for the tongue and mouth and upper extremities, showing an anatomical
association of the processes of articulate and written speech.
But purely motor impulses comprise only a portion of the phenomena of
speech. The external world must be brought into relation with the
mind, and this is done through the perceptions. We may say that
perceptions are apprehended sensations, and this apprehension demands
a localized field of cerebral activity, as well as the motor energies.
It seems natural enough that experiment should have located (Ferrier)
perceptive, visual, and acoustic centres in the posterior cortical
areas and temporo-sphenoidal lobes—that the motor and perceptive areas
should be contiguous and sharing a common blood-supply.
The perceptive visual centre is found to occupy the occipital lobes,
while the acoustic centre occupies the whole length of the first
temporo-sphenoidal convolution.
As motor impulses found a path to the motor ganglia, and finally to
the cord, so the course of sensory perceptive impressions can be
traced back through the posterior internal capsule and through the
optic thalami to the sensory columns of the medulla and cord.
Intuitive and sense perception, even when reinforced with motor power,
cannot result in articulation. The mechanism of speech requires a
co-ordinating centre, and this basal phonic centre of Kussmaul is
located in the medulla near the origin of the hypoglossal and facial
nerves. From the medulla proceed the nerves supplying the machinery of
{568} phonation, the superior laryngeal nerve to the mucous membrane
of the larynx and to the crico-thyroid muscle, the most important
muscle of phonation. The remaining laryngeal muscles are supplied by
the recurrent laryngeal; the motor processes of articulation are
guided by the hypoglossal, facial, and fibres of the
glosso-pharyngeal.
The larynx is a reed, with the addition of numerous resonance-cavities
producing abundant overtones. It may be considered as a box composed
of two segments, the lower of which has vertical motion upon the joint
at the posterior junction of the superior and inferior segments. By
this motion the tongue of the reed (vocal cords, stretching
antero-posteriorly from lower segment to junction with upper segment)
is tightened or relaxed, the vibratory blast of air coming through the
trachea from the lungs. The superior aperture of the tube is guarded
by the epiglottis and false vocal cords. As auxiliaries are the
pharyngeal, oral, and nasal cavities, with the associated bony
cavities of the skull, the soft palate acting as a movable partition
or switch, the hard palate as a sounding-board or resonance-surface.
The reed is applicable to the production of musical sounds; the
tongue, lips, and teeth are required for the checks in those sounds,
constituting the consonants or division utterances.
The curious phenomenon of the falsetto voice is thought by Helmholtz
to be produced by the attenuation of the true cords and the vibration
of their thinned edges.
DEVELOPMENT OF LANGUAGE.—The study of language demonstrates its origin
to have been largely in exclamations and imitative sounds, from which
our vowels can easily have arisen. The growth of all synthetic
language illustrates the aggregation of accessory sounds about the
primitive root-sound, while the common tendency to the insertion of
consonants shows their addition to the primitive vowels. That the long
vowels should have undergone countless modifications from the physical
peculiarities and environment of those speaking them is but natural,
for the number of vowels remaining in actual use in any language is
not large. Consonants serve to make more clear by their separation of
vowel-sounds the meaning to be conveyed; their development resulted
from vowel changes, and their number is small.
The written characters of language represent only the usage of the
majority. Individual speech and pronunciation vary as greatly as do
languages themselves, and it is evident that the speech of any
individual is as truly peculiar as his physical conformation.
To recapitulate, we find ideas, the material of speech, formed in the
cerebral cortex. Speech-volition becomes motor impulse at Broca's
convolution; such impulse passes along the internal capsule to the
corpus striatum, where it is co-ordinated probably in the formation of
syllables, thence to the medulla, whence the mechanism of the larynx
receives its co-ordinated stimulation.
Disorders of Speech.
