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Full text of "Behnke's stammering, cleft-palate speech, lisping"

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BEHNKE'S 

STAMMERING, 

CLEFT-PALATE SPEECH, 

LISPING 



BEHNKE'S 

STAMMERING, 

CLEFT-PALATE SPEECH, 

LISPING 



SECOND EDITION, REVISED AND ENLARGED BY 

KATE EMIL-BEHNKE 




LONDON 

BAILLIERE, TINDALL AND COX 

8, HENRIETTA STREET, COVENT GARDEN 
1922 



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MOtoer 

UBRARV 



PREFACE 

The last edition of the treatise on ** Stammering, 
Cleft-Palate Speech, and Lisping " by my parents 
being exhausted, it has seemed desirable to revise 
and amplify it, adding thereto the results of my own 
work in carrying on the method which has been so 
successful over a period of some forty years in the 
treatment of stammering, defects of speech, and the 
training of the voice for speaking and singing. 

I wish to express my thanks to the medical pro- 
fession, to the Press, and to the public generally, 
for the support and for the approbation of the 
method which they have so frequently and 

generously expressed. 

KATE EMIL-BEHNKE. 

39, Earl's Court Square, S.W. 5. 
September, 1922. 



6fi17f^Q 



CONTENTS 



PAGE 

PART I. By EMIL BEHNKE .... - i 

PART II. By Mrs. BEHNKE 25 

PART III. By KATE EMIL-BEHNKE - - .73 



PART I 
BY EMIL-BEHNKE 



A reprint of a paper on " Stammering : Its Nature 
and Treatment" read before the South Wales Branch 
of the British Medical Association, and before a 
medical gathering at the Central London Throat, 
Nose, and Ear Hospital. 



PART I 

STAMMERING 

Definition 
The terms stamviering and stuttering are regarded 
by some authors as interchangeable, implying the 
same thing. Others insist strongly upon the neces- 
sity of distinguishing the one from the other, as 
implying two entirely different things. 

My own definition is this : 

Stammering and stuttering are impediments of 
speech, consisting of spasmodic, or entirely sus- 
pended, action of any part or parts of the vocal 
apparatus, from the diaphragm to the lips. 

Stammering is a defect in the utterance of con- 
sonants, rather than in the utterance of vowels. 

Stuttering is a defect in the utterance of vowels, 
rather than in the utterance of consonants. 

Both impediments are frequently found in thel 
same person, and both are due to the same cause — 
inability to vocalise. The two terms may, therefore, 
be considered as interchangeable. 

If a stammerer wants to say pa, he has a kind of 

3 



. . 4 . • ''JHE -TREATMENT OF STAMMERING, 

lockjaw, and cannot get the consonant p out at all. 
This feat once accomplished, he generally has no 
difficulty in adding the vowel to the consonant. But 
he may be equally fixed in trying to utter a word 
commencing with a vowel, when, in spite of widely- 
opened mouth, no sound will be forthcoming. 

If a stutterer wants to say pa, the case is exactly 
reversed. He has no difficulty in articulating the 
consonant p, which, on the contrary, he repeats 
over and over again with astonishing rapidity ; his 
difficulty consists in adding the vowel to it. But it 
is by no means uncommon for a stutterer to go 
through the same process of repetition when trying 
to pronounce a word commencing with a vowel. 

It will thus be seen that the defects of speech 

called stammering and stuttering overlap, and it is 

not too much to say that in many, if not in most, 

instances, the one accompanies the other. The 

\ question whether a given case is one of stammering 

Jior of stuttering is therefore^^iin my opinion, more 
theoretical than practical, and I shall consequently, 
in order not unnecessarily to complicate matters, 

"^always use the term stammering to include both 
impediments.* 

* '* Mr. Behnke sets aside this refinement of onomatopoeia 
and asks us, we think judiciously, to employ the term 
stammer for both, thus simplifying the matter at the onset, 
as the conditions are often identical and their differences quite 
non-essential." — Journal of Laryngology, July, 1891. 



; 



CLEFT-PALATE SPEECH, AND LISPING 5 

Mere indistinctness of speech, lisping, the burred 
r, the misplaced h, the defective /, g, or fe, the 
substitution of w for r, of b for m, or of d for n, etc., 
do not come under the head of stammering in any 
sense of the word. Their causes are local, they are 
clear and unmistakable. The causes of stammerings 
on the other hand, are not local, but must be sought 
in disturbed action of the nervous centres concerned 
in the production of speech. If speech is to be 
perfect, there must be harmonious co-operation of 
the several mechanisms of respiration, phonation, 
and articulation, all of which are known to be under 
the direct and immediate influence of that portion 
of the brain which is known as the " bulb," or the 
** medulla oblongata," where the centres of these 
mechanisms are situated close together. 

Spasm in these nervous arrangements may occur, 
and does occur, without any gross material lesion 
of the structure of the bulb, from disturbed mole- 
cular action simply ; and this circumstance enables 
us to understand why special training of the affected 
nervous centre, with the view of inducing har- 
monious action of the three mechanisms concerned 
in speech, may succeed in overcoming the habit of 
stammering in a large number of cases, provided 
there are no local or general complications which 
would render a cure by elocutionary treatment alone 
impossible. 



