training is very important as preceding the training of the body for expression. Mrs. Georgen has said that in physical training the teacher should be allowed to use his own judgment as to how far emotion should be introduced. Now, perhaps I did not make that point clear, but it seems to me that that really was one of the points I wanted to obtain from the convention if possible. How far may the physical culture teacher carry these emotional expressions, and still call it "physical culture?" There is my point. Of course, the one works into the other as the scales do to the finished concerto.

We have our higher expressions in the body certainly. Are they so closely connected with the physical training as the concerto or the sonata to the scales? There is a difference. In the technique of piano playing the whole thing is music from beginning to end. Now, is it right for a physical trainer to carry on the physical culture without notes, so to speak? How can a pupil conceive a higher emotional condition and express it, with out some high ideal transcending the mere direction of the teacher? Now, suppose you have the body in good training to a certain point. Is it right to carry the physical training on through higher grades of emotion without the aid of literature or the imagination? That is my point.

MRS. GEORGEN: May I be entitled to answer the question? I should say that physical culture in the sense of mechanical exercises ceases to be physical culture, when it becomes pantomime. By pantomime, I mean the outward physical expression of the inward emotions, through the body, arms, and facial expression; and I see no objection whatever to studying pantomime as pantomime without the spoken words; in fact, I look upon such study as the only way to obtain true expression of the thought or emotion in speech. In reply to one point the lady made in her paper as to "whether it was not unhealthy to study unhealthful emotions," I should say that as all simulated emotions are produced physically with the aid of the mentality, rather than emotionally, the study of emotion, by bringing the body into the physical condition it would naturally assume under the real emotion, could in nowise affect the health, detrimentally, but would rather tend toward acquiring more perfect health. In verification of this statement, observe our actors, who are the healthiest and the youngest looking class of people that we have, and who live as long as the generality of humanity. Sarah Bernhardt, an emotional artist, is one living exemplification of the fact.

VIRGIL A. PINKLEY: I find the older I grow and the more experience I have, the less inclined I am to teach physical culture separately, and the more inclined I am to teach it in connection with expression from the very first. I find that the right expression of thought calls for all the powers of the body. It seems to me that the two are intimately related.

MISS WARD: Yesterday a friend of mine, who has studied children a great deal, said that the moment a child became self-conscious she lost the grace she before possessed. Now, to a certain extent, is not that putting thought into physical culture before thought has really grown? But we were speaking of children being so graceful. She said: You will observe that a little child is absolutely graceful, until somebody says to the child: "Oh, what a pretty little child!" Instantly she loses that grace. There was once a child who had the smile of an angel, until several persons said before her: "Oh, what a lovely smile!" and she then lost the smile. I wonder if this is not apropos of this subject.

MRS. ROSE ANDERSON: I should like to ask the reader of the last paper what she means by "going beyond the limit of physical training," and I should like to have her explain if going beyond that limit becomes "artificial?" Where does she draw the line of demarcation?

This question could not be answered for lack of time.

THURSDAY, JULY 1, 1897, 9 TO 10 O'CLOCK.

SUBJECT: "Defective Speech: Its Diagnosis and Treatment."

MISS MARY MILLER JONES, Chairman.

THE CHAIRMAN: For a number of years Dr. Makuen has been very much interested in defective speech, its cause and cure. The medical profession in Philadelphia, realizing how much he has done in this direction, instituted for him a chair in our Polyclinic Hospital, the only one of the kind in the world. It gives me great pleasure to introduce Dr. Makuen.

PAPER BY DR. G. HUDSON MAKUEN.

The subject that we have chosen for discussion this morning is one of great interest to us all. Both the elocutionist and the physician are at work upon it, but they are working at the very opposite ends of the line and leaving a large middle territory almost entirely unoccupied. The elocutionist, for the most part, deals with that speech which is already fairly intelligible, while the physician studies those conditions of the physical organism which result either in no speech at all or in speech which is very defective.

For some years I have been trying to bring the two professions nearer together, in order that we may assist each other not only in the good work we are now doing, but also in a still better and more extended work, which hitherto has been undeveloped. I refer to that which deals with the more serious and complicated defects of speech, such as I shall presently describe.

Introductory to the study of defects of speech it may be well to discuss briefly the normal speech. What is speech? Speech has been defined as “articulated voice." Voice, then, is the material out of which speech is made, the cloth from which the garment is cut, the molten lead out of which the bullet is molded. Normal speech, therefore, is the result of the harmonious action of two distinct mechanisms, viz., the vocalizing mechanism and the articulating mechanism. The former produces the voice and the latter articulates it, and the two together constitute what may be called the machinery of speech—and, by the way, a more complicated and more delicate bit of machinery does not exist in the whole human organism. We know the parts and we know how they are put together, but we do not know their exact workings or functions. We have been studying and experimenting both subjectively and objectively, and we have made great advancement in the last few years, but much of our apparent knowledge is only theoretical and remains to be proven. We are still harping on registers and disputing as to the best methods for changing the pitch of voice; both vital questions and yet comparatively elementary ones, because they refer to the purely mechanical element in voice and speech. A more important and still more complicated element remains to be considered. I refer to that which exists in the cortex of the brain; that which sets the machinery in motion and controls and coordinates its parts. This may be likened to an electric dynamo with a controller attached, and it constitutes a third mechanism employed in the production of speech. The study of this mechanism is a most interesting one, and to give anything like a satisfactory explanation of its complex anatomy and physiology would require much more time than I have at my disposal. Therefore, I shall describe its action only in a very general way.

