoken a word, but who, I may say, in all other respects behaves sanely, showing no symptoms of morbid pride or suspicion. He is about the best joiner we have. We know he has a delusion which prevents him speaking, but what it is we can't find out. If he wants instructions about his work he writes, but nothing will induce him to write why he won't speak." 1 Speaking of this form of mutism, S^glas remarks,—" Often it is a special hallucination which is the origin of the patient's mutism. He hears, for example, an imperative voice which forbids him to speak; and, in spite of all entreaties, he keeps silence. In other cases the mutism is the consequence of a delusional idea, which, moreover, may vary in character. Sometimes it is an idea of unwortliiness, of humility: the patient believes himself fallen from his position as a man, and unworthy to communicate by speech with his fellow-creatures. Sometimes it is an idea of expiation: he keeps silence to expiate the imaginary sins that he reproaches himself with. In other cases it is the fear of hurting some one,— 1 Clinical Lectures on Mental Diseases, p. 260.THE ACTION OF THE SPEECH CENTRES. IN INSANITY. 191 of compromising, by speaking, some one that he loves,—that makes him keep silence. A patient under the care of M. Falret, who had shut himself up in absolute mutism, avowed at intervals that it was for fear of compromising his son by speaking. Sometimes this mutism has its source in an idea of hypochondriacal nature: if the patient does not speak any more, it is because he has the idea that he has no longer a tongue, or that his larynx is destroyed." 1 In curious contrast to this last class of patients are those who speak incessantly, owing to the fear that if they do not do so they will lose the power of speech. " I have known," says Morel,2 " a lady possessing a certain dose of hypochondria who, fearing to lose the power of speech, believed herself obliged to repeat the same word, the same phrase." The Action of the Speech Centres in Insanity. Having in the foregoing remarks endeavoured to illustrate, by a few examples, the fidelity with which the mental disorder of an insane person is mirrored by his speech, I think it may now be of advantage to look at the matter from another standpoint. Instead of fixing our chief attention upon the mind, and observing how its thoughts are expressed in language, let us now fix our attention upon the Cerebral Organs of Speech; and observe how, in cases of insanity, these are operated upon by the mind; and how, in some cases, they seem capable of displaying activities on their own account that are almost or altogether independent of any mental stimulus. In the brains of uneducated people there are only two centres for articulate speech: one for the Hearing of it, and the other for its Production. In educated people, two other centres in the brain have been appropriated and trained for speech purposes, namely, one for Beading, and the other for Writing. I shall say for the present as little as possible about the anatomy and physiology of these four centres, as I hope to take up the consideration of that subject in a future chapter. For the present it will be enough to remind the reader that the two receptive centres (those for hear- 1 S^glas, Les Troubles du Langage chez les Alienrfs, p. 29. 2 Morel, Traits des MaL Merit., p. 300, quoted by Seglas.192 the disorders of speech. ing words and reading them) belong to the class of organs that are sensory in function, whereas the two productive centres belong to the class that in function are motor. Let us then, beginning with the two centres for spoken language, take each of the four seriatim, and see if we can gather about each some of the chief phenomena that are, in insane subjects, displayed in its functional operations. In making this attempt I shall avail myself largely of the copious information detailed in the very valuable work of M. S^glas, recently published.1 Verbal Hallucinations. 1. The Word-Hearing Centre.—Among all the gates through which impressions may be made upon the mind from without, the Ear-gate is probably entitled to the first place in point of import- ance. Through it words first reach the mind, and, with words, knowledge and the possibility of intellectual development. Words that are heard, it is now known, imprint memories or images of themselves in a certain part of the brain—the centre for word- hearing. These images can be revived in the mind, by effort of attention and will. It seems probable that, in the processes of internal thought, we owe, in part at least, our distinct internal perception of the words we are using to this internal revival of their sound-images. In the sane and wakeful condition of the mind, we have no difficulty in distinguishing between a word heard from without and the same word revived from within. In dreams it is different: our critical faculties being then asleep, we dream that other people are talking to us, when we ourselves, by internal revival of word-images, are in reality making all the conversation. There seems to be little doubt that, as in dreaming, so in many forms of insanity, inactivity of the critical faculties renders the mind an easy prey to auditory hallucinations. Yet this is evidently not the whole explanation of the matter. It would appear that, in some cases, in which the patient is awake, and in all respects considered sane, words are internally and spon- taneously revived, and start into such prominent distinctness as to " exteriorize" themselves, and so be easily mistaken for words that are heard from without. Socrates was accustomed all his life 1 S^glas, Les Troubles du Langage chez les Alienes, 1892.THE ACTION OF THE SPEECH CENTKES IN INSANITY. 193 to hear what he considered a Divine voice, which always came to him as a prohibition or warning—never as an instigation to action. Joan of Arc saw visions and heard voices from her thirteenth year; and the voices presently called upon her to act in defence of the Dauphin and her country. She lost faith in herself, as a leader of armies, only when the voices had finally left her. "We do not know if Socrates and Joan of Arc, or any of the other eminent historical personages that might be cited, would have put implicit faith in the voices, had they lived in modern times, and known something of the nature of hallucinations. But we know that, in our own times, persons are sometimes met with who are afflicted with voices, although their knowledge is sufficient to inform them of their true nature, and their judgment strong enough to prevent their being imposed upon by them. Seglas records a very interesting case of this kind. After remarking that such cases are common in medical literature, he says,—" Here is a very characteristic case that we have met with in the person of an accountant, aged 38 years, who presented himself as an out^ patient at the Salpetrifcre, complaining of peculiar symptoms which he had had for four months. At the beginning, there were hiss- ings in the right ear; then, insensibly, he began to hear voices in both ears. At first they were confused, like a kind of whispering, now they are distinct; and he recognises usually the tone of the voice of his uncle. Sometimes, he says, he forgets himself and replies. When he is undecided, these voices counsel him. At present, when he reads, he hears pronounced that which he reads, as if some one read aloud at his side; and even when he thinks, his thought is at once formulated aloud in his ear. This pheno- menon, at first intermittent, is now continuous. He is conscious of the subjective nature of these symptoms, and says, of his own accord, that they are hallucinations; but he would like to be cured, because he finds it very fatiguing always to hear spoken whatever he thinks or does; and it worries him greatly in his business as an accountant."1 It is, however, among the obviously insane that auditory hallucinations are most commonly found. In many forms of melancholia, especially such as are associated with delusions of persecution, in epileptic insanity, in chronic alcoholism, and in 1 Seglas, op. cit., p. 157. 2 B194 THE DISORDERS OF SPEECH. mania, nothing is more common than this particular kind of hallucination. The misery of many cases of melancholia seems to be greatly due to the incessant persecution that the patient sustains from the voices. They seldom say things that are com- plimentary or agreeable. Often they seem to the patient to be the whisperings of enemies who are hatching plots against him. Sometimes they sound in one ear, sometimes in both; sometimes it is one voice always, often there are several; and, among them, the voices of men can be distinguished from those of women. They may sound as if speaking near the ear, or tliey may be heard in the far distance, perhaps in another country, and the patient may explain that they reach his ear by the telephone or some form of electricity. Opprobrious epithets seem to be, in most cases, the burden of what is said by the voices; but in some cases friendly voices are heard, from time to time, which may take up the defence of the patient, and deny the insinuations that are being made on the other side. I had lately, in the Eoyal Edinburgh Asylum, an opportunity of conversing with a middle-aged melancholic woman who was troubled with voices. She had been sitting quietly in the room while we were examining other patients, and I had noticed her weep silently from time to time. I asked her pre- sently to tell me why she did so. She told me that it was the voices, a man's and a woman's, which came to her, sometimes from the corner of the room, and sometimes from the window. She proceeded to tell me, with great frankness, what they were saying and insinuating about her; and when I had heard a little of it, I was not surprised that she was feeling aggrieved. 2. The Word-Speaking Centre.—This, as already indicated, is the motor centre from which in speech-production are discharged the motor impulses that pass along the speech tract to the medulla oblongata, and thence to the organs of phonation and oral articula- tion. Reserving, for future consideration, the more detailed dis- cussion of the physiological and anatomical relationships of this centre, I may here ask the reader's attention for a moment to a very important conclusion regarding the function of this centre, and of the motor centres generally, that has now been arrived at by physiologists. The conclusion is that these centres are not purely motor; but are, in fact, as Hughlings-Jackson suggestedTHE ACTION OF THE SPEECH CENTRES IN INSANITY. 195 many years ago, sensory-motor. It seems certain that within them are stored up the memories of past muscular acts, and that these memories are specially recorded in them by the muscular sense, whose cortical centre seems to be in the same portion of gray matter as that for the motor discharge. In building up a memory or picture of any finely co-ordinated movement, other memories are no doubt associated with those imprinted by the muscular sense. Something is contributed, for example, by the tactile sensibility of the skin or mucous membrane; something by the sense of sight; and something, perhaps (though this is doubted by some physiologists), from a memory left in the motor cells by the motor discharges themselves. (In previous movements of the same kind the motor cells had discharged individually so much or so little nerve force; perhaps they retain the memories of these individual discharges, and are thus enabled, by training, to repeat them with exactitude almost automatically.) Without attempting to discuss the question in detail, I think we may accept the con- clusion now arrived at by the most eminent authorities on cere- bral physiology, that the centres in the motor cortex are not purely motor, but that they are also sensory, in so far as there are formed within them, from memories of various kinds, images or pictures of all the delicately co-ordinated movements that they are accustomed to produce. These are known as psycho-motor images or pictures, and are to be associated with the motor centres, just as the psycho-sensory images or pictures are to bb associated with the sensory or receptive centres. When we are about to perform any delicately co-ordinated action, say with the hand, we always call up in the mind the psycho-motor picture of the act before we execute the necessary movements. Having called up the picture, we are at perfect liberty either to execute the movements or to refrain from doing so. When we do execute the movements, we may be said to have exteriorized the picture. Now there are conditions of motor hallucination in which these psycho-motor pictures are so vivid and obtrusive, that the patient is tempted, or compelled, to think that they have been exteriorized or executed, when they have not really been so. Everybody knows that when a limb has been amputated, the patient for a time is apt to complain of pain and other sensations that, to him,196 THE DISORDERS OF SPEECH. appear to be localized beyond the level of the amputation, in parts that have really been removed. These may be described as psycho- sensory hallucinations. It is not so generally known that the patient may have hallucinations of movement in the same parts. Weir Mitchell has paid special attention to this subject, and describes, for example, some of his patients, after amputation of the arm, as most vividly experiencing movements in the fingers of the absent hand, and as being able at will to perform these imaginary movements, even causing the hand to execute the delicate movements of writing. Of course, these patients were merely calling up the psycho-motor pictures of the movements within the motor centres for the hand and arm; but if the pictures were very vivid, the patient experienced almost or altogether the same sensations as if they were exteriorized or carried into execu- tion. Now, speech is a very finely co-ordinated action, rendered possible only after long training, and based, like all finely co- ordinated movements, upon the distinct formation of motor pictures. We are all conscious that when we are thinking we are apt to speak internally. Though not moving the lips or the tongue, we have the most vivid consciousness of the words that our thoughts are using; and we even recognise in them the same variety of tone and emphasis that they would present if they were spoken aloud. No doubt, therefore, we are using in part the psycho-sensory sound-images of the words; but it is equally certain that we use also at the same time the psycho-motor images. It is said that people may, on the whole, be divided into two classes: the auditory class, who in thought employ chiefly the sound-pictures; and the motor class, who employ chiefly the psycho-motor pictures. The reader can judge for himself whether, in expressing his thoughts internally, he employs the auditory or the motor image, or both combined. If he is specially motor he will have a strong tendency to exteriorize the word-images, so as, in thinking, to whisper or even to talk aloud to himself. One of the most valuable parts of S^glas's work deals with the hallucinations which are due to the abnormal vividness of the psycho-motor word-images. It is a subject that he has, since 1888, devoted special attention to; and, of late, others have joined with him in the study of it. I can here only give a few briefTHE ACTION OF THE SPEECH CENTRES IN INSANITY. 197 notes as to the facts that have been brought out by tliese studies. Seglas finds that psycho-motor hallucinations are common in various forms of insanity; and that they are especially so. among those patients who are under delusions of persecution or of posses- sion by evil spirits. He brings out, in strong relief, the contrast between the patients who are subjects of the psycho-auditory hallucinations already described and those whose hallucinations are psycho-motor. The former hear the voices, the latter do not properly hear voices at all (unless they are also the subjects of auditory hallucinations), but are conscious of internal utterances. They are possessed by spirits (good or evil, but mostly evil), or demons, or enemies, who live within their bodies. If the spirits are bad, they torment the patient by saying things that are utterly repugnant and abhorrent to him, by insulting him in every way, or by hatching plots against him (for several personalities may be represented). If good, the spirits comfort the patient by conversing with him, and inspiring him with good thoughts. The spirits may appear to the patients to live in various parts of the body. Some- times they appear to inhabit the epigastrium, or some other part of the abdomen. Thence the utterances may appear to ascend to the mouth. Very often the spirit is supposed by the patient to live in the mouth itself—it may be under the tongue—or in the upper part of the throat; and sometimes, when the spirit is supposed to live lower down, it is felt by the patient to ascend to the mouth when it is about to speak. The whole aspect and expression of the patient suffering from this variety of hallucination are different from those of the patient who hears voices. The latter listens intently, turning the ear to the localities from which the voices are supposed to proceed. This patient has no need to listen with the ear. The utterances are made apparently within his own body. Absorbed in attending to them, he is often found in a state of apparent stupor, with the head bent forward, and the hand pressed upon the chest to keep the utterances from ascending from the epigastrium. It is extremely significant of the real nature of these utterances, to find that what is said by the supposed spirits is often (quite involuntarily) articulated audibly by the patient,—sometimes in a whisper, and sometimes aloud.198 THE DISORDERS OF SPEECH. The hallucinations are really due to the involuntary formation by tlie patient of psycho-motor word-images; and sometimes these are so vivid that they are exteriorized and involuntarily arti- culated. From S^glas's numerous examples I shall select two: one in which the hallucinations are solely psycho-motor, and the other in which such hallucinations are associated with other hallucinations of psycho-sensory nature. (1.) " A patient, whom we have had under observation at the Salpetri&re, supposed herself to be in relation with various celebrated men. At first she conversed with them mentally; they spoke to her internally, in the head, but not in the ear. At such times she felt her tongue move as if she wished to speak. Afterwards she obeyed this solicitation of the tongue, and began to speak under the inspiration of the spirits. She speaks in spite of herself. Her voice at such times is more agreeable than it usually is, and what she says is admirable. It is, as it were, a superhuman power that makes her speak. Lammenais, Paganini, Pinel, speak in this way by her mouth/'1 This is one of the rare cases in which the supposed spirits have had anything agreeable to say. (2.) "Mile. L. is pursued by 4injectors,' who say in her ear all kinds of insults. But a little internal voice, which comes from the stomach, puts her upon her guard, saying to her, for example, 4 They are trying to poison you, mother !' This little voice] makes her move the tongue and open the lips; she understands it by the movements of the tongue. She replies often to this little voice in the same way, by moving the tongue, very much as when one speaks in a whisper. When her thought is in accord with the little voice, she finds that she speaks aloud. She has since found, thanks to this little voice, that she can prophecy, discover thieves, etc."2 A great number of cases have, like the last, both psycho-sensory and psycho-motor hallucinations. Seglas believes that in the ordinary progress of such cases the psycho-sensory appear before the psycho-motor. The appearance of the latter he thinks indi- cative of a more advanced deterioration of brain function than is 1 Seglas, op. cit.} p. 185. 2 Ibid., p. 187.THE ACTION OF THE SPEECH CENTRES IN INSANITY. 199 implied by the existence of the former alone. He holds, therefore, that the prognosis in cases of psycho-motor hallucination must always be very grave. 3. The Word-Seeing Centre.—I do not think it is generally known that among sane people visual hallucinations, of various kinds, are of not very uncommon occurrence in certain circum- stances. They may occur, for example, at night, when the individual has reached the border-land between waking and sleeping; and, of course, they form a very important element in dreams. More rarely, a sane person may experience them with exceptional vividness if his brain be exhausted by want of sleep, or by overwork. In such a condition, he may have them when he thinks himself wide awake, if he be in the dark, or merely shut liis eyes. 1 have myself met with several instances: some among my hospital patients, whose illness had produced persistent sleep- lessness ; and two in professional men, who had been made sleepless by overwork and professional worry. I quite believe that sys- tematic inquiry would show that sleeplessness is capable of pro- ducing them in people of any class, though they be possessed of average health. In my experience, the commonest hallucination in such cases is the appearance of a kind of colourless wall-paper pattern, which may possibly be but a partial revival of the image of the wall-paper pattern of the patient's bedroom or sitting-room, but which, I think, is more probably a creation de novo, as it may change, like the pattern in a kaleidoscope, while it is being gazed at. In aggravated cases, all kinds of visions appear before the mental eye, and they may be so vivid as to be endowed witli natural colouring. An overworked professional man whom I attended had reached this stage; but one sleeping-draught took the colour out of his pictures, and another, on the following night, banished them altogether. Some years ago I had, in my wards at the Eoyal Infirmary, two patients: one a middle-aged man with aggravated neurasthenia, the other a boy with chronic meningitis of tubercular origin, which proved fatal after a course of nine months,—both of whom were troubled with visual hallucinations whenever they shut their eyes or were in the dark. In both I could call up the hallucinations by suggestion. At my ward visits, for example, I used to have such conversations as the following with the boy, he keeping his200 THE DISORDERS OF SPEECH. eyes closed in the meanwhile:—" Now, tell me, do you see your mother's cottage ?" " Yes, quite well." " Do you see your mother sitting at the door?" "Yes." "Who is with her?" "My little sister." "Do you see the horses passing along the road ?" " Yes." " Their tails are tied up with ribbands, are they not?" "Yes." "What is the colour of the ribbands?" " Blue." I have notes of both cases, but as the hallucinations were not verbal in nature, I do not feel that I am entitled to insert them in this chapter. I may add that I have also notes of a third case, in which one of the patients in my ward saw very distinctly, one night, what he took to be the ghost of another patient recently deceased. Visual hallucinations of Printed or Written Words must, one would suppose, be most common among those who are engaged in literary pursuits, and are, therefore, in their daily occupation constantly called upon to look at words, printed or written. Over- fatigue and prolonged sleeplessness in such men ought, one would think, to be capable of producing such verbal hallucinations, especially at times when sleep is being courted in vain. Here is a case in point. In a letter written during his last illness—which was attended with prolonged sleeplessness—the eminent Scottish judge, Lord Jeffrey, describes his experience of these verbal hal- lucinations, which used to come upon him at night when he was trying in vain to sleep. The description is so good that I shall venture to copy here in full, from Lord Cockburn's Life of Lord Jeffrey, the passage that includes extracts from this letter. Lord Cockburn says, " On the same evening he dictated the last letter he ever wrote to the Empsons. In reference to his old critical habits, parts of it are very curious. It was long, and gave a full and clear description of the whole course of his illness, from which he expected to recover, but had made up his mind not tot continue longer on the Bench. ' I don't think I have had any proper sleep for the last three nights, and I employ portions of them in a way that seems to assume the existence of a sort of dreamy state, lying quite consciously in my bed with my eyes alternately shut and open7 enjoying curious visions. He saw ' part of a proof sheet of a new edition of the Apocrypha, and all about Baruch and the Maccabees. I read a good deal in this, with much interest,' etc.,THE ACTION OF THE SPEECH CENTRES IN INSANITY. 201 and 'a huge Californian newspaper, full of all manner of odd advertisements, some of which amused me much by their novelty* I had then prints of the vulgar old comedies before Shakespeare's time, which were very disgusting.' * I could conjure up the spectrum of a close printed political paper, filled with discussions on free-trade, protection, and colonies, such as one sees in the Times, the Economist, and the Daihj News. I read the ideal copies with a good deal of pain and difficulty, owing to the smallness of the type, but with great interest, and, I believe, often for more than an hour at a time; forming a judgment of their merits with great freedom and acuteness, and often saying to myself—This is very cleverly put, but there is a fallacy in it, for so and so . . "1 Lord Jeffrey died, 26th January 1850, aet. 76, on the evening of the day following that on which he had dictated this letter. Griesinger (p. 90), referring to the frequency with which such hallucinations of the senses occur in sane people, especially between sleeping and waking, and noting the fact that visual hallucinations, when vivid, may be brilliantly coloured, says,—"Nothing could be more erroneous than to consider a man to be mentally diseased because he had mental delusions (hallucinations). The most extensive experience shows rather that such phenomena occur in the lives of very distinguished and highly intellectual men, of the most different dispositions and various casts of mind, but especially in those of warm and powerful imagination." He instances the cases of Tasso, Goethe, Sir Walter Scott, Lord Byron, Jean Paul, Benvenuto Cellini, Spinoza, Pascal, Yan Helmont, and Andral, who, for the most part, had experience of seeing visions. Mr Nisbet, however, is no doubt equally ready to quote all these instances as examples of the " Insanity of Genius."2 All sane people have the power of forming internal visual images of things and words, and the faculty is probably strengthened by practice in such occupations as that of an artist; but among sane people it is only in unhealthy conditions, such as those of fatigue of the mind and prolonged sleeplessness, that these images exteriorize themselves, and give the same distinctness of impression as if real objects were being looked at. Among the Insane, visual hallucinations are exceedingly common. 1 Life of Lord Jeffrey, vol. i. p. 407. 2 The Insanity of Genius, by J. F. Nisbet, 1891. 2 c202 THE DISORDERS OF SPEECH. They may exist alone, or be associated with hallucinations of the Qther senses, such as that of hearing. It is only in a few cases, however, that the hallucinations take habitually the form of printed or written words. S^glas records several of these, among others the following:— A patient under treatment in the Bic§tre Asylum, " one day at dinner could read distinctly upon the porcelain lamp the words, ' Je t'aime,' which, according to him, had been thrown upon the lamp by the aid of a mirror. Subsequently he saw letters with his eyes more and more frequently. He said that he then accustomed himself to write with his eyes, and thus to throw words into space. The letters go out from the eye: they are yellow, have the appearance of small printed characters, then they grow in size and retreat to a certain distance, after which they diminish in size and fade away. He has, since that time, been able by this means to correspond from Bic^tre with certain persons at Clichy, and he asks them, in this way, to try to get him a patent for writing with the eyes. Let us add that this patient, who, along with these visual verbal hallucinations, has other hallucinations, auditory and above all motor (mute voices), is extremely visual. When he has taken a good look, for example, at a part of the court- yard, he shuts his eyes, and the place detaches itself very neatly en bloc, and then fades away as it flies towards the west. This faculty of visualization is regarded by him as a special photographic power, which he has at command, and which excites the jealousy of his enemies. The photographs are much more beautiful, he says, when he shuts his eyes, because the eyelid acts then as a reflector; they are then clear and lively."1 4. The Motor Centre for Writing.—It remains for us now only to consider the hallucinations which are, in some few cases, dis- played in connexion with the motor centre for Writing. Such hallucinations are rarer than any of the three other varieties. They are rarer, because, in the first place, motor hallucinations are rarer than sensory, and, in the second place, because the motor hallucinations of writing can be expected to occur only in those who have been much in the habit of writing, and of course these are but a small minority of the general population. 1 Seglas, op. cit} p. 181.THE ACTION OF THE SPEECH CENTRES IN INSANITY. 203 It will not be necessary to explain the physiology of these graphic hallucinations, since almost everything that has been said regarding the physiology of the hallucinations connected with the motor centre for speaking applies equally to them. The writing- centre, like the centre for speaking, is a centre which, according to the most recent views, is not only motor in function, but also sensory, inasmuch as it is the centre for the psycho-motor pictures of the delicately coordinated movements of writing. The picture is first formed, and then it is exteriorized, by being imprinted, as it were, 011 the executive motor cells. Forming the picture, and yet refraining from exteriorizing it, we can write mentally, just as we can speak mentally; though, owing to the act being less habitual to us, it is not so easily accomplished. The psycho- motor picture of writing may, in certain abnormal circumstances, be so distinct that the patient has the hallucination that he is writing when he is not actually doing so. In other cases, the picture may become so very distinct and obtrusive as to compel its own exteriorization. It is then an " Impulsion " which causes the patient to take up the pen and write at the dictation of the " spirit" by which he supposes himself to be " possessed." S£glas records cases of both these varieties. One of his ex- amples of the psycho-motor hallucination of writing without actual impulsion is that of a female patient aged forty. She was the subject of other and more common forms of hallucination, " but on one occasion she exhibited, when under our observation, a motor verbal hallucination of writing. She had come as an out- patient to the Salpetri&re, and while we were speaking, we noticed her carry her right hand to the region of her heart, become very red, and tremble. These symptoms were the ordinary accompani- ments of her hallucinations. At our request she explained to us that whilst we were speaking to her, she had had all of a sudden the idea of taking up a penholder that lay upon the desk. She had not done so, but nevertheless she had felt as if her hand moved, and wrote the reply that she had wished to malce to us. The patient is perfectly conscious of all the varied hallucinations that she experiences, and that provoke in her incessant sufferings. She has no delusional ideas."1 1 Seglas, op. citp. 247.204 THE DISORDERS OF SPEECH. Of several cases recorded by S£glas which exhibit the hallucina- tion converted into an impulsion, one is that of a patient with delusions of persecution, who supposed himself to suffer, when in his bath, frightful tortures from the electrical experiments practised upon him by the spirits. He was in the habit of writing very full descriptions of these tortures. But in the midst of these descriptions, bits were interpolated in an apparently different handwriting, and these the patient declared to be the writing of the spirits, executed by means of his hand. For example, when in one passage he is enlarging upon his sufferings, the spirits suddenly interpolate the clause, "And we hope again to make experiments, and to cause thee to suffer frightfully, in contortions and contractions"1 I have devoted some space to the consideration of these psycho- motor hallucinations, so well described by S^glas, because the subject is a comparatively new one. It is also a subject of great importance; and the conclusions arrived at are evidently in entire harmony with the latest advances in cerebral physiology. The psycho-sensory hallucinations have been long familiarly known.2 A very important question now being discussed by specialists is>—What is the starting-point of the cerebral disturbances which produce these various hallucinations ? Is it a disorder of the mind, which acts upon the speech-centres, and produces hallucina- tions by exciting them in the same way as they are excited by the uncontrolled imagination of a person who is dreaming; or may the disorder be primarily situated in the speech-centre itself? In the latter case, the hallucination in the speech-centre would disturb the mind; and, if the mental balance were not very good and true, it might overthrow the judgment, and be therefore the 1 Sdglas, op. cit.y p. 248. 8 Psycho-motor Hallucinations and Impulsions may occur in connexion with motor centres other than those connected with Speech. It would appear that they may even prompt a lunatic to criminal violence. Dr Elkins, one of the assistant-physicians in the Royal Edinburgh Asylum, has recorded the interesting case of a young man affected with homicidal mania, who on several occasions had attempted to commit murder. " A few days after admission he volunteered the statement that his muscles were urging him to do things that he knew were wrong."—Journal of Mental Science, January 1891.the action of the speech centres in insanity. 205 starting-point of insanity. There seems no good reason for reject- ing either of these suppositions. It seems quite probable that in some cases hallucinations in the speech-centres are excited by delusions in the mind, and that in others delusions in the mind are excited by hallucinations in the speech-centres. The tendency of late has been to concede to the speech-centres a position less immediately and strictly dependent upon the mind and consciousness than they were previously supposed to hold. Their powers of storing up the images of words and even of phrases, and of producing these automatically or by rote, without the active co-operation of the consciousness, have of late been brought into pretty strong relief; so that we now.hear more of Reflex and Automatic Speech than we did some years ago. Reflex speech is now, indeed, attracting the attention of many students of insanity. It is so frequently exhibited by certain classes of the insane that I think it will be well to insert here a few words about it specially. Reflex and Automatic Forms of Speech, exhibited by In- sane Patients.—(1.) Echolalia.—The simplest form of reflex speech is Echolalia. As we have already seen, echolalia is ex- hibited by all healthy children at a certain stage in the process of learning to speak. We have also seen that it is often retained permanently by such imbeciles as have never got beyond the first steps of that process. It consists simply in the echo-like repeti- tion of words that have just been heard. They are mechanically repeated as sounds, without any attempt being made to attach meanings to them. Every parrot that speaks does so by echolalia. Only a few parrots of very superior intelligence (see Darwin and others) have apparently advanced a step further, so as to be able to attach the right meanings to a few of their words and expres- sions. Words and phrases learned by echolalia are repeated by a parrot automatically, when it is in lively humour. If we wish to hear Echolalia practised by the insane, we must go to cases where the mind is decayed; in other words, we must go to cases of Dementia. In all forms of dementia, Eqliolalia is common. In my recent visits to the Royal Edinburgh Asylum, I found it typically exhibited by one of the patients who was the subject of adolescent dementia. I may refer again to the subject206 THE DISORDERS OF SPEECH. when I come to treat of the speech of dementia, and shall also have something to say about it in connexion with aphasia. (2.) Conventional Replies.—A higher development of reflex speech is also often met with in cases of dementia,—especially, it would appear, in cases of senile dementia. It consists in the giving of Stereotyped or Conventional Eeplies to ordinary conventional questions. " How do you do ?" says the questioner. " Quite well, thank you," says the answerer, though he may be very ill indeed. This is a sort of reply we all make sometimes, when we are absent-minded. The poor dement is always absent- minded ; his mind is gone. Such conventional answers are so often repeated in the course of a lifetime that the speech-centres learn them by rote, and can repeat them automatically, if only the stimulus of the conventional question be supplied. Some would have us believe that the process is entirely reflex, and that the con- sciousness has nothing to do with this kind of speech in dements; but, for my own part, I am inclined to think that there must be a little mental consciousness in all these cases, roused into activity, perhaps, by the question; and some feeble glimmering of the meaning of the question, though the answer given may be so far from true. How low the consciousness may have sunk in some of the dements who exhibit this form of reflex speech is demonstrated by such a case as that recorded by Dr George M. Kobertson, senior assistant in the Eoyal Edinburgh Asylum, in a paper which has attracted attention.1 The patient was an old man with senile dementia, so mindless that he " was dirty in his habits, would not touch food if it was placed before him, never made a single request for food or anything else, and would not do the simplest thing that was asked him." When left to himself he was in the habit of talking to himself automatically, thus:—" If you would just come be—with the way—what now !—oh dear, dear! Oh, that is the whole closh—that's what! Oh dear, dear me—an it is the other macock or macockiness—See ! Who is what ?—that—is it ? oh age." Yet this patient, when conventional questions were asked him, could answer them " reflexly " with some semblance of intelli- gence. Here is a bit of Dr Robertson's conversation with him :— " It's a fine day, Ross." " It is that." " It's a wet morning." 1 " Reflex Speech," Journal of Mental Science, April 1888.THE ACTION OF THE SPEECH CENTRES IN INSANITY. 207 " Oh, no, not now." " It's a rainy day." " Yes, it is." " Ross!" "I hear, sir." " You're an old rascal." "Yes." " How are you this morning ? " " Oh, very well, thank you." (3.) Other Forms of Automatic Speech.—(a.) Patients who are the subjects of advanced dementia are frequently occupied in talking to themselves, sometimes in a drawling monotone and sometimes in a whisper. The words of these Monologues are sometimes distinctly articulated, as in the specimen that has just been given. Often, in dementia of long standing, they have be- come for the most part merely semi-articulate sounds, that have only a superficial resemblance to words. But, whether they are composed for the most part of articulate words, or of mere sounds like words, it is impossible, as a rule, to detect any meaning in them. A little study of these monologues is apt to suggest to one's mind that the mental faculties of the patient have little or nothing to do with their production. It seems rather that, in these monologues, the organs of speech are taking exercise on their own account. (b.) In connexion with certain forms of Mania, with great volu- bility of incoherent speech, the question has of late years been debated, whether each incoherent fragment of a sentence represents an incoherent fragment of thought; or, if it is not rather the case that the speech-centres themselves participate in the general ex- citement of the brain, and display their excitement by pouring out automatically the words and phrases whose images are stored up within them. The term "Verbigeration" is now coming into use among alienists. It is a term meant to designate that noisy, inco- herent, and meaningless speech so often met with in certain forms of mania. The term seems specially suitable for the speech of such cases when this is largely composed of the constant repetition of a very few words or phrases. (c.) In the foregoing notes upon pyscho-motor word-hallucina- tions, as described by Seglas, it was indicated that such an halluci- nation, when very vivid, is apt to become an Impulsion, which com- pels the patient to exteriorize the hallucination by pronouncing the word. This again may perhaps be taken as an example of automatic action on the part of the speech organs. Some regard it as a kind of coordinate spasm in the motor word-centre, the motor disturbance resulting in the involuntary ejaculation of a208 the disorders of speech. word. The condition has by some authorities been termed Logo- spasmus Choreiformis; but when the words thus ejaculated are habitually of a dirty and disreputable character, the term Copro- lalia is generally preferred. It is suggestive of the nature of the condition to find that, in coprolalia, a convulsive movement (spasmodic tic) of the arm or face is frequently associated with the ejaculation of the word. Professor Charcot, however, seems inclined to refer coprolalia to a deranged condition of those higher centres that are the organs of ideation, rather than to a mere local disturbance of the lower centre for speech production. I have already made a short reference to coprolalia in the second chapter. It is worthy of remark that in some of these cases the patient is so much possessed and tormented by the word-hallucination, as to feel it as a " veritable foreign body loading his stomach," which he tries to expel by efforts of spitting.1 Superstitious Significance attached to Words by some In- sane Patients.—Everyone knows that among peoples who are savage, ignorant, and superstitious, words have often a mysterious and superstitious significance attached to them. Some are held to be lucky, and others unlucky; and forms of words, often meaning- less in themselves, are used as spells, invocations, or incantations. One is therefore not surprised to find that similar superstitions abound among the Insane; who are held by some authorities to exhibit in some ways a kind of retrogression towards the savage state. Sometimes new words (neologisms) are invented by the insane, to give expression to the delusions which have taken possession of them. Lucky and unlucky words, spells and incantations, are also met with among them. Without going into further detail on this subject, I may quote the answer which a patient in the Eoyal Edinburgh Asylum gave us when we asked him how long he had been in the Institution:—" By the time of sane, I have been here six years; by the time of fuiso- graphic, I have been here ten years; fourteen years by what they call penance." He explained that "fuisographic" is "how your life is put together." 1 See S6glas, p. 163 ; also a paper by Charcot and Magnan, " De l'Onoma- tomanie" {Arch, de Neurologie} 1885).the action of the speech centres in insanity. 209 Agonizing Search for a Name, Word, or Number that has been forgotten.—Under the name Onomatomania (name- or word- madness), MM. Charcot and Magnan have, in a very important series of papers,1 grouped together the phenomena connected with word-possession, word-impulsion, and superstitious interpretation of words, that we have just been examining. In the group they include also a form of Onomatomania that I have not yet alluded to. It is the form in which a person who has forgotten some name, word, or number, cannot prevent his mind from searching for the word in his memory, though the search becomes more and more painful, and even agonizing to him. In the agony of search he may become intensely excited, or even furious; be seized with a constrictive pain, and a sense of suffocation, about the chest, and break out into profuse perspiration. The symptoms are at once relieved if the word is at last remembered, or is communicated to the patient. This condition is sometimes met with among those who are the subjects of pronounced insanity; it is common also among people who, owing to bad heredity, are on the verge of insanity. It is one of the stigmata by which an unstable mental equilibrium, due to bad heredity, may be recognised; being in that respect like the other eccentricities manifested by such individuals, such as the fear of pins, or of cats, or of thunder, perversions of the sexual instinct, dipsomania, etc. The authors of the papers have recorded several interesting cases. Embololalia.—This consists in the frequent interpolation into speech of a useless or meaningless word or syllable. Like " hem- ming and hawing," it is a phenomenon occasionally displayed by sane people. Kussmaul2 has recorded a number of curious cases, among others that of an old general in whom this peculiarity made its appearance after a sunstroke. In his case the word inter- polated was "mama/' He said, for example, "This miserable— mama—fellow has expected—mama—other people to—mama— pick his chestnuts out of the fire—mama." Sometimes it is not a word that is interpolated, but a syllable, which is attached as an affix to other words. 1 " De l'Onomatomanie," Archiv. de Neurologie, torn, x., 1885, p. 157, also Nos. 70 and 71, 1892. 2 Op. citp. 813. 2 p210 the disorders of speech. Sdglas (p. 63) states that these various forms of embololalia are met with occasionally among the Insane. Logorrhcea and Bradylalia.—I have already, in the second chapter, made some reference to these two conditions of speech. Neither of them can be said to be unknown, or even very uncommon, among people who are not insane; but the best examples of both are probably met with among the insane. The " Verbigeration" of the maniac is a kind of logorrhoea ; and the condition is typically presented by some garrulous and rapidly speaking Imbeciles. Bradylalia (slowness of utterance) is met with most frequently in connexion with conditions of depression. It is, as already indi- cated, common in cases of Melancholia with stupor. Formation of Sentences, and Articulation of Words, in In- sanity.—It has already been shown that in some forms of mania with exaltation and excitement the ideas may, for the individual, be unusually brilliant; and they may be expressed with unusual felicity of diction, and with perfect articulation. But such cases are somewhat exceptional, the more common characteristics being voluble incoherence and mere noise, with incomplete and often ungrammatical sentences. Sometimes, again, when excitement is not so great, and speech is more deliberate, there may still be defects in grammar (agrammatismus), which the patient did not exhibit when sane. He may return to a kind of baby-speech, and use me for i, convert the terminations of irregular verbs into those of regular ones, or use the verb only in the infinitive; or, like a child, he may speak of himself only in the third person; or, in obedience to some delusion about his personality, he may, in referring to himself, always use such an expression as " the person of me." Such errors in syntax and prosody are common enough. As to Articulation, I think we may say that in the earlier and more active stages of insanity articulation of individual words is usually perfect. In chronic cases also it very often remains per- fect throughout. Even when insanity sinks into partial dementia, there is often nothing special to remark about the articulation of the words, however barren of meaning the patient's use of them may be. In Advanced or almost Total Dementia, however, as already indicated, the maundering and mumbling Monologuesthe action of the speech centkes in insanity. 211 in which the patient often indulges, besides being destitute of meaning, are often articulated in so slovenly and careless a manner that the individual words, if they are words at all, cannot for the most part be recognised as such. It is a careless and imperfect kind of speech that puts one in mind of the scamped articulation of lalling imbeciles. Yet if such a patient can be roused to reply to questions, the articulation of his replies may be normal, or almost so. There are, however, exceptions to this rule. In Senile Dementia there may be noticeable a paralytic slurring in the patient's replies; and in the dementia of General Paralysis of the Insane there are, along with this slurring, other peculiarities, which indicate that the motor apparatus of articulation is undergoing changes which are paralyzing both its motor power and its power of coordination. I shall have something to say about these para- lytic peculiarities of speech in the next part of this chapter. The existence of this paralytic element in the articulation is of grave significance prognostically. The Wkiting of the Insane.—This is a subject which has been treated of by Seglas and others at considerable length, and there are many points of interest in connexion with it. I can only afford, however, to make a very few notes about it. (1.) It will be readily understood that the incoherence, the verbigeration, and the delu- sions of the patient, are made quite as manifest in his writings as they are in his speech. Some of the insane (graphomaniacs) would write for ever, if allowed to do so; and a few, if not prevented, would have their writings printed for the information of the public. The Inventors would have their inventions made known for the sake of humanity, and the Persecuted would appeal to the public in print for succour from their tormentors. (2.) All kinds of fantastical peculiarities are met with in the Handwriting of letters written by some of the insane. The £'s may be doubly barred, the $s doubly dotted. Punctuation may be wholly absent, or practised in excess; the words may be underlined or doubly underlined to a most unusual extent; and capitals may be used in unnatural profusion. (3.) A paretic or paralytic element may be betrayed in the tremulousness of the handwriting. This may be due to functional debility, as in the handwriting of some melancholies, and of some hysterics; but it may also be due to,212 the disorders of speech. organic changes in the motor centres for writing, as in the tremu- lous writing of many cases of senile dementia, and in the still more tremulous and disorderly writing of patients suffering from general paralysis of the insane. In the latter condition the characters may be converted into irregular zigzags, and so crowded together as to be totally illegible. Aphasia among the Insane.—This is a subject which I propose to defer the consideration of until I have discussed the subject of aphasia as produced by coarse organic lesions of the brain. I shall here only say that aphasia, in all its forms, is of not uncommon occurrence among the insane. In some cases it is a functional and temporary complication of the insanity. In other cases a gross lesion of the brain has caused the aphasia, and, it may be, has also led to the development of the insanity. Speech in Dementia. Permanent injury of the mind is a common result of an attack of insanity. In not a few cases the damage amounts to total disablement and destruction of the mental faculties. The sad and hopeless condition of Secondary Dementia, exhibited by so many of the patients in every lunatic asylum, is thus brought about. I know few sights more impressive than that which one sees on visit- ing, at a lunatic asylum, the day-room set apart for these hopeless dements. There they sit, wrecks from the fires of the various forms of insanity. Passive and inert, inattentive even to the calls of nature, they take no notice of each other. They sit still for the most part, and many of them would never move from their seats if not made to get up, and taken out for exercise. In some, the fire of insanity is quite burnt out, and the mental faculties are totally extinct; in others, it smoulders on in the form of some enfeebled remnant of the delusions with which the mind was once all ablaze. . Some of the patients exhibit curious forms of automatic activity. One may constantly rub his hands together; another may stand upon the floor and perform perpetually a curious swinging or balancing movement; and some may be constantly engaged in muttering to themselves those curious automatic maundering monologues already described, in which few articulate words, and no definitespeech in dementia. 213 meaning, can be detected. Among this assembly of people deprived by insanity of their mental faculties, are usually a few who owe the deprivation to the disease known as General Paralysis of the Insane. In these cases, the terrible disease of which they are the subjects will soon destroy life itself. In this day-room the wrecks left by most of the various severer forms of insanity will be found collected together. Some have been Melancholic; a larger number have been Maniacal; others are Epileptic; others have been Alcoholic; some are cases of Senile Dementia; and others are the subjects of General Paralysis of the Insane. The hopeless condition of Secondary Dementia may be the consequence of any one of the graver forms of insanity. It is among these patients with dementia that the Reflex and Automatic forms of speech already described are so often met with. Echolalia is common among them, especially when dementia is far advanced. The reflex speech exhibited in the giving of Con- ventional Replies to conventional questions is also often met with. Their automatic maundering Monologues have already been described: in some of the cases of advanced dementia to be pre- sently noted, these monologues will be found to have become so degenerate as to have lost all resemblance to words, and be comparable only to the babbling of infants. Even in patients, however, in whom the monologues have been reduced to mere babbling, it is very striking to find that if by any means the attention can be roused, and the patient got to reply to a question, he will reply to it in words whose articulation is prac- tically perfect. I am, of course, speaking now of cases where the dementia is pure, and not complicated by motor paralysis. The speech-centres thus evidently retain their store of verbal images, even for many years after the mental faculties have almost ceased to employ them. A. Cases of Simple Dementia without Motor Paralysis.— When treating, in the fifth chapter, of the Speech of Imbecile Children, I gave, from notes taken at the Larbert Institution, a series of cases showing a gradual ascent in intelligence, and speech-power, from mental zero up to an almost normal level of intelligence. These were cases of Amentia, in which mental Development was more or less incomplete. In dealing now with214 the disorders of speech. cases of Dementia, in which the mind has become enfeebled or been annihilated, it might be possible to give a somewhat similar series of cases. They would begin with cases of slight enfeeble- ment, not far removed from the normal level; and descend, step by step, until the last case displayed a condition of mental zero. But, in order to make up a complete series of this kind, one would require to look for the slighter cases, not in asylums, but at their private homes. The short series of cases of dementia which I now present, having been selected at the Eoyal Edinburgh Asylum, is therefore incomplete, none of the slighter grades being represented. But, such as it is, it may be of use, as showing gradations in intelligence and speech-power. I select, for the series, exclusively, cases of the secondary dementia that so often results from Adolescent Insanity. Dr Clouston, who is the chief authority upon this form of insanity, points out that the dementia resulting from it is very often total, and that it is usually pure and uncom- plicated, being much less frequently than the other forms of secondary dementia associated with paralytic or other conditions that might obscure its symptoms.1 It is a form, therefore, better suited than any other to show the effects of Dementia, pure and simple, upon the speech of the patients. Case I.—Replies in absent-minded manner to questions, occasion- ally reads, but does not understand what he reads. Exhibits Echolalia. Generally sits silent and still all day, unless told to move. Is cleanly.—W. C. (male), aet. 27. Admitted three years ago, suffering from Adolescent Insanity with melancholia. Heredity very bad. In reply to most questions, says, "No, Sir." Occasion- ally, " Yes, Sir." Can give his name and age. Asked where he is, says, " I don't know, Sir." Then says he lives in Edinburgh. Says this place is Hell. Occasionally reads a newspaper, and sometimes does so aloud, but probably does not understand what he reads. Asked why he reads, says, "Because it pleases me." "Do you read any other paper?" "I don't remember." Has gradually spoken less and less with advance of dementia. Now, would sit still in one place all day, unless told to move. 1 See Dr CloustonVpaper on "Secondary Dementia," Journal of Mental Science, October 1888.speech in dementia. 215 Occasionally exhibits Echolalia. Occasionally sings to himself in good tune. Case II.—Patient in much the same condition as Case Z, only a little worse. Echolalia. Babbling monologues. Is dirty.—I. A. A. (male), set. 28. Heredity very bad. Adolescent Insanity (mania) at 23. When this passed off, dementia set in. At first the patient read a good deal, and seemed to understand what he read. Now he never reads, but he often looks at the pictures of the Illustrated News. When spoken to, sometimes repeats the last words spoken to him by Echolalia. Sometimes laughs and grunts to himself in a silly way. Sometimes he babbles to himself unintelligible sounds in a whisper. To-day, in reply to every question, he replies " elves," in a whisper. He varies a good deal, being some- times very silent, and sometimes babbling to himself for a long time in baby-like fashion. Case III.—Deeply demented, being dirty in habits and eating anything she can pick from the floor. Babbles to herself. Can, how- ever', do a little simple house-work; and} when attention is roused, can give her name; and can name correctly, and with perfect articulation, a number of articles shown to her.—M. M. (female), set. 32. The dementia is now of some years' standing. Has a good head, face, and figure; looks healthy; and at first sight looks intelligent enough, eyes being clear and bright (though rather restless), and there being an upright wrinkle between the eyebrows, as if from habit of thought. Patient, however, mutters (babbles) to herself unintel- ligible sounds in a whisper. Can be got to do nothing useful, except to brush the floor with a long brush. Would eat anything she can pick up (cat s meat for example), if not prevented. When a bag of sweetmeats is brought to her, would eat up " bag and everything." Never speaks except when spoken to. Gives her name, and names correctly and with perfect articulation, a watch, a chain, a key, cuffs, a penny, a handkerchief, etc. Requires assist- ance in dressing and undressing. Is dirty. Never shows affection for any one. Does not sing. Case IY.—Speech production nil; but understands simple orders, and is able to dress himself and keep himself clean. Is quite taciturn,216 the disorders of speech. and is dull and listless. No emotions.—J. M. (male), aet. 33. Admitted eleven years ago, suffering from Adolescent Insanity in its maniacal form. From the first beginning of the dementia, he spoke little; but he sometimes whispered to himself, and his replies to questions were always given in a whisper. At present he never speaks, and has not been heard to do so for years. Never laughs or gets angry; emotions seem gone. Is generally sedentary, but sometimes wanders about the room, picking, things off the floor. Is able to dress himself and keep himself clean. Under- stands and obeys simple orders; moving from chair to chair, for example, when asked to do so. When looked at, keeps his eyes shut. When asked to put out the tongue, protrudes its tip slightly beyond the edges of the teeth. Never sings. Case V.—Dementia complete. Habits dirty. Never speaks. Cannot understand anything. Babbles incessantly to herself \ Sings well! and in singing is said to pronounce the words perfectly.—C. T. (female), set. 20. Dementia came on after an attack of adolescent insanity. Was formerly a bright girl. Is well grown and de- veloped, and, physically, appears healthy. She has a vacant but not unhappy expression. Is quite heedless as to evacuations. Sitting in her chair, she occupies herself almost incessantly in doing one of two things, or both of them together. (1.) She rubs the flexed fingers of her right hand rapidly upon the extended palm of her left. (2.) She babbles to herself continually, looking before her, or to one side, as if addressing some one in conversation, and nodding her head from time to time as if to give emphasis to what she is saying. At a little distance one would suppose that she was talking to an imaginary companion; but, on listening more closely, it is found that the monologue is composed of babbled consonant and vowel sounds, very similar to the sounds produced in the babbling of babies, only that the execution is more rapid and vigorous. I tried to write down some of the sounds, but found it very difficult to do so, owing to the rapidity of their utterance. I got, however, th, man, th, what, whe, tan, m, m, hi, i. At my first visit the only words I could catch were man and what, as shown above; but I was told that occasionally bad words appeared in the monologue; and this observation was verified when I saw the patient for the second time, several such wordsSPEECH IN DEMENTIA. 217 being then pronounced with unmistakable distinctness. The monologue in this case has thus degenerated to a stage almost as low as it is possible for it to reach,—to a stage far lower, for example, than the really verbal, though meaningless, monologue of Dr Robertson's case of senile dementia already quoted. The emotions of this patient are gone. She never shows affection and never gets angry. Occasionally, instead of rubbing one hand upon another, she tries to tear her dress ; but her dress is now of such material as to resist tearing. She sings well. As it is generally in the night- time that she sings, I did not hear her; though the nurse kindly tried to entice her to sing, by singing to her her favourite song. The song is " Love's golden dream is past," which, the nurse says, she sings in perfect tune, and with perfect articulation. There is positively no other way in which the patient's attention can be aroused. She never pays attention to anything else, and never replies even to the simplest question. To hear a patient in the condition of advanced Dementia sing well is very startling. It is even more so than to hear the good singing of imbecile children. How is it that the musical faculty is thus often preserved intact, or almost so, when the mind has been laid in ruins? I do not know that physiological science can yet answer that question. To find the faculty intact in such a case as this last one, produces in one's mind the same kind of feeling as one would experience, if, in searching in the ruins of some dwelling-place that had long since been destroyed by fire, one found some pretty domestic ornament, unbroken among the debris. It is not only in the dementia resulting from adolescent insanity that the musical faculty is thus able to maintain itself intact. It may be found equally so in dementia resulting from many other forms of insanity. Thus, there is at present in the Royal Edin- burgh Asylum a man now far advanced in dementia, in whom the condition resulted, in middle life, from repeated attacks of mania brought on apparently by alcoholism. This patient was once a clever workman, and used to play the violin. Although now dull and stupid, he wakes up a little when asked to give his favourite musical performance. This is an imitation of the notes of the bugle, which he does with his mouth, placing the right hand verti- cally against the right side of the mouth. The performance is218 the disorders of speech. surprisingly good and tuneful, the notes being wonderfully like those of the bugle. B. Dementia with Paretic or Paralytic Elements in the Articulation of Words.—The leading element in this paretic articulation is Slurring, which renders the speech thick and slovenly. Apart from insanity, there are many conditions which may cause the speech to be slurred and slovenly. During Inebriation, for example, the speech may be slurred. A few glasses of wine may make it risky for the individual to attempt the articulation of such an expression as " mutual eligibility"; and we know what becomes of "British Constitu- tion " when there is distinct inebriation. Otlier conditions may, in like manner, impair the articulation for a time. Great Mental Fatigue or Depression may cause, for the time, a little carelessness and want of precision in the articulation of difficijlt words. The symptom is also a pommon one, and may be per- manently established, in many cases of Organic Disease of the Brain, due to coarse lesions. But I do not wish to look at these conditions at present. I want now to speak of this symptom, and other associated peculiarities of speech, as they occur in certain forms of Dementia. The two forms of dementia in which it i§j most commonly met with are—(1), Senile Dementia, and (2), Paralytic Dementia—the General Paralysis of the Insane. Jn both of these the symptom is of ominous significance. It shows that paralysis is creeping down from the higher mental t>Q the lower motor centres in the brain. This downward march is apt to proceed until the functions of the brain that are concerned with tlje maintenance of life itself aye finally involved. Referring to this paretic element in the articulation of dementia, Esquirol has said—" L'embarras de la parole est un signe mortel." The axiom applies with double force when the form of dementia is that qf General Paralysis of the Insane. Let us, then, consider the two forms of Dementia in which this paretic element in articulation is specially exhibited. a) Senile Dementia.—When age is far advanced, the mind is naturally more or less enfeebled. This is the rule, though we all know that, in exceptional cases, the mind remains wonderfully strong and vigorous long after the ordinary term of human life hasSPEECH IN DEMENTIA. 219 been overpassed. When the mental feebleness, natural to extreme old age, is exceptionally well marked, the case may be reckoned as one of Senile Dementia. This may set in prematurely, owing to a bad heredity, or to former habits of intemperance or over-work, or of hard living of any kind. It may be predisposed to by athero- matous degeneration of the cerebral vessels. It may be rapidly established after an attack of senile melancholia, or a passing attack of mania, or in consequence of the depressing influence of a great sorrow, or of a mental strain of any kind. In some cases the dementia is total, or almost so; and in these the Monologues, and some of the forms of Reflex Speech already described, will generally be exhibited by the patient: but in a great many cases there is marked enfeeblement rather than abolition of the mental faculties. The old man passes into his second childhood. As in all other forms of dementia, the memory is one of the first of the mental powers to suffer deterioration. New impressions are not retained by it. Though the old man may be able to live in the memories of the past, and to tell long stories of the events of his youth, he is apt to forget such simple things of the present as the day of the week, or what he had for breakfast. It is the exceptionally severe cases that one finds in asylums. Passing over the features which are common to this and the other forms of dementia, let us look for a moment at the Intona- tion and Articulation of speech in senile dementia. In extreme age the Voice loses its former volume, its depth, and its variety of intonation. It tends to become monotonous, and of higher pitch than it was wont to be. ".....his big manly voice, Turning again towards childish treble, pipes And whistles in his sound." But this change in pitch is due rather to physical than to mental decay, and it is not usually met with in cases where senile dementia sets in prematurely. Much more closely associated with the dementia are the changes observable in Articulation. In the articulation there is usually observable a distinct element of Slurring. Here is what Dr Clouston, who has made a careful study of this form of speech, says about it:—" No one can look to a man in his extreme dotage talking without perceiving that the220 THE DISORDEBS OF SPEECH. motor apparatus of articulation is as much affected as the mental apparatus. When looked at carefully, we see, in the first place, that there is a certain amount of slowness, indistinctness, and hesitancy of speech—a paresis, in fact. Then, in some cases, we see that, like the general paralytic patient, there is a certain amount of convulsive tendency, seen in the tremor of the labial and lingual muscles. The first words of a sentence, or the first syllables of a long word, are far more distinctly enunciated than the last, show- ing an easily exhausted stock of nervous force, as well as a paresis. Then there is a want of coordinating power. The words having many th sounds are not properly enunciated, e.g., the patient cannot say, 4 The astonishing thing is that those thieves should think this/ The power of rolling the r's is deficient too. There is also a dis- tinct tendency to reversion, in the resemblance of such speech to that of a child learning to speak. Finally, there are well-marked aphasic symptoms in some rare cases. I have a woman now in the Koyal Edinburgh Asylum who when she wants to say, ' Now you take that/ says, 'Now you ter ter ter.'" There are thus features in senile speech which relate it to the speech of general paralysis of the insane ; but there is not on this account much risk of error in diagnosis. General paralysis is very rare at the advanced age when senile speech appears; and, as Dr Clouston remarks, " A close study of the speech will usually determine the difference. There is not the true general paralytic trembling, or the spasmodic con- vulsions of the smaller facial and labial muscles/'1 (2.) General Paralysis of the Insane— Every one knows the terribly fatal character of general paralysis of the insane. On the average it runs its course in two or three years. The stages of the malady in its common form are also familiarly known. First there is the stage of Mental Exaltation, with its extravagant notions of grandeur, and its foolish and sometimes criminal actions ; also with its slight tell-tale disturbances of speech, which the alienist looks to specially, in trying to distinguish the case from one of ordinary mania with exaltation. Then, in the second stage, with persistence of the exaltation, there is more distinct loss of memory; more evident affection of speech ; and the appearance of incoordination in such other complicated movements as those of 1 Dr Clouston on "Disorders of Speech in Insanity/' Edin. Med. Journ.^ April 1876.SPEECH IN DEMENTIA. 