6 THE TREATMENT OF STAMMERING, 

Warning 
1 A general notion prevails that a child will " grow 
out " of stammering, and in some instances the 
impediment does indeed diminish as the powers of 
reflection and of self-control increase with maturer 
age. But in the vast majority of cases the child will 
no more grow out of stammering than it would grow 
out of a physical deformity ; the impediment will, 
on the contrary, increase, and become more and 
more intractable. 
/' If stammering is attended to when first it shows 
itself, it may be prevented, and as prevention is 
proverbially better than cure, parents ought to be 
watchful of their children from infancy. 

What shall we say of parents who are thought- 
less and indifferent enough not only to neglect the 
first traces of stammering, but who even foster and 
aggravate the impediment by laughing at the little 
sufferer and by mimicking him? A mother who 
was in the habit of doing this once said in my 
hearing to her little boy : *' Ch-arlie, will you have 
s-s-some c-c-cake?" Is it to be wondered at that 
Charlie replied : " P-p-please, m-m-mother " ? And 
is it surprising that his younger sister, as soon as 
she was old enough to talk, also commenced to 
stammer? Charlie acquired the impediment by 
unconsciously imitating his father, from whom both 
\ children probably inherited a predisposition. Baby, 

7 



CLEFT-PALATE SPEECH, AND LISPING 7 

after the father's death, acquired it by unconsciously 
imitating Charlie, and the mother, by her folly, 
perpetuated the defect. It is a sad picture, but not, 
I am afraid, a unique one. 

In another case which came under my notice, a 
mother who was a strict disciplinarian of the old 
school, now happily fading out of existence, looked 
upon the stammering of her little boy as the result 
of obstinacy or carelessness, and thrashed him 
accordingly. It is needless to say that he grew 
morose, sullen, and resentful ; his speech became 
worse, and his whole character was ruined. 

I am not here concerned with the way in which 
children should be treated in general, but only in 
reference to my special subject, and I say em-^ 
phatically that parents should, upon the very first 
indication of an impediment of speech, display the 
greatest loving-kindness, and exercise the most 
patient and untiring perseverance in order to counter- 
act and to correct any hesitation or stumbling. 

Much mischief is also frequently done by school i, 
teachers, who, by indifference, impatience, and want 
of sympathy, intensify the impediment of a stam- 
mering boy, and thus unwittingly make his young 
life a misery. The poor boy, although knowing his 
lesson perfectly, cannot give a ready utterance to it, 
and the teacher passes him over with a cruel ** Oh, 
I have not time to wait for you I Next boy I** 



^ 



8 THE TREATMENT OF STAMMERING, 

Just a few words about the teasing, the bullying, 
and the mimicking that a stammerer is frequently 
subjected to by his companions. Boys will be boys, 
of course, and we cannot expect from them the 
thoughtfulness which comes with maturer age ; but 
they are naturally generous, and a headmaster with 
his heart in the right place will have little difficulty 
in showing them the cowardice of making fun of an 
^affliction which is often worse than a curvature of 
- the spine, though it may, to those without under- 
standing, appear but a trifling matter. Should, 
however, the appeal to their higher nature fail, then 
the offenders must be sternly dealt with as would 
be the bully who torments a little fellow who is 
incapable of defending himself. 

Causes of Stammering 

In order to ascertain the causes of stammering in 
any given case, we have to inquire into it (a) from 
a pathological, (h) from a mental, and (c) from an 
elocutionary point of view. But although I propose, 
for the sake of convenience, to discuss the subject 
under these heads, it must ever be borne in mind 
that, so far from any of these different aspects being 
clearly defined in actual cases of stammering, they 
are, as a rule, inextricably mixed up with each other ; 
and it is this circumstance which often makes it so 
difficult to grapple with the evil. 



CLEFT-PALATE SPEECH, AND LISPING 9 

Pathological Aspect 
I heard some time ago a lecture by a gentleman 
who advertises himself extensively as a curer of 
stammering, in which he asserted that the more he 
had to do with stammerers the more he became 
convinced that there was nothing the matter with 
them physically, that their difficulty was entirely 
elocutionary, and that they could be completely 
cured by elocutionary treatment alone. / deny this 
in toto, and assert, on the contrary , that there are 
very few cases of stammering indeed in which there 
is no necessity for medical aid before elocutionary 
treatment can be of the slightest avail. Thus it is 
absolutely necessary first to treat any affections of 
the mouth or throat, or any general morbid con- 
dition of the system which may be present, and 
which may be exciting causes of stammering, or 
may aggravate pre-existing habitual stammering. 
Stammering is, indeed, sometimes entirely due to 
such nervous affections as epilepsy, hysteria, or 
locomotor ataxy, in which mere voice-training could 
not, in the nature of things, be expected to lead to 
any useful result, as in such cases the speech 
difficulty is but a symptom of a graver disorder. It 
is chiefly in the hope of calling the attention of 
medical practitioners to this matter, and of exciting 
their interest in it, that I have undertaken to write 



lo THE TREATMENT OF STAMMERING, 

this paper, and will venture to relate to you a few 
of my experiences, from which you will draw your 
own conclusions. 