The classification of the disorders of speech should depend on the
anatomical site of the lesions by which they are occasioned. Broadly
{569} speaking, speech disorders resolve themselves into those of the
formative apparatus for ideas and symbols and those of the purely
co-ordinating and conducting mechanism. Abbreviating the schedule of
Potter, we may say that the disorders of speech may be included in
three classes—alalia, or lack of speech; paralalia, defective speech,
the stammering of most observers; and dyslalia, difficult speech or
stuttering.
The anatomy of the blood-supply of the speech-centres affords some
explanation of alalia. The Sylvian artery will be remembered as the
feeder of the speech-centres—an artery often the source of hemorrhage,
as Charcot suggests, from the angle at which it leaves the carotid.
Ducrot explains the frequency of left-sided softening and hemorrhage
from the manner of origin of the left carotid, its axis being more
nearly that of the ascending aorta and furnishing a ready channel for
cardiac clots. In regard to the relative frequency of peripheral and
central hemorrhage, Andral and Durand-Fardel cite 119 cases, of which
but 17 were in the anterior or posterior lobes. It is admitted that
cerebral lesions are largely those of the circulatory system, and the
fact that such lesions result in the suspension of the activity of
restricted areas is due to the circumstance that the cerebral arteries
are terminal vessels giving off no anastomosing branches and supplying
restricted areas only. With blood-supply so arranged it is not
difficult to understand how the different portions of the motor
centres may be separately involved, and thus the motor functions of
speech may become singly at fault.
Inability to remember words and inability to form the motor impulses
necessary for speech or writing are the common forms of alalia or
aphasia, the former being known as amnesic, the latter as ataxic,
alalia. In addition, we may cite the failure of cerebral power
occurring in general softening, in microcephalic brains, and the
curious instances of voluntary silence from some strong belief or
prejudice. Instances of the gradual resumption of cerebral function
after its loss are not wanting; and, occurring where subsequent
post-mortem examinations reveal a limited area of destruction of
brain-tissue, they afford examples of the vicarious performance of
cerebral functions by contiguous areas.
The phenomena of amnesic alalia are commonly seen in cases of recovery
from cerebral hemorrhage, cerebral injury, and severe febrile
affections. Numerous cases are recorded where the memory of things
themselves remained, but the faculty of denoting them had been
destroyed.
Kussmaul distinguishes here two conditions: 1st, where the word is
entirely effaced from memory, 2d, where it still remains, but its
association with that which it represents is suppressed. Cases of the
second class are the most frequent, the fundamental part which the
association of ideas plays in mental activity and the extent to which
memory is dependent on association explaining this fact. A marked
example of the failure of the denotative faculty lies in the cases of
forgetfulness of one's own name, as described by Crichton in the case
of an ambassador at the Russian court, who was obliged to say to his
companion, when visitors asked his name, “For Heaven's sake, tell me
what I call myself!” Piorry mentions the case of an aged priest who
after right-sided paralysis lost entirely the use of substantives;
wishing to ask for his hat, the word _hat_ failed him utterly, and he
was obliged to express himself in the remaining parts of speech: “Give
me that which I place upon the {570} ——;” but the word _head_,
denoting the object most commonly in relation with the _hat_, was
wanting also. When either hat or head was mentioned he spoke the word
without difficulty.
Instances of failure in linguistic faculty are not uncommon. Witness a
case, reported by Proust, of an Italian who after long residence in
France, though understanding his native tongue, could speak only in
French. Cases in which after acute disease one language is gone
entirely while several others are retained are not wanting. A striking
case of amnesic alalia was that of Lordat, a French physician, who
thus described his malady: “I find myself deprived of the value of all
words. If any words remain to me, they become useless, because I can
no longer remember the manner in which I must co-ordinate them to
express my thoughts. I am conscious that I recognize all ideas, but my
memory does not suggest a word. In losing the memory of the meaning of
spoken words I have lost that of their visible signs.”
Fortunately, these cases are among the more tractable of cerebral
disorders. Bristowe has reported a case wherein elementary instruction
in speech-formation was tried with marked success. The patient, aged
thirty-six, after a violent cerebral disturbance without traumatism
became paraplegic, speechless, and deaf. Gradual recovery ensued
until, seven months after his first illness, he was admitted into St.