221 walking, washing the hands, and buttoning the dress. Lastly, in the third stage, the mind is sunken deep in dementia; the speech totally inarticulate; and the body paralysed, not only in its powers of voluntary movement, but also even partly in its reflexes, so that feeding must be carefully performed, lest the patient should choke, owing to paralysis of the reflex for deglutition. Utter ruin of both mind and body could not be more terribly exhibited. Mercifully, in a great number of cases, before this stage is reached, life is cut short by one of the " congestive " or epileptiform attacks that tend to occur in the course of the disease, with increasing frequency from the first stage onwards. In this typical course, the disease proceeds, as it were, from above downwards—first mind is affected and then motion; and the mind displays the typical exaltation that has been referred to. But there are many cases in which the typical course is not strictly adhered to. In the first place, there is a group of cases that never display the typical exaltation with delusions of grandeur. In these the mental failure sets in with simple loss of memory and mental power, and often with depression of spirits. But these cases present the same speech peculiarities, and run ultimately the same course, as cases that have the delusions of grandeur. In a third group, the motor symptoms may appear before the mental, and keep in advance of them almost throughout. When I was making my notes of cases at the Asylum, one poor man in this condition was pointed out to me. His motor functions were deeply involved and his speech much affected, but his mind re- mained comparatively clear, and he seemed to realize his own sad condition in a manner that is rare among general paralytics. It is well known that the victims of this disease are generally men in the prime of life, and often previously of fine physique. Hard living and dissipation, especially if associated with hard work, physical or mental,are usually regarded as its most potent causes; the influence of heredity being by no means so marked as it is in the case of other forms of insanity. Before proceeding to attempt a more detailed analysis of the defects of speech in General Paralysis that can be detected by the ear, let us, in the first place, take note of an associated symptom that is perceptible to the eye : I mean the presence of abnormal movements in the lips and features, and in the tongue.m THE ftft&KBElCS g^IIECH. The most characteristic of these movements are occasional quick, momentary Twitchings or Shiverings in the upper lip, or in the naso-labial fold, or sometimes in the muscular fibres of an eyelid. They occur most markedly when the patient is speaking, or is otherwise moving the lip, as in opening the mouth to protrude the tongue. A portion of the Levator Labii Superioris, or of the Orbicularis muscle of the mouth or of the eyelid, or of a muscle in the chin, suddenly and slightly twitches from time to time. In most cases these slight twitchings do not exhibit themselves when the features are at rest: it is when a voluntary movement is made, as in speaking or opening the mouth, that they appear. With the slight twitches there is often associated, during speech, a general trembling of the lips, like that sometimes seen in the lips of a healthy person during great emotional excitement. The twitching and trembling in the facial muscles may sometimes be brought out With special distinctness if the patient be asked to open the mouth arid protrude the tongue, especially if the mouth is not widely opened, and the tongue is only half protruded. In the tongue, when it is protruded, there is generally much movement. There is often trembling and general restlessness of the whole organ, and there are also, as a rule, wave-like contrac- tions in bundles of its muscular fibres ; yet in some cases, when the mouth is merely opened, and the tongue is not protruded but allowed to lie in position, the movements are absent, the tongue being then quite still. I take it that these wave-like contractions and tremblings in the features and tongue, appearing as they do almost exclusively during voluntary movements of the parts, are due to disease in the motor cells of the Cortex. But as the motor cells of the Medulla are also often involved in General Paralysis, I think we should also, in some cases, find small fibrillar movements going on constantly in the muscles, even when they are otherwise at rest. These fibrillar movements, of medullary origin, should be associated with wasting. We see such wasting and fine fibrillar movement in the tongue, when it is becoming paralyzed owing to the disease in the motor nuclei of the medulla known as G-losso-Labio- Laryngeal Paralysis. I do not suppose that anything comparable, in degree, to the wasting exhibited in this disease will be met with in the general paralysis of the insane ; but one would expectIN DEMENTIA. 223 fine jJlpUar movements of the same kijuJ. ;tp be exhibited, when the disease has involved the motpr cells of the medulla. The t^fcch- ings in general paralysis certainly for the most part involve larger bundles of muscular fibres than do t}ie fibrillar movements of glosso-labio -laryngeal paralysis. They may be termed fascicular rather than fibrillar; and, for the most part, they appear only during the performance of voluntary movements. The question whether true fibrillar movements, associated with wasting, ever occur along with them, my own observations do not yet enable me to answer. As the disease advances, these movements of the features and tongue, very slight, if noticeable at all, at the beginning of the first stage, become more apd more marked j and, at the saijae time, Paresis of Movement in the features and tongue becomes more and more apparent. In the features, the upper lip sometimes assumes a flaccid and pendulous appearance, as if if were imperfectly sup- ported by its suspensory muscles—the " veil-like upper lip." In the tongue, impairment of voluntary movement soon becomes very evident, Dr Clouston says:—" In the second stage of the disease, the want of coordination is very choreic in its character, but with the convulsive tendency in addition. Tell a paralytic patient in the first stage to put put his tongue, and he at once does so; but you see quiverings running down groups of the fibrillse of its muscles. Tell the same man in the second stage to do so, and he puts it slowly out, the whole organ being pushed about in a very unsteady way, through its muscles not acting harmoniously towards the desired end. Tell him, in the end of the third st^ge, to do so, and the only response is his moving the organ about a little, without being able to protrude it beyond the mouth. Any one accustomed to see much of the disease can often diagnose it, $nd the stage it has reached, from the tongue alone."1 But, at beginning of the first stage, perhaps the little occasional shivering or twitching in the upper lip or nasolabial fold is more important and distinctive, in a diagnostic sense, than even the quiverings that run down the muscular fibres of the tongue. Coming now to the consideration of the Defects of Articulation in General Paralysis, we have to note 1 " Disorders of Speech in Insanity," Edinburgh Medical Journal, April 1876.224 THE DISORDERS OF SPEECH. a. The Slurring of difficult consonants, like that so distinctly exhibited by inebriates. At the beginning of the first stage it is often absent, or, if present, may be only exhibited in such test-words as truly rural, British Constitution, or mutual eligibility; but it becomes, with the increasing paresis, more and more marked as the disease advances. In the first stage, it may sometimes be brought out by causing the patient to repeat one of the above expressions several times over. Often after a few such repetitions the limited supply of nerve force gets exhausted, and slurring becomes evident. Similar fatigue and slurring may be induced by causing the patient to repeat an alliterative sentence. At the Royal Edinburgh Asylum, the favourite sentence for this purpose isRound the rugged rock the radical rascal ran." There are few cases, even in the first stage, that will repeat this sentence once or twice without at last getting into a sort of in- articulate slur about the end of it. 5. Even more diagnostic than slurring is the derangement of articulation termed by Kussmaul Syllable Stumbling. For tW purpose of testing patients for this defect, the favourite test-words at the Royal Edinburgh Asylum are Hippopotamus and West Register Street. Here is what one of the patients made of Hippopotamus" Tahippotapotapos." West Register Street is in like manner often put into some such condition as " West Regigistrerer Street." Kussmaul recommends the use of the test-word artillerie, and tells how it is often converted into " artrallerie" or " rartrillerie." He adds that Peking may be converted into " keping," and guten morgen into "goten murgen." What does the evident incoordination of speech in this Syllable Stumbling depend upon ? It is probably, as Kussmaul suggests, a defect in the formation of the psycho-motor word-images; the images being most imperfect when the words are complicated and difficult. A word is composed of letter-sounds arranged in sequence. If the sequence of the letter-sounds is imperfectly remembered some of the letters may be sounded in the wrong places. This is; one of the two characteristics of Syllable Stumbling: the other being a stumbling and rapid repetition of one or more of the syllables. In Slurring, on the other hand, one may suppose the image to be perfect, and that the defect is merely in the power of exteriorizing or executing it.SPEECH IN D.EMKNTIA. 22 J Syllable Stumbling may be exhibited in tlie articuLition of difficult words even in the earliest stage of general paralysis, before any slurring can be detected. Kussmaul says :—" Syllable stumbling may make its appearance in the earliest stage of general progressive paralysis, at a time when the motility in general does not present the least sign of diminution, and when the movements required for the production of sounds, and for all other voluntary objects, are still perfect (Parchappe, Bull, de VAcad. de Med., t. xxx. p. 702)/'1 It becomes more and more marked as the case progresses.2 c. Owing to increasing difficulty of articulation, the utterance of the patient, in the advanced stages, often becomes Slow and obviously Laborious. It may even, for a time, assume something of a " Staccato " character. Ultimately, about the end of the third stage, speech may become totally Inarticulate. d. The above being defects displayed specially by the Oral Articulative mechanism of speech, we have now to remark that the Vocal mechanism does not wholly escape. In the advanced stages, the voice is apt to become monotonous and sometimes high-pitched, and to assume a peculiar iEgophonic Trembling. It has, in fact, been likened to the bleating of a goat. e. It should be noted that the failure of memory which is so marked an element in the symptomatology of the disease may be displayed, when the disease is advanced, in the difficulty the patient experiences in committing a few words to memory. I tried hard to get one poor man to repeat accurately after me the lines, " Mary had a little lamb, Its fleece was white as snow," but he could not master perfectly even the first line; although, in former times, when he was in health, he had often repeated the verses to his children. I remarked, in this case, that any emotional expression, such as "Oh dear me," "This is very sad," was much more per- 1 Kussmaul, op. cit.f p. 808. 2 It is to Syllable Stumbling more especially that Esquirol's axiom as to the deadly significance of embarrassment of speech applies. Slurring is met with even in the monologues of Adolescent Dementia: and these cases notoriously often live for many years. I think Slurring in Dementia should be regarded as a symptom of advancing change in the motor centres only when it is exhibited in the patient's speech even when his attention is fully roused, as in replying to questions. In the Monologues it is due to absence of mind and want of attention, not necessarily to disease in the articulating centre. 2 F226 THE DISORDERS OF SPEECH. fectly articulated than anything the patient said that was not dictated by emotion,—another instance of the power of an emotional stimulus. /. Lastly, it may be added that temporary Aphasia is common in general paralysis, especially after congestive attacks. In the whole range of the disturbances of speech that are met with in connexion with Insanity, there are none of so much practical significance as the disturbances in General Paralysis of the Insane. That is why, in the above notes, I have ventured to treat of these disturbances in some detail. A knowledge of their earlier manifestations is important, not only to the alienist, but also to the ordinary physician and the general practitioner.1 I cannot conclude this chapter without making grateful acknowledgment of all the kind assistance I have received in studying the speech of the insane at the Royal Edinburgh Asylum. Dr Clouston granted me free permission to visit the Institution as often as might be necessary; Dr Eobertson, his senior assistant, selected suitable cases for me; and Dr Middle- mass, one of the junior assistants, helped me greatly in taking notes of them. Without these opportunities for study, and the assistance so courteously given, I could not have written this chapter. 1 It should here be remarked that, while in almost all cases the peculiarities of speech and the other symptoms in General Paralysis render the diagnosis comparatively easy, there are two other morbid conditions which sometimes produce the very same symptoms, viz., Chronic Alcoholism, and Syphilis of the cerebral cortex. But these cases often recover under treatment.mental percepts of objects. 227 CHAPTER IX. Aphasia :—Physiological Preface ; with Notes upon the Leading Features of Aphasia, and upon the History and Literature of the Subject. Mental Percepts of Objects. Psychologists tell us that our primary and most simple idea of an object is formed by the revival in our minds of the impres- sions that the object has made upon the sensorium, through the organs of sense. With the view of bringing home to my own mind the truth of this proposition, I made, some time ago, a series of little experiments with a number of apples. I found these experiments of value to me, not as teaching anything new about the relations of sense- impressions to ideas, but as illustrating those relations in a vivid and interesting way. In the hope that they may, in like manner, be helpful to the reader, I shall here make a brief note of them. They consisted simply in appealing to each of the senses separately, by means of an apple, and in watching how readily the sense-impression would suggest to the mind the idea of an apple; and how the name or word-symbol "apple" would rise up in the mind along with the idea. At the Eoyal Infirmary I got together a few children from the surgical wards, and, having put them together into a room by themselves, I called them one by one into my own side-room. The first, a boy aged six, was shown an apple lying upon the table, and was asked what it was. He said at once, " It is an apple." The second, also a boy of six, had his eyes bandaged, and was asked to smell the object put before his nose. He too said at once, " It is an apple."228 THE DISORDERS OF SPEECH. The third, a boy ol' nine, had a bit of apple put into his mouth, after his eyes had been blindfolded and his nostrils closed. He chewed it, and said immediately, " It is an apple." (Although the nostrils were closed, it is of course quite possible that some of the flavour of the apple may have reached the Schneiderian membrane by the posterior nares.) The fourth, a boy of ten, having been blindfolded, had an apple put into his hands. When asked what it was, he said, after having felt it for a moment, " It is an apple." Hitherto, in the experiments, the mind had promptly come to a correct conclusion from the information supplied to it by the sense appealed to. But now we proceeded to make an appeal to the sense of Hearing, which is much less frequently called upon to receive impressions from apples than any of the other senses. As was to be expected, we found that the conclusion arrived at by the mind from the evidence of sound was not so often correct. We made the sound by paring an apple with a table-knife near the ear of the person experimented upon, after his eyes had been blindfolded and his nostrils closed. Sixteen persons in all, mostly adults, were tried in this fashion, and of the whole number only three answered correctly, " You are paring an apple." The others thought we were paring wood, clipping paper with scissors, rub- bing salt, rubbing two surfaces of cloth together, etc. Lastly, I have frequently had occasion to observe that the Muscular Sense has made itself familiar with one of the proper- ties of an apple, viz., its weight. I have in my possession a beau- tiful imitation-apple, made of some heavy metal, but painted 011 the surface in excellent imitation of a Newtown pippin. With the eye alone, no one can tell that it is not an apple, but when I ask a friend if he has seen " this new variety of apple," it is in- teresting to watch how, in all good faith, he prepares to examine it, and how instantly he detects the deception when the object is put into his hand. From the information given by the eye. the mind thinks it is an apple; but this conclusion is at once flatly contra- dicted by the evidence furnished by the muscular sense. Now I think such little experiments are helpful, when we are trying to realize the relations between sense-impressions and ideas. As I have already indicated, it is now generally held that the primary and most simple idea we form of a thing—say, an apple—MENTAL PERCEPTS OF OBJCETS. 229 is but a revival of the sense-images or memories of it that have been stored up in the cortical centres belonging to the various senses. Each organ of sense has its cortical centre in the brain. Here new impressions, received from without, are constantly pre- sented to the consciousness. If the impressions are not attended to, they appear to pass away utterly in a short time, leaving little or no trace in the memory. But if the attention is either voluntarily directed or involuntarily attracted to them (and some impressions are so powerful, or so fraught with pain or pleasure, as to demand attention), then they are registered in the local memory of the centre; and, so long as the registered impressions remain distinct in the memory, they may be revived in the imagination, either by effort of the will, or, involuntarily, at the suggestion of some associated sense-impression or other memory. Thus each cortical centre for sense-impressions should be regarded as not only a receiving office for fresh impressions, but also a storehouse of old impressions that have been duly attended to, registered in the memory, and linked with associated sense-impressions stored in other centres. When the apple was put to the child's nose, the smell of it was recognised as one already registered ; and the revival of this regis- tered smell called up at once, in the mind, revivals of the other sense-impressions derived from apples ; the members of the group of impressions being so linked together by association that one member cannot be revived without there being a more or less distinct revival of the others along with it. It is this congeries, or complexus, of revived images that we call the Idea, or Percept, of an apple. No doubt, in the complexus, some one of the sense- images is generally more distinct and important than the rest—our percept of an apple, for example, contains the visual element more distinctly than the olfactory;—but all the senses that have received impressions are at least ready to contribute; even the muscular sense being ready, as we have seen, to give distinct evidence when appealed to. This reference to the Muscular Sense leads me to add that according to the teaching of some eminent psychologists, especially of Professor Bain, Memories of Motion are always stored up in the brain along with the memories of sensation, and are revived along with them when the idea of an object is formed. Each230 THE DISORDERS OF SPEECH. organ of sense possesses muscles (such as those of the eyeball, the nose, the middle ear, etc.), and these are called into activity when the organ is actively receiving impressions. It is held that the muscular activities record their memories in the brain, and that these motor memories blend with the sensory in our percepts of things. Dr Ferrier thus illustrates the views on this subject which he shares with Professor Bain,—"Our ideas of form are not mere revived optical impressions, .... but optical impressions combined with ideal ocular movements. Our idea of a circle is a combination of an ideal coloured outline, with an ideal circular sweep of the eyeballs, or it may be of the tactile impressions coin- ciding with an ideal circumduction of the arm or hand, or perhaps both these factors combined.....To revive any of these ideas is to revive both the sensory and motor elements of their composition, and we tend in ideation to repeat the actual movements which were concerned in the primary act of cogni- tion."1 I may here note, as further interesting in this doctrine of an element of motor memory in our primary ideas of Objects, that it recalls to our minds the motor memories that form, in addition to the sensory memories, so important a part in our ideas of Words; a subject I shall return to presently. We come now to a very important question. When the idea of an apple is thus formed in the mind by the blending of the various memories, sensory and motor, that have been revived at their respective centres, how is this blending effected ? Are the revived images gathered together into a special Ideational Centre, in some particular part of the brain, and there blended ; or are the images allowed to remain each in its own original situation, and merely taken cognizance of by the intelligence, while thus remaining in situ ? The latter seems to be the view that derives support from all the facts known to us. There is no proof that there is anywhere in the brain a local ideational centre. If there were such a centre, the local destruction of that particular spot would make ideation impossible. But there is no case recorded in which mere local destruction of a limited portion of the cerebral cortex has produced such an effect. The evidence, as it stands at present, seems all to point to the conclusion that the presiding Intelli- 1 The Functions of the Brain, 2nd edition, 1886, p. 437.MENTAL PERCEPTS OF OBJECTS. 231 gence, which takes cognizance of, fixes, and groups together these impressions, so as to form Ideas from them, is not a faculty that is specially localized in the anterior part, or in the middle or in the posterior part, of the brain-substance, but is one tliat belongs to the cortex as a whole. It would appear to be more especially connected with the more superficial layers of the cortex; but the evidence in favour even of that supposition is not entirely conclusive. It is by this pervading faculty, the Intelli- gence, that the images are revived and taken cognizance of, while they yet remain in situ. It is now generally believed that if one of the cortical centres for sense-impressions were extirpated from both hemispheres, the store of memories amassed at that centre would be utterly obliter- ated from the mind. On this subject Dr Ferrier says:—"The destruction of the visual centre, therefore, not only makes the individual blind presentatively, but blind representatively or ideally, and all cognitions into which visual characters enter in part or whole, become mangled or imperfect, or are utterly rooted out of consciousness."1 Granting, then, that our primary and most simple cognitions of things are merely the results of this revival and blending of sense images, and that the group of images constitutes in fact the Idea in our minds which represents the Thing, let us now look at the relation of this idea of an object to its name. In the first place, it should be noted that the simple idea of a concrete object may be perfectly distinct in the mind, even when we have, for the time, utterly forgotten the object's name. Although we are not liable to forget the names of common and familiar objects, we have, most of us, had experience of forgetting, for a few minutes, the proper name of some familiar acquaintance. We know that, in these circumstances, the mental image of his personality loses nothing, in distinctness and completeness, from the loss of the name. It is so with regard to everything of which the mind can form a clear and distinct image or memory: we can think of it clearly, even when the word expressive of it is for the moment forgotten. I believe that if we had no words to express such actions as walking, running, or flying; or such colours as red, 1 Op. cit., p. 429.232 THK DISORDERS OF SPEECH. blue, or yellow ; or such qualities as prettiness or ugliness; or such emotions as affection or anger,—we could yet, after having had frequent experience of them, recall them to mind, and think of them, without the aid of words. The fact that those deaf-mutes who have not been educated to speak can yet, as their actions show, think rationally, though not profoundly, proves that this must be the case. But there are some forms of thought that cannot be carried on without the aid of verbal symbols. Names of concrete objects are the verbal symbols of the simplest ideas we have of things, ideas so simple that they can be easily grasped by the mind without the aid of their verbal symbols. But we have also a long array of names or nouns that are the symbols, not of concrete individual things, but of classes of things, as well as many nouns that are the symbols of abstract qualities; and such nouns are very largely used even in ordinary conversation. These nouns are the products of that effort to classify things which has always been carried on by the human mind. Any classification of things, however rude, represents much labour of observation and compari- son. Concrete objects have been placed side by side, and the like have been separated from the unlike; and when a number of objects that are related to each other in their qualities have been grouped together, a name is given to designate the group. Then groups are compared, and are classified into groups of groups, and so on, until ideas of things in general have fallen into some kind of order in the human mind. This is a process that has, instinctively and almost unconsciously, been carried on throughout human history; it is also the process that is carried on consciously, and with a definite view to classification, by the cultivators of every branch of natural science. As the conceptions rise from the particular to the general, a name is given to mark each step in the process; and the more general and abstract the conception, the more necessary is it for the mind to invent a name that may be used, in the processes of thought and speech, as a definite symbol for a concept that is itself, of necessity, indefinite and shadowy. " A word or sign," says Sir William Hamilton, " is necessary to give stability to our intellectual progress, to establish each step in our advance as a new starting point for our advance to another beyond. A country may be overcome by an armed host, but it isMENTAL PERCEPTS OF OBJECTS. 233 only conquered by the establishment of fortresses. Words are fortresses of thought: they enable us to realize our dominion over what we have already overrun in thought, to make every intellectual conquest the basis of operations for others still beyond. .... Though, therefore, we allow that every movement forward in language must be determined by an antecedent movement forward in thought, still, unless thought is accompanied at each point in its evolution by a corresponding evolution of language, its further development is arrested." Speaking of the formation of concepts by the abstraction of the resembling qualities in objects, he says,— "The concept thus formed by an abstraction of the resembling from the non-resembling qualities of objects, would fall back again into the confusion and infinitude from which it has been called out, were it not rendered permanent for consciousness by being fixed and ratified by verbal sign."1 Surely these sentences put the relationship of words to the higher and more abstract class of ideas very clearly and succinctly. The great fact having been realized that a sound can be made to serve as a symbol for anything that is perceived or imagined by the mind, the effort of all cultivated speech is to make the symbolic representation as complete as possible. Nouns indicate things, verbs actions, adjectives the qualities of things, adverbs the manner of acting, prepositions and conjunctions the relations of things and actions to each other; and so a whole train of thought finds its expression in a train of words. But, as we have seen, the use of words does not stop here. Words not only express thought, they also support and assist it. When an idea is abstract and vague so that no well-defined image is formed by it in the mind, a word is invented by some thinker who has realized the idea with excep- tional clearness. This word adds to the thought something that has distinct body and definition, so that, afterwards, the thought, with its associated symbol, can be grasped and retained by ordinary minds. Language also facilitates and improves the operation of the thinking faculties in many other ways. The fact, for example, that we have in books the well-digested thoughts of the best thinkers of our own time and of past ages is a fact of infinite importance in relation to the development of the power of 1 Lectures, vol. iii. pp. 138-140, quoted by Bastian in The Brain as an Organ of Mind, p. 418.234 THE DISORDERS OF SPEECH. thought; because books not only supply knowledge, the material for thought, but also do much to train the mind to habits of accurate thinking. Mental Percepts of Words. In the foregoing remarks I have treated of the nature of our mental percepts of objects, and have noted briefly some of the rela- tions existing between thought and speech. I now wish to devote a little attention specially to the question—What is the nature of the mental percept that we form of a word ? We have seen that when the child smelt the apple a percept of the object was immediately formed in his mind, by the revival of a group of images or memories; and we have seen that this group probably included motor as well as sensory elements. But, along- side of this percept of the object, there arose in his mind, at the same time, what I shall venture to call a second percept, viz., that of the verbal symbol of the object, the word " apple. " Now, what is the nature of this second percept ? The tendency of the best physiological and psychological research seems to be to answer this question by saying that the mental percept of a word is, like the mental percept of an object, a blending of memories or images that have been stored up in special centres of the cerebral cortex. The memories are two in number, a sensory and a motor. In the language of a nation a certain articulate sound has come to be the symbolic representative of a certain definite idea. This sound is learned by each child of the nation; at first, it may be, as a mere sound, but presently as a symbol also. It is in the cortical centre for hearing that the sound is first registered. By-and-by, under the guidance of the auditory centre, the child trains the motor centre to reproduce the word heard; and by this training it acquires a second image or memory, which is imprinted at the motor centre. Presently this motor reproduction of sounds becomes so interesting an exercise to the child, that, as we saw formerly, he reproduces many words that he hears, in parrot-like fashion, by Echolalia, without making any attempt to understand them. But before the stage is reached at which echolalia is exhibited, and before, indeed, the child can articulate any single word, a number of word-memories have been imprinted upon the auditory centre, and have even been associated with their properMENTAL PERCEPTS OF WORDS. 235 meanings. At this early stage, as Prof. Bain points out,1 the child will turn his head towards his brother when he hears the name "Johnny" pronounced; though it is very improbable that the word "Johnny" rises up in his memory when he spontaneously looks at his brother. The child has not yet acquired the motor picture of the word. He is as yet at the stage at which the education of the receptive centre is obviously ahead of that of the productive or motor. In the process of learning a foreign lan- guage, we all have experience of a stage in our educational pro- gress that is somewhat similar to this. I mean the stage at which we can read and understand the language, but cannot yet speak it. The sensory word-pictures have already been extensively acquired, and they have been associated with the ideas of which they are the symbols; but the motor pictures have not yet been acquired to the same extent. Until the motor pictures are also fully acquired, we are not able to call up words readily in our minds when we wish to use them in conversation. Practice in speaking the language will alone be able to give us this facility. The sensory images are thus of special importance in relation to the reception and interpretation of speech, the motor images in relation to its production. A foreign language is not perfectly acquired until both sets of images have been securely imprinted. Our mental percepts of words are not perfect until both sets of images are revived simultaneously, and are blended together into one in the consciousness. How this blending is effected is as difficult of explanation as is the blending of the sensory and motor images into the percept of an object. But everything goes to show that in this case again there is no special centre for the process of blending: the images remain in sitiCy and seem to be taken cognizance of simultaneously by the presiding consciousness or intelligence, the nature of which is so great a mystery to us. Here I come to say a few words about a problem regarding which much that is interesting has been written. What is the nature of the Internal Speech which we employ in the process of thinking ? Some hold that we do much of our thinking without the aid of words. Thus Bastian2 says:—" There can be no doubt that when 1 Fortnightly Review, vol. v., 1869, p. 494. 2 Ibid., 1869, note to p. 62.236 THE DISORDERS OF SPEECH. thinking, much of the process is carried on automatically, and our consciousness is engaged but to the smallest possible extent with the mere vehicle for our thoughts, whatever be its nature; we are intent only upon the ideas for which the symbols are used, and not upon the symbols themselves." But, granted that this is true, it is also generally admitted that when we are working out difficult thoughts, and preparing them for articulate expression, wre become more and more conscious of shaping them into words and phrases: and that, in ordinary processes of thinking, words and phrases associate themselves in our minds so readily with the thoughts, that the thought and the word seem to be almost inseparable. Now, what is the nature of this internal speech ? Let us carefully attend to our internal sensations as we mentally repeat a line of poetry, or as we silently read a sentence from a printed page. We find that we are most distinctly and definitely conscious of the words we are thus repeating internally. We are conscious even of the cadences of the internal voice, and of the emphasis that is put upon the more important words. Is it the auditory images that we are conscious of ? Bastian1 says it is; and there can be no doubt that there is a large auditory element in this internal speech, its tones being so distinct in our consciousness. But Bain has long taught that in internal speech the motor element is much more prominently represented than the auditory.2 In proof of this, he points out that internal speech seems sometimes at the very verge of utterance; as is shown by the little movements we may feel in the tongue, from time to time, when we are silently thinking. Strieker of Vienna3 insists even more than Bain upon the pre- dominance of the motor pictures in this internal speech of silent thought; and he thinks that even in internal song the motor images are the predominant ones. We can sing a song silently, in our minds, either with the words or without them. I find, 1 See article oil the " Physiology of Thinking," Fortnightly Review, 1869, p. 57 ; and the author's works on the Brain as an Organ of Mind, 1880 ; and on Paralysis, General, Bulbar, and Spinal, 1886. 2 See The Senses and the Intellect, 3rd edition, p. 399 ; and an article in the Fortnightly Review, 1869, p. 492. 3 Du Langage et de la Musique, 1885. This French translation of the German work is really a new edition, containing chapters on the Physiology of Music not previously published.MENTAL PERCEPTS OF WORDS. 237 when I mentally sing a song, with or without its words, that it is impossible to prevent my pomum adami from moving upwards when the mental melody passes into its highest notes; but, at the same time, I am most clearly conscious of the varying pitch and cadence of the internal voice. Evidently, in internal speech and in internal song, we revive both images, the sensory and the motor; and the two seem to our consciousness to be welded into one. There is good reason to believe that the discussion and difference of opinion regarding the relative importance of the two word- images in Internal Speech may be due to the fact that individuals are differently constituted: in some the sensory image, and in others the motor, being the more vivid of the two. Further, educated people, who can read and write, have, in addition to the two ordinary speech images, also two others, viz., the visual, by revival of which they read, and the graphic-motor, by revival of which they write; and among such people we certainly meet with cases where the visual images are extraordinarily vivid. So that it is reasonable to suppose that, among people generally, the predominant image in internal speech may in some be the auditory one, in others the motor, and in yet others the visual. Prof. Charcot has paid special attention to this subject. His pupil Bernard1 says,—"M. Charcot emphatically teaches that the memories of signs, like other memories, present, in different individuals, different degrees of comparative develop- ment, owing, it may be, to inheritance, or to custom, or to education. One individual will appeal more frequently to the visual memory of signs, another to the auditive, and another to the motor. It may thus happen that the pre-eminence of a centre may become so marked, that it may hold under its sway, not only what properly belongs to it, but also another or several other centres. For example, the visual centre for words may control not only that for writing, but also that for articulate language. In the same way, the motor centre for speech may become independent of the sensorial centre which had presided at its education. Thus are constituted, among speakers, the visueis, the anditifs, and the moteurs. This is not a speculation pure and 1 De VAphasie, p. 48.238 THE DISORDERS OF SPEECH. simple. I have already recorded several notable examples of such selection." Charcot and Bernard think that the majority of people are anditifs. Bearing in mind that the auditory and motor images are revived together, but that the auditory images are of special importance in relation to incoming, and the motor to outgoing, speech, I think we may sum up the ordinary relationships of the two sets of images in the following propositions :— 1. That, when we hear words spoken to us, our auditory images are strongly revived, and our motor images are revived only faintly, if at all. 2. That, when we ourselves speak aloud, our motor images are particularly vivid, our auditory images being much less so. [Never- theless the auditory images play, even here, in most persons, a very important rSle in guiding the formation of the motor images; as is shown by the fact that in cases of word-deafness—which implies the obliteration of the auditory store of images—the motor centre may emit the wrong words when the patient tries to speak; as will further be shown by-and-by.] 3. That, when we use words internally, in process of thinking, the auditory and motor images are revived together with about equal distinctness. [For simplicity's sake, we may term this combination of the auditory and motor images the Primary Couple.] 4. That when we read printed or written words, we revive the visual images, and that these at once call up, by association, the Primary Couple used in internal thought; so that, in reading, at least three sets of images are revived. [There is some reason to believe that the mental percept of a written word is not complete without the presence in it of at least a faint oculo-motor element. This point will, however, be considered in connexion with Word- blindness.] 5. That when we are about to write, we first revive the Primary Couple, in thought. Then we revive the visual image of the letters and words we are about to write; and lastly we revive the graphic-motor images, and forthwith exteriorize them by the act of writing. The act of writing thus implies a revival of all four sets of images—the primary couple that we use in thought and speech, and the secondary couple that we use in writing. [ObserveUNION OF WORDS WITH THEIR MEANINGS. 239 that, in ordinary circumstances, the graphic-motor images are formed in accordance with, and at the guidance of, the graphic- visual images. It follows that the destruction of the visual images (in word-blindness) will damage the power of writing. It is so in most cases; but, in some patients previously much practised in writing, wTord-blindness does not materially interfere with the power of writing; the graphic-motor images having, by long practice of writing, become so strongly imprinted as no longer to require the guidance of the visual images. In such cases the patient may write well, though, being word-blind, he will not be able to read the words he has just written.]1 Union of Words with their Meanings. Using the idea and the name of an apple as examples, I have already directed the reader's attention to the simultaneous rising up in the mind of two percepts—that of the object and that of its name;—and have shown each of them to be constituted in a similar way by the revival and blending of images. Now, how is the idea-percept or meaning attached to its verbal symbol ? Does the meaning, as is held by some, always attach itself in a special manner to the auditory word-image, and filter thence down into the other word-images ? There is a good deal to be said in favour of this view, inasmuch as it is found that word-deafness (oblitera- tion of the auditory word-images) not only cuts off the mind from incoming audible speech, but also makes it difficult for thought to find expression in out-going words. The Primary Couple, in such cases, has been mutilated by destruction of its better half; and, in some of them, the words supplied by the unguided motor-centre are given at random, and may fail to express the thought that is seeking utterance. In most of these cases, however, considerable power of expression remains; and in some the power of expres- sion seems to be but little affected. No doubt these differences are to be explained, as Charcot has explained them, by referring them to the varying development and prominence of the individual 1 There is, however, another explanation of the fact that some word-blind patients can write and others cannot. But as this explanation is new and still sub judice, I reserve its consideration until I take up the subject of Word- blindness.240 THE DISORDERS OF SPEECH. images in different individuals. In the'majority of persons, live auditory image seems to be the most prominent; in the minority the motor. The idea-percept or meaning seems to attach itself to both images of the primary couple, but the attachment is strongest to the more prominent image. In reception of words, the auditory image is most prominent; in production, the motor. The Secondary Couple of images, those for reading and writing, lie, during the process of ordinary thought and speech, in the back- ground, unrevived. Even when revived, as they are in reading or writing, they are not, in ordinary persons, brought into direct association with the idea-percepts. They are connected with these only indirectly, through the primary couple, as has been explained in Nos. 4 and 5 of the foregoing propositions. In only a very few individuals does this law seem to be infringed by the visual images. It is said that, in a few rare cases, literary men have acquired the power of directly associating printed words with their meanings, without translating the printed symbols into " internal speech." But such cases must be extremely rare. The normal law evidently is that the secondary couple shall act as the servants and the symbols of the primary couple, and that the word-percepts of the primary couple shall alone be brought into immediate association and union with the idea-percepts. It has already been indicated that an Idea-percept may be formed in the mind without its associated word-symbol: as when we think of a person or an object whose name we have forgotten. It should also be noted that we can form in the mind the percept of a word, without the percept of its meaning: as when we think of a word whose meaning we have forgotten. To a young child, it is easier to form in the mind the one percept or the other, singly, than to form both together. The child forms in its mind a distinct percept of, say, the pet-dog, long before the word-percept " bow- wow" has come to rise up in its mind, as the dog's name, when the dog is looked at; and, again, at a later stage, the child delights in repeating in parrot-fashion words just heard, without as yet attempting to attach any meaning to them. In the first case it is forming object-percepts, in the second word-percepts, pure and simple. To form the two percepts, word and meaning, simul- taneously, and to weld the two firmly together so that the one will at once call up the other, is a more difficult accomplishment, thatUNION OF WORDS WITH THEIR MEANINGS. 241 comes later.1 How difficult it is, we can realize when we are trying to learn a foreign language. At first, we read the foreign words but do not understand them. They are as yet to us pure word-percepts. Then we use our dictionaries, and find the translation into our own speech. Having acquired the power of translation, we mentally translate the foreign into our own language before we can arrive at the meaning. But if we thoroughly master the foreign language there will, in due time, be no necessity for translation: the foreign word-percepts will gradually establish the same direct relations to the meaning as the native word-percepts, so that we shall be able to think as well as speak in the foreign language. It is a long and difficult process, this of securely imprinting new word-pictures in the cerebral centres, and associ- ating them directly with meanings. The recognition of its difficulty should bring home to our minds the truth that, when we are easily and pleasantly reading a book, we are not imprinting new word-images in our speech-centres, but are only reviving old images, and refreshing them by re-imprintation. These images have been long established in our word-centres, and have been linked in our minds with the ideas of which the words are the symbols. They can be revived from without, by speech that is heard or seen. They can be revived from within, by the thoughts that arise in our minds. Departure of many Words from their Original Meanings. This interesting subject the reader will find fully discussed by Archbishop Trench in a well-known work of his.2 He shows 1 The lower animals undoubtedly form percepts of objects abundantly; but few of them can form percepts of words. The more intelligent of them, how- ever—the dog, for example—can acquire some auditory images of words, and can attach these to their proper meanings, so that they understand the word when it is spoken to them ; but, having no motor-image or articulative power, they cannot themselves speak. The parrot and other speaking birds acquire both images, auditory and motor, so that their word-percepts are complete ; but only in a very few rare cases has a parrot intelligence enough to attach a few of its acquired words to their proper meanings. Thus the chief difficulty in learning to speak intelligently seems to be for the brain to acquire the capacity and the habit of embracing in its consciousness at the same moment two percepts, that of the word and that of its meaning. 2 English Past and Present, chap. vii. 2 H242 THE DISORDERS OF SPEECH. that:—(1.) Words may become changed in meaning by acquiring a signification narrower than that which they originally possessed. Thus, to take one of his examples, the word girl meant originally a young person of either sex, but is now narrowed to half that width of signification. (2.) Words may gradually acquire a meaning much wider and more general than that which they originally possessed. Thus, bombast originally meant the down of the cotton plant; then it became the wadding with which garments were stuffed out and lined, and in this sense it is used by Shake- speare ; and, thirdly, " bombast was transferred in a vigorous image to the big words without meaning or solidity wherewith the dis- courses of some were stuffed out, and knows at present no other meaning but this." (3.) Words, thus sliding away from their original meaning, may at last acquire a meaning altogether different from the original one. Thus a country serf or peasant was at one time styled a villain because he was attached to a villa or farm. Secondly, the word came to mean a serf or peasant who was at the same time a bad character. Thirdly/any thoroughly bad character came to be styled a villain, though he might not be a peasant at all. For further illustrations, I must refer the reader to the interesting work from which the above are taken. But there is a lower depth to which language may sink. Words and phrases, losing entirely their definite meanings, may come at last to be used as mere sounds to give an emphasis to speech, such as might otherwise be given by mere loudness of tone; or they may come to be used as mere emotional or conventional expressions, whose meaning is contained as much in the tone of the voice as in the words employed. Swearing best exhibits both of these degraded uses of words. Nobody has better treated of these degradations of words into mere conventional and emotional expressions than Dr Hughlings-Jackson. In concluding an excellent analysis of common swearing, he says,—"Vulgar people insert an oath 'at the proper intervals of their speech' as a sort of detonating comma, and thus they render forcible, statements which might otherwise strike their hearers as common-place."1 1 Lond. Hosp. Clin. Lect. and Reports, vol. i., 1864, page 453.SPEECH MEMORIES OR IMAGES, ETC. 243 Why the Speech Memories or Images are imprinted almost exclusively within the Cortical Centres of only one of the Cerebral Hemispheres. When Broca, in 1861, published his epoch-making observations upon two cases of Motor Aphasia observed by him in the Bicdtre Hospital, the conclusion that these observations pointed to, viz., that the function of articulate speech is discharged by one of the cerebral hemispheres, not by the two acting together, was naturally regarded by the profession with much scepticism. A priori, it seemed very improbable that the two anatomically symmetrical halves of the brain should be physiologically so asymmetrical as to have-a most important function discharged by one side only. It required the after experience of case after case to convince the profession that the conclusion was really well grounded on fact. Broca himself, almost from the beginning, looked for an explana- tion of the apparent anomaly. So early as in 1863, he expressed the belief that, in a few rare cases, aphasia would be found to be due to disease of the right third frontal convolution. He says,— " The author still hopes that others, more happy than himself, will find at last an example of aphemia produced by a lesion of the right hemisphere. Hitherto it has always been the left third frontal that has been affected. If it were necessary to admit that the two symmetrical halves of the brain have different attributes, it would be a veritable subornation of our convictions in physi- ology."1 When, in 1865, he returned to the consideration of this point, cases of aphasia due to lesion of the right hemisphere had already been published, and, as compared with the number of cases due to lesion of the left hemisphere, had been found to occur in the proportion of about one to twenty. Broca, in these circum- stances, offered the explanation which has since been generally accepted. He pointed out that, for all the finer manipulations, the majority of mankind are right-handed, and therefore left- brained ; and he suggested that we are probably left-brained also for the finely coordinated actions of speech. He says,—"Just as we direct the movements of writing, of drawing, of embroidery, etc., with the left hemisphere, so we speak with the left hemi- sphere." In explanation of the fact that so great a majority of 1 Memoires tf Anthropologie, p. 61.244 THE DISOKDEKS OF SPEECH. people are right-handed and left-brained, he quotes the statement of Gratiolet, that "in the development of the brain the convolu- tions of the left hemisphere are in advance of those of the right/' Keturning once more to the consideration of this subject in 1877, Broca expressed the opinion that the explanation of the earlier development and greater activity of the left hemisphere had been furnished by observations recently made, showing that the left hemisphere has a more abundant supply of blood than the right. Two observers had submitted this question to the test of experi- mental observation, viz., Professor Armand de Fleury of Bordeaux, and Dr Wm. Ogle of London; and both had found the left internal carotid to be larger than the right in subjects who had been right- handed. Dr Wm. Ogle had further examined three subjects who had been left-handed, and had found that in two of them the carotids of the two sides were of equal size ; and that in the third the right common and internal carotids were nearly twice the size of the left. But even if we grant the earlier development of the left hemisphere,1 and its greater blood-supply, it must still be regarded as a very extraordinary thing that of two symmetrical hemispheres one should be so elaborately trained to speech, and the other should, in this matter, be so greatly neglected. It seems the more extra- ordinary when we consider that the muscular movements necessary for speech are not executed on one side only, like the movements of a trained right hand, but are executed bilaterally. The developmental and vascular differences do not seem sufficient to afford a full and satisfactory explanation. It is even conceivable that the larger blood-supply of the left hemisphere may be rather a consequence than a cause of its greater activity. An explanation which, to my mind, seems more adequate and satisfactory has been obtained from the study of the laws of Attention. But, as the relations of Attention to the faculty of speech are of the highest importance, I should like to pause here for a short time, in order that I may gather together a few observa- tions about the Faculty of Attention. Every teacher knows how futile his efforts to instruct are, if the pupil cannot be got to pay attention. In the pupil's mind, if he 1 It is denied by C. Yogt and Ecker; see Kussmaul, p. 738.SPEECH MEMORIES OR IMAGES, ETC. 245 is not attending, the teacher's words are mere empty sounds—word percepts imperfectly perceived, which he is not taking the trouble to interpret by uniting them to the corresponding idea-percepts. The teacher's voice sounds in his ear like a " tinkling cymbal." Every student knows that, if his wits are wool-gathering, he may mechanically read a page from beginning to end, and, at the end, have little or no idea of what it is all about. The word- percepts have been passing in procession through his mind, but, the attention being partly absorbed by other matters, have only here and there excited a little feeble ideation. The student must "gather in his wandering thoughts," concentrate his attention, and read the page again. Even among the brute creation, an animal is intelligent and teachable in proportion as it possesses the faculty of attention. Darwin says,—" Hardly any faculty is more important for the intellectual progress of man than attention. Animals clearly manifest this power, as when a cat watches by a hole and pre- pares to spring on its prey. Wild animals sometimes become so absorbed when thus engaged, that they may be easily approached. Mr Bartlett has given a curious proof how variable this faculty is in monkeys. A man who trains monkeys to act in plays used to purchase common kinds from the Zoological Society at the price of £5 for each; but he offered to give double the price if he might keep three or four of them for a few days in order to select one. When asked how he could possibly learn so soon whether a particular monkey would turn out a good actor, he answered that it all depended upon the power of attention. If, when he was talking and explaining anything to a monkey, its attention was easily distracted, as by a fly on the wall, or other trifling object, the case was hopeless. If he tried by punishment to make an inattentive monkey act, it turned sulky. On the other hand, a monkey which carefully attended to him could always be trained."1 The relations of the faculty of attention to Insanity are curious and interesting. Esquirol has treated of the subject with his usual point and lucidity. He mentions three conditions in insanity which interfere with the normal exercise of the attention:—(1), The crowd of fugitive ideas that hurry through the mind when it is in 1 The Descent of Man, p. 73.246 THE DISORDERS OF SPEECH. the state of maniacal excitement; (2), the perverted concentration of the attention upon fixed ideas and delusions, in monomania and other forms'of delusional insanity; and (3), the enfeeblement of attention, as of the mental powers generally, in dementia. He says that the attention of all the insane is essentially injured by one of these three causes. But "if a strong sensation, agreeable, painful, or unexpected, fixes the attention of the maniac, or diverts the attention of the monomaniac from his delusion ; or if a violent commotion awakes the attention of him who is in the state of dementia, immediately the insane patient becomes reasonable, and this return to reason lasts just so long as the effect of the sensa- tion,—that is to say, just so long as the patient retains the power of directing and sustaining the attention." At the present stage of investigation into the physiology of the brain, it cannot be definitely said in what part of the brain the faculty of Attention specially resides. It has perhaps no special centre. Being, in fact, only the Intelligence in concentrated activity, it should perhaps be regarded as a faculty of the cortex as a whole, .that is capable of exciting special activities in one centre of the cortex or in another, according to the nature of the sensation, action, or idea that is the subject of its exercise for the time being. There seems to be some ground, however, for the hypothesis that the Frontal Convolutions have special relations to the faculty of attentibn. This is the conclusion that experimental physiology points to. Ferrier, after giving an account of the observations that have, been made upon the point, adds,—"The observations of Hitzig and Goltz appear to me to illustrate and confirm the occurrence of a mental deterioration from lesion of the prefrontal regions, which I have characterized as essentially a defect of attention."1 Ferrier finds in the frontal lobes the centres for those movements of the head and eyes which occur when the attention is about to be fixed. He says,—" Destruction of the frontal lobes, according to the degree of its completeness, impairs or paralyzes the lateral movements of the head and eyes. Though some ocular movements may be excited reflexly by retinal im- pressions, there appears to be loss of the power of looking at, or directing the gaze towards, objects which do not fall spontaneously 1 The Function of the Brain, 2nd edition, p. 403.SPEECH MEMORIES OR IMAGES, ETC. 247 within the field of vision. Correlative with the immobility of the head and eyes, there is the aspect of uninterest and stupidity, the absence of that active curiosity which is normally manifested by monkeys, and the mental degradation which seems to depend on the loss of the faculty of attention, and all that it implies in the sphere of intellectual operations."1 It remains yet to be seen if clinical observation upon the human subject will fully eontirm these conclusions. It may be said, however, that the evidence furnished by the clinical cases of lesion of the frontal lobes already upon record does not seem to be entirely in harmony with them. Some of these cases, indeed, seem entirely opposed to them.2 Let us now inquire how the exercise of the attention should result, in obedience to the laws of its operation, in the education to speech of one hemisphere only. We speak, figuratively, of the light of the intelligence or consciousness. When our minds are awake, but in the condi- tion of easy repose, this light may be supposed to be softly diffused in all our faculties. But when our attention is strongly awakened, we become conscious of two things—an increased expenditure, and a concentration of our mental energies. Indeed, the concentration of thought upon one idea may be so marked that the individual may, for the time, become almost oblivious to other matters; and thus it is, no doubt, that so many eminent thinkers have appeared to the public to be " absent-minded." In close thinking, the light is no longer softly diffused; it is gathered or concentrated into a glow in every part of the mind and brain that is actively engaged. If, for example, the mind is engaged in receiving and interpreting impressions coming from without, the light, we may imagine, glows in the cortical receptive centres, as well as in those layers or regions of the cortex, wherever they may be, that are concerned with the higher function of interpreting the meaning of the messages received. Thus brightly illuminated on reaching the cortical centres, impressions from without are promptly received and interpreted. At the same time, they are registered within the gateway; becoming thereby images in the 1 The Function of the Brain, 2nd edition, p. 465. 2 See, for example, the record of the well-known " American Crow-Bar Case" (Bigelow, American Journal of the Med. Sciences, July 1850) ; also Velpeau's case of the loquacious barber, referred to by Bateman, Aphasia, 2nd edition, p. 28.248 THE DISORDERS OF SPEECH. local memory and possessions of the mind, which can be afterwards revived and made use of. They are fixed or burnt in at the first, as afterwards they can be revived and refreshed, by the light and heat of the Attention. Within each entrance gateway for incoming impressions, there are thus amassed, by this process of educative attention, myriads of sensory images of all kinds. Within each exit or motor gate- way, in like manner, there are amassed, by efforts of the attention, the motor memories of finely associated movements. That these various memories of reception and production are linked together into the groups which go to form our primary ideas of objects and of words, we have already seen. Now, clearly, such an exercise of concentrated attention is particularly necessary for the education of the sensory and motor centres concerned with the reception and production of speech. The sounds of speech that have to be distinguished and registered are particularly delicate and complex ; and so also are the muscular acts necessary for its production. If it is sufficient for the purposes of speech that these delicately complex memories of reception and production be impressed upon one side of the brain only, clearly it will be a great saving of nervous energy to train one hemisphere only, rather than to train both. This, in fact, is evidently the explanation of the apparent anomaly that the two symmetrical hemispheres should, in so far as this particular function is concerned, be so markedly asymmetrical in physiological capacity. It was the late Dr Moxon who first suggested such an explanation. In a short but remarkable paper,1 published in 1866, he discusses the operation of the attention in the education of the brain to speech, and to other forms of finely coordinated action. Taking piano-playing as one of his illustrations, he points out that it is comparatively easy for a beginner to play in unison on different octaves with the two hands. This seems to require only one attention for the two hands, that attention being directed to the motor centre for the right hand, which in all probability is made not only to innervate the muscles of the right hand, but also to guide the centre for the left hand. To train the centre in the one 1 British and Foreign Medico-Chirurgical Review, 1866, p. 481.SPEECH MEMORIES OR IMAGES, ETC. 249 hemisphere to play the treble, and that in the other to play the bass, is a much more difficult matter. The attention is then not concentrated upon one hemisphere only, it is divided between the two. He compares the tongue to two hands permanently united into one, and suggests that, like the two hands playing in unison, it performs the delicately associated movements of speech in obedience to the centre in one hemisphere only; acting under the guidance of memories of associated movements, which have been stored up within the centre during the process of its education. He says,—" We cannot, perhaps, conceive in what shape these ideas of associated movements persist, but it is quite certain that they do persist, and that in such perfection that, in ordinary speech, the word, or even the part of a sentence to which we are accus- tomed, comes to the tongue without the attention of the mind to the particular movements required, and often with an appreciably low degree of attention to the word or sentence, as when long strings of sentences are muttered unconsciously by one absent in mind. " Wherever and whatever the local seat of this connexion may be in the brain, it will be seen that if the seat of these ideas of associated movements be destroyed, then the person so injured will be thrown into the condition of a child who has learned to under- stand speech, but not speak it." Further light was thrown on this subject by Dr Broadbent, when, in 1872,1 he formulated his hypothesis regarding the cerebral representations of unilateral and bilateral movements. This hypo- thesis, in a somewhat modified form, is thus given by Gowers,2— " Some muscles of the body, such as the Intercostals and Masseters, are used only with their fellows of the opposite side; others are often used with their fellows, but often also alone, as the zygo- matic^ the trapezii, and the leg muscles; others are chiefly used alone, as the muscles of the hand. Movements are represented exclusively in the opposite hemisphere in proportion as they are unilateral, in both hemispheres in proportion as they are bilateral. In other words, either hemisphere can excite the bilateral move- ments, but only the opposite hemisphere can excite the unilateral 1 Med. Chir. Trans1872, vol. iv. 2 Diseases of the Nervous System, vol ii. p. 69. 2 i250 THE DISORDERS OF SPEECH. movements." As the movements of speech are bilateral, they can be excited from either hemisphere. Broadbent's hypothesis had not long to wait before it received ample confirmation, both from experiment and from clinical observa- tion. Ferrier, in the course of his experiments, observed that "some movements are bilaterally represented in each hemisphere, and are thrown into action conjointly by electrical stimulation of the cortex. This holds good especially of the oro-lingual and trunk movements." Barlow,1 in 1877, published his interesting and important case of cerebral lesion, first in the left third frontal convolution, and then in the corresponding convolution of the right side. The patient, a boy, was the subject of heart disease, and had first an attack of aphasia due to embolism in the artery supplying the left third frontal convolution. But he speedily regained the power of speech, by training the corresponding right third frontal convolution. At a subsequent period, a second embolism plugged the artery of supply of this convolution also, so that the patient again became aphasic; and this time the aphasia was permanent. But not only was there aphasia after the second embolism; there was also true paralysis of the tongue and lips on both sides, as in Glosso-Labio-Laryngeal Paralysis. So long as one of the centres remained sound, these organs were paralyzed only to a very slight extent upon one side, because they are bilaterally represented in the cortex; but their bilateral destruction necessarily resulted in a paralysis of the tongue and lips that was well marked on both sides. These facts, of great interest in themselves, thoroughly explain the apparent anomaly that, in the complex movements of speech, a store of images amassed on one side only of the brain should be capable of guiding the movements of the articulative muscles on both sides. That one side has alone been efficiently educated is proved, of course, by every case of aphasia. The best explanation of its being so is, I believe, that furnished by the suggestion of Dr Moxon, that in the training of the speech centres it is favourable to the operation of the educating attention, that it should, in the fulfilment of its delicate task, be concentrated upon one hemi- sphere, rather than divided between two. 1 British Medical Journal, 1877.SPEECH MEMORIES OR IMAGES, ETC. 251 The organs of sense that are connected with the reception of in- coming speech impressions, viz., those of hearing and of sight, are represented bilaterally in the cerebral cortex, just as are the muscular organs concerned in the production of speech. Thus, each ear, and each eye, is connected with both hemispheres; and each hemisphere is therefore connected with both eyes, and both ears. Destruction of the cortical centre for hearing or vision in one of the hemispheres, will, therefore, not make the patient deaf or blind in one ear or eye;1 and, on the other hand, total deafness or blindness on one side, from disease of the ear or eye, will not cut off either of the hemispheres from the reception of impressions coming from the remaining ear or eye. But, nevertheless, in regard to speech, the education of the auditory and visual centres is uni- lateral. In the auditory and visual centres of one hemisphere only are the sense-impressions of speech, audible and visible, carefully noted by the attention, registered, and amassed; and the hemi- sphere selected is always the same as that for the motor centres of oral articulation and of writing. It is the left hemisphere in right-handed people, the right in left-handed people. Dr Moxon seems to have been the first to suggest clearly the probable relations of the auditory and visual centres in the cerebral cortex to incoming speech and its memories or images. In the paper of 1866; from which I have just quoted, there occur the following sentences:—" The resolution of the power of language into incoming and outgoing language is a very striking fact, and its bearing upon the inquiry as to the site of the faculties of speaking and understanding the speech of others is, I think, very important, when we notice the significant circumstance that (in ordinary cases of hemiplegia of the right side with motor aphasia) the power of motor language disappears with power of motion, whilst the power of sensory language remains with the power of sensation. . . . Does not this indicate that the memory of movements, combined 1 To be more exact, it may be said—(1), that destruction of the cortical centre on one side often causes temporary deafness in the opposite ear, but this passes off as the impressions from the deaf ear are more and more easily conveyed to the cortical centre of the same side along pathways previously not much used ; and (2), that destruction of the cortical centre for vision on one side causes, not blindness of the opposite eye but blindness in the opposite half of the field of vision in both eyes (Homonymous Hemianopsia), and this is usually permanent.252 THE DISORDERS OF SPEECH. for words, lies in anatomical connexion with the centres which give motion to the tongue, etc., whilst the memories of sounds and sights, combined for words, lies in anatomical connexion with the centres of the nerves of the eye and ear ? or, in other words, that the situa- tion of the ideas of associated motions which form the faculties of speech is supra-motory, whilst the situation of the ideas of associated sensations, which form the faculty of word comprehen- sion, is supra-sensory." Considering the date at which these sentences were written, I think them very remarkable; they state so clearly the true rela- tionships of speech, not only to the motor centres, but also to the sensory or receptive centres. The very terms " supra-motory " and " supra-sensory" will recall to mind the terms " psycho-motor" and " psycho-sensory" at present used by some of the French authors. The terms seem to indicate that, in the author's opinion, the speech memories or images are registered, not outside of, but within the gateways of the consciousness. But Dr Moxon was not so fortunate as to verify his hypothesis regarding the relationships of the speech memories to the sensory centres, by the observation and record of actual cases. The great service to science of recording actual cases of sensory aphasia, and of pointing out clearly the distinctions between sensory and motor aphasia, was reserved for others, and more especially for Wernicke. If I were now writing a history of the literature of Aphasia, it would here be necessary for me to give an account of the great number of admirable papers on the subject that were issued during the ten or fifteen years following the publication, in 1861, of Broca's original cases. It would be necessary for me to describe, for example, the stores of accurately observed cases accumulated by Trousseau1 in France, and by Hughlings-Jackson2 in this country. But for detailed historical information I must refer the reader to Kussmaul's treatise, or to the learned and valuable work of Sir Frederic Bateman of Norwich.3 I shall here only, for the reader's convenience, make the briefest note of a few of the leading papers on the subject published in this country during the period referred to. 1 Glinique Medicate, chap. lxii. 2 Lond. Hosp. Clin. Lectures and Reports, 1864, p. 337. 