Case I. is that of a young girl whom I had known 
for some years before her mother brought her to 
me with regard to an impediment of speech. She 
was very tall, very thin, easily fatigued, unable to 
sit upright, constantly desirous of lying down. I 
gave her a few lessons, but was dissatisfied with 
the result, and advised her mother to have her 
thoroughly examined by a medical practitioner. It 
was then discovered that she had slight lateral spinal 
curvature, for which she underwent treatment for a 
considerable time. Some years have passed since 
then, and not only has the spinal weakness been 
overcome and her health fully established, but the 
elocutionary exercises, which she has since resumed, 
have rapidly produced the desired effect, so that she 
has now lost her impediment completely and is able 
to gratify her wish to go on the stage. In this case, 
without doubt, the original cause of the stammering 
was debility of her nervous system, due to spinal 
affection. 

Case II. is that of the son of a medical man. The 
boy's naso-pharyngeal passages were obstructed by 
adenoid growths, which were diagnosed by the 
specialist to whom he was taken to be the cause of 
the impediment. The child was first operated upon, 



CLEFT-PALATE SPEECH, AND LISPING ii 

and then sent to me, and, as a result of this pre- 
liminary treatment, I was enabled to effect a cure, 
which I am convinced I could not have done other- 
wise. 

The surgeon who sent the patient to me furnished 
me with the following explanation of the case : 

"The boy's respiration through the natural 
passages was impeded, and as a result he had one, 
if not all, of several conditions. First, his lungs 
were not sufficiently aerated, and a vicious, in- 
efficient, and jerky respiration resulted. This in 
turn led either to general venous congestion, impli- 
cating the brain, and so causing the boy to be 
neurotic, and in addition, to use a new word, 
aprosectic, which here signifies that he had not the 
power to pay proper attention to his speech-educa- 
tion ; or it may, as it often does, also have impaired 
his hearing, not necessarily of ordinary sounds, but 
of the appreciation of the refinements of speech ; 
and, lastly, actual congestion of the organs of voice 
and speech may have arisen which mechariically 
impeded them." 

Case III. is that of a young man who was 
addicted to masturbation. This had been recog- 
nised by his medical adviser, but denied by the 
patient. The pupil had not, however, been in my 
house many days before I was convinced that his 
doctor's suspicions were justified. 



12 THE TREATMENT OF STAMMERING, 

Of the good effects of surgical treatment for this 
condition as a preliminary to speech treatment I 
have at the present an example under my care. 

If there is any reason to suspect that this practice 
is being carried on by stammerers of either sex, the 
family physician's advice should be sought as to 
the best means of dealing with the matter. 

Other points of irritation besides those just 
mentioned are nasal polypus, deflected septum, or 
any other nasal blockage, enlarged tonsils, elon- 
gated uvula, decayed teeth, intestinal worms, etc. 
\ Having thus insisted that it is in most instances 
impossible for the treatment of stammering to 
progress satisfactorily and thoroughly without 
medical aid, or at least without preliminary medical 
inspection and authoritative assurance as to absence 
of constitutional cause, I must also express my con- 
viction that the cure of stammering by medical 
treatment alone, unassisted by elocutionary aid, is 
equally impossible ; it cannot create new habits of 
speech. These have to be carefully and patiently 
formed by the teacher. 

Mental Aspect 

A stammerer, when alone or in company with 

intimate friends, can frequently talk as easily and 

fluently as persons not afflicted ; yet the moment he 

has to address a stranger his power of utterance is 



CLEFT-PALATE SPEECH, AND LISPING 13 

impeded, or even completely suspended. Here we 
have incontestable proof that his organs of speech 
are perfectly normal, and that his difficulty is not 
physical but mental. 

Amongst mental causes of stammering may be 
mentioned timidity, shyness, distrust, fear of ridi- 
cule, eagerness, impatience, excitement, envy, and 
irritation. A person may even stammer in his 
thoughts in consequence of flightiness and for want 
of concentration ; this will of necessity be reflected 
in his speech. Such cases are generally put down 
to nervousness, which, however, may in some cir- 
cumstances be not the cause but the result. I say 
advisedly that these cases of nervousness in which 
the physician has been unable to detect an objective 
cause are essentially those to be treated by the 
skilled and patient teacher, and that they can neither 
be alleviated by tonics nor by general gymnastics. 

The instructor must first of all gain the most 
absolute confidence of, and influence over, his pupil, 
and then lead him into habits of calmness, of 
deliberation, and of self-reliance. 

It is also important to divert the sufferer's mind 
from his impediment, for the more he concentrates 
his attention upon it, the more will his difficulty 
increase. To this end it is sometimes useful to 
direct the stammerer to accompany each trouble- 
some syllable by some slight movement of a finger, 



14 THE TREATMENT OF STAMMERING, 

the hand, or the foot, etc., as enforced by the late 
Canon Kingsley, thereby diverting his attention 
from the effort to speak to the performance of a 
muscular action, and his impediment is often 
entirely, though only temporarily, removed. This 
is one of the remedies forming the stock-in-trade 
of so many so-called stammer-curers, who indis- 
criminately apply it to all cases, and it has 
consequently fallen into considerable disrepute. 
Nevertheless, it has its legitimate uses, and will, 
judiciously employed, sometimes be of considerable 
assistance. It is, however, nothing more than a 
device, to be used temporarily, until the stammerer 
has by systematic training obtained control over the 
muscles of respiration and articulation. 