Thomas's Hospital in the following condition: Numbness and paresis in
left leg, less in left arm; special senses healthy; no incontinence;
some pain about head and neck; complete loss of speech. It was found
that the patient was very intelligent, wrote legibly, could make all
kinds of voluntary movements with lips, tongue, and teeth, and was
capable of vocal intonation; articulation alone was lacking.
The law of the evolution of language designates as primitive forms of
word-signs those words affirming qualities, while those denoting
relative positions are of secondary formation (Whitney.) Remembering,
also, the fact that amnesia in general “is a regression from the new
to the old, from the complex to the simple, from the voluntary to the
automatic, from the least organized to the best organized,”[1] we are
able to understand the cause of amnesic alalia, and also the steps of
the process of recovery, in which the inverse order is observed.
[Footnote 1: Ribot, _Diseases of Memory_.]
Amnesic alalia can hardly be regarded as susceptible of treatment
other than as a general neurasthenia. Though we may develop memory by
cultivating the association of ideas and by repetition, yet, regarding
it as a general function of the nervous system, it is evident that
recovery from its disorders is conditioned by the general vigor of the
nervous centres. A partial recovery usually occurs in such cases;
complete recovery is more infrequent.
Ataxic alalia, the failure of the motor powers of speech, occurs in
all forms of general paralysis, most typically in bulbar paralysis.
This disease is fully described in the standard works on neurology.
Ataxic alalia will also occur in disseminated sclerosis, posterior
spinal sclerosis, dementia paralytica, and cretinism. It forms in
general disorders an instructive symptom, and is to be distinguished
by a tremulous utterance and by facial spasm from the hesitation of
the stammerer and from the convulsive utterance of the stutterer.
{571} Paralalia embraces all abnormalities of speech, from trivial
mannerisms to difficulties in the utterance of certain letters,
including those painful defects which depend upon physical
malformations.
The free discussion of paralalia would cover the domain of elocution;
the physician is called upon to advise in those cases only where
either a physical malformation is evident or the difficulty
experienced by the patient in enunciating certain letters has led to a
suspicion of the existence of malformation. The former cases lie in
the province of the surgeon; the latter come within the scope of those
elocutionists, speech-trainers, and instructors who hope to cure
stammering and stuttering.
Discrimination between stammering and stuttering will give the
physician a basis for judgment from which he can reasonably offer
encouragement in many cases and avoid the creation of false hopes in
others. As a cardinal point of difference, it will be remarked that in
the case of the stutterer the muscles of phonation are thrown into a
state of spasm when speech is attempted, while in the stammerer their
movements are merely lacking in proper co-ordination. It may also be
observed that the respiration of the stammerer is marked by irregular
contractions of the diaphragm, which render the expiratory blast of
air irregular in its delivery. In the stutterer the spasm is
pronouncedly laryngeal and facial. The nervous embarrassment of the
stutterer is proverbial, and is increased by excitement, while a
moderate degree of excitement, stimulating respiration, greatly
improves the speech of the stammerer.
Whispering, a difficult respiratory act, exaggerates the stammerer's
fault, but the spasm of the stutterer is often relaxed by the
diminished pressure of whispered breath.
As articulation is effected by the larynx and the oral organs, the
stutterer makes his spasmodic articulation particularly noticeable,
while the stammerer finds little difficulty in the utterance of words.
_R_, _L_, _S_, and other letters whose enunciation demands the
continued expiratory blast, are imperfectly uttered by the stammerer,
while these letters when joined to a long vowel-sound occasion little
or no difficulty for the stutterer.
TREATMENT.—It follows that if stammering is recognized as
inco-ordinate enunciation, owing largely to irregular action of the
diaphragm, any training of the respiratory muscles which will ensure a
regular delivery of the expiratory air will improve this defect. It
follows, then, that the treatment of stammering resolves itself into
careful attention to general hygiene, associated with such persistent
respiratory and vocal gymnastics as shall effectually develop
regularity, depth, and co-ordination of action on the part of all the
muscles concerned in the act of respiration. Drugs will be of service
only as aids to the correction of errors in the essential
physiological functions. In the child the powers of imitation may be
enlisted to effect a cure, and the familiar fact that the habits of
childhood are easily formed would indicate this as the best time for
treatment.