3 On Aphasia, and the Localization of the Faculty of Language, 2nd ed., 1890.SPEECH MEMORIES OR IMAGES, ETC. 253 In 1864, soon after the appearance of the treatise by Dr Hughlings-Jackson above alluded to, Dr James Russell of Bir- mingham published a series of valuable papers on Aphasia in the British Medical Journal. In one of those papers (p. 239) he draws a clear distinction between a loss of speech due to a mechanical difficulty in articulation and a loss of speech due to loss of memory of words. [According to Spamer and Lichtheim,1 Dr Russell was the first to make this distinction; but it had already been made, many years previously, by Lordat,2 who clearly distin- guishes between "Amnesie verbale," loss of memory of words, and "Asynergie verbale ," loss of power of pronouncing words that are remembered; and who uses, moreover, the term "Paramntsie verbale" for that emission of wrong words which we now term Paraphasia.] In 1866, Dr Sanders recorded an important case of Aphasia in the Edinburgh Medical Journal. In commenting on the varieties of aphasia, he invented anew, for aphasia due to loss of memory of words, the adjective Amnesic, using this word in the same sense as Lordat had used it; and, for the condition that Lordat had termed Asynergie verbale, he invented the term Ataxic Aphasia. In the following year, 1867, Professor Gairdner read a paper on Aphasia to the Philosophical Society of Glasgow.3 In this thoughtful and instructive treatise, the author distinguishes between the Ideation and the Innervation of language, and records a number of interesting cases. In 1867, Dr Wm. Ogle published a paper on " Aphasia and Agraphia " in the St George's Hospital Reports, vol. ii., p. 83, in which, like the above-mentioned writers, he distinguishes between two forms of Aphasia, suggesting for them the adjectives "Amnemonic" and "Atactic." He is the first to propose the use of the term " Agraphia " for the loss of the power of writing that is often found associated with other forms of Aphasia. The paper includes the records of a number of valuable cases. In 1869, Dr Bastian published in the Medico-Chirurgical Review, vol. xliii., pp. 299 and 470, articles on " The Various Forms of Loss of Speech in Cerebral Disease;" in the course of which he clearly shows the possibility of Sensory Aphasia, his main thesis being that "Words are revived in the cerebral hemisphere as 1 Brain, 1884, p. 471. 2 Analyse de la Parole, 1843. 3 See Proceedings of the Glasgow Philosophical Society, 1865-1868, p. 87.254 THE DISORDERS OF SPEECH. remembered sounds." In 1872, Dr Broadbent published in the Medico-Ohirurgical Transactions, vol. lv., p. 144, a paper on the " Cerebral Mechanism of Speech and Thought/' in which he puts upon record one of the first published cases of what we now term "Word-Blindness," as well as a number of other valuable cases. "In this contribution," Dr Eoss remarks, "as well as in all his subsequent writings, Dr Broadbent sees clearly that the disorders of speech which had hitherto been described under the name of Amnesic Aphasia, are caused by lesion in the area of the posterior branches of the Sylvian artery, and that they result from injury of the sensory mechanism." 1 Thus, even from such a brief summary as the foregoing, it will be seen that, in this country, before the publication of Wernicke's paper, the various forms of Aphasia, sensory and motor, were already gradually being differentiated and recognised. And it would not be difficult to show that similar progress was being made in other countries. Further, we must not omit to note, that, at this period, a new era in Cerebral Physiology was begun by experiments in electrical stimu- lation upon the brains of living animals. The era opened with the ex- periments of Fritsch and Hitzig in 1870, and those of Ferrier in 1873. By this new method of observation, a precision was soon given to the science of Cerebral Physiology that it had never before possessed. Wernicke published his important treatise2 in 1874. In it he records several cases of " Sensory Aphasia " that presented the characteristic symptoms now known as Word-Deafness and Word- Blindness. He carefully describes the morbid appearances, and the locality of the lesion, as displayed in one of the cases upon which an autopsy had been made. More clearly and precisely than any previous writer, he describes the differences between Sensory and Motor Aphasia. He also describes the variety of aphasia that results from lesion of the white conducting fibres connecting the sensory with the motor speech-centre. He thus puts the subject of Sensory Aphasia upon a much firmer basis than it had hitherto occupied. Wernicke's name, therefore, will probably always be associated, in a special manner, with the elucidation of Sensory Aphasia. 1 Dr Robs On Aphasia, 1887, p. 114. 2 Der Aphasische Symptomencomplex, 1874.SPEECH MEMORIES OR IMAGES, ETC. 255 In 1877, Kussmaul published his great and comprehensive treatise on the " Disturbances of Speech."1 He adopted the conclu- sions of Wernicke as to Sensory Aphasia, and illustrated the subject by quoting records of additional cases. He also distinguished, more precisely than Wernicke had done, the two forms of sensory aphasia; inventing the term " Word-Blindness" for the form in which the patient, though not blind, is unable to read visible words, and the term "Word-Deafness" for the form in which the patient, though not deaf, can no longer understand words that are spoken to him. Thus four primary or elementary forms of aphasia came to be generally recognised—two motor forms, and two sensory;—each of the four being due to disablement of a particular centre in the cortex,—a disablement involving an obliteration, complete or partial, of the store of memories or images that have been therein stored. The two Motor forms are—(1), Aphemia (Motor Aphasia), implying the obliteration of the motor memories of oral speech; and (2), Agraphia, implying the obliteration of the motor memories of written speech. The two Sensory varieties are Word-Deafness and Word-Blindness, which imply the obliteration of sensory speech-memories, auditory and visual respectively. The cortical centres involved in all four varieties are situated in the cortex of only one, and the same, hemisphere of the brain. What modifica- tion of this classification, and what additions to it, have been suggested by recent observations, we shall have to consider in future papers. The Nature of the Sounds that constitute Speech; and the Grades of Coordination employed in their production. In the first chapter of this book I tried to illustrate, in a simple way, the composite nature of speech-sounds, by likening the two mechanisms that produce them to the two hands of a violinist: the Yocal Mechanism being compared to the bow-hand, and the Oral Articulative Mechanism to the string-hand. That comparison, however, may now be discarded, since, for our present purposes, it will be more convenient for us to look at the speech mechanisms as they are actually constructed. 1 Ziemssen's Gycl. of Praet. Med., Amer. edition, vol. xiv.256 THE DISORDERS OF SPEECH. All we have to do in this respect is to realize that the executive organs of the two mechanisms are placed at the upper end of the air-passage, and that one is above the other,—that of the oral articulative mechanism being above, and that of the vocal mechanism below. We should also make note of the fact that below the larynx there is a third mechanism, the Respiratory, which furnishes, by expiratory effort, the blast of air without which 110 speech-sounds could be produced, either at the larynx or in the oral cavity. Thus three mechanisms co-operate in pro- ducing the sounds of speech. But, as the sounds are produced at the two first,—the third only supplying the necessary air,—we may pass over the third very shortly. We need only note about it: (1), That the expiratory pressure of air is furnished continuously for each clause or sentence; (2), that it is made to vary in strength according to the requirements of emphasis and emotional expres- sion; and (3), that as yet the cortical centre in the brain from which the expiratory effort for speech is innervated has not been definitely localized. Confining our attention, then, to the Laryngeal and the Oral Articulative Mechanisms, we find that each mechanism is capable of being called into action quite independently of the other; although for the purposes of speech the two must be employed together. Thus, with the Larynx, we can hum a tune without words, the oral articulative mechanism being meanwhile quite passive; and, with the Oral Articulative Mechanism, we can cause the tongue, lips, etc., to go through all the movements necessary for the articulation of a sentence, without producing any audible speech, —if, meanwhile, the glottis is kept either widely open, so that passing air will produce no laryngeal sound, or firmly closed (as in straining), so that air will not be allowed to pass at all. These points have been discussed at some length in the second chapter. As each of the mechanisms, Yocal and Oral Articulative, is thus so capable of displaying activities of its own independently of the other, it is not surprising to find, from the latest experimental researches upon animals, that each mechanism has probably its own separate sub-centre in the brain; and that the two cortical sub-centres, though they may lie in juxtaposition, and overlap each other at their margins, are yet probably distinct, as the corresponding centres are in animals. IfTHE NATURE OF THE SOUNDS THAT CONSTITUTE SPEECH. 257 they are so, electrical stimulation of the one sub-centre would, as in animals, cause adduction of the vocal cords, and the same stimulation applied to the other would cause movements of the lips and tongue; the movements in both cases being bilateral, though the stimulus be applied only upon one side of the brain. The accomplishment of articulate speech is acquired by educating the two sub-centres to act together, in perfect coordination with one another. By what nervous arrangements, in the minute structure of the cortex, the two sub-centres are thus brought to act in coordination, we are as yet, I take it, in almost complete ignorance. But if we analyze the sounds, and see in what manner they are combined to form words, the study of the sounds will help us to understand the action of the cortical centres. Fortu- nately this analysis was made for us, to a great extent, thousands of years ago, by the inventors of the Ordinary Alphabet. In con- structing a Physiological Alphabet, we merely try to give a repre- sentation of the sounds that is truer to Nature than that of the ordinary alphabet; removing the corruptions that have crept into the latter in the course of long use, and correcting the mistakes that seem originally to have been made in the framing of it. Turning, then, again for a moment to the Physiological Alphabet, I think we may say that the sounds represented by its letter-symbols constitute the Sound- Units of speech; and that all our speech is constructed by the arrangement of these sound-units into the Sequences that we call syllables, words, and phrases. The phonograph, faithfully reproducing speech, is able to do so because words previously spoken into it have made on its revolving cylinder impressions of the vibrations of their units or letter- sounds. The phonograph reproduces these vibrations, sounding- unit after unit, and marking the breaks in continuity that occur between syllables, words, and sentences. When a word is spoken, the units composing it are not struck off all at once, like a chord of music on the piano; they are played off in sequence, like a musical phrase, note after note. But the unit, or letter-sound, is a composite thing, requiring, in the case of the vowels, and also in that of the greater number of the consonants, the simultaneous action of both mechanisms; and 2 K258 THE DISORDERS OF SPEECH. involving in each mechanism the coordinate action of many muscles. There is thus not only coordination of the one mechanism with the other, but also coordination of the several muscular move- ments in each mechanism with one another. Further, in speech, over and above the two forms of coordination thus exhibited in the formation of the sound-units, there is a third form, exhibited in the arrangement of the units into words and phrases. This we may call, if the phrase is allowable, the Coordination of Sequence. These distinctions have, I think, hitherto been too much neglected. In order that the reader may see their real importance, let me here pause for a moment, to recall to his mind the leading speech- disorders that have already been considered, and to see how they are each related to the two Mechanisms and the three Forms of Coordination. In brief, then, it may be repeated— 1. That Stammering is due to a fault in the coordination of the one mechanism with the other. 2. That in Hysterical Aphonia there is functional paresis of the vocal mechanism only. 3. That in Hysterical Mutism there is functional paralysis,—in most cases, of the vocal mechanism only; in some, probably, of the oral articulative mechanism only ; and in a few, probably, of both mechanisms. 4. That in Lalling we have—(a.) In bad cases, a " baby speech," in which all three forms of coordination are so defective, from want of education, that words are truncated, scamped, and slurred, so as to be almost or altogether unintelligible; (6.) In slight cases, a lingering defect (from imperfect education) in the internal co- ordination of the oral articulative mechanism, which displays itself in the imperfect pronunciation of certain difficult letter-sounds, such as r or 1, or k or g. 5. That in Slurring we have an impairment or degeneration in the internal coordination of the oral articulative mechanism, which results in the slovenly articulation of the more difficult of the single letter-sounds, and of their combinations; so that, in some respects, articulation shows a retrogression towards the lalling articulation of children. 6. That in the Syllable-Stumbling of general paralysis we have not only a stumbling repetition of syllables, but also a distinctTHE NATURE OF THE SOUNDS THAT CONSTITUTE SPEECH. 259 disorder in the Coordination of Sequence, displaying itself in the occasional placing of units, and even of whole syllables, in wrong places. The two coordinations involved in the production of the units or letter-sounds, and the one concerned with their arrangement— which last I have called the "coordination of sequence,"—are alike rendered possible by the formation of sensory and motor memories, imprinted within the centres in the process of their education. It is these memories of " associated sounds and move- ments " that go to form the word-images or pictures of which so much has already been said. Now, aphasia consists in the obliteration of these memories. Sometimes the obliteration is complete, sometimes only partial. In the slighter cases, only words of certain particular kinds are forgotten, such as proper names, and the names of particular objects. Other words are remembered, and may be pronounced with perfect articulation. Therefore, in these slighter cases, it is only the coordination of sequence that is materially affected. Certain particular sequences or words, not very deeply imprinted, have been wiped out from the memory of the enfeebled centre. In many severe cases, on the other hand, there is complete obliteration of all word-pictures (memories of sequence); and, along with this, there may be an obliteration, equally complete, of the memories of how to produce the units or letter-sounds. In such severe cases, the patient is not only unable to articulate the simplest words, such as Pajpa or Mama, when asked to do so; he is even unable to pronounce properly the letter-sounds of single vowels or consonants. The memories of the Units have, in such cases, been wiped out, along with the memories of their Sequences. It is wonderful to think what a wealth of memories of the sequences of these sound-units must be stored up in the speech- centres of every educated man ; or, to put it in another way, what a wealth of words and phrases lie latent in his speech-centres, ready to be revived upon occasions calling for them. His thoughts clothe themselves in these words and phrases; and the wardrobe is so well furnished that the same thought finds in it a choice of garments, and is enabled to select that which appears to be most appropriate for the expression, not only of the intellectual meaning,260 THE DISORDERS OF SPEECH. but also of the emotional colour or feeling that is associated with it. The very tones of the voice are also, as we have seen, made to contribute their quota to the expressiveness of spoken language. Professor Bain has remarked upon the adhesiveness of thoughts and of words, in virtue of which they link themselves to each other, thought to thought, and word to word, in chains or trains. The property is exhibited, not only by words, but also by the sound- units of which words are composed. It is exhibited even more strongly in the linking together of the units to form syllables and words, than in the linking of words into familiar phrases. It is the " Coordination of Sequence." How securely it can link word to w7ord, we may realize when we repeat from memory a verse of poetry that has been long familiar to us. Perhaps it is owing to this adhesiveness of words, that he who is a perfect master of several languages does not, in conversation, mix up the words of one language with those of another. Some time ago I had the pleasure of conversing with a physician of note, who, born in Scotland, has lived in France since early boyhood, and now practises there. He is equally master of French and English. I asked him which of the two languages he preferred to think in. He told me he sometimes thought in the one and sometimes in the other; he had no preference, and usually found himself thinking in the language of the last person he had been conversing with. I asked him if he ever, in thought or in speech, mixed up the two languages, more or less. He said, Never; they always kept them- selves distinct from each other in his mind. Here let me add, in concluding this part of the subject, that although, for simplicity's sake, I have, in treating of the grades of coordination in the formation of letters, words, and phrases, made reference specially to the Motor Speech-centre, it must, not be forgotten that the very same grades must be represented, in like manner, in the Auditory Speech-centre. Each motor image has its equivalent sensory image; and, as we have seen, the two that form the Primary Couple are welded together in the consciousness into one, so as to form what we have called the primary Word-Percept. In constitution they must of necessity be closely equivalent to each other.depth of imprintation of speech-memories. 261 Depth of Imprintation of Speech-Memories in the Speech-Centres ; Overflow of Speech-Education into the corresponding Convolutions of the opposite Hemisphere ; Recurring Utterances. Depth of Imprintation.—It is a remarkable fact that the various classes of words are not all imprinted, if we may so express it, in the memories of the speech-centres, with equal depth and permanency. Thus, notoriously, Nouns form the class of words whose memories are the least firmly established, and therefore the most easily obliterated. Further, it is known that the memory of a noun will be lost more easily in proportion as the idea represented by it is special or concrete in character. Proper names being, above all other nouns, representative of special individuality, are the most easily obliterated of all; but names of other concrete things, such as a watch, a chain, or a handkerchiefs are also easily obliterated. Abstract nouns and general terms, on the other hand, such as time, thing, day, night, are retained comparatively well. In aphasia, Nouns of this latter class are lost to any extent only in cases in which the names of concrete things are lost still more. In such cases, the less common varieties of verb and of the other parts of speech have also generally suffered more or less; so that speech is fragmentary, and requires to be eked out by pantomime. In very severe aphasia, speech may be altogether lost. But even in severe cases a few words in very common use may be retained, such as yes and no ; and these the patient may continue to use quite intelligently. Now, what is the law underlying this difference in the perish- ableness of words and phrases ? Words and phrases are sequences of sound-units. The memories of the most deeply imprinted will naturally be least easily obliterated. Passing over, for the present, conditions of Brain that are favourable for depth of impression, such as Youth and Intelligence, and looking only to Language, we may reasonably suppose that when speech-memories are being acquired by the centres, the two things most favourable to depth and permanency of impression will be Emphasis in the use of the word, and Frequent Repetition of it in speech. Looking at the nouns, which are known to be the parts of speech most easily obliterated, we find that, as everything, and every class of things, has its name, nouns are almost infinitely numerous; and yet, if we262 THE DISORDERS OF SPEECH. examine a few sentences of written or spoken speech, we find that only the abstract nouns and the general terms occur individually with any considerable frequency in ordinary speech, and that the specific names of concrete things do so only at long intervals. Nouns of this latter class, therefore, being seldom repeated, cari make no very deep impression on the speech-centres. On the other hand, if we look at adjectives, prepositions, verbs, etc., we find that while they are comparatively few in number, they are individually more frequently used, being often repeated. Some of them also, such as adjectives and adverbs, are often used with considerable emphasis. They therefore fulfil the two conditions favourable to depth of imprintation, and are not easily obliterated. Still more distinctly are the two conditions fulfilled by the words yes and no, which are often retained when all else is lost. If, again, we consider how abundantly the speech of many individuals is garnished with " strong language," we need not be surprised to find that, when such an individual becomes aphasic, an old familiar oath may suddenly be emitted under the strong stimulus of emotion. It had previously been deeply engraved, both by frequency of repetition and by emphasis of expression. The opinion has often been expressed that the names of concrete things are easily forgotten because we can think of such things so clearly without recalling their names. But this, of course, is only another way of saying that we do not always mentally repeat the names of such objects when we think of them. The necessary frequency of repetition is clearly, therefore, in this case, the factor that is wanting for depth of imprintation. There are, however, rare cases in which verbs are lost more than nouns; and of this special loss of verbs no adequate explanation has yet been given. Kussmaul (p. 795) gives a note of such a case. Here, translated, is what the patient, a man who was " suffering from aphasia and paraphasia," remarked, when his eyes were being examined; the missing verbs and other words which he failed to recall being given in italics:—" I cannot see at all. Formerly I could ready especially large print; but, naturally with advancing years, I was obliged to read small print through spectacles." OVERFLOW OF EDUCATION INTO THE OPPOSITE HEMISPHERE.—In some cases, words such as yes and no, and, occasionally, underOVERFLOW OF EDUCATION INTO THE OPPOSITE HEMISPHERE. 263 excitement, oaths or other conventional expressions, may be emitted even when it is quite certain that the educated motor centre for articulate speech has been totally destroyed, and is there- fore wholly incapable of retaining the memories of even the most deeply imprinted words. These cases clearly show that, in the process of educating the Broca's convolution to the production of articulate speech, there must, at least in a great number of individuals, be a slight Overflow1 of Education into the corre- sponding convolution of the opposite hemisphere. This latter convolution evidently receives what may be called the crumbs of education that fall from the table of the Broca's convolution. When the Broca's convolution is totally destroyed, these crumbs, acquired by the corresponding convolution of the opposite hemi- sphere, are all that remain of the motor memories of articulate speech, however great may have been the stock of these accumu- lated in the Broca's convolution. It was Hughlings-Jackson who first directed attention to the little store of words thus often retained in the uneducated centre'of the opposite side, when the educated centre has been destroyed. He holds the opinion that the uneducated centre is in a special way related to conventional, emotional, and other forms of what he aptly terms " degraded " speech,—using this term in contrast to intellectual speech, in which each word retains its proper meaning. But, though it is generally admitted that conventional and emotional expressions may be emitted by the uneducated centre after the educated has been destroyed, I do not think it is generally believed that these expressions have been originally relegated to the uneducated 1 The term "overflow," though convenient, is no doubt somewhat figurative, like the term " imprintation " already used. Of course neither term must be taken too literally. In our present state of knowledge, however, it will be found very difficult to treat of either the one phenomenon or the other, without using language that is more or less figurative. If we wished to describe what is here called " Overflow of Education" in terms that are not figurative, it would probably be correct to say that when, in process of education, strong impressions are being made upon the Broca's convolution, feeble impressions are at the same time being made upon the convolution of the opposite side; and that when these feeble impressions have been repeated a very great number of times, they leave, at last, a distinct memory or image in the uneducated centre. This law would, of course, apply to the auditory as well as to the motor centre.264 the disorders of speech. centre. The more common opinion certainly favours the explana- tion that these forms of expression have been imprinted in the educated centre more deeply than any others; and that from the very superabundance of their representation, there has been " over- flow" into the centre of the opposite side. In other words, the law which determines the occurrence of overflow of educa- tion into the opposite hemisphere seems to be the same that determines the deptli of imprintation on the educated side; the two factors that are important for both being Frequency of Repeti- tion and Emphasis of Expression. A certain slight overflow of education into the opposite hemi- sphere being thus observable in many cases in connexion with the motor centre for oral articulate speech, it should be here noted that the same phenomenon is also exhibited in connexion with the receptive or auditory centre for incoming speech. In some cases, when this latter centre is totally destroyed on the educated side, none of the words, though heard as sounds, can be interpreted as words. In many cases, however, a certain proportion of words can still be interpreted, probably because of the previous overflow of education into the opposite hemisphere; and the proportion of these seems, on the whole, to be greater than that of the words capable of being produced, in motor aphasia, by the uneducated motor centre. It is not surprising that it should be so, seeing that the education of the auditory centre begins before that of the others, and, throughout, retains the lead. This possibility of overflow of education into the opposite hemi- sphere, and the varying degree in which it may occur in different individuals, is a confusing element in the study of aphasia. So is also the possible progress of Further Education in what I have termed the uneducated centre, after disease has destroyed the educated one. In young people, this Further Education may speedily bring about an entire restoration of speech; but when aphasia has occurred after completion of bodily growth and development, this education of the uneducated side is usually very difficult, and is often impossible. Recurring Utterances.—We have been discussing the fact that, even in cases in which the educated motor centre has been entirely destroyed, the patient, in virtue of overflow of education into theRECURRING UTTERANCES. 265 opposite hemisphere, may yet be able appropriately to use certain words such as yes or no, or to emit, upon occasion, certain emotional or conventional expressions. These all have more or less meaning. It must now be noted that, in like circumstances, a patient may emit from the uneducated centre, whenever he tries to speak, a word or phrase without meaning. Whatever he may wish to say, it may be always the same syllable, word, or phrase that he emits. These words and phrases are therefore termed Recurring Utterances. It may be well here shortly to discuss their nature. Nothing is more common in cases of severe motor aphasia than to find that the patient can utter nothing but a certain recurring syllable, word, or phrase. One of Broca's very first cases exhibited the phenomenon typically. In reply to all questions, he said tan, tany tan; and, in all ordinary circumstances, the same syllable was repeated if he tried spontaneously to make a remark. Only when he was irritated did he startle his hearers by pronouncing, with perfect articulation, the common French oath, " Sacr^ nom," etc. Trousseau, Hughlings-Jackson, Gairdner, and many others have reported cases showing many varieties of recurring utterances. In one case the word " cousisi" is always emitted; in another, the word " nurse ;" in another the word " yes " is articulated, not with its usual meaning, but as a recurring utterance without any* meaning. In other cases, again, a whole phrase is included in the recurring utterance: as in Dr Russell's case of the manufacturer, seized with aphasia when making an inventory of his goods, who replied " list complete " to every question ; and in another case of a patient, seized with aphasia when in danger, whose recurring utterance was always " I want protection." The question regarding the causes which determine the nature of any recurring utterance is one that has excited much interest. Dr Hughlings-Jackson suggests that, in many cases, the recurring utterance is an expression that has either been emitted, or been at the point of emission, at the moment of seizure, and that has, therefore, in all probability been deeply imprinted by the stimulus of emotion; and many recorded cases clearly indicate that this may be the cause determining the nature of the utterance. But it is not suggested that this is invariably the determining- cause. In some cases, the effort to speak seems to result, by accident as it were, in the production of some meaningless syllable; and 2 L266 THE DISORDERS OF SPEECH. this syllable, once produced, recurs on all subsequent occasions when the patient tries to speak. In others, the attention of friends to the training of the patient results in his being able to pronounce some single word, such as " nurseand this afterwards becomes the recurring utterance. The uneducated speech-centre thus learns a word, or phrase, in one way or another, and, having learned, discharges it, and it alone, whenever the effort to speak is made. As Prof. Gairdner says, it is like a barrel-organ that plays always the same tune when the handle is turned. Just as the aphasic patient may thus, in trying to speak, show that he is possessed, as it were, by a single word, so, in trying to write, he may become possessed, or, to use Prof. Gairdner's expres- sion, " intoxicated," by a single letter. He often is able to write the first and second letters of his name, but, instead of coming to the third, he may repeat the second again and again, as if he could not get the image of it to retire, when it is no longer wanted. In other cases, he may repeat, again and again, some special letter of the name, such as m or n. It is a large and curious question, this, about the non-retire- ment of word-images when they are no longer wanted. The wonder is that, in normal conditions, the images are so easily called up, and that they so promptly retire after being used, when they are no longer wanted. And yet they must not retire too soon. We should not be able to grasp the meaning of a sentence, or even of a long word, if we could not retain it in the memory as a whole, after its completion. There is a curious form of aphasia, described by G-rashey, in which the chief phenomenon seems to be the too quick retirement of images from the consciousness. We shall have to consider it by-and-by, in connexion with Aphasia due to Functional Causes. That word-images sometimes fail to retire, and give trouble by continuing to obtrude themselves upon the mind when they are not wanted—in the form of " possessions," hallucina- tions, or impulsions—we have already seen, in connexion with the study of speech in its relations to Insanity. Something of an analogous failure to retire is, I think, exhibited in these two phenomena of aphasia, the Eecurring Utterances in speaking and the Recurring Letters in writing. It is exhibited also, in a very interesting manner, by many aphasic patients who are gradually recovering the power of speech. "What is this gentleman'samnesia verbalis and paraphasia. 267 name?" I said to such a patient recently. "Dr Anderson," she replied. " And what is your own name V' "Mary Anderson" she said; though she had, a short time previously, given her own name correctly. Amnesia Verbalis and Paraphasia. Articulative Amnesia, and Articidative Ataxia. Amnesia Yerbalis.—As I have already said a good deal about this Amnesia, or forgetfulness of words, and about the law which seems to determine the varying degrees in which different classes of words may be forgotten, it will not be necessary, in this general sketch of leading phenomena, to discuss the subject much further. But I should like to define, as distinctly as I can, the sense in which I mean to use the term Amnesia Yerbalis. By different writers, it has been used with a varying width of signification. I mean to use it solely in connexion with thq productive processes of thought and speech, as signifying a failure to call up in the mind the appropriate word-images for ideas that are seeking embodiment in words, whether for purposes of silent thought or for those of audible speech. For failure in the Interpretation of words that are still heard as sounds, we have the convenient term Word- Deafness. But, for failure to call up words in the memory when they are wanted for purposes of production, we have no term but this of Amnesia Yerbalis. T think that we should reserve the term strictly for this failure in the power of calling up words from within, and let the term Word-Deafness stand as the equivalent term for failure in reception and interpretation. In connexion with Written language, it may be found con- venient, in like manner, to use the term Amnesia Literarum as indicative of a failure (on the productive side) to call up the images of letters and words in the mind when the effort to write is being made; in contrast to Word-Blindness, which implies a failure on the side of reception and interpretation. Without entering into any detail as to the causation of Amnesia Verbalis, we may, I think, here make note of two different con- ditions which may each produce it:— (1.) It is met with in conditions of General Enfeeblement of the Brain, such as may be associated with the debility of severe268 the disorders of speech- fever, or be produced by the pressure of effusion on the brain as a whole. In such conditions, the mind as a whole is enfeebled, and its faculty of language shares in the enfeeblement. In the debility of severe fever, forgetfulness of names and other nouns is common; and cases have been recorded in which foreign languages that the patient had been master of have, for the time, been quite forgotten, though the native language, more deeply imprinted, has been retained. (2.) Local disease in the Speech Centres. That such disease should produce Amnesia Yerbalis, when both the auditory and the motor centre are involved, is easily intelligible; but why should this Amnesia be so well marked in most of the cases in which only one of the primary centres has been destroyed ? Why should the mind not be able to call up with ease the images of the other centre ? I think we can explain this only on the hypothesis that in health the two word-images are habitually revived together as a " Word-Percept." When one of them is destroyed, the word- percept is mutilated and incomplete, and cannot be so easily revived. It is notorious that amnesia of nouns, etc., results when the Auditory word-centre is destroyed. In such cases, as the patient retains the power of articulation (the motor centre being intact), his speech demonstrates the amnesia of nouns, etc., in the most striking way. But when it is the Motor centre that is destroyed, and articula- tion is therefore impossible, Amnesia is not so plainly exhibited. In such cases, Amnesia certainly does not exist if the patient still retains the power of expressing his thoughts in writing; but his loss of the power of writing does not enable us to say with certainty that the patient has Amnesia, and is unable to call up words in his mind. In such cases, some observers, such as Lichtheim, show the patient a common object, and ask him to indicate with his fingers how many syllables its name contains. There can be little doubt that, in most cases at least, destruction of the motor centre, like destruction of the auditory centre, causes serious Amnesia Yerbalis. Paraphasia..—When an aphasic patient, in speaking, uses words which he did not intend to use, and which do not express theparaphasia. 269 thought that is seeking expression, he is said to display the phenomenon of Paraphasia. In some cases, no sooner is the wrong word uttered than the patient recognises his error, and strives to correct it; but in other cases, owing to Word-Deafness, he does not recognise the error, and may go on talking freely, in the full belief that he is expressing himself intelligently, even although the speech produced is mere "gibberish"—as it may be, in rare cases, when the phenomenon is extremely well marked. It is in the Aphasia produced by lesion of the Auditory Word-centre that Paraphasia is most marked. The retention of the power of articulation, in such cases, makes the recognition of Paraphasia very easy. Some think that Paraphasia never occurs except in these cases of Sensory Aphasia. But this is probably a mistake. Paraphasia is essentially one of the possible consequences of Amnesia Verbalis; and, as such Amnesia probably exists in Motor as well as in Sensory Aphasia, we need not be surprised to find a slight degree of Paraphasia exhibiting itself in connexion with Motor Aphasia, when, by education of the opposite convolution, the patient is in process of recovering his powers of articulation, and can speak well enough to exhibit it. Nevertheless, it is true that a marked degree of Paraphasia is especially characteristic of the Sensory, or Auditory variety of Aphasia. Like Simple Amnesia Verbalis, Paraphasia is exhibited most frequently in connexion with nouns, of which one is substituted for another; but, in marked cases, the other parts of speech suffer in the same way. Articulative Amnesia.—Instead of a total forgetfulness of a word, such as a noun, the patient may exhibit only a partial forgetfulness of it. He has a general idea of the word, but fails to remember it in detail. In such circumstances, he pronounces a sound that may or may not be sufficiently like the word aimed at to enable the listener to guess what that word really is. I propose to use the term Articulative Amnesia for this forgetfulness of the details of articulation. It will sometimes be found associated with other symptoms, such as marked paraphasia, which point to the existence of lesions in the auditory centre. This is only an illustration of the fact, that words are represented in all their details in the sensory as well as the motor speech- centre.270 the disorders of speech. Articulative Ataxia (Asynergies Verbalis).—Here, owing to disease in the Motor centre, or in the white substance of the brain immediately subjacent to it, the power of articulation is destroyed, even if the patient is able to call up the auditory image of the word in his mind. It is not always possible to distinguish between an Articulative Amnesia and an Articulative Ataxy. But in general the faults of articulation in lesions of the motor centre are so strikingly characteristic that there can be no difficulty in diagnosing Articulative Ataxia. Lesions in this locality generally make the patient practically speechless. He can articulate scarcely anything; failing even to repeat simple words that he is asked to repeat. The educated centre being destroyed, he is thrown upon the scanty resources of the uneducated centre of the opposite side. Often, as we have seen, he can emit only some Recurring Utterance, or some very common words, such as " Yes " or " No." It is generally when he is recovering the power of speech, by the Further Education of the previously uneducated centre, that he displays more varied faults in articulation. Gradually acquiring an increasing vocabulary, he continues for a long time to display, in a degree that differs greatly in different cases, the Articulative faults of Slurring, Lalling, Syllable-Stumbling, some- times a little Stammering, and often an utterance that is slow and laborious. It is in these same circumstances also, as we have seen, that a case of Motor Aphasia may clearly show Amnesia Yerbalis, and even a slight degree of Paraphasia. Mental Impairment. Echolalia. Mental Impairment.—It is doubtful whether it would be correct to say of any patient affected with Aphasia that his intellect remains altogether unimpaired. Probably there is more or less mental im- pairment in every case. Usually it is less distinct in purely motor aphasia than in sensory aphasia. A patient with purely motor aphasia is often capable of managing his business affairs. He expresses him- self by signs if he cannot either speak or write. He may be able to engage with success in games of skill; and in all respects he may show himself to be intelligent and clear-headed. Yet, to those who knew him previously, there is generally observable a distinct diminution of mental power, or of self-control; and the patientMENTAL IMPAIRMENT. 271 himself is apt to complain that he experiences fatigue, and head- ache, and irritability, if he applies himself to mental work requiring prolonged and close attention. In a large proportion of cases, the loss of mental power and of self-control is obvious. Very often the patient is unable to take any part in managing business affairs, dementia being quite pro- nounced.1 As is so often the case in organic disease of the brain, the patient may be also very emotional and easily moved to tears. In some cases, delusions and hallucinations are developed, so that the patient becomes really Insane. I think there can be no doubt that Dr Bastian is right when he says that destruction of the Sensory speech-centres is much more dangerous to the mind than destruction of the Motor ones. Delusions, and Hallucinations, and Hebetude of mind are certainly more commonly met with in cases of Sensory than of Motor Aphasia. Bastian provisionally formulates the following as a working hypothesis:—" That the tendency to mental impairment with aphasia, and the degree of such impairment, will, other things being equal, increase as lesions of the left Hemisphere which produce aphasia recede in site from the third frontal convolution, and approach the occipital lobe." It seems very probable that growing experience will soon convert this " working hypothesis " into an established law. Echolalia.—We have seen, in connexion with our study of the Speech of the Insane, that Echolalia is pretty often exhibited by patients who are the subjects of Dementia. As Dementia is not uncommon in connexion with Aphasia, the Echolalia which, in rare cases, is exhibited by patients with right-sided Hemiplegia and more or less Aphasic disturbance of speech, should perhaps be attributed rather to the Dementia than to the Aphasia. But there are some very curious and rare cases of Aphasia without Dementia in which the patient can repeat what he hears, and perhaps copy writing that he sees, and yet be totally unable to understand the words he thus repeats or copies. This is a true Echolalia. The consideration of this phenomenon will probably be resumed in a future chapter. At present, I mention the phenomenon only to show 1 For a discussion of the Medico-Legal relations of Aphasia, see Bateman, On Aphasia, chap. x. See also Bernard, Be I'Aphasie, chap. x.272 the disorders of speech. that in testing the speech of an aphasic patient we must not be content with merely testing the Reception and the Production of speech, spoken and written, but must also ascertain how the patient Repeats or Echoes. Can he repeat words spoken to him ; can he write to dictation ; and can he copy from a printed or written page ? Other forms of Loss of the Memories of Signs (Asemia) that are related to Aphasia and sometimes found associated vnth it. Mind-Blind- ness. Expression of Emotion. The Musical Facidty. Loss of other Graphic Symbols.—With the destruction of word-images, in Aphasia, there is often associated destruction of the memories of other symbols, which are allied to those of speech. Thus a Word-blind patient is often also Figure-blind, so that he may fail to'recognise the ordinary Numerals when he sees them. Equally unintelligible to him may also be Algebraic signs, and the signs used for Musical Notation; although, previously, these may have been very familiar to him. There are, however, cases in which the understanding of some of these other symbols may be retained, though speech symbols be lost. Thus patients are often able to read figures though they cannot read words. They are able, for example, to read the figure 3, though they cannot read the word Three. In explanation of this, it has been suggested that figures are more nearly allied to pictures than to words, and sug- gest the number to the mind as a picture suggests an object. Perhaps when figures are much used both hemispheres may acquire the images of them. Amimia and Paramimia.—When intelligence is retained though speech is lost, the patient can in most cases express his thoughts in pantomime (gesture language). He nods his head for " Yes," and shakes it for " No," and indicates numbers with the fingers of the hand that is not paralysed. He also, like an uneducated deaf-mute, imitates actions, and " makes pictures in the air." But some cases of Aphasia show impairment of this gesture language ; and there may be impairment also of the power of understanding the gesture language of others. In rare cases, again, the patient has been found to use pantomimic signs wrongly, nodding his head,amimia and paramimia. 273 for example, instead of shaking it, when he meant to say " No." Amimia is the term used for the loss of gesture language, and Paramimia that for mistakes in its use. That a one-sided lesion of the Brain should in some cases cause Amimia and Paramimia seems to show that in some brains, at least, the education in these signs, as in those of speech, is, at least to a considerable extent, unilateral. Mind-Blindness (,Seelenblindheit, cecite psychique).—It would be better perhaps to term this condition " Object-blindness" than " mind-blindness/' though even that term might be liable to mis- interpretation. What is meant by the term " Mind-blindness " is that though a formerly familiar object is clearly seen by the patient, it is no longer recognised. Familiar friends are no longer recognised at sight, and familiar objects seem strange at sight, so that their natural uses may be mistaken. Like some of the other phenomena which in this chapter I have been briefly summarizing, this condi- tion will require to be noticed in a future chapter. I shall at present only state that this Object-Blindness or Mind-Blindness is sometimes found associated with word-blindness, and, like it, seems to depend upon the obliteration of formerly acquired visual images or memories. In at least one of the recorded cases of it, disease was found in both sides of the brain; and it seems reasonable to suppose that the images or memories of objects must, in most, if not in all brains, be imprinted equally well in both hemispheres. Eetention of the Power of Emotional Expression.—In Aphasic patients, even when Pantomime is impaired, the power of facial Expression of Emotion may remain intact; so that gladness and sorrow are as vividly depicted on the countenance of the patient as on that of a healthy person,—provided always, of course, that the intelligence is not very seriously impaired. Thus when, as is so often the case, there is loss of self-control, the sudden fits of depression of spirits to which the patient is so liable find expression in tears, and flushings, and facial movements, as vividly as similar emotions in children. Evidently Emotion and its expression are functions that belong to both hemispheres of the Brain. The Musical Faculty.—There are on record many cases of 2 m274 THE DISORDERS OF SPEECH. Aphasia in which the patient, though speechless, was yet musical, and able to hum correctly tunes without words. In one very curious case, an aphasic patient, though unable to speak, could yet sing songs with the words correctly,—perhaps by aid of the " un- educated Speech-centres" of the opposite hemisphere. Most of these cases, no doubt, have been cases of motor aphasia. It is still a question for investigation how far the musical faculty is destroyed or diminished by destructive lesion of the left auditory centre. One is disposed to think that music must belong to both hemi- spheres of the brain, at least in so far as it is a natural gift and not merely an acquired art. But in one recorded case, to which I may afterwards have occasion to refer, word-deafness seemed to be associated with a loss of the power of appreciating music. This subject, and many of the others to which I have been briefly referring, are really subjects for future investigation. As yet they have received too little attention. Having already made a note of some of the earlier contributions to the literature of Aphasia, I may here, in concluding this chapter, supplement the list by adding a note of a few of the more im- portant contributions of a later date. I have already referred to, and frequently quoted from, Kuss- maul's treatise on the Disturbances of Speech, It continues to be perhaps the richest mine we have of information upon the subject generally. Bateman's valuable work I have also referred to. A second edition of it was published in 1890. Two other treatises of great value are—(1), That of Bernard, De VAphasie (1st ed. 1885, 2nd ed. 1889), which incorporates the teaching of Professor Charcot; and (2), that of Dr Eoss of Manchester, On Aphasia, 1887. Many important contributions to the subject have also been made in the shape of chapters upon it in works on the Nervous System. Among these may be mentioned—(1), The chapters in Dr Bastian's works on The Brain as an Organ of Mind, 1880; and on Paralysis: Cerebral, Bulbar, and Spinal, 1886; (2), a chapter in Professor Grainger Stewart's work, An Introduction to the Study of the Diseases of the Nervous System, 1884; (3), the chapter in Dr Ferrier's work on The Functions of the Brain, 1886 ; (4), the chapter in Dr Gowers's work on Diseases of the Nervous System, 1888.THE LITEKATUKE OF APHASIA. 275 Among the more important of recent German contributions are— (1), G-rashey, "Ueber Aphasie und ihre Beziehungen zur Wahrnehm- ung," Arch. f. Psych., xvi., S. 654; (2), Lichtheim, " Ueber Aphasie," translated by Dr de Watteville, in Brain, Jan. 1885 ; (3), Wernicke, "Die neueren Arbeiten iiber Aphasie," Fortschr. der Med., 1885, ii., p. 825 ; also i., 1886, p. 371; also ii.? 1886, p. 463. I shall by-and-by have occasion to refer to various important papers on special parts of the subject. The wealth of literature on the subject of Aphasia is overwhelming. If the reader would form an idea of it, let him consult the Index Catalogue of the Library of the Surgeon-GeneraV s Office, U.S. Army, edited by Dr Billings, and the Index Medicus, edited by Dr Billings and Dr Fletcher.276 the disorders of speech. CHAPTER X. Aphasia in relation to Organic Diseases of the Brain :— Prefatory Notes as to the Speech-Centres. Auditory Aphasia. It is hoped that the reader remembers what has been said about the constitution of an Object-percept and of a Word-percept, and about the blending together of these two percepts in the consciousness. Lichtheim has constructed a diagram which is fitted to illustrate the constitution of the two percepts, and the relations of the one to the other; and Wernicke has modified this diagram by adding to it looped connecting-lines between the various centres that furnish the images for the object-percept. In the diagram as here given, I have adopted Wernicke's addition, and have also slightly increased the number of the image-centres for the object-percept, so as to make them representative of all the centres tested in our series of little experiments with the apples. In this diagram, the upper row of circles represents the centres for the various images which may go to form the percept or idea Fig. 1. (After Lichtheim; modified.)NOTES AS TO THE SPEECH-CENTRES. 277 of an object—say, of an apple. The two lower circles, A arid B, represent the centres for the two images, auditory and motor, which go to form the percept or idea of a word—say the word " apple." How, in certain circumstances, a word-percept or an object-percept can be entertained separately in the consciousness ; and how, when the two percepts represent a familiar object and its name, they are in the consciousness blended together almost inseparably, we have already seen. An examination of the diagram helps us to understand how, when the word "apple" is heard, its sound revives not only the word-percept, but also the object-percept; and how, on the other hand, when any one of the sensory images of the object-percept, such as that of smell, is revived from without, the revival calls up the other associated images that contribute with it to form the object-percept, and the revival of this, again, calls up, by associa- tion, a revival of the word-percept. The two arrows passing in opposite directions between A and B indicate the close physiological connexion of these two centres—a connexion so close that, in health, it is probably impossible to call up the image at A without reviving that at B along with it, or to call up that at B without also reviving that at A. But there are also many other points, already discussed, that indeed cannot be illustrated by a diagram and yet may usefully be noted in connexion with the diagram before us. I shall here shortly touch upon a few of them:— (1.) Though it would make the diagram exceedingly com- plicated in appearance, I think it would make it more fully expres- sive of physiological fact, if every connecting line in it (looped and straight) were accompanied, like the line from A to B, with arrows pointing in opposite directions. As to the looped lines, we know already how the revival of any one of the chief images that go to form the object-percept of an apple can call up a revival of the others. This fact of itself shows that the reviving influences can travel in either direction. As to the straight lines between the upper circles and the lower, there can be no doubt that the main direction of current is that of a reflex arc, from A to the upper circles, and from these down to B; and yet it is certain, in the case of A at least, that the currents278 THE DISOKDEKS OF SPEECH. may also flow in the opposite direction. Thus, in motor aphasia, in which B is destroyed, the auditory images of words may, to some extent at least, be revived at A, by descending currents from the sense-image centres, so that the patient may be able to call up words in the mind, though unable to utter them. In auditory aphasia, in which A is destroyed, it is not so certain that a motor image formed at B can, by exciting upward currents from B, throw a reflex of itself back into the sense-image centres, so as to keep the mind informed of the meaning of the words that are being uttered. In many cases of auditory aphasia, the patient seems to have little consciousness of the words he is using at B, and often, in fact, uses wrong words without knowing that he is doing so. But it is not improbable that future inquiry will show that there is great variation in this respect. Even now, we can say that in some cases there is evidence of such a reflex being thrown back from B to the mind. These points, in due course, will be illustrated by examples. (2.) The diagram gives no indication of the fact that, whilst the images which go to form the Object-Percept are probably imprinted equally well, or almost equally well, in both hemispheres of the brain, the images which go to form the Word-Percept are imprinted efficiently in one hemisphere only. This difference, as we have seen, is best explained by the closeness of educative attention required for the efficient imprintation of the intricate word-images. (3.) The diagram does not indicate the possible juxtaposition in the brain of an object-percept image with one of its word-percept images. Take the object a bell, and the word "bell." One of the images or memories which go to form the object-percept of a bell is the sound-memory of its clang. Now, this memory is imprinted in the auditory sense-image centre, possibly in close juxtaposition with the sound memory of the word "bell." But, as indicated above, the memory of the clang is imprinted efficiently in both auditory sense-image centres, and that of the word only in one of them. (4.) A diagram cannot show how, as pointed out by Charcot, the two word-images at A and B may have a relative importance that differs in different people. It will be remembered that in most people the leading and more important image is apparently that at A, so that most people may be termed auditifs; whereasNOTES AS TO THE SPEECH-CENTRES. 279 in a few, the motenrs, the leading image is apparently that at B. It is on this hypothesis that we can best account for the fact that the same lesion, occurring in different individuals, may produce aphasia in different degrees of severity. (5.) The diagram cannot teach anything of the relations of the Intelligence and Attention to the images that go to form the object-percept and the word-percept. Yet the intelligence and attention, as we have seen, are agents of prime importance in effecting the revival of these images; as they were also, originally, in effecting their formation or imprintation. (6.) Lastly, let it be remarked that the idea represented by the combination of the upper circles of the diagram is the idea of a concrete object, such as an apple. It is a " percept," properly so called. Would it be possible to represent diagrammatically a " concept/' such as that indicated by the word " nation" ? Evi- dently it would be impossible. And if it would be impossible to represent diagrammatically any nouns other than those of one particular class, what can we say about adjectives and the other parts of speech ? "Who could localize in the brain the idea represented by the adjective "beautiful"? The fact is that, by localization and diagrammatic representation, we can, as yet, do no more than merely touch the fringe of the great question as to the nature of ideas, and their relation to speech. But it is something, even to touch the fringe of such a question. It is now time for us to look at the localization of the various stores of word-images in the cerebral cortex. In indicating these localizations, I shall employ the very useful outline sketches of the cerebral convolutions that are used by most of the recent French authors. Here, then (Fig. 2), in such an outline sketch, are indicated the positions of the four centres in which are stored the memories or images of speech, audible and visible. A, the posterior half or three-fourths of the left First Temporal Convolution, is the Auditory Speech-Centre, in which are stored the auditory speech-images. B, the Broca's Convolution, is the centre for the motor memories of speech. C, the Angular and the Supra-Marginal Convolutions, is the centre for the visual images of written and printed speech. D, the posterior extremity of the Second Frontal Convolution, is the graphic-motor centre, in280 THE DISORDERS OF SPEECH. which are stored the motor memories which guide the right hand in the act of writing, 2 Fig. 2. If, in the following manner (Fig. 3), we detach the four centres from their connexions, and represent them as circles, Fig. 3. we shall be better able to indicate the relations of the four to each other, and also their relations to incoming and outgoing speech. The exceedingly intimate relations of A and B have already been commented upon : they are indicated by the connecting line and the two arrows. Without detailed discussion of the rela-NOTES AS TO THE SPEECH-CENTRES. 281 tions of A and B with C and D, it may, I think, be said that all the connexions indicated by the lines of the diagram probably exist between them; and that along these lines the influences may travel, as indicated by the arrows, either in the one direction or in the other. What particular images are revived by the acts of Silent Thinking, Speaking, Beading, and Writing, I have already indicated in the last chapter. With such a diagram as Fig. 3 before us, it is an interesting exercise to consider how the diagram would have to be modified, if we wished to represent the speech-centres—(1), in an educated Blind person, who can read by touch; and (2), in an educated Deaf-Mute, who has been trained by the " lip-reading method " to converse, and who can read and write. For representation of the centres in the Blind person, we should have to leave out the centre C, and substitute for it another centre in which are stored the Tactile word-images or memories revived by the blind in reading.1 For representation of the centres in the educated Deaf-Mute, we should have to leave out the centre A, and place alongside of C, in the visual area ofv the cortex, another centre for the visual memories of lip-reading. A fact of great practical importance in relation to the speech centres is, that in the brain they are all situated within the territory supplied by the middle cerebral artery. This fact is made evident by Duret's well-known diagram, which I now reproduce (Fig. 4). In this diagram, the fissure of Sylvius is shown opened up, so as to display the Middle Cerebral or Sylvian Artery in all its length, and to show how the various convolutions surrounding the Sylvian fissure are supplied by branches of this artery. It will be observed that one branch is supplied to the posterior extremity of the third frontal convolution, another to the posterior extremity of the second frontal, another to the posterior half of the first temporal convolution, and others to the supra-marginal and angular convolutions. All four speech-centres are thus within the area supplied by this artery. It is no part of my intention to describe the various forms of 1 According to the results of recent investigation, tactile sensation seems to have a double representation in the brain, partly in the motor convolutions, and partly in the limbic lobe (gyrus fornicatus). See- V. Horsley, in the Nineteenth Century, June 1891. 2 N282 THE DISOKDERS OF SPEECH. organic disease that, by disabling or destroying one or more of the speech-centres, may give rise to aphasia. But I may say, in few words, that among the more important of such diseases are,—(1.) Necrotic Softening, produced by the occlusion of the Sylvian artery or one of its branches. (2.) Apoplexy; which may either destroy a speech-centre by invading it, or disable it by exercising pressure upon it. (3.) Inflammatory conditions, such as Cerebritis, with or without suppuration; or, more rarely, Meningitis, with involve- ment of the subjacent grey matter in the inflammation, (4.) Tumours; which may either destroy a speech-centre by invading it, or disable it by producing pressure upon it. (5.) Traumatic con- ditions, such as fracture of the skull. Occurring over one of the speech-centres, a fracture sometimes causes disablement of it by the compression of depressed bone or extravasated blood, and sometimes destroys it by inciting in it inflammation that leads to abscess or softening. For the analytical study of aphasia, it is best to take cases in which one speech-centre alone is affected, and in which the functions of the brain as a whole are not impaired, either by general pressure or by general inflammation. Most of the cases that fulfil these conditions are produced either by occlusion of a branch of the Sylvian artery or by a limited traumatism, Fig. 4. (After Duret.)auditory aphasia. '283 I now proceed to take up seriatim the consideration of each of the forms of Aphasia. In doing so, I shall follow the same order as was adopted in treating of the Hallucinations of Speech. I shall take first the centre A, in which are stored the auditory memories of speech, and consider what effects are produced by its destruc- tion ; then, in like manner, I shall take B, containing the motor memories of spoken speech; and then, successively, C and D, the two centres containing the visual and motor memories of printed and written speech. Auditory Aphasia. By the term Auditory Aphasia, is meant the aphasia which results from the destruction or disablement of the auditory word- images at A. The centre for these images is one of the two cortical centres in the brain for hearing. It will be remembered that, though there is a centre for hearing in each hemisphere, and though both centres have probably imprinted in them equally well, or almost equally well, the images of common sounds, only one of them, usually the left, has efficiently imprinted within it the sound-images of words. It is, as shown in the accompanying diagram (Fig. 5), the posterior half or three-fourths of the First n Fig. 5. Temporal convolution that thus becomes the storehouse of the sound-images of words.284 TttE DISORDERS SPEECH. I hope I may be excused for using the term Auditory Aphasia in preference either to the term Sensory Aphasia, proposed by Wernicke, or to the term Word-Deafness, proposed by Kussmaul. "Sensory Aphasia" seems too wide a term, as there are other sensory word-images, viz., the visual, which are not here necessarily involved; and "Word-Deafness" seems too narrow, as this form of aphasia, besides producing Word-Deafness, on the receptive side of speech, produces, on its productive side, the equally important phenomena of Amnesia Yerbalis and Paraphasia. Let us look at the two sets of symptoms thus exhibited in Auditory Aphasia, on the receptive and the productive sides of speech.1 Effects on Reception and Interpretation of Speech. 1. Keception and Interpretation of Words heard.—When the centre A is destroyed, and its accumulated store of word- images annihilated, it can easily be understood that word-deafness is a necessary consequence. So long as the images were intact, the revival of them from without, by incoming audible speech, sufficed to call up instantly, not only the associated motor image, completing the word-percept, but also the associated meaning. But, the auditory word-images being destroyed, the incoming word-sounds can no longer call up the meaning. The words are still heard by the remaining auditory centre of the oppo- site hemisphere, but they are heard as sounds merely, not as intelligible words: they sound to the patient like words of a foreign language which he does not understand. Therefore, if the patient answer questions, he does so at random; unless, from the gesture or expression of the questioner, he can get some indication of what is being asked of him. As such patients are often remark- ably quick in drawing inferences from expression and gesture, it is important that the examiner, in testing a case of word-deafness, should carefully command his countenance and abstain from 1 Among special treatises upon the Sensory varieties of Aphasia, the following are three of the best:—(1.) Mile. Nadine SkwortzofF, De la C&ite et de la Surdity des mots, 1881. (2.) Seppilli, "La sordita verbale ed afasia sen- sorial," Revist. speriment di freniatria, 1884, x., pp. 94-125 (a selection from Seppilli's cases is included in Amidon's collection). (3.) Amidon, "On the Pathological Anatomy of Sensory Aphasia/' New York Med. Journ1885, pp. 113 and 181.auditohy aphasia. 235 gesture. In cases originally less severe, and in cases in which recovery is advancing, the patient may understand a good deal of what is said to him; but he is apt to exhibit failure in the under- standing of nouns, especially of those which are the names of concrete things. It is worth noting that patients unable, from word-deafness, to understand anything else, may yet, in some cases, respond when their own names are called. In illustration of word-deafness, I think I cannot do better than select some questions and answers from the conversation which is incorporated in Wernicke's record of one of the cases published by him in the paper which did so much to make the phenomena of Sensory Aphasia generally known to the profession. Let it be understood that in this case, and in all the others to be referred to, hearing was intact. Case I. (Wernicke, Der Aphasische Symptom,encomplex, 1874).— A widow of a workman, aged 59, became suddenly ill in March 1874, with vertigo and headache, but without loss of consciousness ; and spoke confusedly, expressing herself sometimes correctly, but answering questions quite at random. The patient at first under- stood absolutely nothing that was said to her; but one had to take care not to assist her by gesture. Yet when she spoke spon- taneously, she expressed herself with intelligence, though she occasionally mispronounced a word or used a wrong one.. She gradually improved; and on the 20th of April 1874, when Wernicke recorded the last note of her progress, the word-deafness had dis- appeared, and she had also made a great advance in power of expres- sion. Here is a little bit of the conversation held with her, on the 18th of March, when improvement had already begun. It will be observed that she understood the first question, a conventional one. " Good morning; how are you ?" " Thank you; I am very well." " How old are you ?" " Thank you; fairly well." " How old are you ?" " Do you mean to ask how I hear ?" " I wish to know how old you are. How old are you ?" " Indeed, that is just what I do not know .... as I hear folk say." "Would you please to give me your hand ?" "I really do not know how I," etc. (no trace of comprehension). " Where is Eichard ?" " I do not know what I shall say. My name is Frau Adam." " Where is Eichard ?" (Considers a long time), " Mein Sodam (Sohn), mein Eichard."286 the disorders of speech. In this conversation, the commencing improvement in the condi- tion of the patient is shown by her recognition of the meaning of the first question, a conventional one; and in her being able to recognise, though with difficulty, the name of her son Eichard. From the recorded cases of auditory aphasia, it wTould be easy to multiply examples of "Word-Deafness; but one other brief reference to a case may suffice for special illustration of this symptom. Case II. (A patient under the care of Meynert, in Vienna; the case being recorded by one of his assistants. It will be found in Mile. Nadine Skwortzoff's Collection of Cases, Op. cit.y p. 88).—A woman, aged 23. Could not understand even conventional questions. To the question " How do you do ?" she replied, " My country is a beautiful one;" and when she was asked to put out her tongue, she remarked, "My brother John," etc.; and yet she replied intelligently to questions if they were accompanied by gestures that enabled her to understand them. 2. Reception and Interpretation of Words seen.—As the auditory word-centre, A, and the visual word centre, C, lie in juxta- position, they are very apt to be involved together in the same lesion; the patient being then rendered word-blind as well as word- deaf. But in some cases the visual word-centre C is left intact, though the auditory word-centre A is destroyed. In these circum- stances, can the patient read visible words ? Upon this question there is difference of opinion. It must be remembered that, in the ordinary condition of things, the visual centre C is not directly connected with the meaning. Its connexion with the meaning is only indirect, through A and B. Therefore, when A is destroyed, one of the two links connecting C with the meaning is broken. But there remains the other link, B; and the question has yet to be definitely decided how far, in the absence of A, the visual word- image, revived at C, can call up the meaning, by acting upon B. Lichtheim1 and Wernicke2 think that it cannot do so, and that the destruction of A necessarily causes the patient to be unable to understand visible as well as audible speech. They hold, however, 1 Brain, Jan. 1885, p. 439. 2 Fortschr. der Med., ii. 1885, p. 828. See his diagram.auditory aphasia. 