Elocutionary Aspect 
This section may be best commenced by a con- 
sideration of the question whether it is possible to 
form an opinion as to the chances of success or 
otherwise in undertaking the treatment of any par- 
ticular case. The matter having been considered in 
its pathological and mental aspects, I am now only 
looking at it from an elocutionary point of view, and 
experience has taught me to divide my cases into 
two classes — viz., those in which the difficulty can 
be traced to the management of the bellows, and 
those in which it cannot. To illustrate : A patient 



CLEFT-PALATE SPEECH, AND LISPING 15 

presents himself who stammers badly. When trying 
to say the alphabet, he can scarcely pronounce a 
single letter, and upon endeavouring to reply to 
questions put to him, his whole body is thrown into 
violent contortions, so that it is positively painful 
to look at him. I now place him on a couch, flat on 
his back, comfortably raising his head on a pillow, 
and then give him some diaphragmatic drill. As 
soon as he has acquired sufficient control over the 
diaphragm, I direct him once more to say the 
alphabet, taking a very short inspiration before 
each letter by contracting the diaphragm, and then 
attacking the letter by relaxing the diaphragm. I 
control these movements by holding my hand on 
his abdomen, and he now, to the amazement of 
friends who may have accompanied him, pro- 
nounces every letter as quietly and as easily as they 
could do themselves. In these circumstances I am 
always confident of success; cure is certain, pro- 
vided I have the patient under my absolute control, 
and that sufficient time be allowed. 

If, on the other hand, the impediment is as great 
in the circumstances just described as it was before, 
I am doubtful of success ; and I must, in such cases, 
rely upon what I may call local remedies instead 
of being able to devote myself to the removal of 
the fundamental difficulty. The cases in which the 
speech trouble can be traced fundamentally to the 



i6 THE TREATMENT OF STAMMERING, 

management of the breath are, fortunately, in the 
vast majority, and the results obtained by training 
a patient to manage his voice by means of diaphrag- 
matic action are sometimes almost miraculous. 

The following case illustrates my point. The 
Rev. H. H. suffered from spasm of the glottis to 
such an extent as to make speaking almost impos- 
sible, while his efforts were painful both to hear and 
to see. He had been for years under medical treat- 
ment, and had by advice resided for five years 
abroad, without beneficial result. Upon putting 
him to the test just described, I found that his 
difficulty, for the time being, entirely disappeared, 
and I came to the conclusion, therefore, that the 
real seat of the trouble was in the diaphragm, and 
that the spasms in the glottis were merely reflex 
action. I treated him accordingly, and after a very 
short course of treatment received from him the 
following letter: " I am sure you will be pleased 
to hear that last Sunday evening I preached in 

Cathedral in the nave, and was heard perfectly 

throughout the whole building, both in the choir 
and down to the end of the nave. People have 
remarked what a strong voice I have I With God's 
blessing, I owe this to your skill." 

There are some authors who consider that lateral, 
or purely costal, breathing may be exercised without 
diaphragmatic action. Assuming this to be pos- 



CLEFT-PALATE SPEECH, AND LISPING 17 

sible, the effort involved would in itself render it 
undesirable for stammerers; and, moreover, infla- 
tion which is commenced by lateral expansion is 
exceedingly liable to degenerate into clavicular 
breathing. 

The question may be asked why diaphragmatic 
breathing should have such beneficial influence 
upon the propulsion of the voice. To this a variety 
of replies may be given. The chief reason, in my 
judgment, is that by clavicular breathing we set in 
motion machinery which is unyielding and clumsy, 
owing to the bony structure of the upper part of the 
thorax, and over which it is therefore impossible to 
get easy and delicate control ; while the diaphragm 
exercises muscular force on that portion of the chest 
walls which is surrounded only by soft and yielding 
parts, and which can therefore be trained to act with 
the utmost certainty and precision. 

It is a very common fault with stammerers to try 
to speak with empty lungs ; they let out all the air 
they can dispose of, and then try to speak ; which 
is, of course, a hopeless task. In such circumstances 
the patient has to be taught economy of breath, 
which, after having gone through the necessary 
diaphragm drill, is a comparatively easy matter. 
But stammerers attempt as frequently to speak with 
unduly distended lungs, which is just as fatal to an 
easy and smooth delivery ; and this is a fact which 



i8 THE TREATMENT OF STAMMERING, 

does not, I think, receive the attention it deserves. 
To counteract this habit it is necessary to train the 
patient to breathe more lightly and more frequently 
than he has been accustomed to do. 