Childhood once passed, however, the steadiness of purpose of the adult
is requisite to break up a confirmed habit, and active treatment
should be deferred until after adolescence. Most important in all
cases are judicious moral influences exerted by those about the
patient, the ridicule so often visited upon the unfortunate stammerer
being most harmful in its consequences. The many tricks and devices so
often employed in these {572} cases are of use simply by varying the
monotony of vocal drill; they may be employed or abandoned as the
judgment of the physician may dictate.
Regarding the prognosis in these cases, it follows that with a fairly
developed and healthful nervous system, reinforced by proper mental
and physical hygiene, the stammerer's case is far from hopeless in the
hands of a patient and intelligent physician.
An unfavorable prognosis would be demanded by hereditary defects and
vices of the nervous system, by the lack of general nervous vitality,
by enfeeblement of the will and the mental tone of the individual, by
advanced age, and by irremediable hygienic conditions. Under favorable
conditions recovery should be the rule.
DYSLALIA OR STUTTERING.—Recalling to mind the points of difference
between stuttering and stammering, it becomes evident that while the
prospect of success in the treatment of the stammerer is often
favorable, the case of the stutterer presents such difficulties as
render it too frequently hopeless.
We may liken the confirmed stutterer to those rare cases of chorea
which defy treatment, and to those cases of hereditary deterioration
of the nervous system where the most patient and painstaking care
fails to overcome the defect. The laryngeal and facial spasms depend
upon no malformation for their exciting cause; hence surgery fails to
remedy the defect. Drugs which are given with hope of invigorating the
nervous system have only a general tonic influence, while the motor
depressants and antispasmodics find but partial success. We must again
rely upon hygiene, and also upon those aids to enunciation which come
from rhythmical associated movements, such as stamping with the foot,
beating time with the hand, the employment of a sing-song tone, or
other modes of specially rhythmic enunciation. The sing-song mode of
utterance is a familiar resource with parents in attempting to aid a
stuttering child, and the measured forms of articulation offer the
only vocal drill that possesses any permanent value. It is especially
essential in the stutterer's case that the patient be protected from
ridicule and from all disturbing emotions: the burden of difficult
speech is sufficient to greatly depress the nervous system without the
added suffering of emotional distress. It is evident that childhood,
characterized as it is by especial instability of the nervous system,
is the period when we can hope for the best results from care and
training; the long-formed habits of the adult are rarely broken.
We have thus traced the disorders of speech to their origin as
symptoms of grave central lesions of the nervous system, as results of
heredity or of a general neurasthenic condition; very rarely are they
dependent upon malformations of the organs of speech.
The treatment of such malformations, when they occur, is largely
unsatisfactory and is seldom curative.
The thorough treatment of those speech disorders that are not
susceptible of surgical aid would embrace such mental and physical
hygiene and training as should ensure the formation of a thoroughly
conceived vocabulary and its co-ordinated expression by words either
spoken or written. The study of expression in its highest forms would
necessarily conduct the investigator far into the realm of the
plastic, harmonic, and literary arts.
{573}
ALCOHOLISM.
BY JAMES C. WILSON, M.D.
DEFINITION.—Alcoholism is the term used to designate collectively the
morbid phenomena caused by the abuse of alcohol.
SYNONYMS.—Alcoholismus, Ebrietas, Ebriositas, Temulentia, Drunkenness,
Delirium potatorium, Mania potatorium, Delirium tremens, Chronic
alcoholic intoxication, Dipsomania; _Ger._ Trunkenheit, Trunksucht;
_Fr._ Ivresse, Ivrognerie.