287 that there is a form of word-deafness due, not to destruction of the centre A, but to destruction of the subcortical fibres leading from the ears to that centre, and that a lesion of this kind does not interfere with reading, although it renders the patient word- deaf. But this variety of aphasia seems to have been differentiated from clinical observation only, without, as yet, the verification of post-mortem examinations. According to other authorities, the destruction of the centre A, though it usually damages, does not necessarily destroy the power of reading, because the visual images at C can still call up the meaning by acting upon B, through the connecting fibres repre- sented by the line C B (Fig. 3). Here is a brief note of a case which seems to show that this latter view is the correct one. Case III. (This case was originally recorded by 0. Giraudeau, Rev. de Med., ii. 1882, p. 446. It is given in Amidorfs Collection of Cases, New York Med. Journvol. xli., p. 181).—A widow, aged 46. Had suffered for three months from constant headache, and had become quite word-deaf. To all questions she invariably replied, " What is it you say ? I don't understand you. Cure me !" Hearing and sight were intact. She read well, and answered questions which were written and shown to her. She died comatose. " On autopsy, there was found a tumour, the size of a walnut, in the posterior part of the left temporal lobe. Above, it reached the fissure of Sylvius; below, it involved three-quarters of the breadth of the second temporal convolution. It reached forward to within three centimetres of the anterior extremity of the temporal lobe, backward to within one centimetre of the posterior extremity of the fissure of Sylvius. It encroached slightly on the white matter, and was easily enucleated/' I think this case affords strong evidence in favour of the view that, at least in some of these cases, the power of 'Understanding printed or written speech is preserved, though the power of under- standing words that are heard is destroyed. I may add here notes of two other cases in which, as in Case III., the patient, though word-deaf, retained the power of reading. Case IV. (Recorded by Dr Abercromby, in his Inquiry into the Intellectual Powers, p. 149, and quoted by Mile. Slcwortzoff, Op. cit.).—A gentleman had ceased to understand words spoken to288 the disorders of speech. him, but understood very well written names. As he managed a farm, he had in his room a list of the words which he might chance to hear in his conversations with his workmen. When a workman was talking to him on any subject, he listened without at first seizing anything of the words except the sound. He then looked up the words in his written list, and, whenever he saw them, he understood them perfectly. Case V. (Schmidt, 1887; quoted "by Mile. Slcwortzoff).—A female, set. 25. Ten days after parturition, had lost conciousness suddenly, upon making an effort. On recovery, there was no paralysis, but the patient could not understand what was said to her, and had great difficulty in expressing herself spontaneously. " If one wrote down a question upon a slate, she examined the words one after another attentively; tried to pronounce them one by one, and then in more rapid sequence; and then replied." I think this last case shows pretty plainly that the meaning of the word revived at C was reached only through revival of the motor images at B. Why, it may be asked, should not the meaning be reached directly from 0 ? This question has already been discussed; and we have seen reason to adopt the conclusion that printed and written words are only symbols of symbols, and can therefore call up the meaning only by reviving the primary word-percept or symbol, at A and B, or a part of it, either at A or at B. It is only among those who have read a very great deal that the visible word-symbols may, possibly, at length acquire direct connexions with the meanings; and it is not conclusively proved that such direct connexions may, even in such individuals, be acquired. Effects upon the Production of Speech. 1. Spoken Speech.—That Word-Deafness should result from the destruction of the auditory word-images at A is only what anyone would a priori have expected. Obviously, the auditory word-images must occupy the first place, in point of importance, in relation to incoming speech. But it could not so easily have been anticipated that these auditory word-images are also of very great importance in relation to outgoing speech. Yet it is so. In relation to outgoing speech, they are of importance in everyAUDITORY APHASIA. 289 person; and in those persons who are strongly auditifs the importance is probably paramount. In the reception of speech, the word-images are revived from without, by words that are heard or seen; in its production, they are revived from within, by the thoughts that arise in our minds. In most people, the thought that is seeking expression leans towards the motor word-images, but it evidently stimulates also the auditory word-images. It calls up both word-images simultaneously ; and it is only when it is able to do so that it can with perfect ease call up the words of all classes required for its expression. In most cases, destruction of the auditory centre does not annihilate the power of expression, it merely damages it; but in persons who are strongly auditifs, it may practically destroy it. This interference with the power of expression betrays itself in— Amnesia Verbalis; Articulative Amnesia; and Paraphasia.—As already indicated, the degree of Amnesia Yerbalis exhibited by a case of auditory aphasia seems to differ according to the degree in which the individual is auditif. There are cases upon record of what is called " Gibberish Aphasia," in which the word-deaf patient expressed himself in a totally unintelligible jargon, and was yet, owing to his word-deafness, quite unconscious of the fact that he was expressing himself unintelligibly. These may be regarded as extreme instances of Amnesia Yerbalis and Para- phasia; and there is reason to believe that destruction of the auditory centre A can furnish such an instance only when the individual affected is very strongly auditif. In general, the destruction of the auditory centre leaves the patient in possession of considerable powers of expression. The Amnesia Yerbalis in most cases displays itself chiefly or solely in a forgetfulness of nouns, and especially of such nouns as are the names of concrete objects. The patient, when speaking, is from time to time brought to a sudden stop, owing to the forgetting of a noun, and is obliged to explain himself in some roundabout way; or, still more characteristically, he displays Paraphasia in his use of nouns, substituting a wrong noun for a right one, and very often pro- ceeding in his talk without any consciousness of the error. In a few cases the paraphasia takes the form of a recurring utterance. In Auditory Aphasia, Paraphasia is one of the leading and most characteristic of the phenomena,—Word-Deafness on the recep- 2 o290 the disorders of speech. tive side of speech, and Amnesia with Paraphasia on its productive being the leading symptoms of auditory aphasia. Associated with Amnesia Yerbalis there is often that partial amnesia of words which I have termed Articulative Amnesia. The word is remembered in a general way, but some of its articulative details are forgotten, so that, when produced, it is barely recognisable. Here and there in a sentence, a patient with auditory aphasia may produce a word which bears the marks of this Articulative Amnesia; and the words thus imperfectly remem- bered are for the most part Nouns. 2. Effects on Writing.—The same Amnesia Yerbalis, Para- phasia, and Articulative Amnesia that are displayed in what the patient says are also displayed in what he writes, and in his spelling. Writing is, of course, a mere representation of internal speech; and the representation naturally exhibits all the faults of the original. In fact, it seems that, in not a few cases, the character- istic faults are exhibited even more strikingly in what is written than in what is spoken. The name Paragraphia is given to the paraphasia thus exhibited in writing. I now proceed to illustrate these Faults of Outgoing Speech by further brief references to recorded cases. Case VI. (Dr Broadbent, The Lancet, 1878, p. 312.) Case show- ing " Gibberish Aphasia."—A man, aged 49, had had an obscure cerebral seizure which left him aphasic, but not paralysed, except that he had a slight paresis of the right side of his face. His speech was reduced to unintelligible gibberish, in the midst of which one could distinguish a few words from time to time, such as " If you please, Sir." The patient evidently believed, when speaking, that he was expressing himself intelligibly. Requests to make him do things, made it evident that he was word-deaf. For example, when he was asked to give his hand, he invariably put out his tongue. An autopsy showed a very extensive area of softening which involved the left first temporal convolution. Two other typical cases of Gibberish Aphasia will be found at pp. 200 and 201 of Sir Frederic Bateman's work. In one of these, recorded originally by Dr Osborne, the patient expressed himself in so extraordinary a jargon that he was treated as a foreigner atauditoky aphasia. 291 the hotel in Dublin where he was living. In this case, Dr Osborne clearly ascertained that when the patient read aloud, " although he employed strange words having no connexion whatever with the text before him, he really understood the sense of what he was purporting to read." When the sentence beginning " It shall be in the power of the College to examine or not to examine any licentiate " was put before him, this is what he made of it, in reading aloud: " An the be what in the temothar of the throthotodoo to majorum," etc. He recovered in course of time. The case is one of great interest, but it is difficult to be sure, from the facts recorded, that the aphasia was due to disablement of the centre A. Possibly it may have been due to fault of conduction between A and B. It would be easy, from the recorded cases, to give numerous examples of ordinary Amnesia Verbalis and Paraphasia. But it will suffice to give only a few, and I shall try to select cases that will each show some particular feature. I shall begin with a well- known case of extreme Paraphasia, recorded by Trousseau. Case VII. (Trousseau, Clin. Med., 4th ed., vol. ii., p. 674).— " Madame B., mother-in-law of a respected medical man, without ever having had any paralytic symptoms, became somewhat rapidly the subject of very singular affections of intelligence. A visitor calls upon her; she rises to receive him with an air of politeness, and pointing to an arm-chair, says, ' Pig, brute, stupid fool' (' Madame invites you to be seated/ says the son-in-law, who interprets the wish of the patient so strangely expressed). Let us note that the acts of this lady appeared otherwise quite sensible, and, what is curious and not common among aphasics, she did not seem to be annoyed about, or to understand, the meaning of the insulting expressions she made use of." Case VIII. (Dr Eoss, On Aphasia, p. 30.) The case shows Para- jphasia exhibiting itself in the form of a Recurring Utterance.— James Lee, set. 57.. First came under Dr Ross's observation about 1880. Five months previously, had had a fit of some kind, which did not produce paralysis, but left him unable to speak correctly. There is no mention of word-deafness having at any time been exhibited. Besides Amnesia of nouns and Paraphasia, the patient presented a Paragraphia that was even more marked than histhe disorders of s^eeclt. paraphasia. His paraphasia exhibited itself as a Recurring Utter- ance, viz., the utterance"A public house." "He was handed a bunch of keys, and asked to name one of them; he held it "between his thumb and index finger and said,—' It is a public house.' ' That is not a public house/ I said. ' I know it quite well,' he replied; ' I have seen it thousands of times;' and, trying again to name it, he continued, ' It is a—it is a public house. Pooh! I know it quite well.'" This patient was under observation for years. He improved greatly under training. If, in this case, the lesion was situated in the auditory centre A, as seems probable, it was perhaps a lesion not sufficiently severe to produce word- deafness, though sufficient to produce amnesia of nouns and paraphasia. The marked Paragraphia in this case rendered the patient's letters quite unintelligible, though the handwriting was remarkably good. Case IX. (Dr Eoss, On Aphasia, p. 25.) This case, besides Amnesia Verbalis, Paraphasia, and Word-Deafness, shovis Articu- lative Amnesia.—Joseph Lander, set. 51. A seizure, occurring during sleep, made the patient aphasic, word-blind, word-deaf, markedly amnesic, especially of nouns, and paraphasic. A point of special interest is that he exhibited Articulative Amnesia. When Dr Eoss asked him to name things, he often showed that he had a general idea of the name, but failed to remember it in detail. Thus when shown a pencil he said, " It's a pu—; it's a punt—no, that's what bothers me." When asked the day of the week (Wednesday) he said it was Waterday. It is worth noting that this patient was more amnesic than word-deaf. The word-deafness seems to have partly passed off before the patient came under Dr Eoss's care. Case X. {Treated by M. Magnan, in the Asylum of St Anne, Paris. Recorded by Mile. Skwortzoff,\ Op. citp. 71). The case shows, along with the ordinary symptoms of this form of Aphasia, an Amnesia of Verbs and Prepositions, as well as of Nouns.—A man, aged 54. His illness had begun gradually five years previously, with Amnesia and Paraphasia. He forgot Nouns, and in a less degree Verbs ; and the few verbs retained by him were used in the infinitive. Two years after the first appearance of this amnesia,AtTDITORY APHASIA. 2§3 marked Word-Deafness was developed; and this continued during the whole period of his residence in hospital. A point of special interest in this case is that, besides Amnesia of Nouns, there seems to have been, during the patient's period of residence in the Asylum, a total Amnesia of Verbs and Prepositions. " During the whole period of nine months, when he resided in the Asylum, he never 011 any single occasion pronounced a verb or a preposi- tion." Another point of great interest is the fact that, in the gradual advance of the lesion, the Production of speech was inter- fered with before its Reception and Interpretation,—the amnesia appearing before the word-deafness. This seems to show that an incoming Audible Word is a stronger stimulus to and reviver of the word-image, than is an Idea or Meaning seeking expression from within. Effects upon ike powers of Repeating or Echoing words and Copying written words. Destruction of the centre A naturally interferes with the power of Repeating or Echoing words. If there w7ere only one auditory centre, its destruction would, of course, annihilate that power, so that anything like Echolalia would be impossible. But, as there is another auditory centre, in the opposite hemisphere, and as this may be educated to assume the speech functions of the centre A, the repetition of words heard is often possible in auditory aphasia, though it is always difficult till after much practice. Attention to the word-sounds received by this uneducated centre, and to the reproduction of these sounds by the educated motor centre B, is no doubt the basis of the Further Education which in cases of auditory aphasia frequently leads to the complete restoration of speech. At first, in most cases, this reception and reproduction of speech- sounds is obviously difficult to the patient; but it becomes more and more easy as the word-images are more and more securely acquired. Thus, in the case recorded by Schmidt already alluded to (Case Y.), there is this further note about the training of the patient to repeat what was said to her:—" She heard when one pro- nounced the vowels separately, and she repeated them. If one pronounced a monosyllabic word, she did not understand it; but if one separated the different letters in such a manner as to accentuate294 THE DISORDERS OF SPEECH. them clearly, she repeated it. For words of two syllables, it was necessary, to begin with, to pronounce distinctly the first syllable, then the next, and then the two together, in order to get her to understand the word. Little by little, she learned to seize words more quickly; but six months elapsed before she could understand, without its being repeated to her, an entire phrase, though short and pronounced slowly, with accent on every word." It may be noted that in this case the word-deafness, as usual, disappeared before the amnesia verbalis. I think the above quotation affords some valuable hints for the Treatment of auditory aphasia. As to the copying of written and printed speech, it appears that auditory aphasia does not interfere with it. Such is the opinion expressed by Wernicke and Lichtheim, who have paid special attention to the point. The Musical Faculty in Auditory Aphasia. I have already, in a former chapter, indicated that this part of the subject requires further investigation. On the one hand, cases of auditory aphasia due to destruction of the centre A are recorded in which the musical faculty was well preserved; but, on the other hand, impairment of the musical faculty has been found associated with the word-deafness in at least two cases. It is noteworthy, however, that in these two cases (recorded by Wernicke1 and Lich- theim2) the lesion was supposed to be situated, not in the centre A, but in the subcortical fibres leading up to it.3 In Lichtheim's case, the patient, who had formerly been musical, lost the power of recognising even common melodies; and sometimes asked his children to stop singing quartettes, "as they made too much noise." In Wernicke's case, the patient could recognise tunes whistled to him, and could himself repeat them, but displayed a defect in the hearing of the higher tones. Future investigation will, no doubt, show whether the two auditory centres share equally, or unequally, in the faculty of music. 1 Fortschr. der Med1886, xi. p. 474. 2 Brain, Jan. 1885, p. 461. 3 I shall have occasion to refer specially to this view of Lichtheim and Wernicke in a future chapter.AUDITORY APHASIA. 295 Why Auditory Aphasia was so much later in being recognised than Motor Aphasia. Its Curability. It is interesting to consider the question why the first recognition of auditory aphasia was so much later than that of motor aphasia. There seem to be three reasons. 1. That disease or disablement of the left first temporal convolu- tion ("Wernicke's convolution") is not so common as disease or disablement of Broca's convolution. 2. That for a long time, no doubt, many cases of auditory aphasia were mistaken for cases of mental derangement. When a person who obviously could hear, was yet unable to understand what was said to him, and replied to questions in a totally irrelevant manner, it was very natural to suppose that he was suffering from mental derangement. The condition was not well understood until Wernicke, in 1874, clearly defined it, and described its symptoms. 3. That, owing to speedy education of the uneducated right auditory centre, the effects upon speech of a lesion in the educated left auditory centre pass off, in a large proportion of cases, much more quickly than the effects of a lesion of the educated motor centre. Wernicke says that the word-deafness often passes off, and speech is restored, in the course of six or eight weeks. In some cases, however, the symptoms are permanent, or pass away only very slowly. It is important to note that, when recovery takes place, the Word-Deafness generally passes off before the Amnesia Verbalis and Paraphasia. Perhaps this greater curability of auditory aphasia may be due to the fact that the auditory centre is the first to receive education in speech, and that possibly, in connexion with its education, there is more " overflow " to the other side than is the case in connexion with the education of the motor centre. However it may be explained, the fact remains, that in cases of auditory aphasia due to destruction of the centre A the "Further Education" of the auditory centre of the opposite side is easier and faster than is, in motor aphasia, the further education of the uneducated motor centre. The following is an interesting case which illustrates this point, and which shows, further, that speech may be entirely recovered even after total destruction of both of the educated centres, auditory and motor.296 the disorders of speech. Case XI. (Bernard, l)e tAphasie, p. 159).—A woman, aged 49 treated by Charcot in the Salp^triere Hospital. Six years before coming under observation, she had one morning awoke from sleep hemiplegic and aphasic. Two years after this, she had been able to acquire only the power of saying " yes " and " no." At first, the aphasia had been both sensory and motor, so that the patient had been Word-Deaf as well as Aphemic. She had been able to under- stand only a few of the words spoken to her, and these only after they had been several times repeated. Words spoken had seemed to her only an indistinct noise, " like conversation in a crowd." She could not say precisely how long this word-deafness had lasted, but it had disappeared much sooner than her motor aphasia. Little by little she had recovered from the motor aphasia also, so that when, in 1883, she came under the care of Prof. Charcot, her speech had for some years been thoroughly restored. She was admitted into the Salp^triere on account of an intercurrent affection unconnected with the brain or speech, viz., an obliteration, by thrombosis, of the abdominal aorta ; and of this she died in a few days. On autopsy, it was found that, on the left side of the brain, both the Broca's convolution and the first temporal convolution had been completely destroyed by old softening. Besides illustrating the possibility of recovery from an aphasia that is both motor and sensory, this case shows that, in the process of recovery, the education of the uneducated centres is easier and more rapid in the case of the auditory than in that of the motor centre. Summary of Leading Features. In now summing up the leading features of auditory aphasia it may be said that— 1. It is rarer than motor aphasia. 2. It is more easily curable. 3. It interferes with both the reception and the production of audible speech,—its leading symptoms being, on the reception side, Word-Deafness, and, on the production side, Amnesia Yerbalis, Paraphasia, and Articulative Amnesia. 4. It interferes with the Bepetition or Echoing of spoken words. Though the words are heard by the uneducated auditory centre,AUDITORY APHASIA. 297 their auditory images are at first not well retained, and the patient has therefore at first difficulty in getting the educated motor centre to conform to these imperfect auditory images of the opposite side; but, with practice, this difficulty generally disappears. 5. As to Written or Printed Speech, we have seen that there is difference of opinion upon the question whether or not the power of Reading is retained ; but it has been shown above that it is retained in some cases at least. As to Writing, we have seen that the motor act of writing is not interfered with, the handwriting being often good. Nor, apparently, is the power of Copying words in writing interfered with. But when the patient tries to express his thoughts in writing he exhibits faults of expression and faults in spelling equivalent to the faults of his spoken speech, this Paragraphia being, in fact, only a translation into writing of the Paraphasia in the patient's internal speech. And these faults of written speech are often even more marked than are those of spoken speech. Treatment of Auditory Aphasia. The best hints for the treatment of Auditory Aphasia that I have been able to find are those furnished by the record of the case by Schmidt (Case V., p. 288), from which an additional note has been given at page 293. In this case, words were slowly and articulately spoken to the patient, and she was asked to repeat them. Printed words were also shown to her, and she was asked to read them. At first she repeated the words slowly and with difficulty, but with practice she acquired increasing facility. Probably the practice was imprinting the word-images efficiently in the uneducated auditory centre, and at the same time establishing connexions, of the requisite intimacy, between these images and those of the other speech-centres. Even when no special training has been given, the mere habit of listening attentively to the speech of others, and trying to understand it, educates in many cases, as we have seen, the uneducated auditory centre, and in due time establishes connexions sufficiently intimate between its images and those of the other speech-centres. When special training is required, the best that can be given is probably such as was used in the case referred to, viz., training of the patient to repeat words 2 p298 THE DISORDERS OF SPEECH. spoken to him, and to read aloud words shown to him. Of course it will be understood that such training should be prescribed only when the condition of the brain and of the general health indicates that such an exercise is not likely to be injurious or too fatiguing to the patient.motor aphasia (aphemia). 299 CHAPTER XI. Aphasia in relation to Organic Diseases of the Brain— Continued:—Motor Aphasia (Aphemia); Conduction Aphasia. Motor Aphasia (Aphemia). The form of Aphasia now to be considered has, by Wernicke, Charcot and others, been termed Motor Aphasia; but as it was originally described by Broca, and as Broca applied to it the term Aphemia, many writers have, in honour of Broca, wished to retain that term. It was formerly objected to the term Aphemia that the word, in ancient Greek, had a different and an objection- able meaning.1 On this account, Trousseau proposed as a sub- stitute for it the term Aphasia. But it has been found that this term, too, occurs in ancient Greek with a meaning different from its medical one.2 The profession, disregarding these original meanings, has decided to retain both terms. Aphasia is now used as the generic title for the whole of this group of Speech Disorders, and Aphemia is used, by many, as the specific term for the motor variety of aphasia. Before I go 011 to discuss in some detail the characteristics of aphemia, it may, I think, be of advantage to look for a moment at the work which is now being done by the Experimental Physio- logists in connexion with the physiology of the motor speech- centre in the brain. It will, of course, be borne in mind that monkeys, and the other animals experimented upon, are not endowed with human speech, and that, therefore, the centre in the brains of these animals which anatomically corresponds with the motor speech-centre of the human subject, does not fully correspond with it physiologically. Yet the correspondence is real and close, even physiologically; because, though they cannot speak articulately, these animals have 1 It meant infamy. 2 It meant dumbness from fear or perplexity.300 THE DISORDERS OF SPEECH. an expressional language of their own, for the purposes of which they employ largely the same organs as are employed by man for articulate speech, viz., the organ of voice, and the muscles within and around the mouth. Therefore, in analysing the action of the motor centre in these animals, and in localising the various sub- centres contained within it (such as that for adduction of the vocal cords, and those for movements of the lips and tongue), experimental physiology is fitted to throw much light upon the constitution of the motor centre in the human subject. At page 478 of Dr Ferrier's work on The Functions of the Brain, 2nd ed., the reader will find, in the diagram showing the cortical centres in the human brain, that Dr Ferrier has indicated the motor centre for speech by a circle (9*10), within which he includes (1) the vertical part, or " foot/' of the third frontal convolution; (2) the " foot" of the ascending frontal convolution; and (3) part of the " foot" of the ascending parietal. The area thus demarcated is that which is now termed " Broca's convolution." By Broca himself it was termed the " Operculum," because it covers like a lid, and hides from view, the group of short convolutions on the floor of the Fissure of Sylvius known as the Island of Eeil. It will be observed that this operculum corresponds, on the surface 2 T * \ 11 f*\ Fig. 6. of the brain, to the angle between the short ascending and the long horizontal branch of the Fissure of Sylvius. Ferrier (p. 481)MOTOR APHASIA (APHEMIA). 301 says:—"(9) and (10), included together in one, mark the centres for the movements of the lips and tongue as in articulation. This is the region disease of which, on the left side, causes aphasia, and is generally known as Broca's Convolution." In the diagram on previous page, this area is indicated by shading. I do not know whether Ferrier, in thus demarcating the centres for the movement of the lips and tongue in the human subject, was guided entirely by the results of experimental observations on the lower animals, or also took into account the results of clinical and pathological observation upon the human subject. But I suppose he must have taken clinical and pathological observation into account, because I find that the later observa- tions by V. Horsley and his colleagues have led to the demarca- tion of an area for the movements of the lips and tongue that is different from the area given by Ferrier. It is different in this important respect, that it does not include within it the foot of the third frontal convolution. It limits the representation of the movements of the lips and tongue to the foot of the ascending frontal and the foot of the ascending parietal convolutions, and leaves the foot of the third frontal convolution out of account altogether. Neither in the macacque monkey, nor in the orang outang (an anthropoid), have these later experimenters found the foot of the third left frontal convolution to be included within the motor area for the movements of the lips and tongue.1 Now this is a remarkable fact, because, as we shall see by-and-by, clinical and pathological observation lias shown that the foot of the third left frontal convolution has relations to the motor production of speech that are apparently even more important than those of the feet of the ascending frontal and ascending parietal convolutions. How is this apparent discrepancy between the results of experimental and those of clinical observation to be explained ? It seems to me that if the foot of the third frontal convolution is not motor in function, and yet has relations of extreme importance to the motor production of speech, we are almost forced to the 1 For an account of the experiments upon the brain of the orang outang, see V. Horsley and E. Beevor, in the Phil. Trans, of the Roy. Society (B.) 1890, p. 129. For the application of the results of recent experimental researches upon animals to the human brain, see y. Horsley, in the International Journal of Science, vol. xciii. 1887, p. 342.302 THE DISORDERS OF SPEECH. conclusion that it must be, in a special manner, the storehouse of the guiding psycho-motor pictures or memories, which, in them- selves, are so largely sensory in constitution, being made up chiefly from memories of muscular and tactile sensations. Are these psycho-motor pictures, then, stored in the foot of the third frontal convolution, and the executive motor cells contained in the feet of the ascending frontal and ascending parietal convolutions ? We cannot as yet answer this question definitely. We must wait for the results of further experiments upon anthropoid monkeys; and, above all, we must wait for the decisive evidence that can be obtained only from the careful observation of cases in which limited lesions have destroyed one small portion or another of the grey matter within the area of Broca's convolution. Some such cases have already been recorded, and I shall give notes of a few of them; but we are greatly in need of additional evidence of this kind. A very important conclusion arrived at by the experimental physiologists is that, within the area of Broca's convolution, there is a special sub-centre for the motor innervation of the muscles which adduct the vocal cords, and thus place them in position for phonation. This sub-centre is situated, in monkeys, within the foot of the ascending frontal convolution, close behind the precentral sulcus. We owe this advance in the physiology of the motor area to the observations of a number of physiologists, but more especially to those of Krause 1 and of F. Semon and Y. Horsley.2 In this sub-centre, the adductors of the vocal cords have been found to be bilaterally represented,3 so that stimulation of this sub-centre in one hemisphere is found to be capable of pro- ducing equal adduction of both vocal cords. In the human 1 Krause, Archiv filr Anat. und Phys., Physiol. Abth., 1884. 2 F. Semon and V. Horsley, Trans, of the Roy. Society (B.) 1890, p. 187. 3 They have been found to be so in dogs, by Krause ; and in monkeys, by F. Semon and V. Horsley. On the other hand, Masini {Arch. ital. di Laryng. Napoli., April 1888) finds that very light stimulation of the centre in one hemisphere produces movement only of the opposite vocal cord, though stronger stimulation produces bilateral movement. Semon and Horsley, however, have repeated their experiments since the publication of Masini's paper, and they adhere to their conclusion that unilateral stimulation of the centre always produces equal movement of both vocal cords. See F. Semon's contribution to Virchow's Festschrift, 1890, vol. iii. p. 429.motor aphasia (aphemia). 303 subject, the probable situation of this sub-centre for phonation is indicated in Fig. 6 by the letter by in the shaded area. The sub- centre for the oral articulative mechanism (lips, tongue, etc.) lies further back, in the ascending frontal convolution, at and about c, and seems also to extend backwards to the neighbourhood of d, in the ascending parietal convolution.1 Here, then, at b in Fig. 6; we have denoted the probable centre for phonation (the vocal mechanism); and at c and d the centre for the movements of the lips, tongue, etc. (the oral articulative mechanism). Whether or not the foot of the third frontal convolution, at a, is really the store- house of the guiding psycho-motor pictures for spoken speech, we must leave, for the present, an open question; but we may make note of the fact that, although in the lower animals electrical stimulation of this convolution a appears to be incapable of exciting muscular movements in the larynx or mouth, yet in the human subject a destructive lesion at a is even more disastrous to speech than such a lesion at b, c, or d. Effects of Motor Aphasia upon the Production of Speech. 1. Spoken Speech.—Destruction of Broca's convolution (B in Fig. 6) renders the production of spoken speech impossible. This would be the law, without exception or modification, were it not for the existence of the " uneducated centre of the opposite hemisphere." When the educated convolution is destroyed, thoughts seeking expression are thrown upon the very scanty resources of this uneducated convolution. We have already seen how much and how little this convolution can do in such circum- stances. In some cases, it can do nothing at all, the patient being unable to emit any articulate sound whatever. In other cases, the uneducated centre may suffice for the emission of some recurring utterance, or, under excitement, some old familiar oath or other conventional expression. In other cases, again, the words yes and no, and perhaps a few others, may be emitted and used appropriately. We have already discussed these capabilities 1 In the orang outang, this area seems not to extend so far back as to the ascending parietal convolution: it seems to be confined to the ascending frontal. See diagrams of the brain of the macacque monkey and the orang ontang, in an article by Y. Horsley, Nineteenth Century, June 1891.304 the disorders of speech. of the uneducated centre at some length. We have already also seen that, by a process of Further Education, the uneducated centre may, in young people especially, gradually acquire more and more efficiency, until at length it may be able to take the place, and discharge the functions, of the convolution that has been destroyed. In such cases, speech is gradually bettered, and its recovery may be complete. In trying to illustrate the effects of motor aphasia upon the pro- duction of spoken speech, it would be scarcely possible to select more instructive examples than Broca's two original cases—the cases whose publication in 1861 did so much to arouse throughout Europe a great interest in the subject of aphasia. The patients were both inmates of the Bic^tre Hospital in Paris, to which Broca was surgeon. Case I. (Broca, M&moires d'anthropologic, p. 17).—On the 11th of April 1861, there was admitted into the surgical wards of Bic^tre Asylum a man of 51 years of age, named Leborgne. He was affected with a diffuse gangrenous phlegmon of the whole of the right inferior extremity, and of this he died five days after coming under Broca's care. Leborgne had been an old inmate of the Bic^tre Asylum, having lived in it for a period of about twenty years. His history was that he had since youth been subject to epileptic fits. At the age of 30 he had lost his speech, and, be- coming about this time unable to continue at his usual occupation as a lastmaker, he had been admitted into the Bic^tre Asylum. For the first ten years of his residence at the Bic^tre he was active and intelligent, though speechless. He was known in the Asylum by the nickname 'Tan,' because that was the only syllable he could pronounce. In answering questions, or in expressing him- self spontaneously, he said merely Tan, Tan, Tan. He expressed himself well, however, by pantomime. When his interlocutors did not understand his pantomime, he got easily irritated, and added then to his vocabulary " one great oath, one only—' Sacre nom de Dieu.'" After the first ten years in the Bic6tre, his health began to fail. He began to lose the motor power in his right arm ; and the paralysis gradually extended to the right leg. At the same time, sight and intelligence became alike enfeebled. For the last six or seven years of his life he had been constantlymotor aphasia (aphemia). 305 confined to bed. In this condition he was seized with the phlegmonous erysipelas for which lie was transferred to thg surgical ward and placed under the care of Broca. As already said, he died in about five days after his admission. At the autopsy, a very extensive softening was found in the left hemisphere. It involved the greater part of the frontal lobe, as well as the corpus striatum, the Island of Reil, and the con- volutions lying along the margin of the Sylvian fissure. On careful examination, Broca was able to satisfy himself that, in this vast area of softening, the oldest portion was that at about the middle of the frontal lobe. It appeared evident that in this neighbourhood the softening had first begun, and that it was when the softening was limited to this neighbourhood that the patient had been merely aphasic, and not paralysed. The' subsequent hemiplegic paralysis had been caused by the backward extension of the softening. Such was Broca's explanation of the case, arid the explanation received striking confirmation from Case II., which I now proceed to make a note of. Case II. (Broca, Memoires d'anthropologie, p. 34).—The patient, "named Lelong, admitted 24th October 1861, was 84 years of age. He had been a labourer. In April I860, he had had an apoplectic stroke, with temporary loss of consciousness ; for which he had been treated in hospital. He had recovered in a few days, without any hemiplegia, though his walk, without being lame, was a little uncertain. The stroke, however, had rendered him aphasic, so that his vocabulary was reduced to the few words to be presently noted. He was in this condition, able to go about, though aphasic, when, on the 27th of October 1861, six months after the stroke, he fell and broke the neck of his femur. It was for this injury that he was admitted to the Bic6tre Hospital under the care of Broca, and it was from the effects of this injury that he died ten days after admission. Broca's notes about the speech of this patient are very interesting,. He says:—" To the questions one addressed to him he replied only in signs, accompanied by one or two syllables articulated ener- getically and with a certain effort. These syllables had a meaning. They were French words, viz., oui, non, tois (for trois), and toujours. He had a fifth word which he pronounced when 2 Q306 THE DISORDERS OF SPEECH. one asked his name. He then replied, 'Lelo,' for Lelong, his real name. " The three first words of his vocabulary corresponded each to a definite idea. In affirming or approving, he said ' oui,' In ex- pressing the opposite idea, he said ' non! The word tois expressed all numbers, all numerical ideas. And, lastly, whenever these three words were not applicable, Lelong helped himself with the word Houjourswhich, in consequence, had no definite meaning. I asked him if he knew how to write ? ' Qui! If he could do it ? -Non.' 4 Try.' He tried, but lie could not succeed in directing the pen." Broca illustrates these points very fully, by giving details of his conversations with the patient. He tells us that the patient expressed himself well in pantomime, when words failed him. For example, when he was asked what had formerly been his occupa- tion, he imitated very well the action of using a shovel. At the autopsy, a cyst-like cavity filled with serum was found to occupy the room of what is now known as Broca's convolu- tion. It extended far enough upwards to take the place also of the posterior extremity of the second frontal convolution. It was sharply limited and defined in its margin and base, and the hsematin crystals in its wall showed that the cause of the local destruction of cerebral tissue had been the apoplexy in April 1860. Even apart from their great historical interest, these two cases are most valuable: they illustrate so well and so fully the characteristic features of motor aphasia. Broca's convolution being in both cases utterly destroyed, there was, in both, the almost complete annihilation of the power of producing speech. In both cases, the patient was thrown upon the scanty resources of the uneducated convolution of the opposite side; and in both it is evident that a few crumbs of speech had been acquired by this convolution, through " overflow of education." Leborgne can swear " one great oath," when he is irritated. Lelong can articulate, and use intelligently, three or four words, including yes and no. Both patients also exhibit examples of recurring utterances. Leborgne, on all occasions, when he tries to speak, says Tan, Tan. Lelong, when the few words of his vocabulary are inapplicable, always uses the recurring utterance toujours. Both patients are capable of expressing themselves well in pantomime. Lastly,, in bothmotor aphasia (aphemia). 307 patients, though the production of speech is almost completely annihilated, its reception and interpretation are little, if at all, interfered with. It would be exceedingly interesting if we could have before us a series of cases showing the effects of very limited lesions in the various parts of Broca's convolution,—lesions situated, for example, at the positions indicated by a, b, c, and d, in Fig. 6. But, from cases recorded, it is not yet possible to bring together such a series. Here are a few of the best cases of this kind that have as yet been published. Case III. (Eosenstein, Berliner Klin. Wochenschrift, 1868, p. 182). Lesion in the Third Frontal Convolution, presumably in its t(foot" at or about a, Fig. 6.—A woman, aged 22, was admitted into hospital in 1867, suffering from fever of intermittent type, and also from nephritis and uraemia. In the course of her illness, which lasted many months, she had severe headache, vomiting, and convulsions. But she had recovered from these symptoms, and the dropsy and uraemia were also disappearing, when one day she suddenly developed cerebral symptoms of a serious kind. She sat up in bed with dilated pupils and staring eyes. She could under- stand clearly what was said to her, but, in reply to questions, could only say yes, yes. She tried to make her wishes known by gesture. In order to see if she had also lost the power of expressing herself in writing, she was got to make an attempt to write; but, though formerly she had been able to write well, she was now only able to make different kinds of strokes,—no letters. If one of her wishes was guessed, she nodded. She died, a fortnight after the attack, from dropsy in the chest; having remained speechless, though intelligent, till the date of her death. There had been no paralysis. At the autopsy, there was found a clot of the size of a hazel-nut, surrounded by a limited area of secondary softening, in the third frontal convolution. It is to be regretted that its precise situation in the convolution is not given. Let it be noted that in the foregoing case there was loss of the power of writing. I now proceed to make a note of another case of limited lesion in the same locality in which the power of writing was retained.BOB the disorders of speech. Case IV. (Dr Wm. Ogle, St George's Hospital Reports, vol. ii. p. 105). Softening of the foot of the Third Frontal Convolution, a, Fig. 6.—A man of rheumatic constitution, and the subject of aortic and mitral disease. Three days before admission he had fallen down suddenly, without loss of consciousness, and had found himself hemiplegic and aphasic. On examination, his speech was found to be limited to the two words yes and no. At first, he had difficulty in deglutition and in putting out his tongue, but these symptoms passed away in a few days. He understood all that was said to him, and expressed himself well by pantomime. " He could write with his left hand, with sufficient distinctness, words which he could not pronounce when asked to do so. In his writing, there was often a tendency to reduplication of letters. For instance, lie wrote c Testatament' for '■Testament.' But I cannot say whether this was more than the result of defective education." The autopsy showed the brain to be healthy, except at two limited spots, of which the chief "was the posterior part of the third frontal convolution on the left side. Here was a softened and almost diffluent patch, about three-quarters of an inch in breadth, reaching from the highest part of the third convolution, backwards and downwards to the Fissure of Sylvius. The softened part was not actually the most posterior part of the convolution, for there was a narrow unsoftened strip between it and the transverse (ascending) frontal convolution. On cutting into the brain, a second small patch of softening was seen in the centre of the left hemisphere, external to and rather above the corpus striatum, and extending towards the posterior extremity of the Fissure of Sylvius. All the rest of the brain was apparently healthy." The cause of the softening in Broca's convolution was found to be occlusion, by embolism, of a branch of the Sylvian artery. This, I think, is one of the most valuable cases of the kind on record. I have already drawn attention to the fact that in this case the patient retained the power of writing. A very interesting case of limited lesion at the bottom of the precentral sulcus (between a and b} Fig. 6) has recently been put upon record by MM. Balet and Boix, in the Archiv de Neurologie, 1892, p. 231. For purposes of illustration, however, the case is unfortunately not a good one, since, along with the limited lesionMOTOR APHASIA (APHEMIA). 309 in the left hemisphere, there was very extensive disease in the right hemisphere. I therefore merely refer to the case in passing, without quoting it. It is much to be regretted that we have not as yet records of cases of limited lesion at b, c, and d (Fig. 6), respectively. If we may accept the conclusions of the experimental physiologists, the area at b represents the centre for the adduction of the vocal cords in phonation, and, behind this, the area at c and d represents the centre for the oral articulative mechanism (lips, tongue, etc.). In the second chapter, I have shown that the com- plete disablement either of the vocal mechanism or of the oral articulative mechanism renders an individual quite speechless. Does it follow that destruction of the phonating centre at b would have this effect, and that this effect would also be produced by destruction of the centre for oral articulation at c and d? It would follow, I think, undoubtedly, were it not for one possibility. If we are to suppose that the foot of the third frontal convolution, a, is the centre for the guiding psycho-motor images, and that at b and at c and d lie the motor executive centres of the vocal and oral articulative mechanisms, it is conceivable that even after destruction of b, or of c and d, the psycho-motor pictures at a may be capable of having themselves orally exteriorized or executed by establishing new connexions, or rather by availing themselves of connexions previously not much used, with the executive centres of the opposite hemisphere. But it is not of much advantage to speculate about these possibilities,—we have at present so little real knowledge of the functions that are subserved by each individual part within the area of Broca's convolutions. I have touched upon the subject merely to show how desirable it is that we should have careful records of the effects of limited lesions in this area. I may here add that though I have not met with any good records of cases of limited lesions at b, or at c or d> I have, in looking for such, found two good cases recorded by Dejerine (Comptes Rendus des Seances de la Societe de Biologie, March 1891), in which a small area of softening existed internal to &, not in the grey matter, but in the white matter subjacent to it, Both patients were the subjects of motor aphasia, but could express themselves freely in writing. The curious and pnzzling circum-310 THE DISORDERS OF SPEECH. stance about these cases is that there was, in both, paralysis (complete in one and incomplete in the other) of the right vocal cord. This, of course, is not at all in harmony with the results obtained by the experimental physiologists. According to these results, the vocal cords are represented bilaterally in the brain, so that stimulation of the phonating centre on one side of the brain causes adduction of both vocal cords, and destruction of the centre on one side does not cause any paralysis of the vocal cords, either on one side or on both. Though Dejerine notes that the bulb was, in each case, carefully examined, and that no lesion was found in it capable of accounting for the paralysis of the right vocal cord, one is inclined to think that there must have been some lesion low down in the motor tract; because destruction of the whole of Broca's convolution is of common occurrence and has not been observed to produce paralysis of the opposite vocal cord,—the patient retaining his voice in such cases, though he has lost his speech.1 Recognising that it is at present premature to attempt any very precise analysis of the functions of the different areas in the grey matter of Broca's convolution—although experimental physiology is already affording grounds for the belief that such an analysis will be possible at no distant date,—let us return to the consideration of the characteristic features of motor aphasia, as exhibited in the production of spoken speech. Ataxia (Asynergia) Verbalis in Motor Aphasia,—The leading- feature of motor aphasia, when it is well marked, is that the pro- duction of words is rendered impossible, except, it may be, in the case 1 There are upon record a number of other cases in which paralysis of one vocal cord was attributed to an organic lesion in the opposite hemisphere of the brain, the most important being (1) a case reported by Garel (Annales des maladies de Voreille et du larynx, May 1886), in which a paralysis of the left vocal cord was attributed to softening of the foot of the right Ascending Frontal convolution, and (2) a case by Garel and Dor (Ibid., April 1890), in which a paralysis of one cord was attributed to a small lesion in the Internal Capsule of the opposite hemisphere. Both cases will be found given fully in the Thesis by R. Mongorge, entitled Etude sur les Laryngople'gies Unilateral, Lyon, 1890. They are criticised by Semon (Virchow's Festschrift, vol. iii. p. 432), who holds that some lesion lower down in the motor tract must have been overlooked, and points to the fact that, in the experience of every physician, lesion in the foot of the Ascending, Frontal, or in the Internal Capsule, does not produce the loss of voice which would result from paralysis of one vocal cord..MOTOR APHASIA (APHEMIA). 311 of the words that are retained, such as the recurring utterances, a few words in very common use, such as yes and no> and emotional utterances, such as oaths. The patient may possibly be able to call up other words in his mind, by revival of their auditory images, but, if so, he cannot utter them. He cannot utter words, even if they are spoken to him and he-is asked to repeat them. To this disablement of the power of producing or uttering words, the term Ataxia Verbalis has been applied ; and motor aphasia is accordingly often termed Ataxic Aphasia. It cannot be said that the term is a happy one, seeing that, literally, ataxia means want of order, and that, in motor aphasia, the leading feature is not disorder, but is -disablement. I think it a pity that the term Asynergia Verbalis, originally proposed by Lordat in 1843, has not been retained, since asynergia (want of the power of working together) would have been a more appropriate term for this disablement of the complex motor mechanisms of speech than ataxia; and the term Asynergic Aphasia would have been more descriptive of the condi- tion than the term ataxic aphasia. Theoretically, it seems reason- able to believe that asynergia verbalis may be due either, on the one hand, to the obliteration of those psycho-motor images which, in the production of words, are essential for the guidance of the executive motor cells; or, on the other hand,—the psycho-motor images being intact,—to the destruction of the executive motor cells. Further, it should be noted that a disablement of utterance of like character, and as complete as in either of these two cases, will result if the conducting fibres leading from the executive cells are cut across by a sub-cortical lesion. Destruction of the psycho-motor images or memories might, no doubt, be classed as a form of Amnesia Verbalis, if we chose to employ that term in its widest sense, as many have employed it. But, as I have already indicated in the last paper, it is extremely desirable that the term Amnesia Verbalis should be used in a more restricted sense, as the term for one of the most important of the symptoms of aphasia, viz., that Forgetfulness of Words which betrays itself in the loss of the power of calling up words in the mind, when they are wanted for purposes of utterance or of silent thought. We have 110 other term by which we can designate this most important symptom. Using the term in this sense, let us now look at the relation of amnesia verbalis to motor aphasia.312 THE DISORDERS OF SPEECH. Amnesia Verbalis in Motor Aphasia.—We have already seen how prominent a symptom Amnesia Verbalis is in Auditory Aphasia; and how, in that condition, it is associated with its com- panion symptoms, Articulative Amnesia and Paraphasia. In Motor Aphasia, the absence of word-deafness, and the consequent ease with which the patient interprets what is said to him, has led many to think that there can be little or no amnesia verbalis. But this is a mistake. When thought is seeking expression, it leans towards the motor images; and, if these are destroyed, it cannot easily find the words it wants. Possibly it may with diffi- culty find some of them, by reviving the auditory images; in which case Amnesia Verbalis will not be complete. But there is reason to believe that in every case of severe motor aphasia that is due to destruction of the motor images, Amnesia Verbalis is extremely well marked,—even more so, perhaps, than it is in cases of severe auditory aphasia. Trousseau is evidently right when (p. 721) he says, "There is not only asynergia, there is amnesia verbalis. The patients have forgotten the words." He is also evidently right when he attributes to this amnesia verbalis the striking disablement of the power of expressing thought in writing that is exhibited by most of these patients. When motor aphasia is severe, it is often very difficult to prove that the patient has severe amnesia verbalis, because it is difficult to get behind the obvious and prominent asynergia verbalis. In such cases, the retention of the power of expressing thought in writing would prove the absence of amnesia, in proportion as that power is retained. But the absence of the power of expressing thought in writing does not necessarily prove the presence of amnesia verbalis, because the power of writing may be destroyed by lesion in the visual or motor centres for writing. Therefore, in such cases, one is obliged to have recourse to Lichtheim's plan of trying to ascertain whether the patient can call up words in his mind. He asks the patient to indicate with his fingers the number of syllables in the names of familiar objects shown to him. It is, as a rule, only when a patient is recovering from his motor asynergia that the amnesia verbalis can be easily demonstrated. He is then regaining the power of uttering the more common words and phrases, but, in accordance with laws which we havemotor aphasia (aphemia). 313 already discussed, lie finds himself at a loss when he wishes to use a word of less common occurrence, such as the name of a concrete thing. Here is a case which beautifully illustrates this Amnesia of Nouns, in motor aphasia, which persists even when the patient is in process of recovery. Case VI. {Reported by Dr J. Batty Take and Dr John Fraser, Journal of Mental Science, 1872, p. 46.) Shows Amnesia Verbalis. Also illustrates Recovery of Speech after Destruction of Brocas Con- volution.—A female, aged 54, admitted to the Fife and Kinross Lunatic Asylum on December 14th, 1868. Eleven years previ- ously, at the age of 43, she had had an apoplectic seizure. On recovery of consciousness, she had not exhibited any paralysis, but. had been found to be quite speechless. Had been weak-minded as well as aphasic from the day of the attack, but, after some years, had gradually regained her speech to a considerable extent. Had become actually insane only four weeks before admission. After her admission, she rapidly improved in mind, and became almost sane. " During the whole period of her residence, two peculiarities in her speech were observed—a thickness of articulation resembling that of general paralysis, and a hesitancy when about to name anything, the latter increasing very much some months previous to her death." She forgot nouns in a striking way. For example, "she would say, ' Give me a glass of-.' If asked if it was water, she said 'No/ Wine? 'No.' Whisky? 'Yes, whisky.' Never did she hesitate to articulate the word when she heard it She could read, but was never observed to write. She died from caries of the vertebrae. The autopsy showed that the old apoplectic extravasation that had occurred eleven years before her death had resulted in the complete destruction of the posterior part of the left third frontal convolution, the posterior part of the second left frontal, the foot of the ascending frontal, and part of the foot of the ascending parietal. An admirable plate shows the limits of the lesion.1 1 At the date of the publication of this case, the possibility of " further education " in the convolution of the opposite side was not generally recognised ; and the authors of the paper naturally supposed that the case afforded evidence adverse to Broca's views. At the present time, the possibility of such further education is, of course, recognised by every one.314 THE DISORDERS OF SPEECH. This is a most valuable case, showing not only the complete, or almost complete, loss of speech that is produced in the first instance by such a lesion, but showing also recovery of speech by education of the convolution of the opposite side; and showing, further, some of the peculiarities that are presented by such patients when they are in process of recovery. A forgetfulness of nouns (true amnesia verbalis) and a thickness of articulation resembling that of general paralysis of the insane are the two peculiarities noted. As in such cases of advancing recovery of speech we find amnesia of nouns to be so marked a symptom, we may reasonably conclude that amnesia verbalis exists from the beginning in motor aphasia. It probably exists in a proportion commensurate with the severity of the aphasia. The fact that both in auditory and in motor aphasia the patient may be unable to call up certain words, and especially nouns, in his mind, when he wants them for utterance or for silent thought, proves, I think, conclusively that in order to be called up from within with perfect ease the word-percepts must be complete: they must be possessed of both their auditory and their motor images, and these must be revived simultaneously. The loss of either image renders the percept incomplete, and makes its revival comparatively difficult. Hence the amnesia verbalis of both auditory and motor aphasia. The Paraphasia which is so characteristic a symptom of auditory aphasia is rarely exhibited in cases of motor aphasia. If exhibited at all, it is only in a very slight degree ; and, as there is no word- deafness, the patient is at once aware of any error he may make in the use of a word. As amnesia verbalis is so marked a feature in motor aphasia, we may suppose that the imperfect development of the symptom which we have termed Articulative Amnesia may be experienced by the patient in relation to certain words. The auditory image of the word may be imperfectly revived, so that the patient has mentally an imperfect image of it. If so, he will not be able to articulate the word correctly. But it will be seen that, in motor aphasia, it would be practically impossible to know whether the patient's imperfect articulation of the word was due to the imperfect revival of it in his mind, or to the impossibility, owing to the motor asynergia, of articulating it when it is revived. Practically, therefore, it is impossible to distinguish between this Articulativemotor aphasia (aphemia). 315 Amnesia and slight Asynergia (Ataxia) Verbalis, though theoreti- cally it is possible to make a distinction between the two. Lolling and other Faults of Articulation in Motor Aphasia.—When, in recovery from motor aphasia, the uneducated centre of the opposite side is learning to discharge the function of the centre that has been destroyed, the articulation of the patient often exhibits faults which put one in mind of the lalling articulation of children. One of my patients lalled distinctly,—always, for example, using T, an easy letter, for a number of others. He said tage for cage, take for sake. He also used L for W, saying lee for we; and he scamped his words like a child, saying Wison for prison. His case was one of well-marked motor aphasia with right hemiplegia. His intel- ligence was fairly good. Slurring, also, is often met with in these cases of advancing recovery from motor aphasia; and a slight degree of Stuttering is met with occasionally. All these faults in the performance of the previously uneducated centre put one in mind of the imperfect performances of a child who is beginning to speak. The analogy occurred to Trousseau. He says,—" I have asked myself whether it is not simply forgetfulness of the instinc- tive and harmonious movements that we have all learnt from early childhood and that constitute articulative speech; and whether by this forgetfulness the aphasic patient is not put into the condition of a child whom one teaches to lisp his first words, or of a deaf- mute who, cured suddenly of his deafness, tries to imitate the language of the people whom he now for the first time hears speak. There would, however, be this difference between the aphasic and the deaf-mute, that the one has forgotten what he had learnt, and that the other had never learnt it." 2. Effects upon the Production of Writing.—The striking interference with the power of writing that in most cases of motor aphasia co-exists with the disablement of speech attracted the attention of students of aphasia almost from the first. Trousseau, in his splendid chapter on Aphasia,1 expresses himself very clearly on this subject. He says,—a The greater number of aphasics are paralysed in the right hand and cannot write; and if they acquire the habit of writing with the left hand, it is easy to see 1 Olinique MMicale, p. 708.316 THE DISORDERS OF SPEECH. that they cannot trace, in writing, many more words than they can express in speech." He illustrates this proposition by citing a number of cases; among others that of a patient who had only two words in his vocabulary, viz., oui and maman, and who could only write one word, viz., his own name. When asked to write any word, he always wrote his own name; and he did so even when he was asked to write oui or maman. Gairdner,1 in 1867, expresses similar views. He says,—" Not- withstanding some noteworthy exceptions (to appearance) in which aphasic individuals are said, on rather good authority, to have been capable of expressing their thoughts in writing, the usual fact is certainly the opposite,—the aphasic writes at least as badly as he speaks; and when he speaks not at all, he writes not at all." It is in this paper that Gairdner directs attention to that remarkable phenomenon exhibited in the writing of aphasics, the " intoxication " of the brain with a letter. He gives facsimiles of the handwriting of several of his patients, which show admirably how, when the patient tries to write a word—his name, for example —some letter in it is apt to be repeated over and over again, as if the patient could not get the image of it to retire from his mind. When, at a later period, the centres for the visual and graphic- motor images of words in the brain had been differentiated, it was suggested that the troubles of aphasics in writing might be accounted for by supposing that the lesion in Broca's convolution extended into the posterior extremity of the second frontal con- volution, and thus involved the centre for writing. We shall by-and-by have to consider what effect upon writing a lesion so situated may produce. In the meantime it may be remarked that opinion is coming round to the older view of Trousseau and Gairdner, according to which this disablement of the power of writing is one of the common, almost constant, results of motor aphasia. Dejerine thus concludes a recent valuable contribution to the " Study of the Troubles of Writing in Aphasics :"2 —" Thus in proportion as we advance in the study of agraphia we find that Trousseau was right, when, speaking in his celebrated cliniques upon aphasia, of the troubles of writing in aphasics, he said, having in view certainly only the cortical motor aphasics, the 1 Proc. of the Phil. Soc. of Glasgow, 1865-68, p. 104. 2 Comptes Rendus des Stances de la Societe de Biologie, July 1891.MOTOR APHASIA (APHKMIA). 317 only kind known at his epoch, 4 Usually the aphasic is not more able to express his thoughts in speech than in writing; and, although he has retained the movements of his hands and can employ them with as much intelligence as formerly, he is as incapable of composing a word with the pen as he is of com- posing it for its purpose of speech/"1 Bosenstein's case, already quoted (Case III.), shows conclusively that a lesion strictly limited to the third frontal convolution may be as destructive to the power of writing as it is to that of speech. It is universally admitted, however, that there are exceptional cases, in which patients, presenting typically the symptoms of motor aphasia in their spoken speech, can yet express themselves correctly in writing,—thus showing that they have mentally little or no amnesia verbalis. It is generally believed that in these cases the lesion is not cortical, but sub-cortical; and that it is so situated as to cut across the pathways leading to the organs of phonation and articulation, whilst it leaves intact the pathways connecting the motor speech-centre with the centres for writing. Gowers (p. 106) gives a diagram illustrating this possibility. But, granting that the majority of these cases may thus be referred to the category of cases due to sub-cortical lesion, I think it far from certain that this exceptional retention of the power of writing is always to be so explained. There is, for example, Dr Win. Ogle's case (Case IV.), in which the foot of the third frontal convolution was almost wholly destroyed, and yet the patient could, in writing, express himself pretty correctly, though he was otherwise typically aphasic. Is it not possible that that patient was markedly auditif, and that his vivid auditory word-images were in themselves sufficiently potent to call up the equivalent visual and motor images in the writing centres ? I do not see how the patient's retention of the power of writing can be other- wise explained. And then, again,—always supposing the guiding psycho-motor images for oral speech to be specially stored in the foot of the third frontal convolution,—is it not possible that, in a case in which this convolution has escaped while the feet of the ascending frontal and ascending parietal have been destroyed, the word-images formed in the foot of the third frontal are capable 1 Glin. Med., p. 718.318 the disorders of speech. of acting upon the centres for written speech, while no longer susceptible of being orally exteriorised or executed, owing to the destruction of the motor executive cells ? I shall presently, in connexion with the treatment of motor aphasia, make a note of a case of my own, in which writing was retained, and in which I was inclined to attribute the destruction of oral speech to a lesion so situated. When future clinical and pathological observation and experimental research have successfully analysed the functions of the various parts of Broca's convolution, we shall have clearer views upon such questions as these two. Effects upon the Reception and Interpretation of Speech. 1. Audible Speech.—The fact that, in motor aphasia, the reception and interpretation of audible speech are little, if at all, interfered with, has already been abundantly illustrated. The auditory word-images, revived from without by speech that is heard, are quite capable of calling up the meanings of words in the mind without assistance from the companion motor images. There is practically, therefore, no word-deafness in motor aphasia. Yet it is highly probable that in the healthy brain, when the auditory images are strongly revived from without, the motor images are also, though perhaps faintly, revived along with them.1 Has this revival of the motor image no value in assisting the auditory image to call up the meaning? I do not think this question has ever been carefully considered by students of aphasia. My own impression is that the motor images have a certain slight value in this respect. To put the matter to proof, patients with motor aphasia should be tested with the words which are known to be the least deeply imprinted, viz., the names of concrete things. My own method is to ask the aphasic patient to touch, in succession, as I name each part, his nose, his eary his chin, etc.; and my belief is that in a large proportion of cases of motor aphasia the patient fails to interpret some of these names, or 1 Bain says,—" While intently listening to a speech, we are liable to follow the speaker with a suppressed articulation of our own, whereby we take the train of words into a vocal embrace, as well as receive it passively on the sense of hearing. This is an instance of concurring or compound association."— Senses and Intellect, 3rd ed., 1868, p. 353.motor aphasia (aphemia). 319 has a difficulty in interpreting them, which he shows by hesitating and considering before he touches the part. I have had no autopsy on any one of the cases which exhibited this phenomenon, so that I cannot say for certain that there was in them no element of auditory aphasia; but I may say that I regarded the cases as cases of pure motor aphasia. The point, I think, deserves attention. 2. Visible Speech, Written and Printed.