Pronation Drill 
This depends primarily, so far as the larynx is 
concerned, upon the action of the adductors, or 
closing muscles of the vocal cords. If these did not 
act at all, no production of tone would be possible, 
however perfect the remainder of the vocal apparatus 
might be, and it is quite clear, therefore, that if they 
act with uncertainty the voice will be produced with 
uncertainty. If they act smartly and promptly the 
voice will be produced smartly and promptly. It is 
necessary, therefore, to educate these muscles in 
order to jjnsure the proper attack of tone commonly 
called the "shock of the glottis." This is accom- 
plished by directing the stammerer to sing a number 
of staccato tones, each one preceded by a short 
inspiration. For each intake of breath, which is the 
motor element, the abductors, or opening muscles, 
separate the cords and open the glottis, and for 
every tone, however short, the adductors, or closing 
muscles, by causing approximation of the cords, 
close the glottis; and these smartly and frequently 
repeated movements have the effect, not only of 
strengthening the opening and closing muscles of 



CLEFT-PALATE SPEECH, AND LISPING 19 

the glottis, but also of increasing the patient's 
control over them. 

Similar drill should be applied to the soft palate, 
the influence of which upon the voice is much 
greater than most people who have not paid special 
attention to the subject have any conception of ; and 
it should be remembered that, in the case of 
adenoids, enlarged tonsils, elongated uvula, etc., 
conditions so often present in the stammerer, the 
soft palate has been rendered paretic by an over- 
weighting of the muscles. Not only is Hasal quality 
prevented by proper action of the soft palate, but 
the resonance of the voice depends upon it to an 
enormous extent, and it may be seen in a well- 
managed throat to move like something sentient, 
and to occupy a distinctly different position at every 
different pitch at which a tone is produced. Control 
over the soft palate also confers the invaluable power 
of breathing through the nostrils while speaking 
and singing, thereby preventing dryness of the 
mouth and the throat, of which so many voice-users 
complain. 

We now come to a description of some of those 
methods alluded to for the cure or alleviation of 
stammering in cases where the difficulty cannot be 
traced to the breathing apparatus. Much of a 
stammerer's trouble arises from the fact that he 
involuntarily exaggerates all the stops and checks 



20 THE TREATMENT OF STAMMERING, 

taking place in the vocal apparatus from the glottis 
to the lips, which are involved in speech. The more 
he exaggerates these stops and checks the greater 
will be his difficulty to overcome their resistance, 
and he must, therefore, be trained to make these 
closures as shortly and lightly as possible. In this 
matter we are assisted by the drill of the soft palate, 
and I have also devised special exercises for the 
tongue and the lips which greatly assist the 
stammerer in the management of his articulation 
apparatus. 
/^ It is a well-known fact that most stammerers can 
sing without any difficulty. This is because in 
singing there is a continuous flow of the vocal tone ; 
the voivels predominate^ while the consonants are 
but lightly touched in passing. The opposite of 
this takes place in speech. The vowels are passed 
over quickly, and the consonants, which are only 
checks, clicks, and explosive noises, predominate. 
The moral of this is obvious. Let the stammerer 
' exaggerate his vowels at the expense of his con- 
] sonants, and a good many stumbling-blocks will 
thereby be removed from his path. 

/It is equally easy for most stammerers to whisper, 
and this teaches a great lesson with regard to the 
difficulty they so often experience in the attack of 
vowels in speech. In whispering the glottis is open, 
in phonation it is closed. The air passes out of the 



7 



CLEFT-PALATE SPEECH, AND LISPING 21 

open glottis without let or hindrance, and this act' 
should precede the closing of the glottis for phona- 
tiofiy when the production of a vowel will be an easy 
matter. In other words, the attack of a vowel should, 
in case of difficulty, never be sharp or sudden, but 
it should be preceded by a short aspirate. To put it 
differently, the glide of the glottis should be substi- 
tuted for the shock of the glottis. 

There is yet another matter with which everyone 
who has had anything to do with stammerers is 
familiar — namely, that after they have once started 
they have usually no difficulty in any subsequent 
words uttered uninterruptedly in the same breath.) 
The stammerer should therefore dwell on an easy 
syllable, prolonging the vowel of it, and then tack 
on the remainder of the phrase as though it were 
one word, and without any interruption whatever. 
If there be no easy syllable to start with, we must 
make it easy by preceding it with a little indefinite 
vowel sound. 

I will bring this part of my subject to a close by 
mentioning a few special remedies for a few special 
difficulties. A stammerer frequently finds it im- 
possible to pronounce the w. In that case, let him 
substitute 00 for it, saying oo-as instead of was, 
oo-ater instead of water, oo-ill instead of will. 
Similar difficulty often arises with the y and the u. 
Here we must substitute an ee for the y, and precede 



22 THE TREATMENT OF STAMMERING, 

the u by an ee, thus : ee-oung instead of young, 
ee-ot instead of yacht, ee-ooniverse instead of 
universe. I may observe that this method is simply 
dividing the initial vowel into its component parts, 
and saying them separately with great distinction 
and deliberation. 

Time Necessary for Cure 
With regard to this matter it is impossible to lay 
down a hard-and-fast rule, as so much depends upon 
individual circumstances. But in most cases people 
expect a cure to be effected too quickly. The treat- 
ment of stammering, as I have shown, is a very 
complicated process, and can consequently not be 
accomplished in the short space of a few weeks. 
Experience has led me to decline the treatment of 
young stammerers unless they are placed under my 
immediate care and control for at least three 
months. 