These terms are in common use to describe such conditions and
outbreaks in alcoholic individuals as amount to veritable morbid
states or attacks of sickness, but they are not interchangeable, nor
are they all sufficiently comprehensive to constitute true synonyms.
They are names applied to various conditions due to acute or chronic
alcohol-poisoning properly and distinctively comprehended under the
general term alcoholism.
CLASSIFICATION.—It was formerly the custom to restrict this term to
affections of the general nervous system induced by continued excesses
in the use of alcoholic drinks.[1] But the nervous system bears the
brunt of the attack and suffers beyond all others alike in transient
and in continued excesses. The artificial restriction of the term to
the cases caused by continued excesses was therefore illogical in
itself, and has been productive of much needless difficulty in the
treatment of the subject and in the classification of the cases. The
use of the term chronic alcoholism to denote an established condition,
and of acute alcoholism to describe outbreaks of various kinds which
occur in individuals subject to that condition, has also proved a
source of embarrassment to the student. Not less vague has been the
employment of such terms as delirium tremens, mania-a-potu, and the
like, which are unsatisfactory in themselves, and tend to exalt
symptoms at the expense of the morbid condition of which they are only
in part the manifestation. I am of the opinion—which is at variance
with established usage—that the systematic discussion of alcoholism
requires that all forms of sickness, including drunkenness, due to
that poison must receive due consideration, and that the term acute
alcoholism, hitherto used in a sense at once too comprehensive and too
variable, should be reserved for those cases in which the sudden
energetic action of the poison is the occasion of like sudden and
intense manifestations of its effects. Furthermore, the uncertainty
and lack of precision in the use of the terms acute and chronic
alcoholism are due to errors of theory formerly almost universal in
medical {574} writings and popular belief concerning the disease. The
chief source of these errors was the recognition only of the more
acute nervous affections caused by alcoholic excess—delirium tremens,
maniacal excitement, and terrifying hallucinations—and the belief that
these conditions occurred only after a temporary abstinence in the
course of habitual or prolonged indulgence. It has now long been known
that abstinence from drink by no means necessarily precedes the
outbreak of mania or delirium, and modern researches have established
the existence of a chronic alcoholic intoxication of long duration
extending over a period of months or years, in which such outbreaks
merely exhibit the full development of symptoms that have already been
occasionally and partially recognizable.
[Footnote 1: Anstie, _Reynolds's System of Medicine_, vol. ii., 1868.]
The following arrangement of the topics will facilitate the discussion
of the subject in the present article, and serve, I trust, a useful
purpose for the classification of cases in accordance with existing
knowledge:[2]
I. Acute Alcoholism: Drunkenness, Debauch.
A. Ordinary or Typical Form.
B. Irregular Forms.
1. Maniacal;
2. Convulsive;
3. In persons of unsound mind.
C. Acute Poisoning by Alcohol: Lethal doses.
II. Chronic Alcoholism.
A. Visceral Derangements.
1. Local disorders:
_a_. Of the digestive system;
_b_. Of the liver;
_c_. Of the respiratory system;
_d_. Of the circulatory system;
_e_. Genito-urinary system.
2. Disorders of special structures:
_a_. Of the locomotor apparatus;
_b_. Of the skin.
3. General disorders:
_a_. The blood;
_b_. Obesity;
_c_. Cachexia.
B. Derangements of the Nervous System: Cerebro-spinal Disorders.
1. Cerebral disorders.
2. Spinal disorders.
3. Disorders of the peripheral nerves.
4. Disorders of the special senses.
C. Psychical Derangements.
1. The moral sense.
2. The will.
3. The intellect.
4. Alcoholic delirium in general.
5. Delirium tremens.
6. Alcoholic insanity:
_a_. Melancholia;
_b_. Mania;
_c_. Chronic delirium;
_d_. Dementia;
_e_. Paretic dementia.
III. Hereditary Alcoholism.
IV. Dipsomania.
[Footnote 2: This classification is in part based upon that of Lentz,
_De l'Alcoholism et de ses Diverses manifestations, etc._, Bruxelles,
1884—a prize essay.]