—Although, in motor aphasia, the reception and interpretation of audible speech are little, if at all, interfered with, the reception and interpretation of speech that is written or printed are interfered with, as a rule, in a marked degree. This loss of the power of reading (Alexia) is not so absolute as it is in a case of true word-blindness, due to the destruction of the visual images at C (Fig. 2); nevertheless, as a rule, it is very marked. It early attracted the attention of Trousseau, who quotes many instances in illustration of it. In some of these cases there seems to have been an element of what is now termed sensory aphasia, but others appear to have been cases of aphasia purely motor. Of these latter, perhaps the best is the celebrated case of the patient who could only speak one word, viz., the meaningless recurring utterance Cousisi, and who could only write one word, his own name, Paquet. " We ask him his name, 'Cousisi;' we pray him to write it, he writes 'Paquet/ We ask then him to write his address, he writes again ' Paquet;' then, perceiving that he has made a mistake, he turns his head with an air of impatience, saying 4 Cousisi/" This patient, who had been a well-educated man, occupied himself much with reading. " He reads sometimes all day, and I am bound to admit that he follows the lines sufficiently well, that he turns the pages at the right time, and that he seems to understand what he reads; but by a little experiment one can prove quite clearly that he really understands much less than he seems to do. I take the book and read aloud the bottom of a page, and I tell him to follow with his eyes, and turn the page when I come to the end of it; he never does it at the right moment." He had in his possession a number of little printed romances, such as one might read and throw aside, as one disposes of a daily newspaper. Trousseau emarks that it would be an intolerable punishment to any ordinary320 THE DISORD KRS OF SPEKCH. person to be forced to read these stories over and over again. But this patient did so voluntarily. " He reads ; he reads again ; he reads always with the same attention." One of the explana- tions suggested is, that he understands imperfectly, and does not remember well, what he reads. I think most physicians who have watched cases of motor aphasia with care will agree that, in the vast majority, there is an interference with the power of reading, such as is illustrated by this case of Trousseau's. Sometimes it is greater and sometimes less; in almost all cases it is distinctly present. It is therefore the more surprising to find that Lichtheim1 thinks that in pure cases of motor aphasia the power of understanding written and printed words is intact. Lichtheim says,—"According to the diagram, the power of reading aloud should be lost, but that of silent reading preserved intact. I am sure that in uncomplicated cases this must be so, but I much regret that I have not had a case to observe during the last few years. .... It has been often specified [in literature] that the faculty of reading was intact; on the other hand, Trousseau has shown that many aphasics appear eager in their reading and yet do not understand what they read..... I shall return to this point, and show by personal observations how I think this contradiction may be explained." At page 468 he says,—"These cases appear to me to have been instances of total aphasia [combined sensory and motor aphasia] in which the symptom of word-deafness has already been recovered from," but in which the remains of the lesion on the sensory side are sufficient to interfere with the perfectly free transit of incoming speech to the mind. But, in motor aphasia, more or less interference with the power of reading is so exceedingly common—almost constant—that I do not think it can be always explained in this way. An explanation that appears more generally applicable may be founded upon—(1), the suggestion of Professor Bain,2 that the motor images have a cer- tain value in connexion even with the reception and interpretation of speech ; and (2), the fact emphasized by Ferrier, that there is in educated people an exceedingly close relationship between the visual images of letters at C and their motor articulative images o 1 Brain, Jan. 1885. 2 See footnote, page 318,MOTOR APHASIA (APHEMIA). 321 at B,—a relation almost as intimate as is the relation of these motor images at B with the auditory images at A. Ferrier (p. 441) says, " Here the articulatory or motor element is the central point of two sensory cohesions,—the one auditory, the other visual,—which two are regarded as equivalent." If the visual images of letters are more intimately associated with the motor images at B than with the auditory at A, it necessarily results that the destruction of the motor images at B will in every case of motor aphasia cause serious interference with the power of reading; because the visual images at C can only revive the meaning by acting upon it through the images of the primary couple, and the destruction of B breaks one of the connecting links. Effects upon the "power of Repeating or Echoing Spoken Speech, and upon that of Copying Written Speech. When motor aphasia is complete, the power of repeating or echoing spoken words is of course destroyed as completely as is the power of volitional or spontaneous utterance. In both cases, the power of utterance would be lost permanently were it not for the Further Education of the convolution on the opposite side of the brain, which convolution, as we have seen, may gradually acquire articulative power. I think it is worthy of note, at this point, that the acquisition of articulative power by the previously uneducated centre is furthered if the patient is made to attempt the repetition or echoing of words and letter-sounds spoken to him. But I shall have something to say specially about the education of these cases presently. As to copying of written or printed vjords, it is not materially interfered with in motor aphasia. If, owing to paralysis, the patient cannot copy with the right hand, he can do so with his left. It is generally found that he has no difficulty in translating printed into written characters. The contrast between what he has written from copy and what he has written spontaneously is often remarkable. Thus a patient of my own, when asked to write, to my dictation, the words " yesterday at Ayr Police Court," wrote " Glamen a dug gu Puegen Tued Gow Mgu," but when shown the words in print he copied them in writing very legibly. This patient was not, in the proper sense of the term, " word-blind."322 THE DISOKDERS OF SPEECH. He could give some account, though an incorrect one, of the meaning of any sentence in a newspaper that I asked him to read. Other Phenomena occasionally associated with Motor Aphasia. 1. I have already, in a former chapter, made a note of the occa- sional occurrence of Amimia and of Paramimia in connexion with motor aphasia. In Amimia, the patient has lost the power of using such simple pantomimic signs as nodding the head to indicate the affirmative. In Paramimia, he misuses these signs; shaking the head, perhaps, instead of nodding it, when he wishes to indicate the affirmative. It is usually in severe cases of motor aphasia that amimia and paramimia are found as associated symptoms. They generally pass off quickly when the patient begins to improve. In the great majority of cases of motor aphasia there is no impair- ment of this power of pantomimic expression; often the patient is, in this way, able to express himself with striking vivacity. 2. Another symptom occasionally exhibited by severe cases of motor aphasia is an inability to protrude the tongue by effort of the will. Most aphasic patients are quite able to protrude the tongue, and to move it about freely in all directions. But in a few cases the patient is unable to protrude the tongue by effort of the will; and yet he may be able to protrude it instinctively and in- voluntarily. Among the recorded cases of patients unable to protrude the tongue voluntarily, there is one in which the patient protruded it involuntarily in the act of licking his lips as a pre- paration for the effort to protrude it voluntarily; and another in which the patient protruded the tongue instinctively when a sweet lozenge was being carried to his mouth. Treatment of Motor Aphasia. In training a patient with motor aphasia to speak, it is often of advantage to him to pronounce simple words in his hearing and ask him to repeat them. It is largely by practice in such repeti- tion of words heard that the patient, in so many cases, re-acquires the power of speech. He educates in this way the previously uneducated centre. But I think the process may be expedited if it is conducted on scientific principles. It should be rememberedMOTOR APHASIA (APHEMIA). 323 that the patient has lost the power of uttering even the simple letter-sounds. If he can be got to master the letter-sounds in the first instance, it will be more possible for him, afterwards, to pro- duce their combinations in the form of words. It happens that I have had lately under treatment a case of motor aphasia in which the education of the patient after this manner was remarkably effective in restoring to him his power of speech. Nowadays it is scarcely worth while to publish any case of aphasia that does not include a record of the morbid changes in the brain. But I make an exception in this case, not only because of its bearings on the treatment of motor aphasia, but also because the case is one of that comparatively rare variety in which the patient, utterly aphasic as to spoken speech, is yet capable of expressing himself well in writing. Case 'VII. (Personal Observation.) Motor Aphasia with Reten- tion of the Power of Writing. Method of Education resorted to in restoring Spoken Speech.—Patrick Keaney, aet. 25, single, a stoker on the railway, recently returned from America; admitted to Ward 31 on 10th September 1892. Complaints.—Loss of speech. Loss of power in right arm and leg. Disease of the mitral valve of heart. History.—The patient, who is a respectable and fairly well educated young man, states that he never had rheumatic fever or any illness attended with pain about the region of his heart. Up to the beginning of his present illness he always enjoyed good health, but for the last five years he has noticed that he has easily got out of breath on exertion, and that on such occasions he has had palpitation of the heart. In 1889, the patient, in company with a fellow workman, his cousin, emigrated to America. They settled in Pittsburg, where Patrick got employment on the railway as a stoker. He had long hours, and got his meals very irregularly. On the 13th of May 1892, he came home from work feeling very tired, and went as usual to the restaurant, about fifteen yards from his own lodgings, to get his supper. He was taking a cup of tea, when, on raising his cup for the third or fourth time, he suddenly found that the power was leaving his arm, and that he could not raise the cup to his mouth. Alarmed at this, he rose,324 THE DISORDERS OF SPEECH. paid his reckoning, said good-night to the landlady, and went to his lodgings. His cousin (who has returned wifeh him from America) states that when Patrick entered the room at the lodg- ings it was evident that there was something seriously wrong. He did not seem to know what he was doing; he could not speak a word; and he was sweating profusely. Yet he did not appear to be lame in walking. He at once went to bed, and in doing so,, was able to undress himself. In a few minutes thereafter he became unconscious, and in this condition he remained all night, tossing about restlessly in his sleep. When, in his sleep, he tried to raise himself in bed, it was noticed that he was powerless 011 the right side. In the morning, when he awoke, it was found that he was totally paralysed on the right side and totally speechless. He was removed to the Pittsburg hospital, where he was carefully tended for thirteen weeks. The cousin states that for the five first days he did not recognise his friends ; but the patient himself says that this is a mistake. The patient states that in about four weeks after the beginning of his illness he had to some extent recovered power in the right leg, so that he could stand without assistance, and could walk a little, if, in doing so, he supported his right shoulder against a wall. About this time, also, he acquired the power of saying yes and no in answer to questions, always using these words appropriately. After this time, steady improvement continued in the leg; but it was not till over three months after the date of the seizure, when he was at sea, 011 his voyage home, that he observed any return of power in the arm. He then began to move his shoulder, and in a less degree to flex and extend his elbow joint; but no power of movement has even yet been restored to his wrist joint, and only very slight power of flexion has returned to the joints of the fingers. About six weeks after the date of the seizure (two weeks after he first began to say yes and no), the patient for the first time replied to a question in writing; using his left hand in doing so. He was asked, "How are you?" and replied in writing, "Well, I 110 feel so bad." After this, he replied to questions in writing almost every day; and he states that he never from the first had any difficulty in calling up in his mind the words that he wished to write, although, naturally, he found it somewhat difficult to write with his left hand.MOTOR APHASIA (APHEMIA). 325 On 15th August, he sailed from New York, in company with his cousin; and in due time he arrived in this country, and was admitted to the Eoyal Infirmary. On his admission (10th September), it was found that only a slight trace of lameness remained in the right leg. The arm, however, was seriously paralysed. He could move his shoulder joint freely, being able to raise the arm over his head. He could also flex and extend the elbow joint, but he did so feebly. The wrist joint he could neither flex nor extend in the slightest degree. In the fingers, which he kept habitually semiflexed, there was very slight power of voluntary flexion, but none whatever of extension. The mouth was drawn very slightly to the left side, and the tongue, when protruded, deviated very slightly to the right. The heart was much hypertrophied, and there were well-marked bruits of mitral obstruction and regurgitation. From the notes of the case, which have been taken with great care by my former house-physician, Dr W. F. Robertson, I extract a few of the leading particulars regarding the patient's speech. On his admission, almost the only words which the patient could articulate correctly were yes and no; but he made attempts to articulate many other words, and it was strikingly noticeable that he always produced sounds distinctly articulated, never an inar- ticulate slur. Thus, ten days after admission, when he was already beginning to improve, he said, in reply to questions, " Pittsburd " for Pittsburg, " C&seno " for Glasgow, " Tunnes " for Stirling, "Skennes" for September, "Toosday" for Tuesday, " Much-a-day " for Wednesday. When asked what he had had for tea, he said "Ped" for bread, "Butter" correctly,and "Tea" correctly. When he was tested with the Physiological Alphabet, it was found that he had lost the power of producing the greater number of the Consonant sounds. With regard to the vowels, whilst he could always produce the middle vowel-sounds Ah and Oh, he had difficulty with the vowels at the two ends of the list, often converting the vowel-sound ee into eh, and oo into oh. Here is a note of his articulation of the various consonant sounds of the Physiological Alphabet. Labials—P, as in Papa, is given correctly. B in Baba sometimes correct, sometimes as P, patient saying " Paba." M correct. W as wh, wee wee being given as " whey whey."326 THE DISORDERS OF SPEECH. Labia-Dentals.—F generally given as P. V generally as F. Linguo-Dentals.—Thl as F or H. Th2 as N, D, Y, or F. S as F. Z as F. Anterior Linguo-Palatals.—Sh as F. T correct. D as T. N correct. L sometimes correct, but sometimes as D or T or N. B occasionally correct, but generally as N, T, D, or Wh. Posterior Linguo-Palatals.—K sometimes correct, but sometimes as T. G always as K. JVg—as in aing—sometimes as N, some- times as S. H sometimes correct, sometimes as Y. Y sometimes correct, sometimes as Wh. It should be noted that in testing the patient's power of articu- lating those various letter-sounds, simple syllables were used, such as in Papa for P, in Mama for M, etc. In singular contrast with the patient's difficulty of articulation, was his comparative facility of expressing himself in writing. The right hand being paralysed, he used his left. Even in his writing, however, distinct deterioration was observable. We were allowed to inspect several of the letters that he had sent home to his father from America before his illness ; and in them, although he makes a misspelling now and then, and writes the first personal pronoun with a small i, he expresses himself with exceptional intelligence and in creditable English. The deterioration was shown most markedly in the written account of himself which, at my request, he gave us a few days after admission. In this account, there are, besides misspellings, frequent omissions of words, and some insertions of superfluous words. He begins the account as follows:— " Patrick Keaney is was in born in the city Stirly [Stirling] in the year 1867 i worked at varous kinds jobs principally woods i made my mind to go to America i sailed in Ancor-liner Ethopa to youngstown when i went to work in the rolling mills then i went Pittsburg where got work as a fireman to a engine/' etc. Patient could read a book silently, though unable to pronounce the words; but in doing so he easily became fatigued, getting headache and a feeling of confusion in his head. He also easily forgot what he had just read. One of the chief points of interest in the case was the singularly rapid progress the patient made, under tuition, in the re-acquirement of articulate speech. I think no case could have more clearly demonstrated the utility of the Physiological Alphabet as a meansMOTOR APHASIA (APHEMIA). 327 of tuition. We did not trouble the patient with the names of the letters, but taught him from the beginning the letter-sounds of the physiological alphabet. In doing so, we adopted what may be called the "Mother's Method." Beginning with the Labials, we taught him to say papa, apap> appa, thus giving him the consonant P as an initial, a terminal, and a mid-letter. Then we taught him to say baba, abab, abba; then mama, amam, amma; then wee wee ; and so 011 throughout the alphabet. He was shown by " lip-reading " how to place the lips, tongue, etc., for the pronunciation of each letter-sound. Being an intelligent and diligent pupil, he soon was able to go over the whole of the letter-sounds in this triple fashion, from one end of the alphabet to the other, by heart, without looking at the paper. We then supplied him with the children's books known as the "Little Primer" and the "Little Reader;" and often, afterwards, we would find him in the side-room by himself, care- fully reading aloud from his primer such little sentences as " I have a cat," " he has a dog," etc. At the beginning of January 1893, when he left the Infirmary, he could say anything he wished to say, almost without a mistake in articulation; although he still spoke carefully, slowly, and word by word,—in staccato fashion. His writing and spelling had also greatly improved. When I last saw him—July 26th, 1893—there was still something of this char- acter in his speech, but the patient had made much progress since leaving the Infirmary in January. I asked the patient whether at any time since the seizure he had ever experienced difficulty in forming words in his mind. I asked him to consider this question carefully, and reply to it in writing. Here is his reply, dated December 3rd, 1892:—"With regard to my forming words in my mind, i could always form them in my mind but trouble was in getting them out i could not get them out at all and after makeing all the signs i could think of to my friends if they could not understand me i would have to take paper and a pencil and write it down for them." On October 17th, he wrote, "When i came in here i could only say yes and no that was all i could say, but now i could say very neare any thing if i could take time." It is not my intention to enter into any discussion as to the probable nature of the cerebral lesion in this case. From the facts stated, the reader can form his own theory; but I may say that328 THE DISORDERS OF SPEECH. my own impression is that the cause of the paralysis and aphasia was probably embolism in a branch of the Sylvian artery. It is one of those exceptional cases of motor aphasia in which the patient retains the power of expressing his thoughts in writing* there being little or none of that amnesia verbalis which is usually associated with motor aphasia. The patient could call up words in his mind quite easily, only he could not articulate them. How was it that the power of calling up words in the mind was retained ? We have already seen that the retention of this power may possibly be explained on any one of three hypotheses:—:(1.) The lesion in Broca's area may have been a sub-cortical one, leaving the grey matter of the cortex unaffected, and cutting across only the motor tract for spoken speech. (2.) The areas b and c d may have been destroyed, whilst the area a, in the foot of the third frontal, was left intact. (3.) The whole of Broca's area may have been destroyed, but the patient, if strongly auditif\ may have been able to recall the words by reviving their vivid auditory images. I leave the reader to take his choice of any one of these three hypotheses. For my own part, I am inclined to prefer the second. If the lesion was of embolic origin, it was almost certainly cortical ; and if cortical, it evidently extended into the motor regions b and c dy the centres of the articulative organs, because the face was slightly pulled to one side, and the tongue, when protruded, deviated slightly towards the side paralysed. In the present state of our knowledge of the functions of the various parts of Broca's area, we can form no very distinct opinion; but I am inclined to think that the motor images or pictures, presumably stored at a, in the foot of the third frontal, were intact, but could not be exteriorised or executed on account of the destruction of the executive cells at b and c d. The re-education of the patient perhaps enabled him to execute them by means of the executive area in the convolutions of the opposite side. It should be noted that, in this case, the absence of amnesia verbalis made the education of the patient exceptionally easy. There is, indeed, every reason to believe that the patient's own efforts at articulation would naturally, in the course of a year or two, have led to restoration of speech. But no one who watched the case from day to day could doubt for a moment that the progress of the patient was greatly accelerated by his use of theconduction aphasia. 329 physiological alphabet. By its aid, he learned in a wonderfully short time to master all the articulate sounds of which speech is composed, and to combine them correctly, so as to articulate the words he could so easily call up in his mind. In relation to the Education of cases of motor aphasia, I think the case of interest; and I offer it as a contribution to that subject. Conduction Aphasia (the Leitungsaphasie of Wernicke). Auditory aphasia is, as we have seen, produced by lesion at the auditory centre A, and motor aphasia by lesion at the motor centre B. I now propose to say a few words about the variety of aphasia which results when a lesion is so situated as to cut across the conducting fibres which extend between A and B, and keep these two centres in physiological connexion. In crossing from the first temporal to the Broca's convolution, these fibres must necessarily pass under the floor of the Fissure of Sylvius, and under the Island of Beil. A softening or other lesion in the floor of the Sylvian Fissure, or in the Island of Reil, is therefore very apt to cut them across. The variety of aphasia which results from such a lesion was first described by Wernicke, in his original paper of 18741 Its pecu- liarity is that, whilst, on the one hand, there is no word-deafness, and, on the other hand, no asynergic difficulty of articulation,— both auditory and motor centres being intact,—there is marked Paraphasia. The patient, in expressing himself, uses wrong words, and especially wrong nouns, because, the connexion between A and B being broken, the motor images are deprived of the important guidance in the choice of words which is normally given to them by the auditory images. Wernicke {Op. cit., p. 26) says, " The patient understands everything, being thus quite unlike a patient suffering from the form of aphasia [the auditory] just described. He can also say everything, but the choice of the right words is disturbed in the same way as it is in the form just described. The sound-image is here indeed intact, and it is also in normal relation with the other sense-images which go to form the percept; but, as the connecting path is interrupted, it cannot throw 1 Der Aphasiche Symptomencomplex, p. 26. 2 t330 the disorders of speech. into the scale its important influence in directing the choice of the motor images." In another important paper, published in 1886,1 the same observer says,Conduction aphasia is characterised chiefly by its negative symptoms. Where no sensory and no motor aphasia is present, but where, in speaking, there is Paraphasia, the erroneous use of words, we have got to deal with disturbed conduction between the centres A and B." One of the best cases of conduction aphasia yet published has been put on record by Lichtheim. I may here insert a brief note of it. Case of Conduction Aphasia. (Lichtheim, Brain, 1885, p. 445).—A man, aged 46, admitted into hospital at Berne on the 3rd of April 1883. N"o history of his illness could be obtained. Slight paralysis in right arm and leg and in right side of face. Sensation normal. Understanding of spoken speech and of printed and written speech unaffected. In production of speech, exhibits marked paraphasia. " When asked to relate his history, he strings together, in a fluent manner, numerous words of which scarcely one now and then can be made out. The following were noted : ' Evening, five and twenty, and.' Patient is aware of the incorrect- ness of his diction, and tries to assist himself with gestures. He succeeds better with short words and answers. Thus in answer to the question, 'What was there for supper?' he answered,'Bread, meal, potatoes/ with only two mistakes. His own name he mutilates." .... "His writing is very imperfect. He mixes up the order of letters in a word; and usually stops after an attempt of short duration." As to repeating and copying. "When he repeats connected sentences he manifests the same defects as in volitional speech ; single words are pretty correctly rendered." .... " He can copy what is set before him with absolute correctness." At the autopsy the chief lesion was a softening with depression in the Island of Eeil and the floor of the Sylvian Fissure. A point brought out in this case is, that besides being present in his volitional speech, the Paraphasia was also present in sentences repeated to dictation. The Paragraphia should also be noted; 1 Fortschrift der Med., 1886, i. p. 377.CONDUCTION APHASIA. 331 but Lichtheim says that volitional writing was not sufficiently tested. There seems, on the whole, to be little to distinguish this form of aphasia from a case of auditory aphasia in which the word-deafness has already been recovered from, but the amnesia verbalis and paraphasia persist. The absence of word-deafness from the beginning, in conduction aphasia, would seem to be the chief point of difference.332 the disorders of speech. CHAPTEE XII. Aphasia in relation to Organic Diseases of the Brain— Continued. Visual Aphasia.1 I now come to consider the effects of lesion in the centre C, in which are stored the visual memories of letters and words, written and printed. The centre C (Fig. 7) includes the Angular Convolution, which 2 Fig. 7. curves over the posterior extremity of the First Temporo- Sphenoidal Fissure, and the Supra-Marginal Convolution, which curves over the posterior extremity of the Sylvian Fissure. Of the 1 I use the term Visual Aphasia in preference to Word-Blindness, because, as we shall see, destruction of the centre C causes not only Word-Blindness but also Agraphia.VISUAL APHASIA. 333 two convolutions, the Angular constitutes the more important part of the centre. Both convolutions belong to the inferior part of the Parietal Lobe,and both are supplied with blood by the Sylvian artery. It is now universally admitted that destruction of the centre C produces Word-Blindness, with consequent annihilation of the power of reading (alexia). This is its well-known effect upon the Keception and Interpretation of written and printed speech. But what is its effect upon the Production of written speech ? There are upon record many cases of word-blindness in which the patient, utterly unable to read—unable to read even his own handwriting,—could yet write fluently and correctly. There are, however, other cases in which the word-blind patient was also agraphic, being able to write little or nothing correctly. Until recently, it was supposed that when the word-blind patient could write correctly he could do so because much previous practice in writing had imprinted the motor images of writing so securely upon the graphic-motor centre at D that these motor images sufficed for purposes of writing, though all guidance from the visual images at C had been lost, owing to destruction of this, the visual word- centre ; and, on the other hand, when the word-blind patient could not write, it was supposed that the graphic-motor images at D had not been sufficiently well imprinted by practice to enable them to act independently. But recent observation has thrown a new light on the subject. It has recently been shown quite conclusively that the visual images at C are, in all cases, important, not only for the reception and interpretation of written and printed speech, but also for the production of writing. It has been shown, in fact, that when the centre C is destroyed the patient can neither read nor write. As to reading, he is word-blind; as to writing, he has Amnesia Literarum, and therefore cannot call up in his mind the visual images of letters and words required for purposes of writing. It is now considered to be improbable that the graphic-motor images at D can in any single case be so strongly imprinted as to suffice for the act of writing, independently of any guidance from the visual images at C. How, then, are the cases of pure Word-Blindness without Agraphia—in which the patient can write correctly, though lie cannot read even that which he himself has written—to be334 THE DISORDERS OF SPEECH. accounted for ? It is now believed that in these cases the visual word-centre C remains intact, and that so, also, do the pathways for the influences by which it is acted upon from within when words, revived in the mind, are being translated into writing; but that, on the other hand, the pathways along which, as we shall see presently, influences pass from the primary visual centres, in the two occipital lobes, to the visual word-centre C, in the angular and supra-marginal convolutions, are cut across, so that the word-images in C, though they can still be revived from withiny can no longer be reached and revived by impressions coming to them from with- out Destruction of the visual word-centre C, therefore, causes both word-blindness and agraphia; but the cutting off of the visual word-centre C from the primary visual centres in the two occipital lobes causes simple word-blindness without agraphia. The reader may remember the interesting discussion that, some years ago, was carried on by Ferrier and Munk, as to the localiza- tion of the cortical centre for vision. Ferrier originally held that it was in the Angular Convolution, and Munk that it was in the con- volutions in the posterior part of the Occipital Lobe. Clinical and pathological observation is now leading up to the conclusion that both observers were partly right. The subject cannot yet be said to be fully investigated or made clear in all its relations, but everything tends to show that the occipital lobe, especially its posterior extremity, and its inner surface in the neighbourhood of the Cuneus and Calcarine Fissure (see Fig. 12), is the centre for primary visual impressions, and that the Angular Convolution and its neighbourhood form a centre of a higher nature, one of whose functions seems to be the storage of the visual images of things and of words. It is now quite established that the primary visual centre in each occipital lobe is connected with both eyes; and that it is con- nected, not with the whole, but only with the half of the retina in each eye—the lateral half 011 the same side of the head as itself. Therefore destruction of the primary visual centre in the occipital lobe causes Homonymous Hemianopsia; that is to say, it renders the patient blind in half of his field of vision, the right or left half as the case may be; this half-blindness being termed "homonymous" because it is on the same side in relation to both eyes.VISUAL APHASIA. 335 It will be remembered that, in passing backwards to form images on the retina, rays of light cross within the eyeball. When our eyes are directed straight forward, rays of light coming from an object in the right half of the field of vision cross over and form an image of the object upon the left half of the retina. If this left half of the retina be blind in both eyes, it is thus the objects to the right of the patient that are invisible to him; and, as it is the left half of the retina that is blind when the primary visual centre in the left occipital lobe is destroyed, the patient, in such a case, has right homonymous hemianopsia. In other words, the law is that destruc- tion of the primary visual centre in the occipital lobe causes homonymous hemianopsia in the opposite half of the field of vision. Destruction of the higher visual centre at C, causing, as already said, both word-blindness (alexia) and agraphia, does not, according to recent observations, cause hemianopsia. Concentric contraction of the field of vision in both eyes, but most marked in the eye of the opposite side, seems to be often associated with it; but even this is not proved to be a necessary consequence of it. If, how- ever, the lesion at C penetrates deeply into the subjacent white matter, it will cut across the "Eadiation of Gratiolet"—a band of white fibres passing backwards to the primary visual centre in the occipital lobe, and forming part of the pathway between the retina and that centre,—and will produce homonymous hemianopsia as effectually as a lesion of the primary visual centre itself would. In such a case, the symptoms would be word-blindness, agraphia, and homonymous hemianopsia. The last point of importance to be noted is, that this higher centre at C is in relation not only with the primary occipital centre of its own side, but also with the primary occipital centre of the opposite hemisphere. It follows that a lesion of the primary occipital centre on the same side, causing hemianopsia, does not cut- off the higher centre C from incoming impressions, and does not render the patient word-blind. In order that the higher centre be rendered word-blind though itself intact, it must be cut off from its connections with both occipital lobes, by a lesion which cuts across the fibres coming to it from each of them. To sum up these rather complicated conclusions, it may be said, —(1.) That destruction of the higher visual word-centre C causes both word-blindness and agraphia. (2.) That destruction of C,336 THE DISORDERS OF SPEECH. causing word-blindness and agraphia, does not also cause hemian- opsia if the lesion is limited to the grey matter; but that if the lesion penetrates deeply into the subjacent white matter and cuts across the Radiation of Gratiolet it does also cause hemianopsia. (3.) That a lesion in the primary visual centre in the left occipital lobe causes right homonymous hemianopsia, but does not render the patient word-blind, because the higher centre at the angular convolution is still in connexion with the primary visual centre in the right occipital lobe. (4.) That a lesion in the white matter of the occipital lobe so situated as to cut across the fibres passing forwards from both occipital lobes to the left angular convolution renders the patient word-blind but not agraphia As such a lesion necessarily involves also the Radiation of Gratiolet, the patient has at the same time right homonymous hemianopsia. There are thus in practice two classes of cases of word-blindness to be met with,—(1.) The cases in which the patient is at the same time agraphic; such cases being due to destruction of the centre C (2.) The cases in which the patient, though word-blind, is not agraphic; such cases being due to a lesion in the white matter of the occipital lobe, which has severed the fibres connect- ing the centre C with both of the primary visual centres, in the two hemispheres. It is especially to the recent work of two observers, Dejerine and S^rieux, that we owe this clear distinction between these two classes of cases of word-blindness. They have put upon record a series of cases so complete and convincing that the distinction between the two classes of cases may be regarded as established. In bringing these new observations under the notice of the reader, I cannot do better than insert here the diagram employed by Dejerine to illustrate the connexion of the eyes with the primary visual centres, and, through them, with the higher visual word- centre C. An examination of this diagram (Fig. 8) will enable the reader to understand quite easily the relation of the eyes to the primary visual centre in the occipital lobe. In the diagram, the left optic tract and its connexions are, for the sake of distinctness, given in deep black. The reader will, on looking at the diagram, at once understand how section of the left optic tract, B 0, would produce homonymous hemianopsia in the opposite half of the field ofVISUAL APHASIA. 337 vision. He will also see that the same effect would be produced by a lesion further back, either in the Optic Thalamus, in the Fig. 8.—(After Dejerine.) Eadiation of Gratiolet, or in the Primary Visual Centre itself. But he will note that word-blindness will not, in any of these cases, be added to the hemianopsia, unless the lesion be situated at about X, and so cut across not only the fibres which connect the angular convolution with the left occipital lobe, but also those which connect it with the right one. Perhaps additional clearness will be arrived at from the study 2 u338 THE DISORDERS OF SPEECH. of the following diagram, Fig. 9, which is merely Fig. 3 repeated, with the addition of the dotted lines and circles. Fig. 9. In Fig. 9, let L.O.L. and R.O.L. represent the primary visual centres in the left and right occipital lobes respectively. A lesion at X will cut across the fibres passing forward from these centres to the angular convolution C. It will cause word-blindness, but not agraphia. It will also cause homonymous hemianopsia, because, as shown in Fig. 8, such a lesion always involves the Radiation of Gratiolet. On the other hand, destruction of C would cause both word-blindness and agraphia. But it would not cause hemianopsia unless (see Fig. 8) the lesion penetrated deeply enough into the subjacent white matter to cut across the Radiation of Gratiolet. Hemianopsia is thus a very common accompaniment of word- blindness. Whenever word-blindness is present, it should be looked for. It can easily be detected. The patient should be asked to look steadily into the physician's eye, and the physician should then make a flickering movement with the fingers of one hand at the periphery of the patient's field of vision, and bring the fingers, thus in movement, gradually inwards towards the centre of the field of vision. If there is hemianopsia, the patient will not see the moving fingers on the blind side until they have reached the middle of the field of vision, and are directly in the line between the physician's eye and his own. For the more exact demarcation of the field of vision in such cases, the Perimeter or the Campi- meter should be used. I now proceed to give examples of these two classes of cases, invisual aphasia. 339 which word-blindness is the symptom common to both. First, I shall take the cases in which the visual word-centre C is intact, but is cut off from impressions coining from without, by a lesion in the white matter of the occipital lobe; and, secondly, the cases in which C is itself destroyed. Word-Blindness from such lesion in the white matter of the occipital lobe (at X, Fig. 8) as cuts off the centre 0 from incoming influences. It will well repay the reader to look up for himself the excellent series of cases of this kind that have been published by Dejerine and S^rieux.1 I can only afford to insert here a short account of one of them. But the one that I shall select is in itself a very com- plete one. It shows, in the first part of the patient's history, the effects of a lesion situated in the white matter of the occipital lobe (at X, Fig. 8), and then, afterwards, the effects produced by the extension of that lesion into the angular convolution, and accord- ingly into the centre C itself. Case I. (Dejerine, Comptes Bendus des Seances de la SocikU de Biologie, March 1892, p. 64.)—The patient was a man aged 68. After a number of attacks of tingling in the right leg and arm, he suddenly perceived that he could not read a single word; but he still retained the power of writing, and indeed could write with perfect ease. For four years, he remained in this condition— totally word- and even letter-blind, but able to write correctly whole pages of manuscript, though quite unable to read them after they were written. He had also lost the power of reading 1 The following is a list of some of the papers by Dejerine and Serieux, lately published in the Gomptes Bendus de la Soci&e de Biologie at the dates mentioned below:— M. J. Dejerine.—(1.) "Contribution h l'etude de l'aphasie motrice sous- corticale et de la localisation cerebrale des centres larynges (muscles phona- teurs)," 6th March 1891. (2.) "Sur un cas d'aphasie sensorielle (surdite et cecite verbales) suivi d'autopsie," 20th March 1891. (3.) "Sur un cas de cecitd verbale avec agraphie, suivi d'autopsie," 27th March 1891. (4.) " Con- tribution* & l'etude des troubles de l'ecriture chez les aphasiques," July 1891. (5.) Des differentes variet^s de cecity verbale," March 1892. P. Serieux.—(1.) "Sur un cas d'agraphie d'origine sensorielle," 11th Dec. 1891. (2.) "Cas de cecity verbale avec agraphie," 16th Jan. 1892.340 the disorders of speech. musical notes, though he could still sing well. He retained the power of reading figures, and could do mental calculations as well as formerly, lie had right homonymous hemianopsia. Ten days before his death, he became suddenly affected with very pronounced paraphasia, and with total agraphia; without, however, any paralysis of motion or loss of consciousness. There was no trace of word-deafness; and he retained his intelligence to the end. He died suddenly. At the autopsy, there was found,—(1.) an old lesion, a softening which had destroyed the cuneus and some of the neighbouring convolutions of the occipital lobe, and had extended deeply into the white matter, so as also to cut across the fibres passing from the right occipital lobe to the angular convolution. This lesion accounted for the long-standing word-blindness without agraphia, and for the hemianopsia. (2.) A recent lesion, viz., a softening of the angular and supra-marginal convolutions, which accounted for the recent appearance of agraphia and paraphasia; the paraphasia being, no doubt, due to a disturbance of the neighbouring auditory word-centre A. The case is thus in every way a most instructive and complete one. Among the cases of word-blindness which have come under my own observation, 1 have had two in which the patients were under my observation for years, and in which I had opportunities of examining the brain post-mortem. In both cases, there was extensive disease of the occipital lobe. Along with word-blind- ness, they both presented well-marked hemianopsia. As a con- tribution to the subject, I now proceed to make a short record of these two cases. Case II. (Personal observation.)—J. S., set. 72 ; clerk of works; appeared as an out-patient at the Eoyal Infirmary on December 12th, 1889. The patient, who was a man of fine physique, had enjoyed good health until August 1885. He then, at the age of 68, began to suffer from symptoms referable to his nervous system. These included loss of power in the right hand and the left foot, with some muscular wasting and distinct impairment of sensibility in them. He had at the same time some pain in the back ofVISUAL APHASIA. 341 the head; and he suffered occasionally from giddiness, being apt to stagger if he turned sharply in walking. On account of these symptoms, he had been a patient in my Wards from November 11th till December 1st, 1885; but, though I have full notes of this illness, I need not here give further details. I shall only say that he recovered the power in the hand and foot. On leaving the Infirmary, however, he found himself unable to resume his former occupation as clerk of works. He felt that he had no longer sufficient mental energy for it. He therefore, after this time, main- tained himself by collecting accounts for mercantile men. He found himself quite able to do this, as his powers of reading and writing and of making up accounts were as yet apparently unimpaired. On the 12th of December 1889, he called at the Infirmary to inform me that about six weeks previously he had had a severe seizure. About midday, when he was walking in the street, he had suddenly felt giddy and inclined to fall, everything appearing to swim before his eyes; but, after supporting himself upon a railing for half an hour, he had begun to feel better, and, though still light in the head, had been able, slowly and with difficulty, to walk home. Ten days after this seizure, he began to feel the whole right side of the body cold and heavy; the difference of sensation in the two sides being so marked that, to use his own expression, he felt as if a plumb line down the middle of the head and trunk had divided him into two halves. The tactile sensation in the right side seemed to himself to be blunted; but objective examination at the Infirmary, some weeks afterwards, did not confirm this impression. It was at this time, ten days after the seizure, that he discovered that he was word-blind. He could not read even his own name. At first, he was even letter-blind; but, before coming to the Infirmary on the 12th of December, he had recovered sufficiently to be able to recognise the letters individually, though he could read no single word without first spelling it. Examination of the eyes at this time showed typical right Homonymous Hemianopsia, with marked contraction of the remaining left halves of the fields of vision. The contraction was so marked that the patient saw things as if looking at them through a tube. Though word-blind, the patient vgis not agraphia He continued, indeed, to write a remarkably good business hand; and he made very few mistakes in spelling, such as he did make being342 THE DISORDERS OF SPEECH. evidently due, not to his cerebral condition, but to defective educa- tion. Although he expressed himself in writing with ease and fluency, he could read the writing only word by word, after spelling each word letter by letter. As to spoken speech, the patient expressed himself with great liveliness and volubility, being never at a loss for a word, except in the case of proper names, which he was apt to forget. There was no forgetfulness of the names of things, and no paraphasia. His intelligence seemed very good; but he complained of a sense of confusion in his head, "as if a cloud were over his mind;" and this feeling, together with his word-blindness, had made him quite unable to continue his occupation of collecting accounts. After the date of this examination (December 12th, 1889) the patient continued to reside at his lodgings for some months, calling occasionally to report himself at the Infirmary. He then became affected with gangrene of the great toe; and, as this deprived him of sleep, he became delirious at night, and so unmanageable that it was necessary for his friends to have him removed to the hospital of St Cuthbert's Workhouse. He was afterwards transferred to the City Workhouse; and there, eventually, he died of hepatic disease with jaundice, on the 23rd of January 1893. A post-mortem examination was made by me two days after the patient's death, and the brain was committed for examination to Dr Middlemass, Pathologist to the Eoyal Edinburgh Asylum, whose report I now append. Pathological Report by Dr Middlemass.—" An examination of the brain showed that there was no gross lesion except on the under surface. When it was turned over, and the cerebellum removed, there was seen to be a considerable amount of atrophy of the con- volutions on the under surface of the occipital lobe on the left side. There was some falling in of the convolutions in the centre, and on palpation there was slight fluctuation to be felt, as if the posterior horn of the ventricle were dilated. The arrangement of the con- volutions was quite different from that usually described and from that of the other side. They were smaller and appeared to be more numerous, and there was a considerable amount of atrophy. Whether the arrangement of the convolutions was due to the atrophy or not, it was impossible to say absolutely.Fig. 10.—Brain of Case II., from a Photograph by Dr Middlemass.2 Fig. 11.—Sections of the Brain of Case II., drawn by aid of the camera lucida, showing atrophy of the left occipital lobe, and enlargement of the posterior horn of the lateral ventricle. In the Photograph (Fig. 10), the position at which each section was made is indicated by the corresponding number and line.VISUAL APHASIA. 343 " The brain was hardened as a whole, and subsequently trans- verse sections were made to ascertain the exact nature and extent of the atrophy. As a result of these, it was found that there was a softening of the white matter in the floor of the posterior horn of the left lateral ventricle, due probably to the blocking of one of the branches of the posterior cerebral artery. This softening was not of the usual kind in which both white and grey matter alike suffer, but, as sometimes happens, especially in softenings involv- ing the walls of the ventricles, it affected the white matter only. This had degenerated and become gradually absorbed, and as a consequence the horn of the ventricle had become dilated to com- pensate for the loss of solid material. The grey matter of the convolutions had been left, though in a somewhat atrophied condition, and their form was reproduced in the floor of the ven- tricle, but exactly the reverse of their appearance 011 the external surface. A microscopic examination of these convolutions in the fresh condition it was not possible to make, as it was desired to harden the brain as a whole. But an examination of similar conditions in other cases makes it certain, that, though the con- volutions preserved their form in a general way, they were functionally inactive, their central connexions being cut off, and the nerve elements degenerated. An investigation of the sections of the brain showed that the atrophy extended from the tip of the under surface of the occipital lobe, where the dilated posterior horn reached to within an eighth of an inch of the surface, as far forwards as the middle of the crura cerebri. That is to say, the convolutions affected were those designated median and lateral occipitotemporal (Ecker) or lingual and fusiform lobules, together with the posterior half of the gyrus hippocampi. There was no affection of either Broca's convolution or the angular gyrus." Dr Middlcmass photographed the brain, and made a large number of transverse sections of the occipital lobe. Of each section he made an exact drawing by aid of the camera lucida. I am sorry I cannot publish copies of all of these drawings, but I have made a selection of eight of them (see Fig. 11). In each case the exact position at which the section was made is indicated by its number and the corresponding number and line on the photograph, which I also reproduce (Fig. 10). From these sections, the reader will observe how much the posterior horn of the left lateral ventricle344 the disorders of speech. was enlarged, and how markedly the white matter around it, and especially that beneath its floor, was atrophied. In the photo- graph, the atrophied condition of the convolutions at the tip and along the inferior surface of the occipital lobe is- fairly well exhibited; but I may say that in the photograph this appearance is not so striking as it was in the actual brain. There can be little doubt that in this case the extensive disease of the white matter of the left occipital lobe had involved the fibres connecting the angular convolution with both occipital lobes, thus causing the word-blindness. The lesion also involved both the Radiation of Gratiolet and the primary centre for vision in the cortex of the left occipital lobe, thus causing the hemianopsia. Case III. (Personal Observation.)—A much-respected pro- fessional man, aged 70. Had been engaged in active work in South Africa till thirteen years before the beginning of his illness, when he had retired and settled in Edinburgh. During these last thir- teen years, he had continued to enjoy his usual excellent health, except that on ten or twelve occasions he had experienced attacks of giddiness, sufficiently marked to make him stagger, and cause him to support himself with his stick for a moment. It was observed also that, for three or four years before the beginning of his illness, he had, in his walk and carriage, been showing evidence of advancing age. On Saturday, the 22nd of September 1888, the patient had fatigued himself a good deal with walking; but in the evening he seemed in his usual health. Next morning he awoke with a dull headache ; and, feeling ill, he remained in bed nearly all day. On the third day, he seemed a good deal better, and went out for a short time, but still felt unwell. On the fourth day, he was decidedly worse, and kept his bed. It was now observed that when he was taking his food he did not direct the movements of his right hand properly. The expression of his face also showed his friends that he was seriously ill. I was therefore sent for, and saw the patient in the afternoon. I found him suffering from slight motor hemiplegia, with considerable anaesthesia, on the right side, and with well-marked and typical right homonymous hemi- anopsia. At this time, and for several weeks afterwards, the patient was much confused in his mind, especially during theVISUAL APHASIA. 345 night, having delusions about being away from home, etc., and being much troubled with nightmare in his sleep. But he gradually improved, and by about the end of November was able to sit up a little daily. On the 4th of December, and during succeeding days, I made a pretty full note of his condition, doing it little by little, so as to avoid fatiguing him. I found that the motor weakness on the right side had dimin- ished notably, the outer circle of the dynamometer showing with the right hand a grasp of 70, as compared with 90 registered by the grasp of the left hand. The weakness in the right leg had also diminished, so that the patient, when out of bed, was able, though lame, to walk a few steps without assistance. The ana3sthesia of the right side had almost completely dis- appeared. In the arm, however, there was still marked impair- ment of the muscular sense; so that when his eyes were closed heliad great difficulty in guiding the movements of the affected right arm, when he was asked to touch, with the right hand, the left hand or the nose. The right homonymous hemianopsia continued to be as complete and typical as before. Written Speech.—There was total Word-Blindness. The patient was not only word-blind, but also letter-blind. When the name Dugald was placed before him in large print, he could not make it out, but, as is curiously the rule in such cases, he did not hesitate to name each of the letters, though mistaken in every case. This is what he made of Dugald : Dugald K a n i o i He was equally at fault with numerals, naming them as letters, thus— 1 2 3 4 5 6 i r e i u e In like manner he translated the following algebraic symbols thus— + X -f- n e a He could, however, interpret the meaning of pictures or drawings quite easily. I made him a sketch of a man's face, and asked him what it was. He could not recall the word " face," but said that it 2 x346 THE DISORDERS OF SPEECH. was " a most determined Highlander;" and the face had a deter- mined expression. Unfortunately I did not test his power of writing sufficiently, as I was afraid of exhausting him. But I got him to write, with his somewhat weak right hand, his own Christian name. He did so in large and tremulous characters that are barely legible. Spoken Speechi—There was no marked degree of word-deafness ; but there was a slight degree of it, which was shown when the patient was tested with the names of concrete things. Thus, when I asked him to touch, as I named each part, his nose, eye- brows, beard, etc., he often made mistakes in what he touched. There was marked Amnesia of the names of persons and of concrete things. Thus the patient often failed to recall the names of his nearest relations, and could not name articles of furni- ture that were pointed out to him. In conversation, he was often arrested by this forgetfulness of nouns. Here is a little bit of my conversation with him. "How did you sleep last night?" "I got a sleeping thing late in the morning. It is making me heavier and useless. It looked very much to me last night as if there was a little modifying of the — Oh! I don't know how I can't name these things." " Have you any pain in your head now ?" " No ; there is a stupidness, and not so clear. Last night, was very stupid and dull." " Tell me what you feel as regards your speech." " It would be impossible for me to bring up the names of those articles that are used for acting upon speech. Could not name one of them. It is getting worse and worse." Apart from the amnesia of nouns, there was no hesitancy in the patient's utterance; there was 110 stammering; and only now and again was there a slight thickness of speech (slurring) in pro- nouncing a word or syllable. With his total Word-Blindness and consequent inability to read any printed or written word, it was interesting to contrast the readiness with which he recognised words when they were spelt aloud to him. Shown the printed word cat, he made a mistake with every letter in spelling it; but when the letters were spelt aloud to him, and he was asked what it was, he said, "cat, of course," with the greatest readiness. In this condition the patient remained for about four years,VISUAL APHASIA. 347 totally word-blind,1 and never attempting either to read or to write ; and presenting some amnesia of nouns, in his conversation. With the exception of two periods of some weeks' duration, during which his mind was a good deal disturbed by delusions, he was perfectly rational; though intellectually he was no longer the man he had been before his illness. He lived quietly at home, and was able to sit up most of the day, and to go out for a drive in good weather. In the evenings, he was in the habit of hearing his sons say their Latin lessons over to him; and he could always correct them if they made a mistake. Throughout his illness, he was carefully attended by my friend Dr R A. Lundie. He died of a pneumonic attack, on the 15th of October 1892, set. 74. The autopsy was conducted by Dr Leith, Pathologist to the Koyal Infirmary, Dr Lundie and I being also present. On examination of the brain, it was found that the convolutions forming the speech centres ABC and D were normal in appear- ance, the angular convolution C being normal, like the others. The chief morbid appearances were found on the under surface of the occipital lobe. In his careful report, Dr Leith notes that they were exhibited chiefly in the Inferior Temporo-Occipital Convolu- tion (4th Temporal), the Hippocampal Convolution, and the Colla- teral Fissure, and also in the Lingual Convolution, the anterior part of the Cuneus, and the Calcarine Fissure. In these parts, there was thinning of the cortex from atrophy. On section, Dr Leith found that beneath the atrophied cortex there was still greater atrophy of the white matter, this being so marked that at the region of greatest atrophy the remnant of the cortex came into direct connexion with the ependyma of the ventricular horn. At this region of greatest atrophy (the under surface of the occipital lobe, about the middle of the Inferior Temporo-Occipital or 4th Temporal Convolution), there was a marked depression on the sur- face of the brain about 2| inches in length, and from £ of an inch to an inch in breadth. This depression marked the situation of a kind of cyst-like cavity where the grey matter and the subjacent white matter had been almost entirely destroyed, so that the walls of the cavity were chiefly formed of pia mater on the one side and the 1 His son tells me that the patient, on one occasion, two years after the beginning of his illness, made out a name upon a tombstone, though he was wrong in spelling the other letters of the inscription.348 THE DISORDERS OF SPEECH. ependyma of the ventricle on the other. The Collateral Fissure was much widened, and its floor was formed, owing to the dis- appearance of the grey and white matters; by the ependyma of the ventricle. From a sketch made at the autopsy, and from Dr Leith's description, I have indicated in the following diagram (Fig. 12) the area in which the atrophy of the cortex was most Fig. 12.—The shading shows (he region of atrophy of the cortex and subjacent white matter. C, the Cuneus; L, the Lingual Convolution; T0X, the Inferior Temporo-Occipital Convolution; T02, the Hippocampal Convolution; 5, the Calcarine Fissure; 6, the Collateral Fissure. apparent. The area of deepest shading in the Inferior Temporo- Occipital Convolution indicates the situation of the marked depres- sion where there was a cyst-like cavity beneath the pia mater. Dr Leith could not detect any hsematoidin crystals in the walls of the cavity, and he was inclined to think that the cause of the atrophy was not apoplexy but thrombosis of the bloodvessels. He was not, however, able to find any actual thrombus in a blood- vessel, the only morbid appearance observable in the bloodvessels of the brain being a slight thickening of their coats. Here, then, is a second case of hemianopsia and word-blindness in which, as in the last, the lesion involved both the grey and the white matter of the occipital lobe; the region in which the atrophy was best marked being, as in the other case, the under surface of the occipital and temporal lobes. In this last case, the lesion, though it did not involve the first temporal convolution, the centre for auditory word-images, had r1 6visual aphasia. ,349 evidently, by its proximity, disturbed the action of that centre sufficiently to produce the considerable degree of Amnesia Verbalis that was exhibited in the patient's speech, especially during the first months of his illness. The writing, unfortunately, was not sufficiently tested to enable me to say whether the visual word- images at the centre C were also disturbed in like manner; but, as the centre C appeared to be intact, we may reasonably conclude that the word-blindness was due to the cutting off of the centre C from incoming impressions, by the disease in the white matter. The slight motor hemiplegia was 110 doubt due to the disturbance of the motor centres caused by the proximity of the serious disease in the occipital and temporal lobes of the same hemisphere. Word-Blindness with Agraphia, produced by Destruction of the Centre G. In contrast with the three cases which I have already given, I shall now cite a case of word-blindness in which the lesion was situated, not in the occipital lobe, but in the angular convolution, and accordingly in the centre G itself. Several excellent cases of this kind have been put on record by Dejerine and S^rieux. I shall select a very typical one recorded by Serieux; and I ask the reader to note (1) that in this case the word-blindness was associated with agraphia, and (2) that it was not associated with hemianopsia, because the lesion did not penetrate deeply enough into the subjacent white matter to cut across the Radiation of Gratiolet. Case IV. {Reported by Serieux to the Soe. de Biologie, 16th Jan. 1892. See Comptes Bendus.)—A female, aged 63, admitted into the Asylum of Villejuif on the 29th of Sept. 1891. Was intelligent, but had lost the power of reading and writing. Being anxious to regain the power of reading and writing, she practised much with her pen; but her efforts resulted only in such confused collections of letters as the following—these being, moreover, written badly—in a tremulous hand—" an um aa monon mono muosi." The intelli- gence was normal, and there were no paralytic symptoms what- ever. Vision was intact, and it is expressly stated that there was 110 hemianopsia. It was as impossible for the patient to read as350 THE DISORDERS OF SPEECH. to write. She could, however, recognise a few of the individual letters [overflow of education into the other hemisphere ?]; and when a word was composed of these she could sometimes spell it out and pronounce it. Two months after her admission, she had an attack of apoplexy, with haemorrhage into the ventricles, and died. At the autopsy, besides the recent extravasation of blood, there was found in the brain the old lesion which had produced the word-blindness and agraphia. This was a softening exactly circumscribed in the area now recognised as that for visual word-images, viz., the angular and supra-marginal convolutions. Nothing could be more convincing than this case. It and the other cases of the same kind already on record prove conclusively that not only word-blindness (alexia), but also agraphia, is produced by a destructive lesion in the visual word-centre. And be it re- marked that in such cases the patient cannot write with his left hand any more than lie can with his right. The case contrasts with Cases I. and II., in which with lesion in the occipital lobe, and with word-blindness and hemianopsia, the patient was not agraphic, because the visual word-centre, though cut off from the primary word-centres, and therefore word-blind, was still intact, and could, for purposes of writing, have its images revived from within. I hope I have said enough to make per- fectly clear the distinction between these two varieties of word- blindness, — the one with, and the other without associated agraphia. How some word-blind patients may be enabled to read. It is a well-known fact that some word-blind patients, quite unable to read either words or letters on merely looking at them, can yet spell out words shown to them, if they make with the finger a tracing in the air of each individual letter. Charcot, Westphal, and others, have recorded many cases of this kind. By making such a tracing, these patients no doubt revive the graphic-motor images of the letters that are stored in the centre D. But if the centre C, with its visual images of the letters, is destroyed, it is doubtful if the revival of the graphic-motor images at D can, of itself, suffice to bring about this mental recognition of the letters.VISUAL APHASIA. 351 It seems, on the whole, to be probable that the word-blind patients who are able to spell out words on thus making tracings of the letters belong to the category of those whose word-blindness is due, not to the destruction of the centre C, but to the cutting off of that centre from its connexions with the primary visual centres in the occipital lobes. In such patients, the revival of the graphic- motor images at D no doubt excites a revival of the corresponding visual images at C, and thus the mental recognition of the letters is rendered easy. The clear distinction between the two classes of word-blind patients has been made so recently that it is as yet impossible to say if in any case belonging to the class in which word-blindness is due to destruction of the centre C it is possible for the patient to spell out letters on tracing them in the air. It seems very probable, however, that all the patients who can thus spell out letters belong to the other class, whose word-blindness is due to the cutting off of the visual word-centre C from its connexions with the primary visual centres in the occipital lobes. Mind Blindness (.Psychical Blindness) sometimes associated with Word-Blindness. In a few rare cases of word-blindness, experience has shown that the patient not only fails to recognise words when he sees them, but also fails to recognise familiar objects. He may, for example, mistake a basin for a chamber-pot, or a handkerchief for a towel; and on seeing an intimate friend he may fail to recognise him until he hears hiin speak. This condition is known as mind-blindness (Seelenblindheit, ceciti psychique). Essentially, it is probably of the same nature as word-blindness. It seems, like word-blindness, to be due to the obliteration of images that have been stored in the higher visual centre. As the imprintation and storage of the images of things does not require such close attention as the imprintation and storage of words, the images of things are probably stored efficiently in both hemispheres of the brain. There is probably, however, in different brains, some variation in this respect; since a few cases of unilateral lesion have, I believe, been recorded in which a certain degree of mind-blindness (would not it be better to call it object-blindness ?) seems to have been352 the disorders of speech. present. We know, as yet, but little of the subject, and I shall therefore not enter into any detail about it; but I should like to make a short note of a very remarkable case of mind-blindness (object-blindness), associated with word-blindness, that has recently been put on record by Serieux. Case Y. (Reported by Serieux, Comptes Rendus, Soc. de Biologie, Dec. 1891, p. 195.)—A female, aged 62. Had a stroke in 1888, followed by temporary paralysis, and lasting troubles of vision. Had another attack in June 1890, with epileptiform convulsions, hallucinations of hearing, delirium, etc. When examined on the morning of the 16th of Dec. 1890, was found to be suffering from word-blindness and agraphia, and also from word-deafness and paraphasia. The intelligence was intact, except that there was marked mind-blindness (object-blindness). This was exhibited in the inability of the patient to recognise her nearest relations when they called upon her. She said the people about her seemed to be wearing masks, and that the nose was changed, etc. The figure of her daughter appeared to her to be "flat as a skate." This object-blindness, best marked in relation to faces, was also exhibited, in a less degree, in relation to other objects. She could recognise some of these, such as her fingers, a penholder, etc.; but she failed to recognise others,—apparently, for example, mistaking a comb for a penholder, and wiping it as such. After a period of some months, during which there was amelioration in all her symptoms, she died of a pneumonia. At the autopsy, a lesion was found in the cortex of each hemisphere. On the left side, there was a softening in the supra-marginal convolution, and also a limited patch of softening in the posterior extremity of the first temporal. On the right side, there was a large patch of softening involving the angular and supra-marginal convolutions, and also the posterior extremities of the first and second temporal convolutions. This case is of great interest in relation to mind-blindness. It suggests that the visual images of objects are, as I have said they probably are, efficiently imprinted on the higher visual centres of both hemispheres, whereas, owing probably to the greater effort of attention required, the images of words are efficiently imprinted in the higher visual centre of only one of the hemispheres. But the subject has not yet been fully studied.VISUAL APHASIA. 353 Visual Hallucinations apt to he associated with Hemianopsia when the Lesion is in the Cortex of the Occipital Lobe♦ In concluding this chapter, I should like to say a word about an interesting phenomenon that has recently been found to be frequently associated with homonymous hemianopsia when that symptom is of cortical origin. Professor Henschen of Upsala, in his great work on The Pathology of the Brain} directs attention to the fact that in cases of cortical origin of the symptom well-marked visual hallucinations (figures of men, etc.) may trouble the patient in the blind half of the field of vision. He gives in detail a number of cases in which these hallucinations were present. This is a good illustration of the law so strongly insisted upon by Bastian, and so frequently exemplified in practice, that lesions in the posterior parts of the brain are more apt to produce hallucinations and delusions than lesions in the middle or anterior parts. 1 Klin, und Anat. Beitrage zur Path, des Gehirns, 1892.354 the disorders of speech. CHAPTER XIII. Aphasia in Relation to Organic Diseases of the Brain— Continued. Graphic-motor Aphasia. Summary of the Leading Features of the different simple Forms of Aphasia. Additional simple Forms recognised by Lichtheim and Wernicke. Com- pound Forms. Method of Case-taking. Graphic-motor Aphasia. The graphic-motor centre D still remains to be considered. This centre is believed to be situated, as shown in the accompanying diagram (Fig. 13), at the posterior extremity of Ihe second left 2 Sup.1 Fig. 13. frontal convolution, immediately in front of the motor centre for the hand, which extends at the same level across both the ascend- ing frontal and ascending parietal convolutions,GRAPHIC-MOTOR APHASIA. 