In all cases long-continued self-control and disci- ) U-^ 
pline are indispensable. The habit of many years 
cannot be permanently eradicated in a few months ; 
and patients who resume their old ways as soon as 
the time of treatment has expired must not be 
surprised if they are again quickly conquered by 
their enemy. 

Adults, having presumably greater self-control 
than young folks, are frequently able to do without 
guidance after a shorter period. They can continue 



CLEFT-PALATE SPEECH, AND LISPING 23 

the exercises by themselves; but it should always 
be distinctly understood that they do this entirely 
on their own responsibility. 

In conclusion I desire to express my dissent from 
those who affirm that stammerers are usually secre- 
tive, suspicious, sly, and deceptive. This has not 
been my experience in a single instance. I have 
found them, on the contrary, warm-hearted, affec- 
tionate, honourable, and keenly sensitive to kind- 
ness, and to interest manifested in the relief of their 
distressful malady, and I am happy in the pos- 
session of many attached friendships which have 
resulted from close association with speech-sufferers. 
At the same time I am not prepared to deny that 
there are cases in which stammering is combined 
with mental and moral obliquity. 

While preparing this paper I have been once 
more impressed by the difficulty of making matters 
as clear in writing as by viva voce explanations. It 
is, in fact, impossible to substitute written for oral 
instruction on a complicated subject like stammer- 
ing. No lasting results can be obtained without l-- 
personal communication between the teacher and 
the stammerer. It is impossible to lay down rules I — 
which shall suit every case. Each one presents^ — 
individual idiosyncrasies, and must be treated 
accordingly. There is no royal road to the cure of 
speech defects any more than there is a universal 
panacea for other ailments. 



PART II 

BY MRS. BEHNKE 



PART II 

The last edition of the foregoing treatise on Stam- 
mering by my husband, the late Emil Behnke, 
having been exhausted, I have been urgently advised 
to issue my own observations, deduced from careful 
study of the subject, and from experience gained 
during the last sixteen years in the successful treat- 
ment of a very large number of cases of stammering. 

The more I see of this distressing complaint, the 
more convinced I become of its curability in the 
majority of cases, given a scientific method, suf- 
ficient time, and the active and continued co-opera- 
tion of the patient. 

Stammering forms a bar to success in, or even 
admission to, the Army, the Navy, the Bar, the 
medical profession, the Church, scholastic and com- 
mercial work, and also to social intercourse. The 
misery of the sufferers is very great, and besides the 
handicap to their prospects in life, the injury to 
their dispositions and characters is incalculable. 

The varieties of manifestation of the trouble are 
legion. Some stammerers make frightful grimaces, 
screwing up the mouth and eyes tightly, struggling 

27 



28 THE TREATMENT OF STAMMERING, 

violently, getting red and purple in the face in the 
effort to speak. Others thrust out the tongue to an 
extraordinary length, standing with widely-opened 
mouth, hands clenched, body swaying to and fro, 
looking as if in a severe convulsive fit. In some 
the tongue and head are drawn to one side ; in 
others, the head is thrown back. Occasionally a 
case is met with in which the saliva flows out of the 
open mouth. Others clench the teeth with great 
force, biting the tongue and inside of the cheeks, 
often causing blood to trickle down the chin. Some 
make a continuous, irregular, vocal sound, more 
like a low growl than a human voice, without being 
able to articulate a syllable ; lashing out with arms 
and legs with force sufficient to knock down a strong 
man. Others, again, keep absolutely still, the face 
looking like a mask, unable to utter a sound. 

A painful case of this silent battle was that of a 
fully qualified medical man. He had bought a 
good country practice, which he gradually lost 
through this silent stammer which no one under- 
stood, his inability to speak being put down to 
eccentricity or to ** bad manners.** He could always 
speak perfectly at the bedside of patients ; but if a 
relative accompanied him from the sick-room anxious 
to hear his opinion on the child's illness, the un- 
fortunate man could neither utter a syllable or make 
a movement, but stood gazing fixedly before him 



r 



CLEFT-PALATE SPEECH, AND LISPING 29 

till, vanquished in the silent struggle, he would rush 
out of the house unable to utter a single syllable. 
He ultimately had to give up his practice and leave 
the neighbourhood, and subsequently came to me 
for help in conquering this terrible drawback, which 
happily I was able to give him. I found the upper 
airways were considerably impeded by a growth 
which I advised him to have removed. This was 
done, and he afterwards made excellent progress, 
so much so that before long he was able to acquire 
another practice, and is doing very well. 

Small wonder that stammerers become morbidly 
sensitive and refuse to mix at all in society, pre- 
ferring the solitude of their own rooms to the morti- 
fication of being unable to converse ; even contem- 
plating suicide rather than endure continuance of 
life in such depressing conditions ; but under proper 
treatment there are very few absolutely incurable 
cases. 



■vC 



CAUSES OF STAMMERING 

I NOW proceed to enumerate and discuss more 
fully than was possible for my husband to do in the 
limits of a lecture some of the causes of stammer- 
ing. Amongst them are : obstructions of the 
upper airways, heredity, imitation, mental shock, 
severe blows on the head, epilepsy, chorea, hysteria, 
spinal weakness, worms; and, as a contributory 
cause, public-school life. 