Almost all our knowledge of this cerebral speech-mechanism has been acquired since Broca, thirty-six years ago, discovered in the third convolution of the left hemisphere of the brain what he supposed to be the only distinct centre for speech. This has been known ever since as Broca's centre, but later investigations have revealed the fact that there are three other more or less well-defined cerebral centres connected with the speech-mechanism, and Broca's is only the motor centre for speech. There is, connected with this centre, one for the reception of auditory impressions and another for the reception of visual impressions; and connected also with these two is a motor centre for guiding the hand in writing. We have, then, four centres, two sensory and two motor. A lesion of any one of these centres, or any one of the tracts leading to or from them or connecting them, will produce a corresponding defect of speech. [Illustrated with diagram.]

Defective speech, therefore, is usually a symptom and not a disease, and it is a most important guide to the diagnosis of many serious lesions of the brain and nervous system. For instance, a man has a severe illness with some obscure brain symptoms and he gradually loses the power of speech. He can hear and understand spoken language, he can write from dictation and he can understand written or printed language and can copy it. Therefore, we must conclude, first, that the auditory centre is intact, else he could not hear words; second, the visual centre is intact, else he could not see written or printed words; third, that the graphic motor centre is intact, else he could not write words; and fourth, that there is some lesion either in the motor speech-centre itself or in one of the tracts connecting this centre with the other centres, or with the two peripheral mechanisms of speech, viz., the vocal and oral mechanism.

Let me cite an actual case reported from Vienna, illustrating a lesion in the auditory speech-centre: A woman, aged twenty-three, was asked, "How do you do?" and she said, "My country is a beautiful one." She was asked to put out her tongue, and she said, "My brother John." She could read and write, but she could not understand the simplest spoken words unless they were accompanied by appropriate gestures to indicate their meaning. She was what we call word-deaf and had a lesion of the auditory speech-centre.

The following case illustrates a lesion of the visual centre: A man asks you your name and you say, "My name is John;" and he writes it down. You then talk together for a while and he forgets your name. He looks at it written and then asks for it again, and you say, “Why, there you have it written;" but he can not read even his own writing. He can understand spoken words, he can write them and speak them, but he can not read written language. He is therefore word-blind and has a lesion in or near the visual speech-centre!

Now, I repeat, there are four more or less well-defined special speechcentres located in the left hemisphere of the brain. These are the sen sory centre for the reception and the storing up of auditory impressions; the sensory centre for the reception and the storing up of visual impressions; the motor centre for guiding and controlling the hand in writing; and the motor centre of Broca, for running what I have called “the machinery of speech." Of course, these specially localized centres are not the only parts of the brain employed in the production of speech. They are simply the chief areas so employed and they must work in harmony with all the other parts of the brain if we would have good, intelligent speech.

From what I have said you will readily understand that this is a very intricate study. There is practically no end to it, and you will understand also its important bearing upon the subject under discussion, viz., the diagnosis and the treatment of defective speech.

There are two general classes of speech-defects: The congenital and the acquired; or those that have always existed and those of more recent origin. My first question, therefore, to every case is "How long has the

trouble existed?" The answer to this question will often suggest a possible cause. If, for instance, the answer be "Always," then we may conclude that the defect either is congenital or was acquired during the first year and a half or two years of the patient's existence, and we immediately think of heredity as a possible causal factor and we inquire into the family history. "Have any relatives been similarly afflicted? Is there any consumption, insanity or idiocy in the family? Were the parents related previous to marriage?" Then we look into the patient's own history, before, during, and after birth. "Has he ever been injured? Has he ever associated with or tried to imitate persons similarly afflicted? Did he ever receive a fright? Was he ever ill-used, scolded or ridiculed? Has he had the acute, infectious diseases? Are his hearing and sight good? Is he a bright or a dull boy? Can he write?" These are some of the questions that may assist in the diagnosis of all cases of defective speech, and many additional ones should be asked in special cases.

It is convenient, for our purpose, to make still another classification of these defects, to put in one class all those of cortical or cerebral origin, and in another all those dependent upon some lesions or structural irregularities in the peripheral or external machinery of speech. The whole speechapparatus, including the three mechanisms that I have described, may be likened unto the modern electric carriage. The peripheral mechanisms, viz., the vocal and the oral mechanisms, correspond to the carriage itself, complete in all its parts and ready for motion. The cortical mechanism is well represented by the electric dynamo and the man on the box who runs it. The dynamo stands for the special speech-centres that I have described, and the man for the intelligence furnished by the various other related regions of the brain.