355 It is interesting to look back upon the gradual evolution of knowledge regarding the various form of aphasia, and to note the views that at different times have been held regarding the causa- tion of agraphia. At first, the possibility of the existence of a special centre for the memories of the movements of writing seems scarcely to have been contemplated. The agraphia which was found to be so common an accompaniment of aphasia was supposed to be simply a necessary consequence of it. It was recognised as unreasonable to expect that words could be written, if, owing to amnesia verbalis, they could not even be remembered. We have already seen that opinion, in the present day, is coming round to this old view; which is now held to be a sufficient explanation of the agraphia in a great number of the cases presenting that symptom, though it is not supposed to be the proper explanation of it in all cases. The next step in the evolution was the localization by Exner, in 1881/ of a special graphic-motor centre in the posterior extremity of the second frontal convolution, at D. It must be confessed that the facts adduced by Exner in favour of this localization are not very convincing; but nevertheless they afford a certain amount of evidence in favour of it. The localization proposed by Exner was accepted by various eminent writers on aphasia; and it thus came to be the fashion, for a time, to refer the symptom agraphia, in most cases, to destruction of this centre D. Lying, as it does, in juxta- position with Broca's convolution, the centre D is, indeed, in a great number of cases of lesion of that convolution, found to be involved along with it. But, within the last few years, much has been done to detract from the supposed importance of the centre T). In the first place, Wernicke directed attention to the fact that we can write not only with the right hand—with whose motor centre the centre D is in connexion,—but also with the left hand, with the elbow, with the right or left foot, and even with the teeth. It seemed to Wernicke that in the act of writing the visual images were the important ones; because, given a clear and distinct visual image of a word and its component letters, all that any movable part of the body to which a pencil can be attached requires to do, in order to 1 Untersuchungen iiber die Localization der Functionen in der Grosshirnrinde des Menschen, 1881, p. 57.356 THE DISORDERS OF SPEECH. produce the word in writing, is to make a drawing from that image. There can be no doubt that there is much truth in this doctrine. The fact that, as we have seen, the destruction of the visual centre C is destructive of the power of writing, is corrobora- tive of it. But, though we grant the importance of the visual images at C in relation to writing, I do not think we should 011 that account imagine that the graphic-motor images at D are of no importance whatever. We should remember that the congenitally blind, who have 110 visual images at all, can yet be trained to write or print their names in ordinary characters.1 Having no visual images, these congenitally blind persons must depend exclusively upon the psycho-motor memories of writing—the "kinesthetic memories " of the act, as Bastian would term them. If, again, we compare, in our own persons, our facility in writing with the right hand with our awkwardness in writing with the left, we shall be able to realize how much more the right hand has learned to do than merely to draw the visual images revived within the centre C. When we write with the left hand or with the foot, we do, indeed, carefully and laboriously draw these visual images; but when we write with the right hand we utilize also the psycho-motor images that are probably stored at D. These are promptly revived by the visual images at C, and they are exteriorized or executed with the facility which comes of practice. Nevertheless, it cannot be denied that the centre D has fallen, of late, from the position of high importance in relation to agraphia that it occupied in the opinion of writers on aphasia some years ago. The recent observations by Dejerine and S^rieux with regard to the centre C, and its relations to agraphia, have done much to diminish, in the current estimate, the importance of the centre D. Opinion, moreover, as we have seen, is coming round to recognise again the truth of the old view of Trousseau and others, that in a large number of cases of aphasia in which the patient cannot ex- press himself in writing the agraphia is really due to the amnesia verbalis that attends upon aphasia, whether the lesion be at A or at B. It would be interesting if we could have before us the record of a case in which a small and isolated lesion h^d destroyed the 1 This, by the kindness of W. H. Illingworth, the Head-Teacher, I have been enabled to verify by personal observation at the Edinburgh Blind Asylum.graphic-motor aphasia. 357 centre D, and it alone. A single case of this kind would show us definitely in what degree agraphia is produced by such a lesion ; and it would show us, moreover, whether the agraphia thus caused is displayed only when the patient attempts to write with the right hand, or also when he attempts to write with the left. But, accord- ing to Dejerine,1 110 single case has yet been put upon record in which the lesion was thus strictly limited to the centre D. One case has indeed been put upon record, by Henschen of Upsala,2 in which such a limited lesion had partly destroyed the centre D; but in that case there was also, in the same hemisphere, another limited lesion, which had destroyed, in like manner, the centre C. In all the other recorded cases in which autopsies have been made, it appears that the lesion destroying the centre D had -also affected the centre B, or other neighbouring parts. We are left, therefore, to the doubtful evidence that has been furnished by cases in which there has been no autopsy. From such evidence, it is only per- missible for us to guess that, when agraphia exists as an isolated symptom (without alexia or any trouble of spoken speech), the lesion may possibly be situated in the centre I). We shall be the more cautious, however, in coming to any definite conclusion, if we bear in mind what has been pointed out by Lichtheim,—that in motor or sensory aphasia with agraphia, when recovery takes place, the power of speaking is always restored before the power of writing; and that agraphia may thus, in such cases, linger as an isolated remnant of an aphasia due to lesion, not in D at all, but in A or B. Dejerine states that all the cases of apparently pure and uncomplicated agraphia that have hitherto been put 011 record appear to be really cases of this description. Let us take, for example, two of the best of them, which will be found detailed in a paper on this subject by Pitres;3 the first being a case that occurred in the practice of Prof. Charcot, and the second a case that occurred in the writer's own practice. Case I. (Prof. Charcot.) A Russian officer, aged 52. In August 1882, the fingers of his right hand became suddenly enfeebled so that he could not hold a pen; but this paresis soon almost en- 1 Compt. Bend, de Soc. de Biologie, 30th July 1891, p. 99. 2 Klin, und Anat. Beitrage zur Path. Gehirns, Erster Teil, S. 173, Tafel xxxv. 3 Revue de Medicine, 1884, p. &64358 the disorders of speech. tirely disappeared, so that the patient could write again. He could speak Eussian, French, and German. Six months after the occur- rence of the paresis in the hand, when he was at an evening assembly, he found, to his great surprise, that when addressed in French or German he could not reply in either of these languages; though he understood perfectly what was said to him in them, and could still express himself in Eussian with his ordinary facility. . Little by little, he improved; regaining the power of speaking French, though that of speaking German still remained lost to him. "When at this stage, he found, one day, 011 attempting to write a letter, that he could not write a single word ; the loss of the power of writing being out of all proportion to the slight motor weakness which still lingered in the right hand. He then, 011 the 1.0th April 1883, consulted Prof. Charcot. The intelligence was found to be normal, and there was no word-blindness, the patient being able to read aloud French, German, or Russian. But he could not write in any one of these languages. When asked to write, " Je demeure Hotel de Bade," he could only write "Je dem." He could only write the name of Prof. Charcot in French and Eussian, but not in German. It was found that there was still a little difficulty in the movements of the right hand, with slight cutaneous anaesthesia, and incomplete loss of the sense of position of the fingers. Some days after the date of this examination, the patient died suddenly. There was no autopsy. Although it is probable that, in this case, the centre D was afl'ected, there was evidently serious disease in other parts of the brain, with some involvement of the centre A or B; and it is there- fore probable that the agraphia was not due solely to disablement of the centre D. It is not stated how the patient could write with the left hand. Case II. (M. Pitres). The patient was seen two years after a cerebral seizure, which had occurred in 1882, and had caused lasting paresis and rigidity of the right leg, slight paresis of the right arm and hand, and right homonymous hemianopsia. He was found to have agraphia when he attempted to express his thoughts in writing with the right hand, though with that hand he could copy letters and figures. He had already educated himselfGRAPHIC-MOTOR APHASIA. 359 to write with the left hand, and with it could write very legibly. With the right hand, he could not write even numbers, except from copy. When asked to write the number 125 with the right hand, he had first to write it down with the left, and then copy it with the right. There was no word-blindness, and no trouble of spoken speech. This interesting case is very difficult of explana- tion. It is evidently not, any more than the last, an example of limited and isolated lesion in the centre D. The hemianopsia, indeed, suggests that there may also have been a lesion in the left occipital lobe. Cases of isolated and limited lesion of the centre D, where the careful clinical records have been supplemented by accurate description of the pathological changes, have not yet been pub- lished. They are needed, before the exact importance of the centre D, in relation to the physiology and pathology of written speech, can be said to be fully ascertained. Mirror Writing. A point of interest in connexion with the writing of aphasic patients who are not the subjects of true agraphia, is that, in some few cases, when the patient attempts to write with the left hand he is apt to write from right to left, instead of from left to right. This is called mirror writing. A good many cases of it have been recorded; some of them being cases of patients with aphasia, and others being cases of patients suffering from diseases other than aphasia. Bernard,1 for example (p. 237), records a very good case in whicli this mirror writing was well exhibited by a female patient suffering from locomotor ataxy, who wrote with her left hand because the attempt to write with the right always brought on violent pain in the right arm. This patient does not seem to have been fully aware of the peculiarity of her writing, being much surprised at receiving no replies to the letters she often sent to her friends. Of course such writing can, with the aid of a mirror, be read quite easily by any one. It seems to be almost natural for the left hand to write from right to left. Bernard (p. 235) says,—" Some have seen in mirror 1 De VAphasie, p. 237,360 thr disorders of speech. writing a pathological phenomenon, a new manifestation of aphasia ; but this is an opinion which has not been accepted. " In the Indo-Germanic race, the only race in which writing is centrifugal, mirror writing is the normal form of writing with the left hand." Of course there must be something pathological in the patient's intelligence, if, when writing in mirror-fashion, he imagines that he is writing in the ordinary way. Brief Summary of thk Leading Features of the various Elkmkntary Forms of Aphasia already considered. In now reviewing briefly the leading symptoms produced by destructive lesions in each of the speech-centres A, B, C, and D, it may be useful to keep in view the following diagram (Fig. 14). This is merely Fig. 9, with the addition of the circle M—which stands for the idea or meaning to be expressed or to be evoked— and the dotted lines connecting M with A and B, the centres of the primary couple, with which alone, in most persons, the ideas or meanings are in direct connexion. Fig. 14. Let us begin with the two centres C and D, the centres for the visual and motor images of printed and written speech; and let us take first of all the centre D. (1.) The Centre D, and Graphic-motor Aphasia.—We have just seen how unsatisfactory is our knowledge of the exact-relations of this centre to the production of writing. On the whole, however,LEADING FEATURES OF ELEMENTARY FORMS OF APHASIA. 361 it seems probable that a destructive lesion of D would render the patient agraphic, at least as to the right hand; but it is doubtful whether it would interfere at all with writing by means of the left hand. The left hand would probably still be able to draw the visual images of letters revived at C. (2.) The Centre Gy and Visual Aphasia.—(a.) We have seen that destruction of this centre is now proved to have the double effect of producing word-blindness (alexia) and agraphia. We also know that destruction of the grey matter of the centre does not produce hemianopsia, but that hemianopsia is produced if the lesion extend deeply enough into the subjacent white matter to cut across the Radiation of Gratiolet. (6.) We have seen that a lesion in the white matter of the occipital lobe that cuts off the visual word- centre 0 from impressions coming to it from the primary visual centres of the two occipital lobes renders the patient word-blind, but that such a lesion does not produce agraphia, because the centre C itself remains intact, and its images can still be revived from within, when the effort to write is made. In, apparently, all cases of this last kind, hemianopsia is associated with the word-blind- ness ; because the lesion involves also the Radiation of Gratiolet. (3.) The Centre A, and Auditory Aphasia.-—Destruction of the auditory word-centre A causes, on the receptive side, word-deaf- ness, and also marked interference with the power of interpreting visible speech, printed or written. On the productive side, it causes amnesia verbalis, with its companion symptoms, articulative amnesia and paraphasia. This form of aphasia is often rapidly recovered from; and, in the process of recovery, the word-deafness generally disappears before the amnesia verbalis and the paraphasia. (4.) The Centre B, and Motor Aphasia.—Destructive lesion of this centre annihilates, or almost annihilates, the power of produc- ing speech; owing partly to the asynergia (ataxia) verbalis which is its leading effect, and partly to the marked amnesia verbalis which it also produces. Though there is scarcely any interference with the reception and interpretation of audible speech, we have seen that there is some reason to think that there may be slight interference with the reception and interpretation of those words 2 z362 THE DISORDERS OF SPEECH. whose memories are the least deeply imprinted, viz., the names of concrete things. There is usually distinct interference with the reception and interpretation of visible speech, printed or written. (5.) The Conducting Fibres between A and B, and Conduction Aphasia.—We have seen that a lesion which cuts across these fibres produces the form of aphasia known as Conduction Aphasia (Leitungsaphasie), whose characteristic symptom is the single one— paraphasia. In this variety of aphasia, there is neither, on the one hand, any word-deafness, nor, on the other hand, any defect of articulative power; because the centres A and B are themselves both intact. It may be well to add here a few notes summarizing the causes which may produce Alexia and Agraphia. Alexia.—(1.) When we remember that, as shown in Fig. 14, the meaning to be evoked by incoming words is in direct relationship only with the images of the primary couple A and B, it is not surprising to find that the destruction either of A or of B interferes more or less markedly with the interpretation of visible words printed or written. It is generally admitted that there is such interference with the interpretation of visible speech when the centre A is destroyed ; but a case has been cited which seems to show that there are exceptional cases in which, even in the absence of the centre A, the power of interpreting visible speech is retained, owing to the close relationship existing between the visual images of letters at C and the motor images at B, and the direct connexion of the latter with the equivalent ideas or mean- ings. (2.) Some suppose that when B is destroyed there is no interference whatever with the power of silent reading, as the visual images at C can still revive the auditory images at A, and thereby call up the meanings; but we have seen reason to believe that this is probably a mistake, since, in motor aphasia, alexia is almost always exhibited, in greater or less degree. (3.) Total alexia, true word-blindness, is exhibited, either when the centre C is itself destroyed, or when, itself remaining intact, it is, by lesion in the white matter of the occipital lobe, cut off from the impressions which normally act upon it from the primary visual centres of the two occipital lobes.other simple forms of aphasia. 363 Agraphia.—If we try to summarize the causes which may pro- duce agraphia, I think we may say,—(1), That- it may be due to the amnesia verbalis which results from a lesion either in A or in B; (2), that it may be due to the amnesia literarum which results from a lesion in C; and (3), that a partial agraphia, displayed at least in the performance of the right hand, may, probably, be pro- duced by a lesion at D. Brief Note of certain other Simple Forms of Aphasia that are recognised by llchtheim and wernicke. In the able paper from which I have already quoted (Brain, January 1885), Lichtheim, putting aside for the time the centres for written language, C and D, and looking exclusively to the centres of the primary couple A and B, recognises seven possible varieties of simple aphasia, due either to lesion in one or other of these two centres or to lesion in one or other of the conducting pathways that lead to and from them. I have already treated of three of these seven, viz., the aphasia resulting from lesion at A, that from lesion at B, and that from lesion in the conducting path between A and B. I now wish to consider very briefly the four additional varieties which are included in Lichtheim's classification. He gets these additional four by supposing the existence of lesion below and above each of the centres A and B, in the positions indicated in the diagram (Fig. 15), by the figures 4, 5, 6, and 7. Wernicke, who has adopted this classification, proposes for these seven varieties the following names:—Nos. 1 and 2 he terms Fio. 15.—After Lichtheim; modified.364 THE DISORDERS OF SPEECH. respectively Sensory Cortical and Motor Cortical Aphasia; No. 3 Conduction Aphasia (Leitungsaphasie); Nos. 4 and 5 respectively Subcortical and Transcortical Sensory Aphasia; Nos. 6 and 7 respectively Transcortical and Subcortical Motor Aphasia. But some of these proposed terms are unfortunately somewhat am- biguous in meaning. Perhaps there will be less ambiguity, if, for our present purpose, we substitute for " Cortical" the term "Pictorial" (to signify the relation of the lesion to the word- pictures or memories) and designate the varieties as follows:—1 and 2 as respectively Pictorial Auditory and Pictorial Motor Aphasia; 3 as Inter-pictorial Aphasia; 4 and 5 as Infra-pictorial and Supra-pictorial Auditory Aphasia; and 6 and 7 as Supra- pictorial and Infra-pictorial Motor Aphasia. Passing over Nos. 1, 2, and 3, which have already been fully considered, let us look at the four others that are included in Lichtheim's classification. No. 4. Infra-pictorial Auditory Aphasia.—The distinguishing feature of this variety is the existence of simple word-deafness, without Amnesia Verbalis or other associated symptoms of speech disturbance. Speaking, reading, and writing are intact; but, the auditory centre being, by a lesion in the afferent tract below it, cut off from incoming impressions, the patient is word-deaf, and therefore cannot understand what is said to him, though he hears the words as sounds. The educated centre A is simply cut off from the incoming words that normally reach it from both ears. In illustration of this form, Lichtheim gives (p. 461) the case of a journalist, aged 55, who, in 1877, had an apoplectic attack, with complicated troubles of speech, including paraphasia. From these he partially recovered. Then, in 1882, he had a second attack, with aggravation of his speech troubles; but again recovered, so that eventually none of the symptoms remained, except a simple but total word-deafness. There was no difficulty in speaking, reading, or writing. He continued, indeed, to write articles for his journal, which were as good as those written before his illness. Though word-deaf, he was not deaf to other sounds. It was note- worthy, however, that he had lost his ear for music, so that he no longer recognised melodies. The case has already been referred to. Tt was this patient who sometimes asked his children to stopOTHER SIMPLE FORMS OF APHASIA. 365 singing quartettes, as " they made too much noise/' There had, of late years, been 110 improvement in the word-deafness. Wernicke lias recorded a case of the same kind (also already referred to), in which, in like maimer, curious to say, there was also an affection of the musical faculty, the patient having lost the power of appreciating certain notes of high pitch. In this case, too, there was no progressive improvement; and Wernicke is inclined to think that this form of word-deafness may not be so curable as that produced by lesion at the centre A itself (pictorial auditory aphasia). No. 5. Supra-pictorial Auditory Aphasia.—Here the path be- tween A and M is cut across, so that auditory word-pictures revived in A fail to call up the ideas or meanings in M. Incoming audible speech, therefore, is not understood; nor, according to Lichtheim and Wernicke, is incoming visual speech—the patient having alexia as well as word-deafness. He can understand neither what he hears nor what he reads; and yet, the word-images in the centre A being intact, and capable of revival from without, he can repeat with ease, though without understanding it, whatever he hears said to him; and, in like manner, can read aloud with ease, though lie does not understand what he reads. He can also easily write to dictation, and easily copy from print or from writing. A true Echolalia, with no understanding of what he is saying, is thus the most characteristic symptom. In his written speech, it has its equivalent in the power he retains of writing to dictation or of copying, without understanding the words written or copied. With regard to volitional speaking and writing, as the patient cannot, from M, call up the auditory images at A, which are so important for the guidance of the motor images at B, he exhibits amnesia of nouns, paraphasia, etc., and, in like manner, as a consequence of the paraphasia, he exhibits paragraphia. At page 454, Lichtheim records, 111 detail, a case which exactly corresponds with-this picture. No. 6. Supra-pictorial Motor Aphasia.—The path between M and B being cut across, it is impossible for the patient to express his thoughts in volitional speech. When he tries to speak voli- tionally, his attempts result in the same kind of failure as is exhibited in an ordinary case of pictorial motor aphasia, due to destruction of B. Nor, according to Lichtheim, can he express his366 THE DISORDERS OF SPEECH. thoughts any better in writing. Apart from volitional speaking and writing, everything is normal. The patient can understand both what is said to him and what he reads. He can also, with correct articulation, repeat words that are spoken to him (under- standing them, in this variety); and can correctly and easily write to dictation and copy writing (understanding, in both cases, what he writes). At page 447, Lichtheim records a case entirely agreeing with this picture. No. 7. Infra-pictorial Motor Aphasia.—To get the symptoms which characterize this variety, we must suppose the lesion to be so situated as to cut across only those fibres which connect the centre B with the lower centres, in the medulla, for the nerves of speech; and to leave intact all the connecting fibres between B and the other speech centres, as well as the fibres between M and B. Given such a lesion, the only disablement that would result from it would be disablement of spoken speech, both volitional and on attempted repetition of words heard. Otherwise everything would be normal: there would be no amnesia verbalis, no difficulty in volitional writing, writing to dictation, or copying, and no word- deafness. If, owing to accompanying paralysis, the patient could not write with the right hand, he would yet be able to do so with his left. Lichtheim, at page 449, refers to numerous cases already on record which present all the features of this type. The case of Patrick Keaney, which I have put on record in a former chapter, might stand as a fairly good example of it. Wernicke, who has adopted Lichtheim's classification, and who was, in fact, the originator of part of it, holds, witli Lichtheim, that the simple forms of aphasia affecting spoken speech are seven in number. But he has pushed the classification still further. He applies it also toWritten speech; and differentiates seven equivalent varieties of aphasic disturbance of written speech, which may exist when spoken speech is intact. His seven varieties are—(1.) Cortical Alexia; (2.) Cortical Agraphia; (3.) Conduction Agraphia; (4.) Subcortical Alexia; (5.) Transcortical Alexia; (6.) Transcortical Agraphia; and (7.) Subcortical Agraphia.1 He illustrates these seven varieties by means of a diagram similar to Fig. 15, but differing from it in having the centres C and D substituted for A 1 I have arranged both this list and the forgoing one in an order different from that in which they are given by Wernicke and Lichtheim.OTHER SIMPLE FORMS OF APHASIA. 367 and B; and in having, instead of M, which stands, in Fig. 15, for the idea or meaning to be evoked or expressed, another letter, which stands for the word-percept (belonging to A and B) which has to be evoked by reading, or expressed by writing. If the reader desires to do so, he can reconstruct the diagram in this way, and work out these seven varieties of aphasic derangement of written speech for himself. Whilst quite prepared to grant that such speculations are often highly valuable as preparing the way for actual discoveries, I do not think that Nos. 3, 5, 6, and 7 of these aphasic disturbances of written speech are yet so well attested by actual cases as to make it necessary for me here to describe their symptoms. We have already considered Nos. 1, 2, and 4 (the cutting off of the centre C from incoming impressions), in detail. I leave the reader to study Wernicke's treatise1 for himself; or to construct the diagram on the lines indicated, and imagine for himself the symptoms that would be exhibited in each of the four remaining varieties. Even as regards Lichtheirn's seven varieties of aphasia in rela- tion to spoken speech, it cannot be said that Nos. 4, 5, 6, and 7 have yet established for themselves so firm a position as Nos. 1, 2, and 3 are generally allowed to hold. It has not yet been shown where exactly in the brain the lesion capable of producing each of them must be situated. There is, in fact, an anatomical difficulty in con- ceiving where a lesion could be situated that would cut across the afferent fibres and leave the efferent intact, or vice versd; because the afferent and efferent fibres belonging to A and to B are joined to the grey matter of these centres on only one and the same side of the cortex, so that a subcortical lesion, unless situated at some distance from the centre, must almost necessarily cut across, not only the efferent or only the afferent fibres, but both together. Cases, however, are now being recorded which lend support to the classi- fication ;2 and Lichtheirn's own cases are strongly corroborative of it. As evidence, the latter are defective only in one respect, viz., that none of them include records of pathological changes. Whether or not Nos. 4, 5, 6, and 7 will yet establish for them- 1 Fortsch. der Med.y ii. 1886, p. 463. 2 See, for example, A. Pick, Ein fall transcorticaler Sensorischer Aphasie, Neurol. Centrabl., Leipzig, 1890, ix. p. 646 ; and G. Brock, Ueber einenfall von transcorticaler Motorischer Aphasie (Graduation Thesis), 1892.368 THE DISORDERS OF SPEECH. selves as firm a position as that of STos. 1, 2, and 3, we cannot at present say; but it is nevertheless certain that the study of this classification affords valuable lessons in the analysis of the symp- toms of aphasia, and helps to explain combinations of symptoms that, without this classification, would be inexplicable. The last of Lichtheim's varieties, No. 7, presents, as we have seen, an apparently possible form of subcortical motor aphasia, whose characteristics are due to the circumstance that only one set of the fibres in connexion with the motor centre has been cut across, viz., the set whose function is to convey the commands of the motor speech-centre in Broca's convolution—that is, of the centre B—down towards the organs of articulation and phonation. All the other sets of connecting fibres are, in this form, preserved intact. But it should be understood that this is not the only possible form of subcortical motor aphasia. On the contrary, it is quite possible for a lesion in the white matter beneath Broca's convolution to cut across all the various sets of connecting fibres that are related to it. In such a case, the grey matter of Broca's convolution would be cut off from its connexions with all the other speech centres, and also from its connexions with the higher centres for thought. Its disablement, therefore, would be complete, and the resulting symptoms would, in every way, be the same as those that are pro- duced by a lesion destroying the grey matter of the centre B itself. Thus cut off from all its connexions, and rendered functionally inert, the grey matter of the centre B would inevitably undergo atrophy. I shall return to the subject of subcortical aphasia, when, in a future chapter, I take up the consideration of the effects pro- duced by disease in the various parts of the motor speech tract. I must now ask the reader to make note of the point at which we have arrived. We have considered the varieties of simple aphasia that can be produced by the destruction of a single speech centre, or by the cutting across of connecting fibres passing to or from each of them; and now we are come to the beginning of the efferent motor tract which leads downwards from Broca's convolu- tion to the organs of articulation and phonation. At this point I leave the speech tract for the present, to return to it afterwards. In the meantime, I wish (1) to say a few words about the Com- pound Varieties of Aphasia; (2) to treat of the best method ofcompound varieties of aphasia. 369 case-taking; and (3) to take up, in the next chapter, the consider- ation of the relations of aphasia and other speech-derangements to Functional Disorders of the cerebral cortex. When I have finished this consideration, I shall return to the motor speech tract; and my final task will be to note the various diseases that may cut that tract across, or may more or less interfere with its conducting power, at various levels in its course. Compound Varieties of Aphasia in connexion with Organic Disease of the Brain. For the analytical study of aphasia, no cases are so valuable as simple cases of isolated lesion in a single centre or conducting tract, such as we have hitherto been considering. But it should be remembered that such simple cases, representing one or another of the pure types, are comparatively rare. Much more commonly, the lesion is not thus confined to a single centre or tract, but several centres and tracts are involved at the same time. On the one hand, the disease may be so extensive as to destroy several of the centres; and, on the other, even when only one centre is destroyed, the other centres may be functionally disturbed or disabled, owing either to the proximity of the lesion, and the diffusion of irritation from it, or to the pressure which certain lesions, such as apoplexy or tumour, may exercise upon them from a distance. Thus, mixed or compound cases of aphasia are more common than simple or pure ones. It would, no doubt, be comparatively easy to describe a consider- able variety of these complex combinations, by merely adding the symptoms of one pure type to those of another. But the reader can make these combinations for himself. It will be sufficient for me here to note, in the briefest manner, three of the most common of the compound varieties of aphasia. (1.) There is the type of Compound Sensory Aphasia, in which both sensory centres—viz., the auditory speech-centre A and the visual C—are involved together. That these two speech-centres should be so often involved together becomes easily intelligible, when we remember that they lie in juxtaposition, and that they are supplied by neighbouring branches of the Sylvian Artery.370 the disorders of speech. (2.) The Compound Motor type, which results from the involve- ment in the same lesion of the centres B and D,—the motor centres for speaking and writing. There is no doubt that these two parts of the brain are very often involved together. Juxtaposition and vascular supply, as i*L the former case, explain the association. But the reader will remember that the agraphia which so often attends upon motor aphasia is not always due to involvement of the centre D, being often really due to the amnesia verbalis that attends upon lesion at B. (3.) The type of Total Aphasia. This type is presented when a lesion of the left hemisphere is so extensive as to destroy or disable all four centres, A, B, 0, and D. And, indeed, it may be said to be presented whenever the centres A and B are both destroyed, though C and D escape; because without the primary couple A and B, the centres C and D are, in almost all persons, if not quite in all, incapable either of conveying a message to, or of transmitting one from, the mind. Occlusion of the Sylvian Artery near its origin may have the effect of disabling all four centres. And, again, an apoplexy in the substance of the hemisphere may for a time disable all four centres by compression. It will be readily understood that the intellect, in all such cases of total aphasia, is very seriously impaired. In connexion with these various types of aphasia, a fact first noted by Lichtheim has already been alluded to. It is that, in the process of recovery from total aphasia, due to lesion at A and B, the faculty of articulate speech is recovered first. Not till long after- wards are the powers of reading and writing restored; and, indeed, these powers may never be completely restored, even though the restoration of articulate speech has long been perfect or almost so. This seems to be a fact, though the explanation of it is not yet very apparent. Method of Case-Taking. When we are taking notes of a case of aphasia, it is well that we should have in our minds some definite plan that may help us to record the symptoms in a connected and intelligible manner, and prevent us from omitting any points of real importance. I do not think it a good plan to take each of the centres separately, andmetitod otf case-inking. 371 inquire how the functions of each are affected. The functions of the various centres overlap each other too much for this. It is far better, I think, in the first instance, to get all the facts of the case without reference to the centres, and only then to consider what evidence they afford as to the functional condition of each of the centres. To get at the facts of the case, the easiest method is, I think, to take each of the two forms of speech, the spoken and the written, separately; and with regard to them, to inquire (1) how the patient receives and interprets; (2) how he produces volitionally; (3) in the case of spoken speech, how he repeats or echoes; and, in the case of written speech, how he writes to dicta- tion, and writes from copy. Full information upon these points will cover nearly the whole ground of the symptomatology of aphasia. Let us try to make a more detailed note about how such information is to be brought out, when we are examining a case after this method. Spoken Speech.—(1.) How is it received and interpreted? Is the hearing good ? The hearing being good, is there any difficulty in interpreting the meaning of words heard (word-deafness) ? The patient's replies to questions, even if these replies are made only by gesture, will show whether or not he understands what is said. Ask him to put out his tongue, to shut his eyes, to give his hand, etc. He should also be tested specially as to his power of inter- preting nouns and verbs. Ask him to touch, one by one, as the parts are named, his nose, ear, eye, chin, etc. Ask him to try to whistle, to shut his eyes, to smile, etc. If the examiner carefully refrains from giving the patient hints, by gesture or expression of countenance, of what is wanted, the recorded answers to such questions will indicate whether word-deafness is present, and in what degree. (2.) Hoiv is it produced ? When there is pronounced motor aphasia, and speech is reduced to a recurring utterance, one or two familiar words, and, upon occasion, an emotional or conventional expression, the whole vocabulary of the patient should be carefully noted down. When, in either motor or auditory aphasia, there is a considerable vocabulary, we should— {a.) Eecord words or phrases of the patient showing evidence of defective power of articulation. For example, we should note372 the disorders otf speech. any specimens of lalling, stammering, syllable - stumbling, or slurring. (b.) Look for evidences of amnesia verbalis, and its companion symptoms, articulative amnesia and paraphasia. In doing so, we should show the patient common objects and ask him to name them; and, in recording his answers, we should make note of difficulties in remembering nouns, etc., as well as of mistakes in the use of them. When the patient is practically dumb, we should test him for amnesia verbalis by asking him to write answers to questions; or, if he cannot write, by asking him, after Lichtheim's method, to indicate with his fingers the number of syllables in the names of common objects shown to him. If there is paraphasia, we should note whether the patient is immediately conscious of the errors he makes in the use of nouns, etc., or, on the other hand, is quite unconscious of them. (3.) How is it repeated or echoed ? The patient should be got to attempt the repetition or echoing of words spoken to him. If he is word-deaf, and cannot understand a mere verbal request to attempt this, the examiner must try to get him to understand what is wanted by putting the request in the language of gesture and repeating the word or phrase over and over again. If the patient is able to echo words or phrases, the attempt should be made to ascertain whether, in doing so, he understands what he is saying. Written Speech.—(1.) How is it received and interpreted ? Is the sight good ? Is hemianopsia present ? Is the patient able to understand questions put before him in writing or in print. If he is speechless, and cannot by speech indicate how much he under- stands, show him in writing or in print such requests as, " Put out your tongue," " Give me your left hand," etc.; and note how he complies with them. If there is some power of interpreting written or printed words, try to ascertain how much there is by asking the patient to read silently a sentence in a book or news- paper and then questioning him about it; framing the questions, if the patient is speechless, in such a manner that he will be able to answer them by gesture or pantomime. (2.) How is it produced ? Ask the patient to write his name. If he succeeds, put simple questions to him, and ask him to answer them in writing. If he writes with comparative ease, ask himMethod of case-taking. 373 to write, at his leisure, the history of his illness. Note in his performance evidence of—(1) paragraphia (which is usually only the written translation of paraphasia); (2) intoxication of the mind with a letter or word; and (3) faults of spelling or syntax. If the right hand is paralysed, let the patient try to write with the left. If the right hand is not paralysed but is agraphic, let him furnish examples of the performance in writing of both the right hand and the left. (3.) How does the patient write to dictation and from copy ? Try him in both ways; and if he is able to do either or both, try to ascertain if he understands the meaning of what he writes. Associated Phenomena.—(1.) Gesture language (Pantomime). Does the patient understand the gesture language of the examiner, and does he himself employ gesture language intelligently ? Or, on the other hand, are there evidences of amimia or of paramimia ? (2.) Extra Graphic Symbols. How does he understand and employ such graphic symbols as numbers, algebraic signs (if previously known to him), musical notation (if he was previously a musician), etc. (3.) Is there any evidence of Mind-blindness {Psychical Blindness), as shown by inability to recognise common objects shown to him, and to indicate their uses; or by inability to recognise intimate friends at sight ? (4.) The Emotional and Intellectual Faculties. Are the emotions lively and their expression vivid, or are they dull ? Is self-control well maintained, or does the patient frequently exhibit emotional disturbance ? What is the condition of the Intelligence as exhibited in expressive actions, and in capability of engaging in games of skill, of conducting business affairs, etc. (5.) The Motor and Sensory Functions. All symptoms of motor or sensory paralysis should, of course, be carefully described. These, I think, are the points we should bear in mind when we are making notes of a case of aphasia. The greatest care must, of course, be taken, not to overtask the damaged brain of the patient. If there is risk of doing so, the work should be done gradually,— little by little.374 THE DISORDERS OF SPEECH. Note on Terminology. I never use the term " Mind-Blindness " without feeling it to be a very poor term for the symptom it is meant to designate. The term, as already explained, is meant to designate a patient's loss of the power of recognising at sight objects formerly familiar to him ; this loss being due to the fact that the old visual images or memories of the objects, imprinted on the brain by efforts of the attention, are now no longer revived by the sight of the objects when they are looked at. That the images are not revived is either because the centre containing them has been destroyed, or because it is now cut off from its normal connexions with the primary visual centres in the occipital lobes. I have, in the text, suggested the term Object-Blindness, as a substitute for Mind-Blindness: but it cannot be said that even that term is altogether ap- propriate ; because the objects are still seen, though they are no longer recog- nised—the patient having the feeling that he is seeing them for the first time. In this respect, however, the term Object-Blindness would be no worse than are, for allied conditions, the current terms Word-Blindness and Word-Deaf- ness, which are open to precisely the same kind of objection. I remember, some years ago, when I was taking notes of a case of word-blindness in the Infirmary, one of my surgical colleagues, who happened to enter the ward, asked me what was the case I was working at. I told him it was a case of word-blindness. " Can the patient not see the words ?" he asked. " She can see them," I said, "but cannot recognise them." "Then why do you call her Word-Blind ?" said he. As everyone beginning the study of Aphasia has this difficulty in comprehending the terms Mind-Blindness, Word-Blindness, and Word-Deafness, would not it be well to find improved substitutes for them, and discard them altogether ? The Greek word ayi>oj but the paralyzed muscles motor ceii; m., a d0 not often waste markedly or rapidly; because muscle. 1 See, for example, his work on Cerebral Localisations, 1887, already re- ferred to. 2 Diseases of the Nervous System, vol. i. p. 116.ANATOMY AND PHYSIOLOGY OF THE MOTOR TRACTS. 419 though cut off from the trophic influences of the cells of the first trophic realm, they are still in full connexion with the cells of the second realm, and continue to be supplied with trophic power from them. On the other hand, let the lesion be situated in the cells or fibres of the second trophic realm, and then not only is there paralysis, as complete as in the other case, but there is also rapid wasting of the paralyzed muscles; because, with the interruption of motor conduction, there is, in this case, also complete cutting off of the trophic supply that had streamed to the muscles from the cells of both trophic realms. I should have liked to complete the description of the accom- paniments of each of these two forms of paralysis,—to have alluded, for example, to the exaggeration of reflexes, and the tendency to spasticity in the muscles, exhibited when paralysis is due to lesion in the first trophic realm ; and to the absence of reflexes, the flaccidity of the wasting muscles, and their "reactions of degeneration," when the paralysis is due to disease of the second trophic realm;—but these are matters treated of and explained in every text-book, and I must not make this sketch too long. I content myself with asking the reader's special attention to the wasting of muscles that is characteristic of a paralysis due" to lesion in the second trophic realm; and with reminding him that in chronic slowly advancing cases, such as are exhibited in the diseases progressive muscular atrophy and progressive bulbar paralysis, this wasting is often attended by fine fibrillar movements in the wasting muscles. One other matter I should like to allude to before concluding these brief notes upon the anatomy and physiology of the speech- tracts. I have already indicated that, according to the results of experimental investigation by Krause, and by Semon and Horsley, the motor representation of adduction of the vocal cords is bilateral, so that stimulation of the centre for this movement on one side of the brain causes equal adduction of bothTvocal cords. I would now like to add that Semon and Horsley have also subjected the motor tract for adduction of the cords to experi- mental investigation, and have found that stimulation of any part of the tract in its first trophic realm causes precisely the same bilateral adduction of the cords as is produced by stimulation of the cortical centre from which it springs.420 the disorders of speech. Pathology of the Motor Tracts for Speaking and for Writing. Before passing to the consideration of the tracts for phonation and oral articulation—the speech-tract proper,—it may, I think, be well to make here a short note about the pathology of the motor tract for writing. This will clear our way for the consideration of the speech-tract proper. Note on the Pathology of the Motor Tract for Writing. The tract for writing is, of course, the tract for the movements of the right hand. Its first trophic realm begins in the cortex, as the motor centre for the hand, which is situated about the middle of the left ascending frontal and ascending parietal convolutions, close behind the centre D, as already explained. Its second trophic realm begins in the right anterior cornu of the spinal cord, at the lower end of the cervical enlargement. Apart from what has already been said about the supposed relations of the motor centre for the hand with the centre D, I have little to say about the motor tract for writing that can apply specially to that act, and not also to the other movements of the hand. In common cases of gross cerebral lesion producing right hemiplegia, the tract for the hand is of course very frequently involved, along with the rest of the general motor tract; and, again, in lesions in the upper part of the spinal cord there is often paralysis of one or both hands. But, as we have seen, if the speech centres are intact, and the left hand unaffected, the patient can still write with that hand, though the right be paralyzed. Of greater interest in relation to the act of writing is the fatigue-neurosis known as Writer's Cramp, which has already been considered in the third chapter of this work. It will be remembered that, in cases of this fatigue-neurosis, it is not always easy to determine which part of the tract for writing has been specially enfeebled by the fatigue ; and that in some cases there is ground for the belief that it is the cortical cells of the first trophic realm that are enfeebled, in others the spinal cells of the second trophic realm, in others the nerve-fibres of the second trophic realm, and in others, perhaps, the muscular fibres themselves.pathology of the motor speech-tracts. 421 Pathology of the Motor Tract for Speaking. The task that still remains for us is, to make note of the various lesions that may interfere with or destroy the speech-tract, at one or another level in its course. We shall have to treat first of the lesions that may damage the speech-tract in its first trophic realm ; and next, of those that may damage it in its second trophic realm. The speech-tract, as we have seen, is composed of fibres belong- ing to the vocal mechanism (such as those whose stimulation causes bilateral adduction of the vocal cords), and of fibres belong- ing to the oral articulative mechanism. In treating of the pathology of the tract in its first trophic realm, it will, I think, be well to take these two sets of fibres together, and to regard them as constituting a common tract; because, throughout their course in the first trophic realm, the two sets of fibres lie so close together that it is scarcely possible for a lesion to damage one set without also damaging the other. When, however, we come to consider the second trophic realm of the speech-tract, it will be best to take each set of fibres separately; because the two sets are, in the second trophic realm, represented by different nerve trunks, and are therefore, in conditions of disease, often damaged or destroyed separately. Lesions in the First Trophic Eealm. 1. Unilateral Lesions in the Cerebrum.—Speech, as we have seen, is a function which is discharged essentially by one hemisphere of the brain, viz., the hemisphere that has been educated to it—this being the left hemisphere in right-handed people, and the right in left-handed people. We have already studied in detail the com- plete or almost complete destruction of the faculty of producing speech which results when the motor centre B, in the educated hemisphere, is destroyed. We have also seen that if a sub-cortical lesion entirely destroy the white matter immediately beneath the centre B, the centre will be rendered functionally inert, and there will result an aphasia in every way identical with that produced by destruction of the centre itself. Further, we have seen that a sub-cortical lesion at a little distance from the centre B may be422 THE DISORDERS OF SPEECH. so situated as to cut across only the fibres proceeding downwards from B towards the medulla, and leave intact all the fibres con- necting B with the other speech-centres. In this case, the type of aphasia produced is that which has been termed the sub-cortical or infra-pictorial motor type. It is characterised by the absence of amnesia verbalis, and by the retention of the power of writing —with the left, if not with the right hand. Patrick Keaney's case may be taken as a fair example of it. Here, now, comes a question of some difficulty. If only one common strand of motor fibres (for the vocal and the oral articilla- tive mechanisms) passed downwards from Broca's convolution to the cells of the second trophic realm in the medulla, then, clearly, the cutting across of that single strand by disease would always produce the same effect—complete motor disablement of speech,—at what- ever level in the tract the lesion might be situated. In other words, motor aphasia of the infra-pictorial type would be produced, whether the tract were cut across at a little distance from Broca's convolution or at a great distance from it—say, in the crus cerebri. But we know that this is not the case: we know that the infra-pictorial type of motor aphasia is typically produced only when the motor tract has been damaged in the upper part of its course, somewhere between Broca's convolution and the upper part of the internal capsule. Lesions in the internal capsule involving the speech-tract, it is generally believed, do not produce aphasia (except indirectly by pressure, etc.); nor do lesions lower down, in the crus or pons. Such lesions may for a time seriously interfere with articulation, producing a dysarthric disturbance of speech that commonly takes the form of slurring; but the words attempted are evidently the right ones, though, from the slurred and slovenly articulation, it may be difficult to recognise them. After a time, even this dysarthria may pass away, though the break in the motor tract that originally caused it remains. Two problems, therefore, present themselves for solution. (1.) Why does a lesion in the speech-tract at or below the internal capsule not produce infra-pictorial motor aphasia ? and (2.) Why, in the majority of cases, is the dysarthria produced by such a lesion recovered from, after a time ? These two problems can be solved only by our adopting the view that the speech-tract which leaves Broca's convolution isPATHOLOGY OF THE MOTOR SPEECH-TRACTS. 423 not a single, but a double tract. In other words, there is not only the tract which passes downwards in the same hemisphere directly towards the medulla, but also a second tract which, passing across from Broca's convolution, by the corpus callosum, to the corres- ponding convolution of the opposite side, establishes connexions between the two convolutions, and enables them to act in motor unison under the guidance of the psycho-motor pictures stored in Broca's convolution. After forming this connexion with the motor convolution of the right side, this tract, it is believed, passes to the internal capsule of that side, and then downwards towards the medulla, in a course similar to that of the direct tract in the left hemisphere. This second tract from Broca's convolution has, conveniently, been termed the "callosal speech-tract.'' Wernicke1 suggests that in the normal condition of the brain three-fourths or four-fifths of the energy requisite for the innervation of speech may be furnished by the left hemisphere, and the remaining fraction by the right hemisphere. There seems every reason to believe that, between Broca's convolution and the upper part of the left internal capsule, the two parts of the double speech-tract —the direct for the left hemisphere, and the callosal for the right —lie close together or very near each other; and that in this part of their course they are often cut across together by the same lesion. It would appear, for example, that a lesion in the upper and anterior part of the Island of Eeil may, by penetrating into the subjacent white matter, cut them both across, and so produce the infra-pictorial variety of motor aphasia. At and below the upper part of the internal capsule, on the other hand, they increasingly diverge from each other, and are less and less likely to be cut across by the same lesion, until, on reaching the base of the brain, they come near each other again in the Pons; and therefore lesions at and below the upper part of the internal capsule usually produce merely a dysarthria or difficulty of articulation, and not an aphasia of the infra-pictorial motor type. The dysarthria is usually most marked, and most apt to be permanent, when the tract belonging to the left hemisphere is cut across; but dysarthria is also of pretty common occurrence when the lesion is in the right hemisphere; and Wernicke is in such cases inclined 1 " Ueber die motorische Sprachbahn, mid das Verhaltniss der Aphasie zur Anarthrie," Fortschr, der Medicin, ii. 1884, p. 412.424 THE DISORDERS OF SPEECH. to attribute it to the cutting across of the tract in that hemisphere. In either case, the dysarthria often,after a time, passes away; and it does so most speedily when the lesion is in the right hemisphere, —because the remaining division of the speech-tract may soon acquire the power of discharging perfectly the function that in health is discharged by the two divisions together. I shall not attempt here to describe the gross lesions of the brain that are capable of destroying or temporarily disabling the speech-tract in one or other of the cerebral hemispheres. It will be sufficient to remind the reader that the chief of them are apoplexy, softening, and tumour; and that by any one of these conditions the speech-tract may, in some part of its course, either be directly involved and destroyed, or, lying in the neighbourhood of the lesion, be merely disabled without being destroyed. 2. Bilateral Lesions in the Cerebrum.—A gross cerebral lesion is, in the vast majority of cases, unilateral; one single focus of disease being developed in one or other hemisphere. But it occasionally happens that two foci are developed, either simultaneously or in succession ; and even that the two occupy corresponding positions in the hemispheres. Such symmetrical lesions may involve the speech-tracts on both sides. I have already, in a former chapter, illustrated the effects pro- duced by symmetrical destruction of the motor speech centres, by reference to a well-known case reported by Dr Barlow. In that case, it will be remembered, there was, first, motor aphasia from destruction of Broca's convolution. But this was recovered from, by the convolution of the opposite side being educated to assume the function of speech. Then there occurred a second lesion, which destroyed the convolution of the opposite side. The result was not only a return of motor aphasia—which now remained permanent,—but also the establishment of paralysis in both sides of the mouth and tongue—a form of paralysis so similar in its symptoms to the paralysis caused by disease of the bulbar nuclei that it has been termed Pseudo-Bulbar Paralysis. The chief difference between the two is the absence of wasting of the tongue and other affected muscles in the pseudo-bulbar paralysis, and the marked wasting that attends upon true bulbar paralysis—a difference due to the fact that in the one case it is the first, and in the other the second trophic realm, that is the seat of the disease.PATHOLOGY OF THE MOTOR SPEECH-TRACTS. 425 Pseudo-bulbar paralysis being thus the well-known effect of bilateral destruction of the motor centres for phonation and oral articulation, it will be readily understood that the very same effect may be produced by bilateral lesion of the motor tracts leading from these centres. But in this case there would, almost certainly, be other paralytic accompaniments. There might, for example, be paraplegia in arms and legs—a pseudo-spinal along with the pseudo- bulbar paralysis;—because the various motor strands in the general motor tract lie closer together than the various cortical motor centres from which they spring, and are therefore far less liable to be singled out by a gross lesion and destroyed separately. These symmetrical gross lesions are rare, and are therefore not very important. Of far greater interest and importance, in relation to speech, are the fine lesions—of the nature of sclerosis of the connective tissue—which affect both hemispheres simultaneously, and often seriously interfere with the conduction of motor power along both speech-tracts. As a typical example of such bilateral sclerosis, I shall select the disease known as Multiple or Insular Sclerosis. It is the most commonly met with of the group, and it produces well-marked effects upon the production of speech. Without attempting to describe the symptoms and pathology of Multiple Sclerosis, I may remind the reader that it is a disease most common between the ages of 20 and 35; that among its most characteristic symptoms are:—the embarrassment of speech, to be presently noted; nystagmus; coarse trembling or jactitation of the arms and hands, during performance of voluntary move- ments; weakness, incoordination, and sometimes spasticity of the legs; enfeeblement of the intellect; and, in the later stages, the occurrence of apoplectiform attacks, the development of symptoms pointing to involvement of the bulb—such as loss of the power of swallowing,—and a general failure of nutrition which betrays itself in a tendency to the formation of bed-sores. Dr Gowers states that the duration of the disease is from two to fifteen years, the average duration being from two to six years. Pathologically, the disease consists in an overgrowth of the connective tissue of the brain and spinal cord—an overgrowth that is not diffuse or general, but is limited to scattered spots or patches in the white matter of the brain and cord, and also in the white matter of the crura, pons, medulla, and cerebellum. As 3 H426 THE DISORDERS OF SPEECH. microscopic examination of the sclerosed patches shows that the axis-cylinders of the nerve fibres are often partly preserved in the midst of the overgrown connective tissue, it is supposed that the disease primarily consists in an overgrowth of the con- nective tissue, and that the atrophy of the nerve fibres is a secondary consequence of the pressure put upon them. In the speech of Multiple Sclerosis, the most striking charac- teristic is the well-known slow and laborious utterance, in which, with evident effort, each syllable is enunciated separately and deliberately. This is the "staccato speech" of multiple sclerosis. Sometimes it is termed " scanning speech," because the effect of it on the ear of the listener is not unlike that produced when someone is heard scanning deliberately a line of Latin poetry. When the staccato character is extremely well marked, some individual syllables may, now and again, be shot out with explosive violence. The slow staccato utterance of multiple sclerosis is believed to be due to the interference with conduction in the motor speech- tracts that is produced by the compression of the nerve fibres at points where they are passing through patches of sclerosis. Along with the staccato utterance, there is often drawling of the syllables. As the disease advances, the staccato element is apt to become less striking, and the drawling and slurring more and more marked, until speech is at last reduced to an inarticulate drawl. I have in my ward, at the present time, a patient with multiple sclerosis, whom I have had under observation for about eight years. At, first his speech was markedly of the staccato type; but, for the last two years, it has become more and more slurred and inarticulate. When, for example, he now tries to say "good morning," the words are produced as a monotonous drawl, in which only traces of the m and n and something of the vowel sounds are recognisable. He is in the last stage of the disease: totally paralyzed in the legs, and almost totally so in the arms; and requiring to be fed with the stomach-tube, as he has lost the power of swallowing. Though staccato utterance is most typically exhibited in multiple sclerosis, it would be a mistake to suppose that it occurs only in that disease. We have already seen that an element of staccato utterance is often present in the speech of general paralysis of thePATHOLOGY OF THE MOTOR SPEECH-TRACTS. 427 insane; and is met with also in the speech of some aphasic patients, when they are beginning to regain the power of speech by- training the convolutions of the opposite hemisphere. Charcot emphasizes the resemblance between the speech of multiple sclerosis and that of general paralysis of the insane. He says,1 " I even believe that, in a good many cases, apart from the help obtained from the consideration of accompanying phenomena, the distinction would be almost impossible. And that the resemblance may be still closer owing to the circumstance, that in multiple sclerosis, as in general paralysis of the insane, emission of words is sometimes preceded or accompanied—as you may remark in our patient—by a slight, as it were convulsive, contraction of the lips." Kussmaul, however (p. 664), holds that Syllable Stumbling, the most characteristic of all the features in the speech of general paralysis, never occurs in multiple sclerosis. In general paralysis, he says,—" Both articulate sounds and syllables are misplaced and thrown into confusion. To borrow Westphal's admirable illustration, the general paralytic, in trying to say ' artillery,' calls it ' artrallerary'; the patient with insular sclerosis, on the other hand, pronounces it' ar-til-ler-y/ " Alongside of the above notes about the speech of multiple sclerosis, I shall now insert a brief note about the speech of Fried- reich's disease; as there is a pretty close resemblance between this speech and the speech of multiple sclerosis. Yet I would first state that we have 110 right to regard Friedreich's disease as a condition that causes its peculiar speech by interfering with conduction in the first trophic realm of the motor speech-tract. Friedreich's disease is essentially not a disease of the brain, but one of the spinal cord. Like tabes dorsalis, it is a sclerosis of the posterior columns of the cord; and, in its general symptoms, it resembles ordinary tabes dorsalis. But it differs from ordinary tabes in many particulars, some of the distinguishing features of Friedreich's disease being—(1), That it is very markedly a family disease, and often affects brothers and sisters in the same family-— one after another acquiring it as they grow up to manhood or womanhoodand (2), that, like multiple sclerosis, but not like tabes, it causes both nystagmus and a peculiar affection of speech. 1 Legons sur les maladies du systeme nerveux, 1875, p. 236.428 THE DISORDERS OF SPEECH. From the study of the eases of this disease published by Fried- reich1 and others, it may be seen that the characteristic disturbance of speech has in it, almost always, more or less of that staccato element which is so markedly present in the speech of multiple sclerosis. But this element may not be very striking. Often the utterance is merely slow and drawling, with that thickness or imperfection of articulation which is, I think, best described as " slurring," but which Friedreich in his description terms "lalling." It is a thick slurring articulation like that of inebriation, but differing from it in being slower and more laborious, and in having often in it a more or less pronounced element of staccato enunciation. Friedreich tells that some of his patients had some- times to attempt difficult words over and over again, before succeeding in their enunciation. In the very chronic course of Friedreich's disease, the derange- ment of speech is not one of the first symptoms to be developed. Its appearance is often delayed for a year or several years after the characteristic ataxia has shown itself in the limbs. Friedreich attributes the derangement of speech to changes in the medulla, and especially to a descending neuritis in the roots and trunks of the hypoglossal nerves; but this conclusion does not seem to have been confirmed by other observers, as Gowers remarks that—" The precise origin of the affection of articulation and of the nystagmus has not yet been traced."2 In tracing down the speech-tract, I may now pass over the Crura Cerebri with a very brief note. There is, indeed, scarcely anything to be said about the effects of lesions in one or other of the crura, further than that they closely resemble the effects of unilateral lesions of the tract in the internal capsule. A dysar- thric disturbance of speech, of the nature of slurring, and usually of temporary duration, is apt to be produced when the speech-tract is cut across in either the right or the left crus. As in the case of lesion in the internal capsule, it is generally most pronounced when the lesion involves the left crus; but it may be more or less distinctly present, for a time at least, when it is the right crus that is involved. 1 Virchovfs Archiv% 1863, Bd. xxvi. and xxvii.; also ibid., 1876, Bd. lxviii. and lxx. 2 Diseases of the Nervous System, vol. ii., p. 355.PATHOLOGY OF THE MOTOR SPEECH-TRACTS. 429 3. Lesions in the Pons.—Leyden was right when, in 1867,1 he pointed out that in relation to dysarthric and anarthric disturbances of speech lesions of the pons are of special importance. It must be remembered that the speech-tracts from the two hemispheres are here no longer widely separated from each other. They are brought near together, even in the upper part of the pons, in which they lie parallel with each other. In the lower part of the pons, again, they actually cross each other in the middle line, on their way backwards to the nuclei of the medulla. This disposition of the two tracts in the pons renders them liable to be affected together; and when they are destroyed together, total anarthria— utter speechlessness and voicelessness—results. It will be readily understood that in such cases there is also, as a rule, total para- plegia of both arms and legs; as the general motor tracts from both hemispheres are, like the two speech-tracts, apt to be involved together, owing to their juxtaposition. Coarse lesions in the pons, such as apoplexy, softening, and tumour, are the common causes of such total paralysis of speech and of voluntary motion; and such effects are most apt to be produced when the coarse lesion in the pons is central in its situation. On the other hand, uni- lateral lesion, in the upper part of the pons, may involve only one of the general motor tracts, including the portion of it that forms the tract for speech; and the result will then be, not a para- plegia, but a hemiplegia, and not an anarthria of speech, but a dysarthria. Even in such cases of unilateral lesion, however, the dysarthria is apt to be more than usually severe; because, along with destruction of one of the speech-tracts, there is apt to be also more or less disablement of the other, owing to pressure or to collateral disturbance. The two lie so near each other in the pons that one can scarcely be destroyed without such disturbance of the other. In cases of central lesion of the pons, with total paraplegia, and total paralysis, it may be, of the face and eyes, as well as total speech- lessness, it is, I think, well for us to remember, when in the presence of the patient, that though he may appear to be profoundly coma- tose he may really, for aught we know, be conscious. I remember one case of this kind in which the son of the aged patient, sitting 1 Berliner Klin. JVochenschr., 1867, Nos. 7, 8, and 9.430 the disorders of speech. by the bedside with his left hand in the right hand of his father, was startled by feeling his father press his hand repeatedly. The son may have been mistaken in thinking that the pressure was a message to him, communicated through the only channel that remained open,—the pressure may have been automatic and in- voluntary —but I think it within the limits of possibility that the son was right in his opinion. The case was one of rapidly spreading lesion in the pons, which, after causing severe neuralgia in the right side of the face, caused left hemiplegia, and then ophthalmo- plegia and partial right hemiplegia, with, ultimately, apparent coma. Some voluntary motor power may have lingered in the right hand, even when the patient was, to all appearance, in a condition of deep coma. I mention the case because it made a very strong impression upon me. Since knowing of it, I have always, each session, been careful to ask my students to bear in mind the possi- bility that a patient with severe lesion of the pons may really be conscious, though apparently comatose. Lesions in the Second Trophic Eealm. In the foregoing notes upon lesions in the first trophic realm of the speech-tract, I have taken the part of the tract for the vocal mechanism and the part for the oral articulative mechanism together; because they lie in juxtaposition throughout their course, and when affected by disease are almost necessarily involved together. But in now treating of the second trophic realm, it will be best for us to take the two parts of the tract separately; because each part, springing from its own root-cells in the medulla, is continued to its muscular distribution in the form of separate and distinct motor nerves, which can easily be affected by disease independently of each other. I shall first consider the lesions of the nerve trunks, and then the lesions of the medullary nuclei from which they spring; and I shall begin with the motor nerves of the Yocal Mechanism. 