Obstruction of the Upper Airways 
Affections of the mouth, throat, or nose, or any 
general morbid condition of the system which may 
be present, and which are exciting causes of stam- 
mering, or which may aggravate pre-existing 
habitual stammering, should be treated before 
speech treatment is commenced. 
7 Inadequate breath-supply and absence of breath- 
control constitute a marked feature in the majority 
of cases, whether of children or adults. These 
2> deficiencies are, as a rule, traceable to certain 
physical conditions. 

In looking over my cases recently, I found that 
out of one hundred, taken consecutively in the order 

30 



THE TREATMENT OF STAMMERING 31 

in which they came to me, seventy-nine had some 
sort of obstruction in the upper respiratory passages, 
such as adenoids, enlarged tonsils, chronic ton- 
silitis, elongated uvula, deflected septum encroach- 
ing on the nostril space, broken bone causing 
obstruction not only by its position, but also by 
the constant irritation it set up, leading to swelling 
and suppuration, post-nasal catarrh and polypus. 

In the majority of these cases treatment had 
removed the obstruction before they came to me. 
Those whom I found to be suffering from any of 
these troubles I advised first to obtain medical aid. 
With the upper airways blocked, or even partially 
blocked, by such obstructions, the lungs were very 
inadequately supplied with air, and the type of 
breathing was " high chest " or clavicular. 

In all instances the chest was badly developed, 
in many cases measuring from three to six inches 
less than their average. In some the general health 
was more or less "below par," a natural conse- 
quence of deficient supply of oxygen. 

Case of Mechanical Blockage of the Nose 
CAUSING Stammering 

A singular and interesting confirmation of the 
theory that blockage of the upper respiratory pass- 
ages is a potent cause of stammering, has been 
afforded me by the diagnosis of a case now under 



32 THE TREATMENT OF STAMMERING, 

my care. The patient, when quite a little child, 
pushed a button with a metal shank into her nostril. 
No one had seen the action, and the presence of the 
button was, for a long time, unsuspected. The 
child cried when her nose was wiped, and was un- 
able properly to blow it, or to breathe through it. 
She snored, not only in sleep, but often when 
awake in the daytime. She became very ill, and 
was medically attended for six months without 
obtaining relief. Eventually the nose was exam- 
ined, and the button was discovered and extracted. 
There was a good deal of inflammation and sup- 
puration, which remained for a considerable time 
after the button was removed, causing the little 
patient to be very ill, and she began to stammer 
between the age of five and six years. The stam- 
mer remained, and continued during twenty-five 
years. 

The case answered to treatment remarkably well. 
In fifteen days this lady obtained sufficient control 
over her breathing and vocal muscles to be able to 
prevent herself from stammering, whether in read- 
ing or in talking ; and in another two or three weeks 
of steady, uninterrupted work the tendency was 
altogether overcome. 

Here we have a case of artificially impeded nasal 
passages causing stammering, in much the same 
way that growths, such as adenoids and other 



CLEFT-PALATE SPEECH, AND LISPING 33 

abnormalities, have caused it in hundreds of in- 
stances. Inquiries elicited the informaton that 
there was no history of the impediment on either 
side of the family, nor was there any association 
with a stammerer, whether nurse, companion, or 
relative ; yet conditions always observed to exist in 
other cases were present in this. Neither heredity 
nor imitation was the cause of the trouble, and there 
appears to be no reason to suppose that the nerve 
centres controlling the muscle movements in speech 
were affected. The respiratory powers were, how- 
ever, very deficient. When this lady commenced 
work with me, her lung capacity registered only 
130 cubic inches; it should have been 209 cubic 
inches. In a fortnight she easily registered 164 
cubic inches — a gain of 34. 

The amount of chest expansion on the first day 
she came to me was only one inch ; at the end of the 
fortnight's work it was three and a quarter inches, 
and her general appearance was healthier and 
brighter. 

The case, and the result of its treatment, prove 
satisfactorily the correctness of the opinion that a 
most powerful factor in the causation of stammering 
is the existence of any sort of impediment in the 
nasal or post-nasal passages, interfering with the 
access of air to the lungs. 

It also shows the necessity of properly directed 

3 



34 THE TREATMENT OF STAMMERING, 

breathing exercises designed to suit each case, in 
order efficiently to re-establish the right muscle- 
habits, and to prevent the closing together again of 
those passages from which growths or other block- 
ages have been removed, otherwise the advantage 
sought for by surgical measures may be nullified. 

No persons should be entrusted to give these 
breathing exercises who have not a thorough know- 
ledge of the physiology and anatomy of the parts 
concerned. They should possess the ability to 
devise exercises suitable for each individual patient. 
To treat all patients alike is to court failure. 