Now we will suppose the carriage to be gliding smoothly along, in and out among other carriages, on a beautiful asphalt pavement. Suddenly, in crossing a street at right angles, it is struck by a trolley-car and the man is thrown from the box and receives an injury to the head. He takes his place again, however, and finds that the carriage no longer runs smoothly. It may not start promptly, or it goes a little while and then stops. If it were a human being and he talked that way, we would say he stammers. Well, the man sees that something is wrong and he takes the carriage to the factory, and it is found that one of the wire coils in the dynamo has been twisted. This is easily repaired and he starts out again. The carriage is in perfect running order, but there is danger ahead; for it is liable to collide with whatever comes in its way because the man in the box has not recovered from his fall and he does not know how to run the dynamo. In other words, his general intelligence is impaired.

I have dwelt upon this description at length, because it illustrates very well a case that consulted me some months ago. The patient was an unmarried woman, thirty years of age, and she stammered very badly. Her family history was good; no consumption, insanity, or idiocy, but she had several near relatives that stammered. Her speech developed normally until she was five years of age, when she had a severe attack of scarlet fever, and she dates her trouble from that time. She spent three months in some vocal institute in this city, but failed to get permanent relief. Then followed, as a natural consequence of her speech-defect, a long line of nervous affections, which finally so weighed upon her mind as temporarily to dethrone her reason and make it necessary to put her in an asylum. She recovered from her attack of acute mania, and afterward underwent one or two serious operations for the relief of various nervous conditions. She had given up all hope of being cured of her defect of speech, when she was referred to me. I found that she breathed very badly and had no voluntary control over the diaphragm and the various other related muscles in the region of the waist. A very short time sufficed to show her the importance of voluntary respiratory action in the

process of speech-production, and after her fourth visit she ceased to stammer, nor has she stammered during the intervening three months, although she has been put to the severest tests. Moreover, she now declares herself to be in perfect health and she is happy for the first time in her life. Now what were the conditions in this woman's physical and mental organism, which caused and continued this horrible stammering, and what was it that wrought the almost miraculous transformation which I have described? Structurally, the peripheral mechanisms were intact and we could find nothing wrong with them except their faulty habits of action. The trouble, therefore, existed in the cortical speech-centres and the tracts uniting them with the peripheral mechanisms.

To go back to our illustration, the carriage itself was all right, but there was a twist or a kink in one of the wires of the dynamo. These wires were weak originally, you will remember, and had a natural inherited tendency toward this same kink, so that even an attack of scarlet fever such as most of us have experienced without great injury was sufficient to bring about this untoward result. The kink in this case had existed for more than twenty years, and it was apparently removed in two weeks by a course of physiological training carried on through the medium of the peripheral speech-mechanisms. Her speech to-day is far better than that of the average woman, but she has not regained entirely her mental equilibrium. The man on the box has not recovered from the fall, and when she begins to talk, you feel like getting out of the way.

I will now describe two cases illustrating difficulties of diagnosis and successful methods of treatment in cases of defective speech.

1. A young man, M. B., aged nineteen, presented himself at my office in September, 1893. He sprang from an old Philadelphia Quaker family, and he was accompanied by an aunt who acted as his interpreter, for he could not utter a single intelligible word or syllable. His family history was far from good, and he inherited a bad physique, which he made still worse by careless habits and a lack of healthful exercise. The fact is he had grown disheartened to such an extent as actually to unfit him for any kind of work, physical or mental. He could not read either aloud or silently; he could not spell or write words from dictation, and he could not speak words except in a very mutilated manner. I asked him about his parents, and he said they were "gay," meaning that they were dead. His physicians had assured him and his family that he was suffering from some congenital organic defect of the brain and that he need never hope to be better. This was a most natural inference, for his manner, his speech, and his whole general appearance were strongly in favor of the diagnosis of imbecility. I observed, however, that he had considerable confidence in himself and the air of one who thinks (but he could not say it) that he is not as green as he looks. Taking advantage of this fact, I endeavored to teach him to speak. I called in an assistant, and for five or six weeks we worked with him diligently, but with very little success. I had noticed in the beginning that his tongue seemed too short and an operation was suggested to remedy this condition, but his people absolutely refused to allow him to take an anæsthetic. Having failed to benefit him without an operation, I explained to him the condition of affairs and he consented to allow me to do the operation with local anesthesia. There was considerable pain, which he endured bravely, and I succeeded in making the tongue a full inch or an inch and a half longer, and from that time his improvement was most satisfactory. In ten months after the operation I took him before the Philadelphia County Medical Society and he recited Brutus's speech against Cæsar, not only with almost perfect articulatory precision, but with very considerable dramatic effect. The following autumn he went to a well-known preparatory school, where he has given an excellent account of himself, and he expects to enter Harvard in September of next year.

2.

Another case, somewhat similar to the last, though differing in some