1. Lesions in the Second Trophic Realm of the Motor Tract for the Vocal Mechanism.—The reader will remember that the motor nerves for the larynx take their origin in the medulla from the nerve-cells of the spinal-accessory nucleus; that the root-fibresPATHOLOGY OF THE MOTOR SPEECH-TKACTS. 431 proceeding from this nucleus soon join themselves to the trunk of the vagus; and that, after joining the vagus, they are continued down in the neck as part of its trunk, until—(1), a small number of them leave the vagus to form the motor portion of the superior laryngeal nerve; and (2), the bulk of them leave the vagus at a much lower level, to constitute the great motor nerve of the larynx, viz., the recurrent laryngeal. As to the Superior Laryngeal nerves, it will be remembered that the muscles of the larynx deriving their motor innervation from them are the crico-thyroid muscles and the small muscles which depress the epiglottis during deglutition. According to some authorities, filaments from them are also supplied to the inter- arytenoid muscle, and to the lateral crico-arytenoid muscles; but this is doubted by others, and seems to be contradicted by the evidence obtained from the study of paralysis due to lesions of the recurrent nerve. The crico-thyroid muscles, undoubtedly supplied by the superior laryngeal nerves, help to fix the thyroid cartilage during phonation, and to tighten the cords during the production of high notes. They act by approximating the cricoid cartilage to the thyroid, in front. Bilateral paralysis of the superior laryngeal nerves is said to be of not uncommon occurrence as an accompani- ment or a sequela of Diphtheria, and Sir Morell Mackenzie states that in such cases the chink of the glottis, in phonation, instead of being straight, is bent in zigzag or sinuous fashion, owing to the undue slackening of the cords. The patient, it would appear, may be either voiceless or merely husky. But the chief symptom of paralysis of the superior laryngeal nerve is paralysis of sensa- tion within the larynx. It will be remembered that, besides containing the motor fibres above mentioned, the superior laryngeal is also the sensory nerve for the larynx. Within the nerve, and within the trunk of the vagus, its sensory fibres course along with the motor; but in the medulla the two sets of fibres are separated from each other, the sensory fibres being connected with the nucleus of the vagus, and the motor with the nucleus of the spinal- accessory. It will be readily understood that the sensory and motor symptoms characteristic of paralysis of the superior laryngeal nerve may be produced either by a lesion of the nerve itself or by a lesion of the trunk of the vagus above the point at which the nerve branches from it.432 THE DISORDERS OF SPEECH. The Recurrent Laryngeal nerve is, of course, the great motor nerve of the larynx. With the exception of the crico-thyroid muscles above mentioned, it supplies all the muscles which act upon the vocal cords. It thus supplies both the adductors which close and the abductor which opens the glottis. Careful observation within recent years has brought out some interesting facts about the two sets of fibres—adductor and abductor—that go to make up the recurrent laryngeal nerve. On the one hand, it has been found that when the whole nerve is stimulated with electricity, the effect is not an equally balanced contraction of adductor and abductor muscles, resulting in absence of movement in either one direction or the other, but is a movement of adduction, which closes the glottis. And, on the other hand, it has been found that when the whole nerve is gradually compressed from without by a tumour, the result is not a slowly increasing paresis equally marked in adductors and abductor, but is a paresis which shows itself first in the abductor movement, and goes on to paralysis of that movement before there is any distinct paresis in the movement of adduction. How are these two facts to be explained ? There has been much controversy about their explanation, and it would take a great deal of space to make a statement of all the hypotheses that have been advanced. I shall content myself with making a brief note of two different explanations, which are each supported by high authority. Dr Gowers1 holds that there may be no inherent difference in the properties of the two sets of fibres, and that both of the phenomena above noted may be explained if the bulk and strength of the adductor muscles are—as they seem to be—greater than those of the abductor; or if, as he thinks is the case, the weaker abductor acts at a disadvantage as compared with its opponents, owing to the nature of its attachment to the arytenoid cartilages, and the angle at which it pulls. If we grant that, in the muscular and mechanical arrangements within the larynx, it is thus provided that adduction has a distinct preponderance of power over abduction, then we can understand how it is that stimulation of the whole nerve trunk may cause closure of the glottis, owing to this preponderance of the adductor power; and 1 Diseases of the Nervous System, vol. ii. p. 262,PATHOLOGY OF THE MOTOR SPEECH-TRACTS. 433 how, again, when the whole nerve trunk is being slowly weakened by pressure, paresis may show itself first in the movement that is originally the weaker. Dr Semon,1 however, explains the phenomena in a very different manner. He holds that, in the two sets of fibres com- posing the nerve trunk, there are inherent physiological differences. To the adductor fibres, he attributes a greater inherent excitability; and to this, he thinks, is due the closure of the glottis which occurs when the whole trunk is stimulated. To the abductor fibres, on the other hand, he attributes a greater vulnerability; and in this he finds the explanation of the fact that paralysis of abduction precedes paralysis of adduction, when the whole trunk is being slowly disabled by pressure from without. If, hereafter, it should be thoroughly established that, in these cases of pressure on the nerve, there is distinctly greater wasting in the abductor muscle than in the adductors, then Dr Semon's explanation must be accepted; but if, on the other hand, the degree of wasting is equal in abductor and adductors, then Dr Gowers's explanation will have the advantage. A third explanation of the early appearance of paresis of abduction in these cases of pressure on the nerve trunk was offered by Sir Morell Mackenzie, ifi his work on Diseases of the Larynx. He suggested that, in the trunk of the nerve, the abductor fibres might be arranged peripherally in the outer zone of the nerve-trunk; whereas the adductor fibres might be collected in the centre. This would account, he thought, for the earlier appearance of abductor paresis. But experimental stimulation of the nerve fibres in the trunk has not confirmed this suggestion. Dr Risien Russell,2 especially, has made a series of conclusive experiments upon the nerves of living animals. Dissecting out the nerve bundles from each other, and stimulating them indi- vidually with electricity, he has been able to distinguish the adductor from the abductor bundles, and has found them not to be arranged as suggested by Mackenzie, but to be mixed up indifferently throughout the thickness of the trunk. 1 " Geschichte der Lehre von den motorischen Kehlkopflahmungen," a con- tribution to Virchow's Festschrift, vol. iii. p. 407. 2 Proceedings of the Royal Society, vol. li. p. 102.434 THE DISORDERS OF SPEECH. Let us now, from a more strictly clinical and practical point of view, consider, for a moment, the effects of pressure upon the trunk of the recurrent nerve. As a typical example, let us take a case of Aneurism of the Arch of the Aorta, with pressure upon the left recurrent nerve. In the course of such a case, there is apparently always a first stage, during which the paralysis betrays itself by no symptom whatever, except, it may be, a very slight alteration of the voice. This is the stage at which, as yet, there is only paralysis of the abductor muscle, without paralysis of the adductors. If the patient be examined with the laryngoscope at this stage, the left cord is found fixed near the median line—in the position it ought, normally, to occupy only during phona- tion. It remains there even when, on the patient taking a long breath, the opposite cord is abducted to its full extent. It seems to be the tone of the unopposed adductor muscles that thus keeps the cord of the affected side fixed permanently in the position for phonation. In this stage, the voice is normal, or only very slightly altered ; and there is no difficulty of breathing, because the other "gate of the glottis" is open during respiration, and can be swung open to the fullest extent when a long breath is taken. In fact, this stage of recurrent paralysis can only be diagnosed with the aid of the laryngoscope. With continued and increasing pressure upon the nerve trunk, there is, by-and-by, developed the second stage, characterized by the addition of adductor paralysis to the already existing para- lysis of abduction. In this stage, the cord of the affected side is no longer stretched near the median line—in the position for phonation,—as it was in the first stage. The tone of the adductor muscles which kept it there being now lost, the cord falls back from the middle line into the " cadaveric position "—a position midway between that of adduction and that of abduction ; —and there it lies immobile, both during attempted phonation and during deep inspiration. When the patient attempts to phonate, the cord of the opposite side is strongly adducted; and, in its effort to meet its paralyzed neighbour, it even crosses the middle line, so as to leave but a narrow interval between itself and the paralyzed cord. The interval is sufficiently narrow to enable the patient to whisper; and, in the whisper, there is generally a feeble vocal element due to the vocal vibration of thePATHOLOGY OF THE MOTOR SPEECH-TRACTS. 435 sound cord. The symptoms and the laryngoscopic appearances of this, the second stage of recurrent paralysis due to aneurism, are familiar to every physician ; but the first stage is not so familiarly known, as there may be no symptoms betraying its presence, and as it can only be diagnosed with the aid of the laryngoscope. Unilateral paralysis of the recurrent nerve, such as is thus so often due to aneurism of the aorta, may also be due to other causes, and occur in connexion either with the left or with the right recurrent. Thus the pressure from a tumour in the mediastinum, or from a glandular tumour in the neck, or from the enlarged lateral lobe of a goitrous thyroid body, or, again, the involvement of the nerve in cancerous disease of the oesophagus, or its compression, on the right side, by the newly-formed con- nective tissue of a pleuritic thickening at the apex of the right lung,—all of these conditions may produce paralysis of the recurrent nerve on one or other side; and the paralysis may present a first and a second stage, as when it is due to the pressure of an aortic aneurism. Further, it should be remembered that recurrent paralysis is sometimes due to pressure upon the trunk of the vagus, at some point above the level at which the recurrent nerve is given off. If the point pressed against be so high in the neck as to be above even the point at which the superior laryngeal is given off, then, along with recurrent paralysis, there will be also paralysis of the superior laryngeal nerve, with its characteristic anaesthesia of the larynx. In some rare cases, Bilateral Paralysis of the recurrent nerves has been found to be due to pressure, either upon the two recurrent nerves or upon the two pneumogastrics. This bilateral paralysis presents the same two stages in its progress as have already been described as occurring in unilateral recurrent paralysis. First, in the stage of simple abductor paralysis, the cords lie in the position of adduction, close to each other in the middle line; and then, in the stage of combined abductor and adductor paralysis, the cords have retired from the middle line, and lie in the cadaveric position, at some distance from each other. It will be readily understood that in the first stage there is great danger of suffocation. The cords lie so close to each other that there results that crowing stridulous inspiration so characteristic436 the Disorders of speech. of bilateral abductor paralysis. The noise is loudest when the patient makes any exertion, and when he is asleep; and during sleep a paroxysm of laryngeal dyspnoea may set in, and may end fatally. Tracheotomy is thus often advisable, in bilateral paralysis of the abductors. Though inspiration is noisy and difficult, expiration is easy; and the voice, in speech, may, in this stage, be natural. When, in the second stage, the cords retire into the cadaveric position, breathing becomes easy, all stridor disappearing; but, in this stage, the voice is lost, because the adductors are now paralyzed, as well as the abductors. Before leaving the laryngeal nerves, I may refer, in a word, to the occasional occurrence of neuritis in one or other of their branches of distribution, and to the resulting paralysis of one or other of the individual muscles of the larynx. I have already, in the second chapter of this work, made some brief reference to the loss of voice which may be caused in this way, by the paralysis of some single adductor muscle. It still remains for us to consider the Nuclear Cells in the Medulla, from which the motor nerves of the larynx spring. As already indicated, these cells form part of the nucleus of the spinal-accessory division of the eighth cranial nerve. It has been asserted that some of them are also contained within the nucleus of the vagus, but this opinion still requires confirmation. There are many lesions, coarse and fine, which may affect the motor and sensory nuclei in the medulla; but, as some of these affect, indifferently, the cells of either the oral artieulative mechanism or the vocal mechanism, or affect both sets of cells simultaneously, and as others, such as the lesion in glosso-labio- laryngeal paralysis, are primarily developed in the cells of the oral artieulative mechanism, I think it will be well to reserve any enumeration of them until we come to look at the nuclear origins of the nerves for the oral artieulative mechanism. But there is one lesion which is of special interest in the present connexion, as, on invading the nuclei of the medulla, it seems to have a special proclivity to affect the motor cells of the vocal mechanism,—I mean the spread of degeneration into the medulla in cases of tabes dorsalis (locomotor ataxy). It is now well ascertained that, in the course of ordinary tabes dorsalis, two forms of laryngeal complication may be developed,PATHOLOGY OF THE MOTOR SPEECH-TR ACTS. 437 in consequence of this invasion of the spinal-accessory nucleus. These are—(1), Temporary paroxysms of laryngeal dyspnoea (" laryngeal crises which by some authorities are attributed to temporary spasm of the adductor muscles, and by others to temporary paralysis of the abductors; (2), permanent paralysis of laryngeal muscles. This paralysis seems always to affect the abductors in the first instance. It may be confined to these throughout, or, in course of time, may involve also the adductors. Often, especially at first, the paralysis is unilateral; and then, so long as it is purely a unilateral abductor paralysis, it can only be detected with the laryngoscope,—there being no symptoms, such as loss of voice, or laryngeal dyspnoea. When, however, the adductors are also affected, and the cord has fallen back from the median into the cadaveric position, then there is loss of voice, as in the advanced stage of unilateral recurrent paralysis in cases of aneurism. If there is bilateral paralysis of the abductor muscles alone—as, in tabes dorsalis, there often is,—then the patient suffers from the marked and dangerous laryngeal dyspnoea which has been already noted as characteristic of that condition. This will disappear, but the voice will be lost, if the paralysis ultimately involves also the adductors. These laryngeal complications of tabes dorsalis must be commoner than is usually imagined. Dr Semon says that in the first twelve cases of tabes examined by him in the " National Hospital for Epilepsy and Paralysis," he found no fewer than seven to be affected either with unilateral paralysis of the abductor, or with unilateral paralysis of both the abductor and the adductors, or with severe bilateral paresis of the abductors. But he adds that in the next fifty or sixty cases not a single case presented any symptom of laryngeal paralysis.1 Seeing that in so many of these cases the abductor is affected alone, or is affected first, before the adductors are also involved, Dr Semon has been naturally led to the conclusion that in the medullary nuclei of the laryngeal nerves there is the same com- parative vulnerability in the abductor nerve-cells that he believes to exist in the abductor nerve-fibres of the recurrent nerve. And 1 Op, citp. 444.438 THE DISORDERS OF SPEECH. this conclusion would be irresistible, if it were proved that all degenerative conditions invading the medullary nuclei singled out the abductor cells in similar fashion. But this is not proved. The leading degenerative disease of the medullary nuclei is Progressive Bulbar Paralysis (glosso-labio-laryngeal paralysis); and when that disease, in its latter stage, spreads from the nuclear cells of the oral articulative mechanism into those of the vocal mechanism, it attacks first the adductor cells,—not the cells for abduction. It does not, however, often cause complete paralysis of the adductors. " The laryngeal palsy," says Dr Gowers, " rarely becomes complete, and it is still rarer for the power of abduction to be specially lost, common as abductor palsy is in some other forms of central degeneration." Some explanation other than that offered by Dr Semon may yet be found—possibly one connected with the anatomical position of the abductor cells,—to account for the frequent occurrence of abductor paralysis as a complication of tabes dorsalis. In dealing with any case of laryngeal paresis or paralysis, a very important question for us to determine is, whether the paralysis is of functional or of organic origin. As recent investigation has thrown considerable light on this question, perhaps it may be well for us to devote here a little attention to it. If we take first the Bilateral forms of paresis or paralysis, we may make note of the following general conclusions:— 1. That a bilateral paresis of the Adductor muscles, without any affection of the abductors, is almost always of functional origin, and is commonly due to hysteria. When it is slightly pronounced, it causes "hysterical aphonia." When it is better marked, it causes the common variety of hysterical mutism. This subject has already been fully discussed in the second chapter. We must, however, admit that in a few cases this paresis of the adductors may be of organic origin, — if it is true that when progressive bulbar paralysis invades the nuclear cells of the vocal mechanism the adductor cells are the first to be affected. 2. That a bilateral paresis or paralysis of the Abductors, without apparent affection of the adductors, is very generally of organic origin,—being most commonly the result of lesion in the bulbarPATHOLOGY OF THE MOTOR SPEECH-TRACTS. 439 nuclei, and, in rare cases, the first effect of pressure upon both recurrent nerves or both pneumogastrics. It is believed by some authorities, however, that this paralysis may in a few cases be of functional causation. Gowers, for example, states that temporary attacks of it, attended with the characteristic dyspnoea, have been known to follow an ordinary laryngeal catarrh; and he expresses his belief that the laryngeal paroxysms of dyspnoea which occur occasionally in some cases of hysteria may sometimes be due to temporary paralysis of the abductors, and not always to spasm of the adductors, as is usually supposed. 3. That a bilateral paralysis involving both Abductor and Adductor muscles is always of organic origin. There seems to be no exception to this rule. If we now pass to the Unilateral forms of paralysis, we can say in brief about them, that whether they affect adductors or abductor, they are practically all of organic origin. Possibly, however, it may yet be found that there are rare cases of Hysteria in which there is adductor paresis of one cord only. This possibility I shall discuss presently. As to the Situation of the lesions accountable for these various forms of paralysis when they are of organic origin, we can say that in the vast majority of cases, if not in every case, it is somewhere in the second trophic realm of the motor tract. It is either in the medullary nuclei, or in the trunks of the nerves, or in their branches of distribution. Being due to lesion in the second trophic realm, these paralyses are attended with the characteristic wasting of the paralyzed muscles. The rare exceptions to this law—that the organic lesions capable of producing paralysis in the larynx are situated in some part of the second trophic realm of the motor tract—are furnished by bilateral lesions involving the first trophic realm, in both hemi- spheres or in both crura; and by central lesions in the pons which disable both tracts. In such cases, as we have seen, there is pseudo-bulbar paralysis—a paralysis always bilateral ;—and all voluntary control over the larynx, as well as over the muscles of the tongue and lips, is lost. If the motor representation of the vocal cords in the cerebral440 THE DISORDERS OF SPEECH. cortex is perfectly bilateral (as Semon and Horsley believe it to be), then it is not possible for any unilateral lesion in the first trophic realm—whether in the cortical centre or in the tract—to produce paralysis of one vocal cord (unilateral paralysis in the larynx); because the cortical centre and tract of the other side would continue to innervate both cords. Nor, a fortiori, is it possible for any disablement there from functional causes, such as hysteria, to produce unilateral laryngeal paralysis. But if further investigation should show that Masini is right in stating that the motor representation of the vocal cords in the cortex is not perfectly, but is only imperfectly, bilateral—just as is the motor representation of the tongue, lips, etc.,—it would then appear that it is possible for a unilateral lesion in the first trophic realm (either in the cortical centre or the motor tract) to produce paresis of the opposite cord,—just as a unilateral lesion in the first trophic realm of the tract for the oral articulative mechanism pro- duces a slight paresis in the opposite side of the mouth and of the tongue, as is seen in ordinary hemiplegia. And if an organic lesion on one side can thus produce a unilateral paresis in the opposite cord, so perhaps may a functional disablement on one side, due to hysteria. As we saw in a former chapter, cases of cerebral lesion in one or other of the hemispheres attended with motor paralysis in the opposite cord have already been published. It is, however, suggested by Dr Semon and others, that in these cases some other lesion, in what I have termed the second trophic realm of the tract, must have been present, though overlooked. We must wait for further evidence, before we can be quite sure which party in this controvers}7 is right. If cases of hysterical hemiplegia should be met with in which there is loss of voice from adductor paresis of the vocal cord 011 the same side as the hemiplegia, they would lend support to the opinion of Masini that the motor representation of the vocal cords is only imperfectly bilateral; since they would tend to show that even a functional unilateral disturbance of the cerebral cortex is capable of producing a unilateral paresis of the opposite cord. The weight of evidence, however, at the present time, is strongly in favour of the conclusion of Semon and Horsley, that the representation of the vocal cords is perfectly bilateral, and that it is, therefore, impossible for any organic lesion orPATHOLOGY OF THE MOTOR SPEECH-TRACTS. 441* functional disturbance in the first trophic realm to produce uni- lateral paralysis or paresis in the larynx. The common bilateral paresis of the adductors in hysteria is commonly believed to be due to functional paresis of motor power, or, shall we say, the power of will, in both hemispheres.1 2. Lesions in the Second Trophic Realm of the Motor Tract for the Oral Articulative Mechanism.—This realm begins in the motor nuclei of the medulla, and extends, in the form of various motor nerves, to the muscles of oral articulation. The nuclei from which the nerves spring are the motor nuclei of the seventh pair, the hypoglossal nuclei, and portions of the nuclei of the spinal accessory. The nerves are the portio dura of the seventh, the hypoglossal, and the nerves from the spinal - accessory nucleus which supply the soft palate and the muscular wall of the pharynx. As I do not think it would be of much advantage to attempt here an elaborate description of the lesions of the nerve trunks, I shall content myself with reminding the reader of a few leading facts about these lesions. First, about the portio dura of the Seventh, I need scarcely say that unilateral paralysis, due to neuritis of the nerve trunk (Bell's paralysis), is one of the commonest of all the forms of local para- lysis. Though the mouth is pulled towards the opposite side, and, the lips on the paralyzed side are flaccid, the articulation of the labials and the labio-dentals is only slightly interfered with. In rare cases, both nerves are paralyzed; and then the whole face is expressionless, and the lips are flaccid on both sides. Commonly, these cases are due to the pressure of a tumour at the base of the brain upon the nerve roots. But, some years ago, I had, in my wards, a case in which this bilateral paralysis had been caused by injury of the nerve trunks, at or about their exit from the stylo-mastoid foramina. In the bilateral cases, the enunciation of the labials 1 For fuller information regarding the Paralyses of the Larynx, see the chapter on the subject by Dr Gowers in his work on Diseases of the Nervous System, vol. ii. p. 256 ; or the article by Dr Semon referred to in the footnote to p. 433 ; or the chapter by Dr M'Bride in his work on Diseases of the Throat, Nose, and Ear, and an article by the same author in the Edinburgh Medical Journal, July 1885,442 THE DISORDERS OF SPEECH. and labio-dentals is impossible; but, as the other parts of the articulative mechanism are intact, speech is not very seriously damaged, and is always easily intelligible. It is most striking to hear and see a patient with double facial paralysis laugh: there is something so incongruous between the sad, flaccid, and immobile countenance, and the merry sounds that come, as it were, from behind it. The patient just referred to, whose double paralysis was due to injury, used sometimes to laugh heartily; and she always produced a strong impression on her hearers when she did so. Paralysis of the Hypoglossal nerve from lesion of the nerve trunk is so rare, that I think we may pass it over. It would, of course, produce paralysis of the tongue on the same side, with very marked wasting; but would probably not interfere very seriously with articulation. Paralysis of the fibres from' the Spinal-accessory nucleus which supply the soft palate is of importance, because it is a frequent complication or sequela of diphtheria. In such cases, it is usually bilateral. It causes the soft palate to droop, and to remain droop- ing even when the patient takes a long breath or sings a high note. During deglutition, it permits the escape of fluid through the nose. In speech, it produces the peculiar and characteristic nasal snuffle. One of the advantages of studying the function of speech with close attention is that such an alteration of speech as is produced by the presence of even a slight nasal snuffle is at once detected by the trained ear. I can recall, at the present moment, a case in which the presence of a slight nasal snuffle in speech led to the immediate detection of a diphtheria, though the patient was making no complaint about the throat; and another case—one of suppression of urine from blocking of both ureters—in which it led to the examination of the throat, and the detection of an oedema of the soft palate and uvula,—the beginning, as it proved to be, of an acutely advancing dropsy, which caused death in a few hours, by invasion of the lungs. Many other conditions besides paralysis of the soft palate, and oedema of it, may produce a nasal snuffle in speech—as, for example, perforating ulcer of the soft palate, and split palate;—and some people snuffle in speech either from habit and carelessness, or from not having learned in childhood how to manage the soft palate in speaking.PATHOLOGY OF THE MOTOR SPEECH-TRACTS. 443 More important than the lesions of the nerve trunks, are lesions of the medullary nuclei from which they spring. Affections of these nuclei produce the type of paralysis known as Bulbar Paralysis. There are a few cases in which this type of paralysis is suddenly or rapidly produced by such gross lesions as apoplexy, or acute inflammatory softening, in the medulla; but such cases are com- paratively rare, and usually prove rapidly fatal. More common and important are those in which disease is of the degener- ative and sclerotic type. Such disease slowly involves the nuclei more and more, until there is total paralysis of the muscles supplied from them. This slow degeneration of the bulbar nuclei is sometimes a complication of certain diseases of the spinal cord, such as chronic progressive poliomyelitis (progressive muscular atrophy), or tabes dorsalis, or multiple sclerosis. Sometimes it is a disease per se, being, throughout its course, confined to the nuclei of the medulla. It is then known as Progressive Bulbar Paralysis, or Glosso-Labio-Laryngeal Paralysis. This is the most important of the varieties of Bulbar Paralysis; and I think it will suffice for the purposes of this chapter if I make a very few notes about it. Progressive bulbar paralysis is always bilateral; and the nuclei first affected are usually those for the innervation of the tongue. Thence the disease spreads to the nuclear cells for the lips, and to those for the soft palate and the pharynx. It is only, as a rule, when all these parts have, in course of time, become totally, or almost totally, paralyzed, that the disease overflows, as it were, into the nuclei for the innervation of the larynx. I need not, in detail, describe the well-known symptoms of progressive bulbar paralysis, but I may remind the reader that, in the advanced stage of the disease, the lower part of the face becomes expressionless as a mask, the lips being entirely paralyzed and remaining helplessly apart so that the patient cannot prevent the dribbling of saliva from the open moutli; that the tongue not only lies paralyzed in the mouth, but generally presents a wrinkled and shrunken or shrivelled appearance, due to marked wasting of its muscular substance, and often in its wasting fibres presents fine fibrillar movements like those in the wasting muscles of a patient with progressive muscular atrophy; that the palate hangs drooping444 THE DISORDERS OF SPEECH. and paralyzed; and that the paralysis of the pharynx renders deglutition impossible. It will be readily understood that as the paralysis extends from tongue to lips, and from lips to soft palate and pharynx, correspond- ing deteriorations of articulation appear in the patient's speech. These, however, need not be described; as the best key to them is to be obtained from the study of the Physiological Alphabet. Sometimes the lips are affected before the tongue; and then it is the labials and the labio-dentals that first suffer. When the palate becomes affected, the characteristic nasal snuffle appears. In the advanced stage of the disease, if the larynx be yet unparalyzed, the patient, though totally unable to articulate, may still, when he tries to speak, be able to emit monotonous vocal sounds of a grunting character. As to the final invasion of the larynx by the paralysis, it seems certain that, in the great majority of cases of this disease, the first muscles affected are the adductors,—not, as in tabes dorsalis, the abductors. It is rare for the patient to exhibit that laryngeal dyspnoea which is so characteristic of bilateral abductor paralysis. Usually he first exhibits a want of explosiveness in his cough; and afterwards the voice becomes enfeebled, though it is rarely altogether lost. Anaesthesia of the mucous membrane, from involvement of the sensory nuclei, is sometimes added to the motor paralysis. Owing to the combined motor and sensory paralysis of the larynx, the air-passages are imperfectly protected from the entrance of food or fluid, if the patient attempts to swallow; and it therefore becomes necessary to feed him with the stomach-tube. I would here make a special note regarding this loss of ex- plosiveness in the patient's cough, which often forms the first indication that, in' the spread of bulbar paralysis, the larynx is beginning to be invaded. Some years ago, I noticed it in two cases of my own; and I made a note of it in a paper on " Extra- auscultation," recently contributed to the first volume of the Edinburgh Hospital Reports. I now find, however, that Dr Gowers had already made careful note of it, in his work on Diseases of the Nervous System. But I should like to direct attention to the explanation I have suggested for this want of explosive-PATHOLOGY OF THE MOTOR SPEECH-TRACTS. 445 ness in the cough, as it is different from the explanation offered by Dr Gowers. Dr Gowers evidently holds the common opinion that in the closure of the glottis which is preliminary to the act of coughing, and which attends upon the act of straining, the glottis is closed efficiently against the exit of air by the co-aptation of the true vocal cords,—that, in short, it is closed in the same manner as it is for phonation,only with greater strength and firmness. He therefore regards the loss of explosiveness in the cough as simply a first indication of adductor paresis. But, as I have already explained in a former chapter, the closure of the glottis for coughing or straining is a very different thing from its closure for phonation; because in phonation only the true cords are co-aptated, whereas in the preliminary stage of coughing and in straining the false cords are co-aptated as well as the true; and it is, I believe, the false cords, with the Ventricles of Morgagni, which, in valve- like fashion, hold in the imprisoned air during the preliminary or compressive stage of a cough. I do not know that the innervation of this important closure of the false cords has ever yet been adequately investigated. It may be that the muscular fibres which effect the movement are innervated, like those which depress the epiglottis, by the superior laryngeal nerve. But whether this be so or not, I think it highly probable that the nuclear cells for the move- ment are, in the course of progressive bulbar paralysis, invaded before the nerve-cells for the ordinary adductors of the larynx, and that thence results the early loss of explosiveness in the cough. In my paper in the Edinburgh Hospital Reports I have termed the unexplosive cough above mentioned the "Bovine Cough," because an ox has no Ventricles of Morgagni or false cords, and its cough is therefore an unexplosive grunt or wheeze. In a normal cough, there are both an explosive element, due to the action of the false cords, and a vocal element, due to the action of the true cords. In the Bovine cough, the explosive element is lost, but the vocal may be retained. In severe cases of hysterical aphonia, on the other hand, the vocal element is often lost, while the explosive is retained; though in mild cases both elements are retained. I have at present, in my wards, a severe case of this kind, in which the aphonia amounts almost to complete mutism, and has hitherto resisted treatment, even by our skilled446 THE DISORDERS OF SPEECH. specialists; and in this case the absence of the vocal element of the cough and retention of the explosive element are well exhibited. I think this condition of things shows that there may be adductor paresis of the true without adductor paresis of the false cords. Further, we can, each of us, in our own persons, cough at will, either—(1), in the normal way, with both elements in the cough; or (2), like the patient in the above-mentioned case of hysterical aphonia, with the initial explosive element, but with- out the accompanying vocal element; or (3), after the manner of the ox, with the accompanying vocal element, but without the initial explosive element. Does not all this show that there are two laryngeal mechanisms employed in the act of coughing, viz., that of the false cords and that of the true ? It is now close upon thirty years since I first demonstrated the valvular action of the false cords and ventricles of Morgagni during the act of straining, and at the initial stage of coughing; and it is eleven years since my conclusions were confirmed by the joint investigations of Dr Lauder Brunton and Dr Cash, which I have already referred to. When will physiologists and physicians recognise that the subject is worthy of attention ? Alongside of these notes regarding the probable spread of degeneration, in the second trophic realm, from the nuclear cells of the oral articulation mechanism into the nuclear cells for the closure of the false cords, I should like to put a note reminding the reader of a point discussed in the first chapter of this work, viz., the occurrence, in a rather rare variety of stammering, of an overflow of energy, from the over-stimulated centres of the oral articulative mechanism into the centre for the closure of the false cords. There results, it will be remembered, when the patient attempts to speak, that closure of the " upper glottis," which gives its special feature to the " gutturo-tetanic " variety of stammering. I think it probable that this overflow occurs in the cortical cells of the first trophic realm. In concluding this chapter, it may be well for us to ask ourselves what general conclusion it tends to lead up to regard- ing the diagnostic value of the dysarthric disturbances of speech that are produced by lesions of the motor speech-tracts. I think, on the whole, it should teach us that in diagnosingPATHOLOGY OF THE MOTOR SPEECH-TRACTS. 447 the seat of any lesion involving the tract, either in its first or iu its second realm, we should not rely exclusively, or even mainly, upon the specific speech-disturbances present. There is too much sameness in the alterations of speech, whatever may be the part of the tract involved, to warrant an exclusive reliance upon them. A thick, slurring, and more or less laborious articulation is the leading characteristic in nearly all such cases. Yet there are varieties in the degree of the dysarthria which may sometimes help us to diagnose the seat of lesion. A total anarthria is more common in lesions of the pons or of the medulla than in lesions of the hemispheres or of the crura. A special slurring upon Unguals or labials may suggest the early stage of bulbar paralysis; and a nasal snuffling may suggest a paralysis of the soft palate, perhaps of diphtheritic origin. Again, predominance of the staccato element in the speech ought to suggest multiple sclerosis, though something of the staccato element may, as we have seen, be present in other conditions. On the whole, however, we shall do well, in trying to diagnose the nature and locality of disease in any case of dysarthria or anarthria, not to trust too much to the specific alterations of the speech, but, whilst giving these their due weight, to arrive at our conclusions only after having taken fully into account the associated symptoms of paralysis, and all the other symptoms of the case. My task is now finished. I began this work by considering the nature of Stammering, a disorder which, by the disruption it exhibits in the harmonious action of the vocal and oral articulative mechanisms, is admirably fitted to illustrate the semi-independence of each of these mechanisms, and to enable us to realize the beautiful coordination with which, in normal speech, they work together. I have now finished by tracing down the motor tracts of the two mechanisms to their terminations in the executive muscles, and by noting the leading conditions of disease that may interfere with motor conduction in them. In the course of the work, we have been led to consider many matters of great interest and importance; for it is a great subject we have been discussing,—a subject full of interest in all its relations. I hope that this work, as a contribution to the study of the subject, will448 THE DISORDERS OF SPEECH. be found practically useful. There are few studies, I think, so well calculated to give material help in the diagnosis of nervous diseases as the careful study of the Disorders of Speech. I trust that this work will prove of practical value as an aid in the prosecution of this important study.APPENDIX. A.—Notes of Threw Cases of Speech-Disturbance. Two of these (Nos. 1 and 2) have bee>t tjndkr observation too recently to be available for the text of this work. the third case is referred to in the text, but only very briefly. 1. Case of Infra-pictorial Auditory Aphasia (the Subcortical Sensory Aphasia of Lichtheim and Wernicke). David Brown, set. 40, carter, married-, born at Strathmiglo. Formerly resident in Glasgow, but has recently been living in Fife with his half-brother. Admitted into Ward 31, 7th Jan. 1894. Summary of Symptoms.—Some deafness ; very marked word-deafness ; some logamnesia ; occasional paraphasia ; suffers from aortic regurgitation. History.—The history of this case has been very.difficult to obtain, owing to the patient's word-deafness and impaired utterance. Some information, liowever, has been obtained from the half-brother, who has lately seen a good deal of the patient, and still more from the patient himself, by means of questions put to him in writing, or rather in print. He can read and under- stand questions put to him in this way, though he cannot understand them when they are put to him by word of mouth. The house-physician, Dr Bell, has accordingly been at great pains to obtain a history of the case from the patient in this way. At the age of ten, the patient had an attack of rheumatic fever, with cardiac complication ; and it is probably from this attack that the present incom- petency of the aortic valve dates. He seems, however, to have enjoyed fairly good health after this attack, and to have been quite able for his work, until the beginning of his present troubles in July 1892. Early in July 1892, when driving his cart in the streets of Glasgow, he had a Sudden attack of giddiness or faintness. When it came upon him, he was sitting on a cross bench in the cart. It made him fall back into the body of the cart. He says his head was not hurt by the fall, and he does not appear to have lost consciousness. When the attack passed off, which it did almost immediately, he was able to seat himself on the bench again, and go on driving. Although it is not to this first attack that the patient attributes his troubles of speech, it seems nevertheless clear that it was immediately after this attack that his friends began to notice in his speech some word-deafness 3 L450 THE DISORDERS OF SPEECH.—APPENDIX. and some paraphasia. His brother, who saw him about the end of July, states that already there was a difficulty in understanding what was said to him, and also a difficulty in expressing himself. For example, he remembers the patient saying "twenty miles ago," instead of "twenty years ago." It is also known that the patient from this time gave up going to church, because he no longer understood what was said by the preacher. Otherwise, he continued to be in pretty fair health, and to b,e quite able for work, until he had a second seizure, about five months after the date of the first. This second seizure occurred in December 1892. Like the first, it occurred when he was driving his cart. On this occasion, however, he fell, not into, but out of his cart. He thereby sustained an injury of his head, with a cut over the right eyebrow, which has left a scar. He states that he did not lose consciousness, and that immediately after the fall he was able to remount his cart and go on driving. After this seizure, which occurred on a Tuesday, the patient continued at his daily work until the Saturday of the same week, when he had a third seizure. This third seizure occurred on the Saturday evening, when he was sitting by the fire at home, after having washed himself. It set in suddenly with severe giddiness, which caused him to fall on the floor. There was no loss of consciousness, and he was able to- get up immediately after his fall; but the giddiness did not speedily pass off as in the previous attacks,—the patient finding, on getting up, that he staggered much in walking. Immediately, also, he became aware that the attack had rendered him, for the time, completely word-deaf. He states that he recognised quite well such sounds as those caused by the shutting of the door, footsteps on the floor, etc.; but that he could not understand one word his wife said to him, though he heard the sound of her voice. As he was suffering severely from headache, and was feeling chil]y and ill, he at once went to bed. Next day, the medical man who was called in ordered that his head should be blistered. The patient remained in bed, at this time, for about six weeks, suffering much from the pain in his head. He then began to get up daily. Presently, he tried to resume work ; but, finding himself quite unable for it, he continued to live quietly at home until July 1893. We are informed that while thus living at home he was often greatly depressed in spirits, and that on one occasion he was detected in the act of attempting to commit suicide. In July 1893, he had a fourth seizure. It occurred when he was taking a walk in the street; and it seems to have taken the form, simply, of severe head- ache. It made him become, for the time, not merely word-deaf, but absolutely deaf; so that he could not even hear sounds or noises. It also made him be- come completely aphasic as to production of speech ; so that, on arriving at his house, he could not speak a word to his wife. As he was thus evidently getting worse, it was thought best to send him to the Western Infirmary of Glasgow ; to which Institution he was accordingly admitted on the 8th of July. Shortly after this date, while the patient was still in the Infirmary, he was visited by his half-brother ; who reports that he could not get him to understand a single word, and that his power of utterance was almost com- pletely disabled. He could, however, understand questions put to him in writing ; so that when his brother told him in writing that he was going toINFKA-PICTORIAL AUDITORY APHASIA. 451 Strathmiglo to see their mother, and asked him if he would like to go too, he indicated his willingness by nodding. At the same time, however, he took hold of his brother's coat and said "awa." From this word and gesture, the brother understood that the patient's clothes had been pawned,—a surmise which, on inquiry, turned out to be correct. The patient left the Western Infirmary at the end of August 1893, to go to the Convalescent House in connexion with that Institution. Here he remained till the end of September, when he returned to his own home much improved in health. In October, it came to the knowledge of his half-brother that the patient was in destitute circumstances, and very unhappy at home. He therefore visited him in Glasgow, and induced him to accompany him to his own house in Fife. Here the patient remained till his admission to the Royal Infirmary of Edinburgh. Though, on his first arrival in Fife, he was so weak that he could scarcely walk, he soon began to improve; and before long he became quite active. He also improved as to his understanding of speech and his power of utterance. It was, in particular, noticed that questions that were often asked him became more and more intelligible to him, though other words and questions remained unintelligible to him. As before, he could read and understand written or printed matter. It happened that while he was living in Fife the well-known Monson trial was going on in Edinburgh. He took a great interest in it, and daily read about it in the newspaper. From hi$ remarks it was evident that he followed the various incidents of the trial quite intelligently. State on Admission.—The patient is a small man—height 4 ft. 10 ins., weight 8 st. 11 \ lbs.—but has a good figure, and is lively and active. He has an intelligent expression of countenance, and is bright and cheerful. Examination of the heart reveals a double bruit at the base; but there is no distinct hypertrophy of the heart, and the pulse, which is rather weak and occasionally intermittent, has little in it of the water-hammer character. He states that he has often, for a few minutes, a pain in the region of the heart, which is apt to radiate upwards towards the neck. He is never troubled with palpitation, but is apt to be breathless on going up a hill. He complains of frequent and severe headaches, which, he says, often keep him awake at night, and are apt to be especially severe in the morning. There is no motor paralysis or lameness, the patient being quite active on his legs. His grasp, however, is not very strong, and it is noticeable that it is weaker in the right than in the left hand, the right hand giving 40 and the left 45 on the inner circle of the dynamometer. Taste, smell, and eyesight are normal, and the eyes are lively in expression, and do not show any difference in the pupils, or any sluggishness in their movements on exposure to light. During periods of headache, however, the eyes look rather congested and heavy. Examination with the ophthalmoscope shows the fundus to be normal. Hearing.—In the left ear, the patient is very deaf, being unable to hear the ticking of a watch until it is pressed against the pinna. With the right ear he can hear the ticking of a watch held 8 or 10 inches from the pinna. Dr M'Bride, who kindly examined the patient's ears for me, reports as follows :—452 THE DISORDERS OF SPEECH.—APPENDIX. " Left ear—membrane thickened posteriorly and inferiorly, indrawn atrophied patch anteriorly. .Right ear—membrane thickened posteriorly, with an atrophic patch in centre of thickening, and also a distinct atrophic patch in front. The tuning-fork gives such uncertain results in this case that we can hardly draw any conclusions." The following is an abstract of the notes regarding the condition of the patient's speech:— 1. Spoken Speech. (a.) Reception and Interpretation.—It is very difficult to get the patient to understand questions put to him, and this difficulty is far greater than can be accounted for by his partial deafness. It is always greatest when he is asked a question which is new to him, however simple the question may be. Old questions which we have asked him often and taught him the meaning of, he replies to readily enough ; and it is noticeable that he hears and understands these old questions quite readily though they be not put to him in a loud voice. When, on the other hand, he is asked a new question, it is interesting to watch the close attention and wistful expression with which he watches the movements of the questioner's lips, and at the same time listens, in trying, without success, to make out the meaning of what is said. Perhaps these observations will best be illustrated by a few specimens of the patient's replies —(1) to old familiar questions, and (2) to new and unfamiliar questions. (1.) Old familiar Questions. " Did you sleep last night ?" " Yes." " Did you sleep well 1" " Yes, the forepart" (of the night). " Have you any headache 1" " Yes, last night was sair " (sore). u Where 1" Indicated, with his hands, both sides of his forehead. " Had you a horse at one time 1" " Yes, once, a good one." " How old was he 1" " Seven years." " How many hands high 1" " Seventeen." ■ " Did he bite V' "No me, no me." " Whom did he bite ?55 " Anybody going pats, pats " (past). " What did you do '{" " The chain." " Where did you fix the chain ?" " From the haims to the bit." From the above, it might be supposed that the patient had no difficultv whatever in understanding what was said to him. But it must be remembered that every one of these questions had already been very often put to him during the previous six weeks of his residence in hospital, gesture-language and printing having been used by the questioner to help the patient in interpreting them. He had thus at length become familiar with every one of them, so that he could interpret them without extraneous aid. In contrast with the above performance of the patient when asked familiar questions, I now proceed to give a few specimens of his performance when asked, on the same day, questions that were not familiar to him.INFRA-PICTORIAL AUDITORY APHASIA. 453 (2.) New and unfamiliar Questions. _ _ 1 ' " Are you going out to-day 1" In reply, patient merely shook his head. Thrice the question was put to him, and thrice he shook his head. On its being put for the fourth time, he said, in tones of interrogation, " Up the day, up the door ?" (trying to repeat the words spoken to him). On the question being again twice repeated to him, he said " Key." During all this time he watched the questioner's lips very closely, and looked very wistful and attentive. I now indicated to him by gesture that I wished him to repeat the words of the question one by one after me. He did so as follows :— "Going" patient said " Goin." "Out" „ "Oot." " To-„ " You, to." " Day " „ " Gee, jay, sing." Although the word " Day " was repeated to him twelve times, he could not be got to pronounce it. He only said " Sing," etc., instead of it; and no better result was got even when the word was shouted to him close to his right ear. I now put the question to him in gesture-language, by pointing out of the window, and making with two fingers the gesture for walking that is used by deaf-mutes. He understood me at once, and said in reply, "Yes, walk, fine." With other unfamiliar questions the patient's performance is seldom better than the above. We asked him, for example, the question, " How is Lilly ?"— referring to another patient with speech-trouble in the ward. He repeated without difficulty the words " How is," but he could not be got to repeat the word " Lilly," or to understand the question. Instead of " Lilly," he merely said " Sing," etc., experimentally. It should here be noted, that if the patient succeeded in repeating correctly any word or sentence spoken to him he usually at once understood its meaning. (b.) Production of Spoken Speech.—The patient can express his thoughts in speech without much difficulty, but frequently mispronounces words, and sometimes uses wrong words (paraphasia). He evidently has no special amnesia of nouns, as he readily enough names objects shown to him. He was, one day, shown about fifty different objects, and, as a rule, named them correctly. For example, he named correctly a number of coins shown to him. In other cases, he mispronounced certain names that were difficult of pro- nunciation,—converting the word " scissors/' for example, into " skisserits," and the word " moustache " into " muisaret clache." In like manner, he converted " wall" into " wait," and "pocket" into "pock pock." He often talks pleasantly to the other patients in the ward, though he can- not understand what they say to him. In talking he expresses himself in single words, broken sentences, and gestures. In this way, he on one occasion made the patients quite understand that, when he lived in Glasgow before his illness, he used greatly to enjoy the singing of a street-singer who had lost both legs. He told them that he always gave this man a penny when he heard him sing.454 THE DISORDERS OF SPEECH.—APPENDIX. (c.) Echoing of Spoken Speech.—As already indicated, the power of echoing or repeating words is very greatly impaired. It is impaired, evidently, because of the difficulty the patient has in getting a good auditory image of the word,— and not because of difficulty in articulative production. To the examples already given, may be added the following:— For "Thinkest," he says " Thickest." „ u Thou/5 „ "Now." "So" „ " Snows." 2. Written Speech. (a.) Reception and Interpretation of Written Speech.—The patient's eyesight is good, and there is no hemianopsia. It may here be remarked that the patient has been educated sufficiently at school to enable him to read, with ease, any ordinarily easy words when they are in print. For example, he can read the newspaper, and can understand it fairly well. Any simple question put to him in print, he reads at once, and replies to intelligently. For example, when the request " Put out your tongue " was put before him in print, he obeyed. When asked u How old are you 1" he answered, " 76, 77, 40 years,"—the last being correct. When asked in print "How long have you been ill?" he answered correctly, "Fifteen months/ When requested to " shut the door," he did so. And when asked " How often did you fall (from attacks of giddiness) when driving your cart ?" he answered correctly, " Twice, two times." It was in this way—by printed questions and getting the patient's oral replies to them—that Dr Bell, with much labour, elicited the facts of his history. (b.) Production of Writing.—Though the patient can read written easy words and sentences, he has, unfortunately, not been sufficiently well educated to enable him to express himself in writing. He can write his name in fairly legible characters, but when asked to write anything else he shakes his head sadly, and says—" Canna do it, doctor ; canna spell." (c.) Copying of Printed Characters.—He copies a printed word fairly well, but if the word is withdrawn from his sight, and he is asked to print it again, he makes misspellings in doing so. 3. Gesture Language. The patient both interprets the gesture language of others and expresses his own thoughts in gesture language with great readiness and intelligence. 4. Music. A feature of great interest in this case is that the patient's illness has entirely deprived him of his musical sense. Before his illness he was fond of music ; and his half-brother informs us that he could himself sing well,—his favourite song being " Dowrn in the trade winds fourteen days." But now when asked, in print, to sing this song, he smiles, shakes his head, and says, " No, canna do it now ; yes, could do it before." When asked, " When could you sing 1" he said,INFllA-PICTORIAL AUDITORY APHASIA. 455 " Before my speech, before this." When we got him to attempt the repetition of a note sung to him, he was always much out of tune ; and when we played to him upon the piano the notes of " Auld lang syne," he said, " Hear the noise, canna hear the tune now." He made use of the very same words when he spoke of listening to the hymns he had heard sung in the Infirmary chapel. Commentary.—The element in this case, which makes exact diagnosis rather difficult, is the existence of a considerable degree of actual deafness, and the presence in the ears of the abnormalities mentioned in Dr M'Bride's report. But no one studying the case with care can have the slightest difficulty in concluding that the defect of hearing is little more than an accident in the case, being in itself not at all capable of explaining the patient's difficulty in interpreting speech, to say nothing of the defects in its production. The patient can hear the ticking of a watch held at the distance of eight or ten inches from his right ear. It will be remembered that a deafness even twice as marked as this does not materially interfere with the reception and inter- pretation of speech, if the person addressed be loudly spoken to. Therefore, in looking for an explanation of the Word-Deafness (auditory logamnesia), and the other symptoms of this case, we must look beyond the mere partial deaf- ness of the patient. I think it will help the reader to understand the theory of the case I am about to offer, if he will refer to Fig. 15 (Lichtheim's diagram), in Chapter XIII. The patient's difficulties being chiefly those of reception and interpretation, we must ask ourselves—with the diagram before us—whether the case is one of Pictorial Auditory Aphasia (No. 1), or Infra-pictorial Auditory Aphasia (No. 4), or of Supra-pictorial Auditory Aphasia (No. 5). My own belief is that, essentially, the case is one of Infra-pictorial Auditory Aphasia (No. 4); but that it also contains a slight element of Pictorial Auditory Aphasia (No. 1). I think the centre A itself must be slightly damaged, because there is in the case occasional Paraphasia, as well as a considerable degree of articulative amnesia. I do not think there can be any element of Supra-pictorial Auditory Aphasia (No. 5), because the interpretation of printed speech is wTell preserved. I believe, then, that the lesion is so situated as to cut across the tracts con- necting the centre A with both ears, and to encroach upon and slightly damage the centre A itself. We do not yet know enough about the pathology of Infra-pictorial Auditory Aphasia to be able to say precisely where in the brain a lesion producing it must be situated. Probably, however, it must be situated in the white matter beneath the centre A. If it is so situated, we can understand how, at the same time, the centre A itself may also be more or less involved. That the case is essentially one of Infra-pictorial Auditory Aphasia, I think we must conclude, because along with the very striking difficulty in the reception of spoken words, which is the leading symptom, there is only slight paraphasia, showing that the centre A cannot be much involved;—and because the interpretation of printed speech, which is easy to the patient, would have been impossible to him had his case been essentially one either of Pictorial or Supra-pictorial Auditory Aphasia. With regard to the loss of the Musical Sense which has been inflicted on this patient by his ailment, it is interesting to find that in the two cases of456 THE DISORDERS OF SPEECH.—APPENDIX. Infra-pictorial Auditory Aphasia (Subcortical Sensory Aphasia) recorded by Wernicke and Lichtheim (and referred to in the text) there was similar loss of the musical sense ; and it is worthy of remark that in this case, as in these two, the loss was not only on the receptive side, but also on the productive,— the patient being not only incapable of recognising tunes, but also incapable of himself whistling or singing them. When the cerebral centres for music are intact, old memories can be revived within them ; and by virtue of these an individual may be able to produce music even though he be stone-deaf, and therefore utterly incapable of appreciating music produced by others. This was indeed the very condition of Beethoven in his latter days. Stone-deaf as he was, he yet at this time produced some of his very best compositions. In the case under consideration, the patient is not very deaf, but he has lost all internal sense of music. Though in memory he can still recall the pleasure he formerly had in listening to the Glasgow street-singer, his musical faculty is gone. He cannot now recall the songs that he himself used to sing, any more than he can recognise them when he hears them played or sung by others. 2. Case of Aphasia after " Congestive AttacksThe case also ;presents an example of Syllable-Stumbling; and illustrates the difficulty of distinguishing between " General Paralysis of the Insane" and one of the forms of Syphilitic affection of the Cerebral Cortex. J. L., set. 33, warehouseman, recommended by Dr Sloan, admitted Feb. 15th, 1894. History. — The patient states that he contracted syphilis about eight years ago. Although no secondary symptoms followed the primary sore, he became the, subject of "syphilophobia,"—the fear of constitutional syphilis preying so much upon his mind as to drive him, from time to time, almost insane. He remained, however, steadily at work and physi- cally in fairly good health, until June 1893, when he began to be troubled with sore throat and dyspepsia. These complaints he took to be symptoms of constitutional syphilis ; the consequence being that he became more than ever disturbed in mind by the fear of syphilis, and that he had recourse to stimulants for the relief of his mental distress. Early in October, on a Saturday, he took so large a quantity of stimulants that he had to remain in bed all Sunday. On Monday, when he went out to his work, he was still suffering from headache. He continued at work till breakfast time, and then left the warehouse to walk home for breakfast. On his way home he entered a public-house to get a glass of spirits for the relief of his headache. His hand, however, was so weak and unsteady that he dropped the glass when he was in the act of carrying it to his mouth. The weakness of the hand was so marked that he had even great difficulty in extracting from his pocket the money to pay for the liquor. Along with this weakness and unsteadiness of ths hand, the patient presently found that thereAPHASIA AFTER "CONGESTIVE ATTACKS." 457 was loss of speech. When asked by the man in the shop what was the matter with him, he found that he could not say a word in reply. Feeling alarmed, and being much excited, he walked home so rapidly that a fellow-workman, who saw him in the street and wished to speak with him, found he could not overtake him. His wife states that when he reached home his face was extremely congested, and his expression wild and confused. He was speech- less, and his wife thought that the right hand and arm were paralyzed. For two days he remained in bed so confused and stupid that on one occasion he micturated involuntarily. On the third day (Wednesday) he spoke for the first time, asking his wife what o'clock it was. His pronunciation, however, was imperfect. For "clock" he said aclo" ; and he called a potato a "cap." On Thursday he spoke better, but still slowly and with difficulty. On Thurs- day night he was somewhat delirious in his sleep. After this time he steadily improved, so that on Friday the paralysis of the hand and arm had disappeared ; and next week he was able to read the newspaper, to express himself pretty freely in speech, and to walk to his doctor's house to report himself. He was off work at this time for about six weeks. Though gradually improving, he remained dull and listless, and much inclined to sit and mope at home by the fireside. This condition persisted even after he had returned to work ; and from this time his health remained, on the whole, so indifferent, that he was never able to work more than two or three days in the week. His syphilo- phobia continued to trouble him as severely as ever. A second congestive attack occurred about four months after the first. It began on the day before that of the patient's admission to the Infirmary ; set- ting in during the evening with pain in the head, increasing difficulty of speech, dulness of mind, and difficulty in micturition. Next morning, on the advice of Dr Sloan, he was removed to the Royal Infirmary, where he was admitted to Ward 31. State on Admission.—The patient was a tall and well-built man. All the various systems were apparently free from disease except the nervous system. He was confined to bed, and his expression was extremely dull and stupid. As to production of speech, the patient was almost totally aphasic ; his reply to almost all questions being "Yes." When asked what he complained of, he pointed to the left side of his head and said, " A nasty, nasty, nasty, well nasty." As to reception and interpretation of speech, though he understood most of the remarks made to him, he evidently failed to understand some of them. For example, he failed to understand the requests to put out his tongue and to touch his nose. He was so stupid on the day of admission that his urine had to be taken off with the catheter. Next day he was considerably brighter, being able to name correctly a number of objects shown to him, such as a watch, a chain, etc., though failing to name others, such as a pair of scissors. In trying to write he misspelt even his own name, but he evidently knew that he had made mistakes and endeavoured to correct them. After this he continued to improve steadily, so that in a few days he was able to get up and walk about the ward. His speech also improved rapidly, and he was soon able to express himself pretty freely. In his pronunciation, however, there remained marked thickness or Slurring, and there was also very decided Syllable-Stumbling. The employment of the test-word " Hippopotamus " brought out the Syllable-458 THE DISORDERS OF SPEECH.—APPENDIX. Stumbling in a most striking manner—the patient's renderings of it being " Hatitopotamus, Hatipotibumus, Tahippotopossimus," and the like. When he was talking it was very noticeable that his upper lip quivered on one or other side in the manner so commonly observed in General Paralysis of the Insane. During the remainder of the patient's residence in hospital, his improvement was progressive. His speech gradually lost all its peculiarities except a trace of the Syllable-Stumbling, and an occasional trace of the labial shiver. He practised the pronunciation of " Hippopotamus " diligently, and before his dis- charge he was able to pronounce it correctly, though it evidently still cost him a little effort, which showed itself in a staccato enunciation of the syllables. As to mind, at the date of his discharge, March 27, 1894, the only peculiarities noticeable were the persistence of the syphilophobia, which was still occasion- ally very distressing to him, and a certain emotional facility of mind, which betrayed itself especially in irritability of temper and in risibility. The patient was treated at first with mercurial inunction and administration of iodide of potassium, and afterwards with iodide of potassium alone. Commentary.—The case is one of a type not unfrequently met with in medical practice. On the whole it conforms in its symptoms to the type of General Paralysis of the Insane ; but it does not in all respects reproduce the picture presented by typical examples of that disease. There was here none of the primary mental exaltation so often exhibited by typical examples of General Paralysis ; nor did the patient present the characteristic difference of the pupils, nor the fibrillar movements of the tongue. But, on the other hand, there was evident deterioration of the mental faculty ; as was shown by the patient's emotionalism, by his syphilophobia, and by his diminished power of work. There was also in the speech marked slurring, pronounced syllable- stumbling, and the accompanying quivering of the upper lip so common in General Paralysis. Lastly, there was the history of two distinct congestive attacks like those of General Paralysis ; and after each of these there was the aphasia which in that disease so often follows upon such attacks. Is this case one of General Paralysis of the Insane, or is it one of syphilis affecting the cerebral cortex 1 In reality it is often impossible to distinguish the one condition from the other. My own impression is that it is one of General Paralysis. If it is, the patient will have other congestive attacks, and will gradually get worse. It is, however, possible enough that the case may be one of cortical syphilis ; and it is in view of this possibility that the patient has been recommended to continue the use of iodide of potassium. Chronic alcoholism is also known occasionally to produce a group of symptoms exactly corresponding to those of General Paralysis ; and it is possible that the patient's over-indulgence in alcohol may have been at least one of the causes in operation. The case is, I think, illustrative of the difficulty of diagnosis in many such cases. It presents a group of symptoms presumably more familiar to the ordinary physician than to the alienist, viz., the symptoms of General Paralysis without the common mental exaltation of the first stage of that disease. Alongside this case I could, from my hospital notes, place a number of others in which the same group of symptoms was presented; but this one case willMUPTIPLE SCLEROSIS. 459 perhaps suffice to illustrate the difficulty of diagnosis, and also to illustrate the occurrence of aphasia after " Congestive Attacks." 3. Case of Multiple Sclerosis. This is the case to which I have briefly referred in the fifteenth chapter, when treating of the speech disturbances produced by Multiple Sclerosis. The patient, D. R, was first admitted to my wards on July 16th, 1885, when he was 23 years of age. His history was as follows:— Until he received the injury to be presently described, he had always enjoyed fairly good health; although he had occasionally been irregular in his habits, as to the use of stimulants. He stated that he had never had syphilis, but had once had gonorrhoea. At the time of the injury he was in the service of the tramway company ; his duty being to wash, during the night, the cars that had been running during the day. He received the injury in the following manner :— Eight months before admission, when engaged, one night, in washing the cars, he carelessly undid the fastening of the brake of a car which was standing upon an incline. The handle of the brake thereupon flew round with great force, and struck him on the forehead so violently as to drive him back about five yards. He was somewhat stunned; but he retained consciousness, and was able, immediately, to fasten the brake, and so to prevent the car from running down the incline. He felt sick, however, and had to rest from work for a time ; though in about an hour he recovered sufficiently to resume work. He continued at work for about five hours, till his usual time of going home in the morning. In walking home, he was so giddy that he staggered several times. After this, he continued nightly at work for about two months ; but his giddiness gradually increased, so that he sometimes fell when walking, and then sometimes had difficulty in getting up again. It was on account of this giddiness that he first sought admission to the Royal Infirmary. Admitted on the 16th of July 1885, he was a patient in my ward till the 10th of September. His chief complaints were marked staggering, and a feeling of giddiness, in walking. His gait, indeed, was so like that of a person some- what inebriated, that on one occasion he was supposed by an Infirmary official to be in that condition, and was reported accordingly. His tendency was to stagger to the right side and somewhat forwards. At this time there was no distinct alteration of speech, but there was already occasional nystagmus, as well as slight impairment of vision and hearing. As to mind, he was fairly intelligent; and he was cheerful and happy in disposition. Indeed, there was something suggestive of mental weakness in his remarkable cheerfulness, which seemed so little warranted by the circumstances of his case. As yet there was no distinct loss of muscular power in the limbs, and the knee-jerks were only slightly exaggerated. His residence in the Infirmary, and subse- quently in the Convalescent House, led to an increase of weight, and to improvement in his general appearance, but to no improvement in the symptoms for which he had sought admission. From the copious notes taken of this case, from time to time up to the date of the patient's death on the 31st of March 1894, I extract the following460 THE DISORDERS OF SPEECH.—APPENDIX. particulars,—premising merely that, after he left the Infirmary, he was for years seen at it, from time to time, as an out-patient, and that, finally, he was re-admitted as an in-patient some months before his death. I shall first give a few extracts from the notes taken while he was an out-patient, and then a brief account of his condition when he was, for the second and last time, an in-patient. Under the date October 26th, 1885, it is noted that of late he has begun to experience a good deal of confusion of mind every morning on awaking ; and also that his sight is becoming impaired. In June, 1886, it is noted that the difficulty of walking has greatly increased. So marked was now the incoordination, that he could not even stand without help. He now, also, was troubled with ringing in the ears, occasional headaches, occasional shiverings, and various disturbances of sensa- tion, such as itchiness of the nose, etc. He had recently been living in the workhouse for some weeks. July, 1886.—From this date, the patient made a living by selling cheap books in the streets ; some charitable persons having provided him with a supply of books, and with a bath chair to sit in when selling them. October, 1887.—It is now for the first time noted that the upper extremities are becoming affected in a manner characteristic of Multiple Sclerosis. They presented coarse trembling and jactatory movement, whenever the patient attempted to perform any voluntary act with them. When, for example, he attempted to carry a tumbler full of water to his mouth, the involuntary jerking of his arm caused him to throw the water about in a manner most characteristic. March, 1889.—Inability to walk or stand without help, and the trembling and jactatory movements of the arms persist; and it is noted that the patient has become sillier in his manner. Several new symptoms are now noted,—viz., (1) the staccato speech so frequently found in Multiple Sclerosis, and (2) marked divergent strabismus of both eyes. The Nystagmus formerly noted had now disappeared. July, 1891.—He is reported to be worse in every respect. As a new symptom, there is now noted marked failure of vision,—the patient, though still able to count fingers, being unable to describe the pictures on the walls. Examination of the eyes showed the visual acuity to be one-fifteenth of the normal. In his Speech, there is noted, besides the well-marked Staccato element, an element of Slurring, also very distinct. It was typically exhibited in the pronunciation of the test-words " British Constitution/' etc. It is also noted that the patient has begun to speak in a bleating monotone. April, 1893.—At this date, I found the patient, one day, at his accustomed place in the street, sitting in his bath chair with books upon his knee for sale. He was scarcely able to respond to my greeting, his speech being now almost totally inarticulate, though the voice was well preserved. He was now almost quite blind; but he recognised my voice at once, and tried to shake hands with me, though scarcely able to do so, as his upper extremities were now almost completely paralyzed. His wife, who, at my request, came to the Infirmary next day to report as to his condition, stated that of late he had been getting much worse. Even she could now scarcely make out what he wished to £ay.MULTIPLE SCLEROSIS. 461 Several times of late, he had micturated in bed. As great heat completely overpowered him, she feared much that he would not survive the heat of the approaching summer. October 19th, 1893.—At this date, the patient was, for the second time, admitted into Ward 31 as an in-patient. His wife stated that two months before the date of his admission he had, one day, a seizure of some kind, during which his head fell over to one side. It was after this seizure, on the same day, that the act of swallowing was first observed to be difficult. A second seizure had occurred a few days before his admission. In the morning, he had been taken out in his bath chair to sell books in the street as usual; but in the afternoon he had been seized with an attack of giddiness. After this seizure, he had gradually lost the power of swallowing; and for two days before admission he had not been able to swallow anything. During these two days, he had been sweating a great deal, and passing his urine involuntarily in bed. On admission, the patient was in a helpless condition. He was extremely emaciated, and had a bed-sore over the middle of the sacrum. He was feverish, the temperature being 102° F. His legs were drawn up, both knee- and hip- joints being strongly flexed. His arms were semi-flexed at the elbow-joints ; and his fingers were also flexed, the hands being almost clenched. He was quite unable to swallow; and on the day of admission was so weak that we thought him dying. But he rallied considerably on being fed with the stomach- tube; and he continued in life, though extremely feeble, for about five months after admission. Throughout the whole of this period, he was fed systematically with the stomach-tube. Though he was, on admission, at once put upon a water-bed, and was throughout nursed with the greatest care and attention— every effort being made to protect his skin,—it was yet found impossible to prevent the development of several other bed-sores. For some weeks before his death, there was almost total paralysis of movement in both lower extremities, and of the left upper extremity. In the right upper extremity, there was a little more power of movement than in the left. Besides the flexure of the limbs already noted, there was marked arching of the back, with retraction of the head. The-mouth was kept habitually open, owing to the flaccidity of the lips, whose motor power was evidently much impaired, though not entirely paralyzed. Movement of the tongue was also greatly impaired, the patient being able to protrude the point only about one-eighth of an inch beyond the margins of the teeth. There was considerable wasting of its substance, but its surface was not wrinkled, and there were no fibrillar movements. Throughout the period of the patient's stay in hospital, there was involuntary evacuation of both bladder and rectum. In the text of this work I have already described the speech of this patient as it was during this second period of residence in the Infirmary. When he tried to speak, he produced only a monotonous vocal drawl, which was so inarticulate that when he tried to say " good morning" only something of the M and N, and something of the vowel-sounds, could be distinguished in it. The patient lost strength very gradually, and died, eventually, by simple asthenia, on the 31st of March, 1894. On the following day, an autopsy was made by Dr Muir, Pathologist to the Royal Infirmary, who found the case to462 THE DISORDERS OF SPEECH—APPENDIX. be a typical one of Multiple Sclerosis. Dr Muir has worked out, with great care, the microscopic anatomy of the lesions, and I hope will, at an early date, put the results, of his examination on record. He has, in the meantime, kindly furnished me with the following brief note of the general results of the examination:— "The central nervous system showed a very extensive and widespread disseminated sclerosis. The highest-up patch was a small grey area, with ill-defined margin, above the posterior horn of the left ventricle. All the basal ganglia on both sides contained numerous irregular areas of degeneration and sclerosis, which gave a remarkable patchy appearance. These encroached upon, and somewhat narrowed, the internal capsule. The cerebrum, in addi- tion, showed general atrophy. The convolutions were narrow, the sulci widened ; and there was an excess of subarachnoid fluid, as well as milkiness of the arachnoid. The ventricles, also, were dilated. " The crura, pons, and medulla showed numerous whitish and grey patches, which gave the sections so irregular an appearance that it was practically impossible to recognise many of the normal structures. In the medulla, the posterior part was most affected. " The spinal cord was also extensively involved, and irregularly so ; but the posterior columns had suffered most. At many places the outline of the grey matter, especially of the posterior horns, was quite lost, owing to the encroach- ment of the sclerosis. All the columns showed scattered patches here and there, at different levels. The cord as a whole appeared distinctly atrophied. " There appeared to be distinct muscular atrophy of the limbs in addition to the general wasting present. The right lower limb was rather more wasted than the left, especially in the calf muscles. The nerves in relation to these parts were considerably attenuated. These were kept for microscopic exam- ination." Commentary.—This case of Multiple Sclerosis affords a consecutive history of the development of the disease from its beginning to its termination, during a chronic course of nearly ten years. As is well known, the disease differs in its course according as it first affects one part of the nervous system or another. In this case, I think there is ground for the belief that the part first affected was the Cerebellum. Probably the initial blow on the forehead injured the Cerebellum by contre-coup, and lit up within it the pathological changes of multiple sclerosis some time before the disease spread to other parts. This would account for the fact that staggering and giddiness in walking were the first symptoms to show themselves. The early Nystagmus may also have been of cerebellar origin. On the other hand, the Staccato Speech that appeared later in the course of the case was probably due to the invasion of the Cerebrum by the disease, and the paralysis of the limbs to the invasion of the Spinal Cord. Lastly, the inarticulate drawling in speech, and the final loss of the power of swallowing, may be explained by the invasion of the bulbar nuclei and nerves.graduation thesis. 463 B.—Keprint of Graduation Thesis. (From the Edinburgh Medical Journal of September 1866.) Observations on the Physiology of the Larynx. By John Wyllie, M.D., M.R.C.S., Senior President of the Royal Medical Society, and lately one of the Resident Physicians in the Royal Infirmary. (An Inaugural Dissertation, for which a Gold Medal was awarded by the University of Edinburgh at the Medical Graduation of August 1865.) This paper is intended as a contribution to the Physiology of the Larynx, and not as an exhaustive treatise on the subject. It embodies the results of a somewhat lengthened series of experiments and observations on the following topics:— ls£, On the descent of the epiglottis during deglutition. 2nd, On the valvular action of the glottis. 3rd, On the production of voice. I.—On the Descent of the Epiglottis. In former times the epiglottis was thought to be the only safeguard against the entrance of food into the windpipe, and its integrity was therefore regarded as of almost vital consequence. But more recently, cases were recorded in which it had been entirely removed by accident or destroyed by disease, and yet in these the bolus did not find its way into the larynx, for this was still effectually prevented by the closure of the glottis, so that the act of deglutition continued to be performed with safety, and even with ease. Magendie, also, in his experiments, repeatedly removed the epiglottis of the dog without apparently putting the animal to much inconvenience.1 Many physiologists were therefore led to regard this valve as only of secondary importance, and merely accessory to the glottis in the performance of its function. In our own time, however, another class of cases is being observed with the aid of the laryngoscope, in which the glottis is permanently incapable of closure, owing in some to paralysis of the intrinsic muscles of the larynx, and in others to the presence of tumours upon the vocal cords; and yet, in the majority of these, the larynx seems, by the epiglottis alone, to be as securely guarded as it was when the parts were healthy. There are, then, at the open- ing of the windpipe, two protecting valves, either of which is in itself capable of closing it when food is passing ; but a double security is obtained by their simultaneous action. Of the two, perhaps the epiglottis is the more important in performing this function, for by its shape and position it seems specially fitted to roof in the larynx ; and, in ordinary circumstances, it alone is actually of service, for no food comes in contact with the. glottis, which nevertheless is closed as an additional protection. What, then, is the mechanism by which the depression of the epiglottis is accomplished ] On this subject various theories have been propounded. For example, it has been maintained that " the larynx is closed, or rather is covered, 1 Magendie's Compendium of Physiology, p. 240.464 THE PHYSIOLOGY OF THE LARYNX.—APPENDIX. by the epiglottis depressed mechanically by the alimentary bolus,"1—an explanation which must have appeared improbable to any one who thought of such an arrangement protecting the larynx from fluids as well as solids. A second and much more currently accepted theory is, that during deglutition the root of the tongue is pushed downwards upon the epiglottis, which is thus in its turn depressed upon the larynx. This view is modified by some, who suppose that when the larynx is elevatecT, the epiglottis must be pressed upwards against the base of the tongue, which in thus effecting its closure acts the part only of a passive agent, as it were. Thirdly, it is maintained that the action in question is accomplished solely by the special depressor muscles of the epiglottis, and that after the passage of the bolus the valve is raised again "by its own elasticity and that of its ligaments." This view, which was formerly promulgated by Santorini, has lately been supported by Czermak, who concludes, from his experiments with the auto-laryngoscope, that "the epiglottis is not passively depressed, for example by the base of the tongue, but this depression is actually caused by the proper muscles of the epiglottis itself'."2 A tactile examination of the epiglottis during deglutition fully confirms this statement in so far as it refers to the base of the tongue. The theory, however, that the action of its special depressor muscles is the sole agency which effects the descent of the valve, is met by a serious objection. For, the epiglottis being raised after the passage of the bolus—" by its own elasticity and that of its ligaments "—it naturally follows, if we accept this statement, that, in accom- plishing its depression, the muscles must have overcome some resistance from thes^ ligaments. One would, therefore, expect to find a development of muscle commensurate with such resistance ; but a dissection of the parts shows us that these depressors of the epiglottis are mere thin bands of muscular fibre, which, if the larynx be not well-developed, are too apt to escape observation altogether. Again, if we turn to the lower animals, we find in certain of the ruminantia, a strong muscle attached to the front of the epiglottis and stretch- ing forwards, in some, into the substance of the tongue, and in others, the sheep for example, dividing in front into two processes, each of which becomes attached to one of the stylo-hyal bones, just above their articulation to the front of the os hyoides. With the existence of this strong elevator muscle we find 110 corresponding development of the depressors, they are here as weak and thin as in the human subject. It is, then, very improbable that, in depressing the epiglottis, they alone should be the agents employed. Let us see if, in the phenomena of deglutition, we can find anything which may render them assistance. When the parts concerned in the act of swallowing are carefully dissected, two ligaments are found which are specially adapted to support the epiglottis when the larynx is at rest.3 First, there is the glosso-epiglottic ligament. This has been called by some anatomists the frcenum epiglottidis. It seems to be the prolongation backwards of the fibrous septum of the tongue, and at its origin many of the muscular 1 M. Meyer. 2 Czermak's Monograph, translated by the Sydm. Society. 3 These ligaments have been carefully described by Bishop in his article on the Larynx, in Todd's Cyclopaedia of Anatomy and Physiology, and by other special writers on the larynx; but they are overlooked by the author of an ordinary text-book,GRADUATION THESIS. 465 fibres of the cortex are inserted into it. Posteriorly, it crosses the hyoid bone, and becomes attached to the epiglottis about its middle. It stands out promin- ently in the mesial line, its sharp edge being enclosed in the middle glosso- epiglottic fold of the mucous membrane. The microscope shows it to be chiefly composed of elastic fibres, but notwithstanding this fact, it is by no means easily stretched when it is isolated. This ligament is the representative, as Magendie pointed out, of the elevator muscle of the epiglottis in the rumi- nantia, to which I have already referred. I have, in several cases, observed muscular fibres clustering around it even at the epiglottic attachment. The Epiglottis and its Ligaments. A, The epiglottis. B, The base of the tongue. C C, The cornua of the hyoid bone. D, The glosso-epiglottic ligament. E, The hyo-epiglottic ligament. The second ligament is the hyo-epiglottic (E), one of equal importance. This is a well-marked membranous expansion stretching from the concave edge of the hyoid bone downwards to the anterior surface of the epiglottis. Its line of origin extends in many cases backwards almost to the point of the great cornu on either side, but often this attachment is not so extensive, the fibres taking their rise almost exclusively from the body of the bone. Its insertion is beneath that of the glosso-epiglottic ligament upon the lower thickened half of the valve. The direction of its fibres varies according to the point of origin, those arising near the points of the great cornua being directed forwards, down- wards, and inwards, whilst the central fibres from the body of the bone are directed simply downwards and backwards. When the larynx is at rest, and the hyoid bone is separated by an interval 3 N466 THE PHYSIOLOGY OF THE LA.RYNX.—APPENDIX. from the thyroid cartilage, these two ligaments dip downwards to their insertion, an£ 3* be marked C1, D1, etc., whilst the octave below C will be marked Bn Ax, etc., and that lower still as Ba, A2, etc. Experiment 1.—The larynx was that of a woman aged about fifty years. The cartilages were very little ossified. Attached were the hyoid bone, the epiglottis, and about three inches of the trachea. The arytenoids were fixed with a needle and a ligature in the manner just described, and a leather tube about five inches long was inserted into the opening of the windpipe. On supporting the larynx by the cricoid cartilage alone in a horizontal position, the note produced by blowing very gently through the tube was G. No difference in pitch was produced when the short tube was taken out and replaced by another a foot in length. By pressing backwards the thyroid cartilage, the note could be lowered to Ga ; on the other hand, by pulling the thyroid forwards, the arytenoids being fixed, the pitch could be raised to G, so that the compass of the voice embraced two octaves. I could occasionally produce the note A, but it was of a screaming imperfect character. The effect of gently depressing the epiglottis, so as to have only a narrow opening between its margin and the arytenoid cartilages, was to lower the pitch one full tone.1 I next proceeded to test the effects of weights attached to the thyroid cartilage so as to stretch the vocal cords. With this object in view, I tied the free ends of the figure-of-eight ligature to a projecting piece of wood, thus suspending the larynx by its arytenoid cartilages. I then passed another strong needle through the angle of the thyroid cartilage, just opposite the attachment of the vocal cords, and to this, the larynx being held in a horizontal position, I suspended the weights with the following effects. The fundamental note being G1? the addition of 1 Miiller found this to produce a difference of only half a tone. •GRADUATION THESIS. 477 1 oz. raised pitch to 6, sharp. 2 „ „ A, I; C c d d d 10 oz. raised pitch to D 11 12 13 14 15 1 lb. 2 E E E E E G a No further note produced. It will be observed that, as the voice rose in the scale, a greater and greater weight was required to produce each successive note. I was obliged also to increase the force in blowing almost in a similar proportion, for the gentle blast which produced the fundamental note and those near it, caused no vocal sound at all when a few additional ounces were suspended. At any time during the lower notes, the pitch could be raised by simply increasing the current of air independently of the increase of weight; but in each case, following Miiller, I have marked the note produced by the gentlest possible current. With the view of showing how much the elevation in pitch is due to the weights alone, and how much to the increased force of the blast of air, I next made the following observations. Observing the note produced when a weight, for example one pound, was used, I suddenly removed it altogether, and marked the pitch to which the voice fell, the current of air remaining the same. The result was as follows :— removed : 1 lb. 8 oz. 4 „ G d c c A, a, flat. 2. Keeping the parts in the same position, I next suspended the weights from the hyoid bone, with results identical with those of last table, except that after passing 11 oz., which produced E as before, a greater weight was required to obtain each successive note ; 25 oz. being required to produce G, instead of one pound. 3. The larynx was that of a powerful man, aged about forty. The lowest note which I could produce with it by pressing backwards the thyroid cartilage was E2. The arytenoids being fixed with a needle as before, I now attempted to imitate by weights the action of the crico-thyroid muscle. This was done by passing a string through the lower border of the thyroid cartilage on each side at the middle of that muscle's line of attachment. Tying each end of the string in this position, I suspended the weights from the intervening loop, Whilst the cricoid cartilage was fixed, and the larynx was held in an oblique position, so that the direction of the string was the same as that of the fibres of the muscle. The following were the results :— Fundamental note, E | oz. raised pitch to Fj 1 2 „ 3 „ 4 „ 5 „ 6 „ 7 „ sharp, sharp. 9 F f: g G D D P sharp.. 11 12 13 17 18 22 23 24 2 lb. or 32 10 oz. raised pitch to E F F G still G A still A B B Cl No further note produced.478 THE PHYSIOLOGY OF THE LARYNX.—APPENDIX. The notes from G upwards were of a screaming imperfect character. The following are examples, as before, of the effects of increased force in the current of air :— 1 lb. = G : removed = G 8 oz. = D : ,, = Ft 4 ,, = A j : ,, = E = fundamental note. 4. With the same larynx I again applied the weight so as to imitate the action of the crico-thyroid, as in last experiment, but in this case the string suspending the larynx was attached, not to the needle transfixing the arytenoids, but to another passed for this purpose transversely through the posterior surface of the cricoid cartilage. The cricoid, therefore, and not the arytenoids, was the fixed point. Owing to the larynx having already been considerably- used, the fundamental note produced on blowing very gently was now Cx, instead of Ej, as formerly. Fundamental note, Cx I 2 oz. raised pitch to Dx 1 oz. raised pitch to Dx | 3 ,, ,, E, Here I was much puzzled to find that whilst when I blew with moderate force the note was E,, the pitch rose to Gx when X diminished the current of air, and this transition sometimes occurred even whilst the force which I employed in blowing remained the same. On examining the vocal cords, I found that the space between them became perceptibly wider and of greater length at the moment the lower note was produced. To continue the experiment:— 4 oz. raised pitch to Gx i 6 oz. raised pitch to F (weak). 5 ,, ,, C I 8 ,, No note produced. These results are very different from those of last experiment. The curious alternation in the pitch which occurred when three ounces were suspended, and also to a less extent during the other notes, I attributed to the apices of the arytenoids being pulled forwards by the tightening of the false vocal cords, and of the mucous membrane. The slight traction of these parts, I supposed, might imitate to some extent the action of the thyro-arytenoid muscles, to be afterwards described, rotating the cartilages slightly inwards, and at the same time depressing the points of the vocal processes so that the cords were tightened as well as approximated ; on the current of air being in- creased, these effects were undone, the vocal processes were raised from below, and the cords were separated to the same extent as before. This is the only example of sudden and unexpected alternation between two perfect notes that I met with in all my experiments upon the dead larynx. Muller, who seems to have met with it frequently, speaks of it thusIf a slight tension of the ligaments is maintained, it depends upon the manner of blowing whether the note be of the ordinary tone or falsetto (the falsetto note being most easily produced by blowing very gently), and the two different notes thus produced may be very distant from each other in the musical scale, even so much as an octave."1 In his experiments, Muller always fixed the arytenoid cartilages to a wooden board. 1 Muller, Physiology, vol. iL p. 1013.GRADUATION THESIS. 479 5. In examining the living larynx, we found that during the highest notes of the voice the hyoid bone was pulled strongly forwards by the genio-hyoid muscles, and the thyroid cartilage at the same time was drawn upwards and forwards behind it by the thyro-hyoid muscles. The object of the following experiment is to ascertain what effects the traction of these muscles, exercised in this direction, will have upon the voice. The larynx being once more suspended by the arytenoid cartilages, as in all the experiments except the last, it was held in an oblique position with its superior opening looking downwards. A string was then fixed to each side of the thyroid cartilage about the middle of the oblique line. To this the weights were suspended, the obliquity of the cartilage being such that the string, depending vertically, crossed its superior margin several lines posterior to the point of the pomum Adami. This I conceive to be the general direction of the muscular fibres when they are thus strongly contracted :— Fundamental note = Dx 1 oz. raised pitch to flat. 2 „ „ Ex 3 „ „ F1 4 ,, ,> G, 6 ,, ,, Gj sharp. 7 „ ,, A, 8 oz. raised pitch to flat. 9 „ „ C 10 „ „ D 13 ,, ,, E flat 19 „ „ F 24 „ „ G 2 1b. „ G It must always be borne in mind that in this experiment the arytenoid and cricoid cartilages were fixed and immovable, so that the .weights exercised their whole force in pulling forward the thyroid cartilage, whereas in the living body the muscles raise the larynx en masse. But making due allowance for this difference, it will still be admitted that the thyro-hyoid muscles in thus acting upon the larynx must tend in some degree to separate the upper part of the thyroid from the arytenoid cartilages, thus stretching the vocal liga- ments, and consequently raising the pitch of the voice. 6. In any larynx prepared for vocalization when the apices of the arytenoid cartilages are simply pressed forward with the point of the finger, the effect is to raise the voice in a very remarkable manner. By this simple means I could frequently produce the note G, the highest in last table ; and it may be remarked that the vocal sounds thus obtained were always very powerful, though of a somewhat punchinello character. By resting weights upon the posterior surface of the cartilages, I attempted to estimate the amount of force required in this experiment, and found that— Fundamental note being Cj 1 oz. raised pitch to 4 oz. raised pitch to E. 8 „ „ F, There was, however, great difficulty experienced in applying these weights accurately; and it was found that, by properly directed pressure with the finger, more striking results could be obtained, even when much less force was employed. The cartilages on being pressed forward were observed to rotate slightly inwards upon their articulations, so that the vocal processes became more closely applied to each other, whilst at the same time they were slightly depressed within the cavity of the larynx. The vocal cords were thus actually stretched from before backwards as well as approximated, and owing480 THE PHYSIOLOGY OF THE LABYNX.—APPENDIX. to their being brought into actual contact posteriorly, the length of the chink through which the air passed was diminished. 7. Exactly the same effects were produced upon the voice by pressing the arytenoids together between the finger and thumb. 8. Simple lateral compression of the thyroid cartilage was also productive of the same effects, but the notes in this case were soft and weak, instead of being loud and shrill as in the last two experiments. In one larynx I could by this means elevate the pitch to C1. In this experiment, as in the two preceding, the glottis was observed to be constricted, so that the cords vibrated only in part of their extent. The space between the alae of the thyroid being wedge- shaped, another effect of their compression was to force backwards the cricoid cartilage, so that the vocal ligaments were tightened. 9. The larynx was that of a man aged about thirty years. In this case the hyoid bone and epiglottis were removed. I also dissected away those muscular fibres of the thyro-arytenoid which lie parallel to the direction of the vocal cord, and within the angle of its free edge, my object being to observe the effect of isolating the cords as much as possible. The result was that extreme difficulty was experienced in producing any vocal sounds at all. When, however, I supplied the place of the muscular fibres just mentioned by small soft rolls of wet paper, the musical tones were produced with almost as much ease as in the other experiments. This observation points out, I think, one function of the thyro-arytenoid muscle, namely, that of supporting the vocal ligaments when their free edges are in a state of vibration. 10. A tube about fifteen inches long, furnished with perforation like that of a clarionet, was affixed to the upper part of the larynx in such a manner that the connexion between them was air-tight. On producing the voice in these circumstances a difference only of one full tone was observed between the note sounded when all the perforations on the side of the tube were left open^ and that obtained when they were all closed with the fingers. This is in accordance with the experience of Miiller, and in opposition to the theory of Bishop—the vocal-tube theory. 11. The effect of simply increasing the current of air from the gentlest to the strongest blast that could produce a note was to elevate the pitch generally one-fifth, rarely one-sixth, and sometimes only one-fourth. This also accords with Miiller's observations. 12. Before concluding the experiments from which I have thus given a selection, I had acquired a command over the dead larynx sufficient to enable me to perform upon it a variety of slow airs, not very correctly, but still in such a manner that they could easily be recognised by my audience. In doing this I could employ at pleasure one of four different methods of raising the pitch 1st, By pulling forward the thyroid cartilage, as in the first experiment; 2d, By pushing forwards with the point of the finger the arytenoid cartilages, as in the sixth experiment; 3c?, By pressing the arytenoids together between the finger and thumb, as in the seventh experiment; 4thf By compressing the thyroid cartilage laterally, as in the eighth experi- ment,GRADUATION THESIS. 481 I always at the same time regulated the current of air so as to blow gently in the low notes, and more powerfully when I required to rise in the scale. The lowest base tones were invariably produced by pressing gently backwards the thyroid cartilage. I now proceed to inquire if from these experiments any light is thrown on the many difficult problems connected with the production of voice. We have seen that in the dead parts there are three distinct methods by which the pitch of the voice may be elevated:— 1st, By tightening the cords ; 2d, By increasing the current of air ; 3d, By bringing the vocal ligaments partially into contact, so that they vibrate only in a portion of their extent. In the living body it is universally admitted that the first of these is the chief means employed in raising the pitch of the notes. It is exceedingly probable that the second acts as an assisting agent, for we are conscious of using a greater effort in singing the high notes than the low, just as in the dead larynx we required to increase the current of air as the notes rose in the scale. As to the third method we are left in greater doubt. On the one hand the laryngoscope shows us that during phonation the vocal cords never come into actual contact in the posterior half or three-fourths of their extent, but owing to the projection of the epiglottis we are as yet uncertain of what may take place at their anterior extremities. On the other hand we find among Magendie's observations the following:—" I laid bare the glottis of a noisy dog by cutting between the thyroid cartilage and the os hyoides, and I saw that when the sounds are grave the ligaments of the glottis vibrate in their whole extent, and that the expired air passes out in the whole length of the glottis. In acute sounds the ligaments do not vibrate in their anterior part, but only in their posterior; the opening is therefore diminished."1 Moreover, we found that of the three means by which this constriction of the glottis may be artificially produced in the dead larynx (Experiments 6, 7, and 8), the only one which we could also employ in the living was the lateral compression of the thyroid cartilage, and in both cases this was observed to produce the same effect upon the voice. This lateral compression occurs naturally during the highest treble tones. It is therefore very probable, though it cannot be said to be absolutely proved, that in certain conditions the pitch of the voice is raised by a shortening of the vibrating portion of the vocal cords, owing to their anterior extremities having come in contact. When compression of the thyroid cartilage occurs during the production of high notes, it must, I think, be due to the action of the palato-pharyngeus and the middle constrictor of the pharynx, the attachments of which are such that both of them, when contracted as they are in these circumstances, must pull the upper parts of the alse towards the middle line ; this action is favoured by the box of the larynx at the same time being carried forwards along with the hyoid bone. The falsetto voice has been explained by supposing that during its production the vibrating portion of the cords is shortened in the manner just alluded to. 1 Magendie's Compendium of Physiology, p. 137. 3 p482 THE PHYSIOLOGY OF THE LAUYNX.—APPENDIX. This is the opinion of Bishop, Willis, and others ; and the supposition seems a very feasible one. It is also favoured by some of the facts which I have observed. It was noticed, for example, that during the transition from the true voice to the same note of the false, the vocal processes became somewThat more closely approximated.1 In the same circumstances the muscles of the pharynx were more strongly contracted. If this contraction be really the cause of the lateral constriction of the thyroid cartilage, as just explained, we see at once the means by which the vocal cords are thus partially brought into contact. I hesitate, however, to conclude from these limited data that the cause of the falsetto voice is the lateral constriction of the thyroid cartilage, the more especially as I find Muller ascribing to it in his experiments upon the dead larynx exactly an opposite effect. "The deepest note," he says, " which I could produce in one of my experiments by relaxing the vocal cords was the middle C of the base clef; by exercising slight tension on the cords, and blowing with greater force, I could produce the octave above this (C1), but I could in that way raise the notes no higher. By compressing the larynx laterally, however, about the situation of the vocal cords and below them, I was able to produce a series of higher notes to the extent of another octave (C2), without any falsetto tone, although under other conditions falsetto notes could be produced from the A sharp, below the second C (C). The prevention of the falsetto notes, which was here attained by the lateral compression of the larynx, seems during life to be effected by the action of the thyro-arytenoid muscles."2 It astonishes me to find Muller speaking so confidently of distinguishing the true and false tones in the voice of the dead larynx. In my own experiments I never succeeded in doing so ; I even found that very little difference could be observed between the sound of the male and of the female larynx, further than the fact that the voice of the former was set several notes lower than that of the latter. The absence of the peculiar characteristics in both cases I ascribed to the removal of the pharynx and the other parts of the " vocal-tube/' From the observations which I have just mentioned, and from the fact that by artificially compressing my own larynx, I am enabled to add to my falsetto register several notes which I cannot otherwise reach, I have been led to adopt the opinion of Bishop and Willis, namely, that the falsetto voice is produced by a shortening of the vibrating edges of the vocal cords, owing to their having come into actual contact anteriorly ; and this I believe to be due in part at least to the constriction of the thyroid cartilage by the palato-pharyngeus and the middle constrictor of the pharynx. This theory accounts for the height of the notes which we are able to produce in the falsetto voice without any great muscular effort, whereas their soft throat character is probably clue to the sounds having been made to pass through the greatly contracted pharyngeal cavity. With reference to the action of the thyro-arytenoid muscle, this is a question much disputed by physiologists. On the one hand it is maintained by Mr Willis, and most other English wrriters, that by its agency the low notes are 1 In the thesis as originally printed, the words false and true in this sentence were, by a slip of the pen, transposed.—J. W., August 1894. 2 Miiller's Physiology, page 1015.GRADUATION THESIS. 483 produced, whilst, on the other, the opposite action has been ascribed to it by some of the German authors, namely, that of elevating the pitch of the voice. Now, in my experiments upon the dead larynx, it was remarked that, 1st, Pressing forward the arytenoid cartilages has always a most marked influence in raising the pitch. Exper. 6. 2d, Pressing backward the thyroid operates with equal certainty in lowering the notes. As the muscle therefore stretches between the thyroid and arytenoid cartilages, the effect of its contraction upon the voice will depend entirely upon which of these is the fixed point. A little experiment upon one's own larynx will show at once that it is an easy matter to press back the thyroid cartilage during the production of low notes, so that if the muscle acts in these circumstances it can have little difficulty in approximating the upper part of the thyroid cartilage to the arytenoids. Its action, however, cannot be altogether favourable to the lowering of the vocal pitch, for, in their con- traction, those fibres contained within the fold of the vocal ligament near its free margin must render somewhat tense the edges of the cords, thus destroy- ing the laxity which is necessary for the production of bass notes; at the same time, the forward traction of the arytenoids with the consequent depres- sion of their vocal processes must tend, so far as they go, to raise the pitch of the voice. It is therefore evident that if the thyro-arytenoid muscle is intended to produce low notes, it must act under most unfavourable circumstances. On the other hand, let us suppose that its agency is employed in elevating the pitch of the voice. As the vocal tones rise in the scale we observe that the larynx is pulled upwards and forwards by the thyro-hyoid muscle, and at the same time the lower border of the thyroid cartilage is pulled upon in a downward direction by the crico-thyroid. Between these two muscles the thyroid cartilage is thoroughly fixed, and the thyro-arytenoid must, therefore, in contracting, produce its effects solely upon its arytenoid attachments; pulling them forwards, it must exercise the same powerful influence in raising the notes, as we observed was produced by pushing the cartilages from behind in the sixth experiment. Those of its fibres also contained within the folds of the vocal ligament will act by rendering the edges of these cords more tense, and at the same time by supporting them during their vibration. There can be no doubt, then, that the thyro-arytenoid is one of the muscles which tighten the cords and raise the pitch of the voice. Ecker has thus expressed the German view regarding it : " When these muscles contract, their fibres lose their slightly wavy direction, thereby the free margins of the vocal cords approach each other; seeing that the processus vocales are drawn forwards, inwards-, and downwards, even to touching, so that only a small linear split remains. As the thyro-arytenoid muscles fill the fold of the vocal ligament nearly to its free margin, necessarily, on the contraction of the muscle, the free margin of the fold becomes sharpened. In this position the vocal cords are drawn as much as possible into the lumen of the air passage. Probab!y they vibrate in their whole extent, and the chest-notes are produced." We have as yet, I believe, no satisfactory explanation of the manner in484 THE PHYSIOLOGY OF THE LARYNX.—APPENDIX. which the lowest notes are produced. We know that the vocal cords are relaxed by the upper part of the thyroid cartilage moving backwards, but we are still in doubt as to the cause upon which this movement depends. I cannot bring this paper to a conclusion without expressing my sincere thanks to Dr Grainger Stewart, and also to Dr Sanders, for their kind advice and assistance, and for the interest they have all along taken in the investiga- tion of these very complex questions.INDEX. Abercromby, 287. Acousmatagnosia, 375. Acousmatamnesia, 375. Adhesiveness of words, 260. Agglutinative languages, 162. Agraphia, recurring letters in, 266 ; in relation to auditory aphasia, 290 ; in motor aphasia, 315 ; in conduction aphasia, 330 ; in visual aphasia, 333 and 349; in graphic-motor aphasia, 355 ; general summary as to foregoing, 363 ; in relation to supra-pictorial auditory aphasia, 365 ; in supra-pictorial motor aphasia, 365 ; in functional aphasia, 396 and 398. Alcibiades, 136. Alexia, in relation to auditory aphasia, 286 ; in motor aphasia, 319 ; in visual aphasia, 333 and 349 ; general summary as to foregoing, 362 ; in supra- pictorial auditory aphasia, 365 ; in functional aphasia, 405 and 408. Alphabet, ordinary, 15 ; physiological, frontispiece, and 6. Alphabetical letter-sounds used in different languages, 169. Alston's type for the blind, 177. Amidon, 284 and 287. Amimia, 272. Amnesia verbalis, definition of the term, 267 ; in auditory aphasia, 289; in motor aphasia, 312 ; in supra-pictorial auditory aphasia, 365 ; in functional aphasia, 378. Angular convolution, 332. Aphasia, physiological preface, 227 ; auditory, 283; motor (aphemia), 299; conduction, 329 ; visual, 332 ; graphic motor, 354; summary as to fore- going, 360 ; infra-pictorial auditory, 364; supra-pictorial auditory, 365 ; supra-pictorial motor, 365 ; infra-pictorial motor, 366 and 422 ; compound varieties, 369 ; total, 370 ; method of case-taking, 370 ; due to evanescent organic and to functional causes, 377. Aphemia, see Motor Aphasia. Aphonia, hysterical, 38. Apoplexy, as a cause of aphasia, 282. Arago, 25. Armand de Fleury, 244. Armitage, T. R., on teaching of the blind, 177. Arnold, on teaching of deaf-mutes, 5, 143, and 144. Arnott, Neil," 3, 4, 21, 28, 30, and 34. Articulation, in insanity, 210.486 INDEX. Articulative amnesia, definition of term, 269; in auditory aphasia, 290; in motor aphasia, 314. Articulative ataxia or asynergia, nature of, 270 ; in motor aphasia, 310 ; in infra-pictorial (subcortical) motor aphasia, 366 and 421. Asemia, 272. Astasia abasia, case of disturbance of speech in, 399. Asynergia verbalis, see Articulative Ataxia. Ataxia verbalis, see Articulative Ataxia. Attention, faculty of, 244. Auditifs and Moteurs, 278. Auditory speech centre, 279. Auditory aphasia (sensory aphasia), 283 ; its effects on reception and inter- pretation of speech, 284; effects on reading, 286 ; effects on speech- production, 288 ; effects on writing, 290 ; effects on repeating or echoing, 293 ; effects on the musical faculty, 294 ; summary of leading features of, 296 ; treatment of, 297. Automatic exercises of the speech organs in children, 97. Automatic and reflex speech in the insane, 205. Aztec writing, 171. Babbling of children, 97. Bain, 229, 235, 260, 318, and 320. Ballet, G., 388 and 396. Ballet and Boix, 308. Bamberger, 85. Barlow, 250 and 424. Bastian, C., 131, 233, 235, 253, 271, 274, 353, and 356. Bateman, Sir Frederic, 252, 271, 274, 290, 388, 391, 407, and 410. Beevor, E., 301 and 412. Bell, Melville, 3, 4, 5, 32, and 145. Berger, 78 and 79. Bernard, 237, 274, 296, 359, and 389. Billings, 275. Billroth, 85. Bishop, 71, 464, 475, and 482. Blind, printing for the, 176 ; the speech-centres in the, 281. Block-printing, 175. Blushing, 95. Bock, H., 45. Boudet, 46. Bovine cough, 445. Bradylalia, 139 and 210. Braidwood, Thomas, 144. Braille's type for the blind, 177. Bristowe, 5. Broadbent, 128, 249, 254, and 412. Broca, 243, 244, 265, 299, 300, 304, and 305. Broca's convolution, 300.INDEX. 487 Brown, H. W., 88. Briieke, 34. Brunton, Lauder, 20 and 446. Burn-Murdoch, 409. ; Burton, Captain, 157. Cartaz, 45 and 47. Cash, 20 and 446. Catalepsy and ecstasy, as causes of aphasia, 398. Cerebritis, as a cause of aphasia, 282 and 379. Charcot, 44, 45, 46, 47, 85, 208, 209, 237, 274, 296, 350, 357, 396, 399, 404-, 405, 418, and 427. Chinese, language of the, 160 ; writing of the, 172. Chorea, speech-troubles in, 400. Chouppe, 389. Cicero, 76. Clarus, A., 390. Classification of languages, 161. Clouston, 121, 139, 185, 190, 214, 219, and 223. Cluttering, 139. Cockburn, Lord, 200. Concepts, 279. Concussion and compression of the brain, as causes of aphasia, 382. Conduction aphasia, 329. Congestion of the brain, as a cause of aphasia, 386. Congestive attacks of general paralysis, as a cause of aphasia, 396 and 456. Consonants, nature of, 8. Conventional replies, in dementia, 206. Coprolalia, 56, 208, 403, and 409. Crichton, 405 and 408. Crowing, in children, 99. Crying, in children, 89. Czermak, 35, 464, 467, and 468. Darwin, 88, 90, 91, 92, 93, 94, 95, 96, 103, 110, 165, 170, 205, and 245. Deaf-mutes, gesture language of, 141 ; education of, 143 ; speech-centres in, 281. Deformities, gross oral, 136. Degerando, 143. Dejerine, 309, 316, 336, 339, 349, and 357. Dementia, simple, speech in, 213 ; senile, speech in, 218; of general paralysis, speech in, 220 ; reflex and automatic forms of speech in, 205. Demosthenes, 27. Departure of words from their original meanings, 241. Depth of imprintation of speech-memories, 261. Development of speech, in the child, 87 ; in the human race, 149. Diabetes, as a cause of aphasia, 389. Diphtheria, as a cause of laryngeal paralysis, 51 and 431.488 INDEX. Disgust, expression of, in children, 93. Dor, 310. Dnret, 281. Dysarthria of speech, in fevers, 393 ; due to lesion of the speech-tracts, 411. Echolalia, in children, 100, 116, 234, 240 ; in imbeciles, 122 and 126; in dementia, 205, 214, and 215 ; in aphasia, 271 and 365. Ecker, 473. Ellis, Alex. J., 3. Embololalia, 209. Emotional expression, in aphasia, 273. Epiglottis, mechanism of its closure, 463. Epileptic cry, 400. Epilepsy, as a cause of aphasia, 399. Erb, 78. Esquirol, 120, 188, 218, and 245. Evanescent organic affections of the brain, as causes of aphasia, 378. Exner, 355. Facial expression, in children, 93. Falsetto voice, 481. Farrar, Archdeacon, 153, 156, 159, 160, and 169. Fatigue neuroses, of professional voice-users, 64. Fear, expression of, in children, 94. Fere, 83 and 389. Ferrier, D., 230, 231, 246, 250, 274, 300, 320, 334, and 413. Fletcher, 275. Foster, 33. Frankel, B., 64, 66, and 67. Fraser, J., 313. Friedreich's disease, speech in, 427. Fritsch and Hitzig, 254. Frowning, in children, 93. Functional aphasia, from tobacco-smoking, 388 ; from snake-bite, 388 ; from plumbism, 389 ; from diabetes, 389 ; from uraemia, 389 ; from gout, 390 ; from infectious fevers, 390; in insanity, 393 ; in general paralysis, 396 ; in hysteria, 396 ; in catalepsy and ecstasy, 398 ; in epilepsy, 399 ; in megrim, 403 ; from intestinal irritation, 409. Functional disorders of the brain, in relation to disorders of speech, 377. Gairdner, Wm., 253, 265, 316, 383, 405, and 407. Gall's type for the blind, 177. Garel, 310. Gaskell, Mrs, 91. General paralysis of the insane, speech in, 220 ; aphasia in, 396. Gesture language, of childhood, 96 ; of deaf-mutes and savages, 155. Giraudeau, C., 287. Glottis, valvular action of the, 466.INDEX. 489 Goltz, 246. Goquillot, 148. Gottstein, 64. Gout, as a cause of aphasia, 390. Gowers, 249, 274, 317, 418, 425, 428, 432, 438, 441, and 444. Grammar, definition of, 167. Graphic-motor aphasia, 354. Grashey, 266, 275, and 384. Griesinger, 120, 184, 185,187, and 201. Grimm, 168. Guillaume, 26 and 32. Guilty expression, in children, 94. Guislain, 184. Hadden, W. B., 129. Hallucinations, verbal, auditory, 192 ; psycho-motor, 194 ; visual, 199 ; graphic-motor, 202. Hallucinations, visual, 199 ; sometimes associated with hemianopsia, 353. Hamilton, Sir Wm., 161 and 232. Hare-lip, 136. Hartmann, 1*28 and 136. Hauy, Valentin, 177. Heinicke, 144. Helmholtz, 6 and 7. Hemianopsia, homonymous, its causation, 334, 336, and 337; its occurrence in megrim, 403. Hemming and hawing, 209. Henschen, 353 and 357. Henoch, 379. Hessels, J. H., 174. Heymann, C., 389. Hitzig, 246 and 254. Horsley, Victor, 281, 301, 302, 303, 411, 412, 414, and 419. Hovelacque, 164. Hullah, John, 5, 60, 75, 76, 146, and 168. Humphreys, M. W., 108. Hysteria, as a cause of aphasia, 396. Hysterical aphonia, 38 ; mutism, 41 ; stammering, 53 ; barking, 54 ; sneezing, 55 ; spasm of larynx, 56. Idiographic writing of the Chinese, 172. Imbeciles, speech of, 120. Indian picture-writing, 171. Infectious fevers, as causes of aphasia, 390 ; as causes of dysarthria, 393. Inflectional languages, 163. Infra-pictorial auditory aphasia, 364 and 449. „ „ motor aphasia, 366. Insanity, speech in its relations to, 183 ; action of the speech-centres in, 191 ; aphasia in, 393, 3 Q490 inMX. Interjections, origin of, 157. Internal speech, nature of, 235. Invention, words of a child's own, 103 and 160 ; words of an imbecile's own, 124 and 126. Ireland, Wm. W., 120, 121, 126, and 129. Island of Reil, 329. Jackson, Hughlings, 194, 242, 252, 263, and 265. Jackson, Scoresby, 392. Jeffrey, Lord, 200. Joan of Arc, 193. Kingsley, Charles, 3. Kingsley, Norman W., 5 and 136. Krause, 302 and 419. Kiihn, R., 390. Kussmaul, 3, 19, 21, 26, 30, 31, 32, 44, 130, 134, 144, 169, 190, 209, 255, 274, 398, 399, 410, and 427. Ladame, 397. Lalling, of children, 117; upon a single consonant, 134; contrasted with stammering, 137 and 258 ; in imbeciles, 123, 124, and 126 ; in dementia, 207 ; in motor aphasia, 315. Landois and Stirling, 34. Languages, classification of, 161 ; radical, 162 ; agglutinative, 162 ; inflectional, 163. Larynx, thesis on the physiology of the, 463. Laughing, in children, 91. Leichardt, 157. Leith, 347. Lennox-Browne and Behnke, 62 and 169. L'Ep^e, Abbe de, 143. Lewis, M. J., 78, 79, 82, and 85. Lichtheim, 253, 268, 275, 276, 286, 294, 312, 320, 357, 363, 364, 366, and 370. Lindner, Gustav, 109. Logagnosia, 374. Logamnesia, 375. Logorrhoea, 139 and 210. Logospasmus choreiformis, 56, 208, and 403. Longuet, J. R., 390. Lordat, 253 and 406. Lubbock, Sir John, 92. Lucas's type for the blind, 177. Lunn, Charles, 62. M'Bride, P., 64 and 441. M'Kendrick, 34. Mackenzie, Sir Morell, 38, 39, 40, 41, 67, 72, 74, 431, and 433. Mackness, 75.INDEX. 491 Macready, 75. Magendie, 463, 467, and 481. Magnan, 209 and 292. Mandl, 62, 71, 74, and 76. Mania, speech in, 188. Masini, 302 and 440. Mayo, 467, 469, and 471. Megrim, as a cause of aphasia, 403. Melancholia, speech in, 185 and 394. Meningitis, as a cause of aphasia, 282 and 379. Mental impairment, in aphasia, 270. Merkel, 3, 8, and 32. Meyer, G. H. von, 34. Meyer, M., 464. Meynert, 286. Michel, 68, 71, and 74. Middlemass, 342. Middleton's life of Cicero, 76. Mimic reading, of children, 99. Mind-blindness, 273, 352, 374, and 375. Mirroring of the mind, by speech, 184. Mirror-writing, 359. Mitchell, Weir, 399. Mongorg6, R, 810. Monomania and moral insanity, speech in, 189. Morel, 3 91. Motor aphasia (aphemia), 299 ; its effects on production of speech, 303 ; on production of writing, 315 ; on reception and interpretation of speech, 318; on reading, 319; on repeating or echoing spoken speech, and on copying writing or print, 321; occasional phenomena in, 322 ; treat- ment of, 322; infra-pictorial (subcortical) varieties, 366 and 422. Motor speech-centre, 279. Motor speech-tracts, their anatomy and physiology, 411 ; their pathology, 420. Moxon, 248 and 251. Miiller, J., 28, 475, 476, 477, 478, 480, and 482. Muller, Max, 5, 150, 164, and 167. Multiple (insular) sclerosis, speech in, 425 and 45 i). Munk, 334. Musical faculty, in imbeciles, 114 and 125 ; in dementia, 217 ; in aphasia, 273 ; in auditory aphasia, 294 ; in infra-pictorial auditory (subcortical sensory) aphasia, 364. Mutism, hysterical, 41. Natier, M., 45, 47, and 396. Necrotic softening, as a cause of aphasia, 282. Negative and affirmative, origin of gestures for, 96. Nisbet, J. E., 201. Ogle, Win., 244, 253, 308, and 388.492 INDEX. Onimus, 83. Onomatomania, 209. Onomatopoeia, 158. Orfila, 24. Osborne, 290. Overflow of education, into opposite hemisphere, 262. Pagan, 383. Paralysis, bulbar, acute cases, 443; invasion of the bulbar nuclei in tabes dorsalis, 437; in progressive muscular atrophy and in multiple sclerosis, 443; idiopathic progressive bulbar paralysis, 443. Paralysis and paresis, laryngeal, of the adductors, 38, 51, and 438; of the abductors, 57, 432, 436, 437, and 438 ; of the superior laryngeal nerve, 431 and 435; of the recurrent laryngeal (a) unilateral, 432; (b) bilateral, 435. Paralysis of the nerves of the oral articulative mechanism, of the portio dura of the seventh nerve, 441 ; of the hypoglossal, 442 ; of the nerves of the soft palate, 442. Paramimia, 272. Paraphasia, its nature, 268; in auditory aphasia, 289 ; in motor aphasia, 314; in conduction aphasia, 329. Percepts, of objects, 227 and 276; of words, 234 and 276. Perez, 88 and 97. Picture-writing, Indian, 171; Aztec, 171; Chinese, 172; Egyptian, 173. Pitman, Sir Isaac, 4. Pitres, 47, 53, 54, and 357. Pliny, 91. Pointing, gesture of, in children, 96. Pollock, F., 88. Pon3, lesions of, in relation to speech, 429. Poore, G. V., 78, 80, and 82. Pragmatagnosia, 375. Pragmatamnesia, 375. Preyer, W., on the development of speech in the normal child, 88 to 110. Primum cognitum, the, 161. Printing for the blind, 176. Professional voice-users, 59 ; their laryngeal troubles, 63; their pharyngeal troubles, 70. Pseudo-bulbar paralysis, 250 and 424. Radical languages, 162. Rage, expression of, in children, 93. Rebus writing, 172. Recurring letters, in the writing of aphasic patients, 266 and 316. Recurring utterances, their nature, 264; in auditory aphasia, 291; in motor aphasia, 306, 316, and 319. Reflex and automatic speech, of the insane, 205. Reflex irritation, as a cause of aphasia, 408.INDEX. 493 Retirement of word-images, when no longer wanted, 266; too quick retire- ment, 266 and 385. Revilliod, 44. Robertson, G. M., 206. Romanes, Gr. J., 88, 104, 159, 163, and 164. Rosenstein, 307. Ross, 254, 274, 291, 292, 387, and 399. Russell, James, 253. Russell, Risien, 433. Sajous, 74. Sanders, 253 and 484. Santorini, 464. Scamping or smudging, of letter-sounds and syllables, 118. Scanning speech, of multiple sclerosis, 426. Schech, 71, 72, and 74. Setoff, 83. Schott, 85. Schulthess, 28 and 30. Seglas, on the speech of the insane, 190 to 211, also 394. Semon, F., 302, 310, 411, 414, 419, 433, 437, 440, and 441. Senile dementia, speech in, 220. Sensory aphasia, see Auditory Aphasia. Seppilli, 284. Serieux, 336, 339, 349, and 352. Shrugging of the shoulders, gesture of, in children, 96. Shyness, in children, 95. Sicard, Abb£, 143. Sigismund, B., 88. Skwortzoff, Mile. Nadine, 284, 286, 288, and 292. Slurring, in children, 118 ; in imbeciles, 125; in dementia, 218; in general paralysis, 224; definition of, 258; in motor aphasia, 315; in fevers, 393; due to lesion of the motor speech-tracts, 422 and 447. Snake-bite, as a cause of aphasia, 388. Snuffling, nasal, from split-palate, 136; from paralysis of palate, 442. Socrates, 192. Song, 170. Sounds, expressive inarticulate, of infants, 89. Southward, J., 174. Spalding, his own case, 405. Spamer, 253. Spasms, of larynx, etc., rhythmical, 53; non-rhythmical, 56. Speech-production, in children, 105. Spencer, Herbert, 170. Split-palate, 136. Staccato speech (scanning speech), in multiple sclerosis, 426; in Friedreich's disease, 427; in general paralysis, 225; utterance sometimes slow and laborious in motor aphasia, 270. Stammering, nature of, 2; phenomena of, 16 ; causation of, 22 ; treatment of,494 INDEX. 23; prognosis in, 27; rare and exceptional varieties of, 27 ; in relation to hysteria, 53 and 396 ; contrasted with lalling, 137 and 258; in nprmal children, 119 ; in imbeciles, 124 and 126; in motor aphasia, 270 and 315. Stein, T., 86. Stewart, Dugald, 149. Stewart, Sir Thomas Grainger, 274 and 484. Strieker, 236. Stuttering, its relation to stammering, 30. Snlkiness, expression of, in children, 94. Superior laryngeal nerve, paralysis of, 431. Superstitious significance attached to words by the insane, 208. Supra-pictorial auditory aphasia, 365. „ „ motor aphasia, 365. Surprise, expression of, in children, 94. Syllable-stumbling, in general paralysis of the insane, 224; contrasted with other faults of articulation, 258 and 427; in motor aphasia, 270» Taine, 88. Talma, 76. Taylor, F., 129. Tears, in children, 90. Terminology of aphasia, note on the, 374. Thesis, author's graduation, 463. Thomson, J., 379. Thyro-arytenoid muscles, action of, 482. Tic, spasmodic, troubles of speech in, 402. Tobacco-smoking, as a cause of aphasia, 388. Tongue, congenital paralysis of, 136. Tongue-tie (shortness of the frenum linguae), one of the possible causes of "burring," 135. Toxaemia, as a cause of aphasia, 388. Traumatism, as a cause of aphasia, 282. Trench, Archbishop, 241. Trophic-realms in the motor tract, 417. Trousseau, 53, 252, 265, 291, 299, 312, 315, 319, 390, and 407. Tuke, J. Batty, 313. Turkish language, 163. Tylor, E. B., 141, 142, 154, 159, 171, and 174. Uchermann, V., 129. Understanding of spoken words, in children, 101. Unilateral imprintation of speech-memories, 243. Uraemia, as a cause of aphasia, 389. Verbigeration, in the insane, 207. Visual centres, their localisation, 334. Visual speech-centre, 279. Vocal mechanism, developmental defects of, 137. Voice, in old age, 219.INDEX. 495 Voice production, points in the physiology of, 60 ; its three functions, 111"; an exercise for the lungs, 111 ; a means of expressing emotion, 112 ; with oral articulation a means of expressing thought, 115 ; its mechanism, 473. Vowels, 6. Walclenburg, 128. Waller's law, 418. Wedgwood, Hensleigh, 153, 154, 157, 158, and 160. Wernicke, 252, 254, 275, 276, 285, 286, 294, 295, 299, 329, 355, 363, 366, and 423. Westphal, 393 and 427. Wheatstone, 7 and 471. Whispering, physiology of, 33. Wilde, Sir Wm., 127, 136, and 137. Willis, 7, 471, and 482. Wolff, on writer's cramp, 85. Word-deafness, in auditory aphasia, 284 ; possible existence in motor aphasia, 318 ; in infra-pictorial auditory aphasia, 364 ; in supra-pictorial auditory aphasia, 365. Worms in the intestine, as a cause of aphasia, 409. Writer's cramp, 78 and 420. Writing, origin of, 171 ; of the insane, 211 ; loss of the power of, see Agraphia. Xylography (block-printing), 175. PRINTED BY OLIVER AND BOYD, EDINBURGH.Published by OLIVER & BOYD, Edinburgh. wvwvwwvwwwv\ Just Published, 8vo, with Illustrations, price 18s. THE DISORDERS OF SPEECH. » By John Wyllie, M.D., F.R.C.P. Ed., Physician to the Royal Infirmary, Edin- burgh ; Lecturer on the Practice of Medicine and of Clinical Medicine in the School of Medicine, Edinburgh. Part I.—The Functional Disorders of the Vocal Mechanism. Part II.—The Development of Speech; and the Developmental Derangements. Part III.—Speech in its Relations to Diseases of the Nervous System. " A book which for comprehensiveness, clearness of style, and practical usefulness is certain to hold its own for a long time as a standard authority.....The chapter on stammering is the best and most original in the book.....There is throughout evidence of careful and mature thought."—British Medical Journal, Feb. 26th, 1895. " Dr John Wyllie has shown himself to have every qualification necessary to treat the subject as it has never before been treated, and to write by far the best treatise yet seen on this most difficult department of medicine. The book is a good specimen of the highest kind of medical work of this century. It is philosophical in conception and scientific in its comprehensive execution. It is, above all, the result of years of patient clinical observations and of subtle practical insight..... When he gets to Aphasia, Dr Wyllie is at his very best. No clearer bit of physiological psychology, or one more instructive to medical men, exists than his first chapter on that subject.....Dr Wyllie gives the most lucid description we know of the various forms of aphasia and their localisa- tion in the brain."—Edinburgh Medical Journal, Jan. 1895. "Dr Wyllie's most practical discourse on stammering cannot fail to be of great value to his medical brethren.....The reader will find an excellent and comprehensive description, clinical and pathological, of the several forms of aphasia, and may rest assured that the most modern and accepted views are set before him.....We strongly recommend Dr Wyllie's book."—Liverpool Medico-Ghirurgical Journal, Jan. 1895. " We may say that for fulness of detail and clearness of description these chapters [on Aphasia] have few, if any, equals in our language.....In a subject of such difficulty as aphasia, the method of the author will be found to give enormous assistance, and we hope that it will be very generally practised. . . . . In conclusion, we must again express our high appreciation of this work, which cannot fail to excite the interest, not only of those who have to do with diseases of the nervous system, but also of psychologists and of every one interested in the study of language in its largest sense."—Dublin Journal of Medical Science, Feb. 1895. " The book is invaluable."—Birmingham Medical Review, Feb. 1895. " A work of the greatest interest, and one that can readily be understood by all."—Medical Chronicle, Feb. 1895. 8vo, price 7s. 6d., with Illustrations. The Neuroses of Development. ByT. S. Clouston, M.D., F.R.C.P.E., Physician-Superintendent, Royal Edinburgh Asylum for the Insane; Lecturer on Mental Diseases, Edinburgh University. " These lectures may be said to break new ground in a direction which is full of suggestiveness and, interest. They are written with characteristic freshness and vigour, and there is scarcely a point which is not illustrated by references which show at once a wealth of experience and an enviable power of discrimination and classification.....It is a work which is full of interest, and is likely to have a very wide sphere of influence, and we are sure that no one can look into it without having suggested to him some fresh point from which to regard many of the commonest nervous disorders."—Lancet. " In common with everything from the pen of the author, it is replete with useful practical knowledge. The work is not only one of absorbing interest to the alienist, but is one that cannot fail to be of inestimable value to the general practitioner."—Journal of Nervous and Mental Diseases, New York.2 Just Published, with Illustrations and Diagrams, 8vo, price 6s. The Insanity of Over-Exertion of the Brain: Being the Morison Lectures for 1894. By J. Batty Tuke, M.D., F.E.C.P.E., F.R.C.S.E. " A welcome and cheering contribution to the literature of insanity in its newer development. .... We cordially recommend the study of this volume to the profession. It is written in excellent, trenchant style, and is readily within the grasp of even the busy practitioner."—Medical JPress and Circular. " Dr Batty Tuke affords information of the newest studies on the structure of the brain, some of which come from sources not accessible to the English reader*"—Edinburgh Medical Journal. " This interesting work shows the rapid strides toward a more scientific investigation of mental disease which are being taken by alienist physicians of the present day."—Manchester Medical Chronicle. * " The subject of treatment is very clearly dealt with."—Birmingham Medical Review. Fourth Edition, Revised and Enlarged, 10s. 6d. Insanity and its Treatment: Lectures on the Treatment, Medical and Legal, of Insane Patients: containing the New Law of Lunacy. By G. Fielding Blandford, M.D, Oxon., F.R.C.P., late Lecturer on Psychological Medicine at the School of St George's Hospital. Seventh Edition, largely rewritten, price 6s., Illustrated. Manual of the Operations of Surgery, FOR THE Use of Senior Students, House Surgeons, and Junior Practitioners. By Joseph Bell, M.D., F.R.C.S. Ed., Consulting Surgeon to the Royal Infirmary, and Surgeon to the Royal Edinburgh Hospital for Sick Children. Many new operative procedures have been added, and the Chapter on Eye Operations has been revised and to a great extent rewritten by Mr W. G. Sym, F.R.C.S. Ed., Assistant Ophthalmic Surgeon to the Royal Infirmary of Edinburgh. " The most noticeable feature of the book is the singularly clear way in which everything is explained." —Hospital Gazette. "We do not know of any work which has more successfully fulfilled the objects for which it was written than the volume before us."—Edinburgh Medical Journal. Fourth Edition, Revised, Small Crown 8vo, price 2s. 6d. Bell's Notes on Surgery for Nurses. "This is a charming little book.^ It contains just the kind of information that a surgical nurse would require, and is written in such a simple and interesting style that it cannot fail to draw attention to the salient features which the writer wishes to describe."—British Medical Journal.3 8vo, Price 10s. 6d., with 12 Plates, Vol. I. Diseases and Deformities of the Foetus: AN Attempt towards a System of Ante-natal Pathology. By J. W. Ballantyne, M.D., F.R.S.E., F.R.C.P.E., Lecturer on Diseases of Infancy and Childhood, Minto House, and on Midwifery and Diseases of Women, Medical College for Women, Edinburgh. " We should expect this book to take its place as a standard work of reference on the subject of which it treats."—Lancet. "We may congratulate Dr Ballantyne as the author of a work which may profoundly influence the hitherto not very satisfactory science of teratology, reducing it to its proper place as a depart* ment of pathology."—British Medical Journal. " This is a most timely publication. .... The author has avoided all strictly theoretical deductions, stating and grouping his facts most carefully, and drawing conclusions solely from data established or confirmed by himself."—The Practitioner. "We cordially recommend Dr Ballantyne's work as one which will prove of real value as well as interest to future workers in various branches of pathology and medicine, and one which is a credit not only to the author, but also to the Medical School to which he belongs."—Edinburgh Medical Journal. "We doubt if there is anyone in the English-speaking world better fitted than Dr Ballantyne to write on the subject of this work."—Archives of Pediatrics, New York. " The increasing interest in the subject of embryology makes this volume timely, and in no single work is it possible for any one studying this subject to obtain the information presented by Dr Ballantyne."—New York Medical Journal. The SECOND VOLUME of the above, dealing with Congenital Diseases of the Subcutaneous Tissue and Skin, is now ready, price 10s. 6d. BY THE SAME AUTHOR. Demy 8vo, price 10s. 6d., with Coloured and other Illustrations. AN Introduction to the Diseases of Infancy: The Anatomy, Physiology, and Hygiene of the New-born Infant. "A work of very high order of merit."—Practitioner. "The author is dealing with a subject in which he is thoroughly versed, and has brought together and reduced to order a mass of information which we should be at a loss to find elsewhere. .... The book may be heartily commended to all serious workers."—British Medical Journal. Price 2s. 6d. The Structures in the Mesosalpinx: Their Normal and Pathological Anatomy. By J. W. Ballantyne, M.D., F.R.C.P.E., F.R.S.E., etc., etc., and J. D. Williams, M.D., B.Sc., Freeland-Barbour Fellow (Univ. Edin., 1888-90). "Drs Ballantyne and Williams are to be congratulated on having produced this little book, which is a mine of information on the subjects of which it treats."—Lancet. "In glancing over a work like this, what strikes us is the patient and careful method of examining each specimen; that nothing is guessed at or copied from other works to fill in and form padding; and that only things dissected out, or made evident microscopically, are described. Hence the great intrinsic value of such work."—Birmingham, Medical Review.4 8vo, price 8s. 6d., cloth, gilt top, with Illustrations. Transactions of the Medico-Chirurgical Society of Edinburgh. Session 1893-94. %* Previous Volumes can be had. 8vo, price 8s. 6d., cloth, gilt top, with Illustrations. Transactions of the Edinburgh Obstetrical Society. Session 1893-94. Previous Volumes can be had. % 8vo, price 5s. 6d. Electricity in the Treatment of Uterine Tumours. By Thomas Keith, M.D., LL.D. Ed., and Skene Keith, F.R.C.S. Ed. 8vo, price 10s. 6d., with 36 Photogravure Plates and 12 Chromo-Lithographs. Sputum: its Microscopy and Diagnostic and Prognostic Significations. By Francis Troup, M.D., M.R.C.P.E., L.R.C.S.E., Assistant Medical Officer to the Longmore Hospital for Incurables, Edinburgh. Royal 8vo, price 5s. Subjective Symptoms in Eye Diseases: being Chapters on the. Disorders of Vision Symptomatic of Diseases in the Eye and Central Nervous System. By George A. Berry, M.B., F.R.C.S. Ed., Ophthalmic Surgeon, Royal Infirmary, Edinburgh; Surgeon, Eye Dispensary of Edinburgh; Lecturer on Ophthal- mology, Royal College of Surgeons, Edinburgh. Edinburgh : Oliver and Boyd. London: Simpkin, Marshall, Hamilton, Kent, and Co., Limited.This book is a preservation facsimile produced for the University of Illinois, Urbana-Champaign. It is made in compliance with copyright law and produced on acid-free archival 60# book weight paper which meets the requirements of ANSI/NISO Z39.48-1992 (permanence of paper). Preservation facsimile printing and binding by Northern Micrographics Brookhaven Bindery La Crosse, Wisconsin 2014