In several instances of stammering in quite young 
children, when the diagnosis indicated the presence 
of obstruction of the upper airways, I have advised 
their being taken to a surgeon for its treatment or 
removal. This done in time — that is, as soon as the 
stammer begins to manifest itself — has in some cases 
effectually arrested the trouble. When the stammer 
has established itself as a habit, surgical treatment, 
while removing the exciting cause, cannot remove 
the result ; it cannot create new speech habits. These 
have to be carefully and patiently formed by the 
sufferer under a thoroughly competent teacher. 

Heredity 
There seems to be reason to consider the 
existence of heredity as causing a tendency to 
stammer. It is, however, difficult to obtain accurate 



CLEFT-PALATE SPEECH, AND LISPING 35 

information in some cases, on account of disinclina- 
tion on the part of parents to admit the existence of 
the trouble in other members of the family ; and one 
only hears accidentally that a grandfather, uncle, 
aunt, cousin, or other relative used to stammer. 
Some of these contracted the habit by imitation of 
the stammering relative ; but there are many others 
who have never had communication with — or even 
seen — their stammering relatives. In these cases the 
question of imitation is eliminated, and that of 
heredity may be considered — heredity, that is to say, 
of the special neurotic condition noticeable in the 
majority of cases. 

Among the records of my work during a given 
period — namely, four years — I find that in six cases 
the father stammered ; in three, the mother ; in four, 
an uncle ; in one, an aunt ; in three, girl-cousins ; in 
one, the grandmother ; in three, the grandfather. 
In one of these families four children stammered 
badly. 

In another instance in which the grandfather 
stammered, in each of the families of his two sons 
and one daughter some of the children stammered, 
the trouble having skipped a generation and re- 
appeared in the third generation. There seems, 
therefore, to be sufficient reason to consider heredity 
as a factor in this distressing complaint. Doubtless 
there were other hereditary stammerers among those 
who came to me for cure during those four years, 



36 THE TREATMENT OF STAMMERING, 

but I was not able to get reliable information about 
them. These cases are, as a rule, rather difficult to 
treat, and they are liable to a recurrence of the 
trouble if after being cured they are in constant 
association with members of their family who still 
stammer. There is a nervous instability in many 
of them, making it difficult for them always to hold 
themselves under control when speal^ing. 

> Imitation 

This is an admitted cause of the trouble. One 
boy, who was brought to me, had acquired the 
habit through mocking the gardener, who stam- 
mered. His imitation was so excellent that he was 
constantly asked to give an exhibition of it for the 
amusement of friends, with the result that, after 
a time, he stammered worse than the gardener; 
and it was long before the family realised that it had 
become impossible for him to speak otherwise. He 
made excellent progress with me, and quite lost the 
defect. 

Another lad was very fond of the groom, who 
stammered badly ; and as he was always accom- 
panied on his rides by the man, and as every 
minute of his playtime was, if possible, spent in the 
stables, he began to stammer. He came under my 
care after being turned down in his medical exam- 
ination for the Army on account of his defect. 



CLEFT-PALATE SPEECH, AND LISPING 37 

After being under treatment he went up again for 
examination, and passed without the least stammer. 
In another case a girl was in the class of a 
governess who occasionally stammered. The girl 
soon spoke much worse than the teacher, and it was 
not without difficulty that she was cured. Many 
such instances might be quoted; but those given 
suffice to prove that imitation is a cause of stammer- 
ing. 

Mental Shock 
A girl of eleven years of age was alone with 
her mother who died quite suddenly from heart 
failure. The girl received such a shock that' 
for some hours she could not speak nor produce 
any vocal sound. By degrees she recovered her 
voice, but stammered horribly, with violent con- 
tortions. She was extremely shy and timid, dread- 
ing to stammer if she attempted to speak, and was 
becoming morbid about it. Great tact and care 
were necessary in treatment. Everything was done 
to improve the general health and the nervous con- 
dition, while also treating the speech defect. She 
ultimately spoke perfectly unless worried or anxious, 
or if her health was in bad condition, when there 
was a slight return of the stammer, which passed 
away again with renewed health and careful practice. 



38 THE TREATMENT OF STAMMERING, 

Constitutional Causes 
In constitutional causes such as epilepsy, hysteria, 
some forms of chorea, locomotor ataxy, etc., the 
speech difficulty is but a symptom of a graver dis- 
order, which it would be useless to attempt to 
benefit by treatment suitable for ordinary stam- 
mering. Complaints affecting the lungs and respira- 
tory tract, notably the sequelae of scarlet fever or 
measles; occasionally also influenza; whooping- y 
cough, from the excessive strain on the diaphragm 
during severe paroxysms of coughing ; debility 
and indigestion, are causes of stammering which 
call for medical, as well as elocutionary, assistance. 

Public-School Life 
Public-school life appears to be a serious 
difficulty for many boys who stammer, or who 
have a latent tendency to this trouble. Parents 
often say to me of their son : ** He never 
stammered until he went to school " ; or, ** The 
stammer came back in a few weeks after he went 
to school.** Head and assistant masters are not 
now impatient and harsh with the stammerer, as 
was formerly frequently the case; but it is impos- 
sible to keep a whole form at a standstill, time after 
time, for the answer which takes minutes instead of 
seconds to get out. The poor boy knows that the 



CLEFT-PALATE SPEECH, AND LISPING 39 

class is waiting on his account ; he is acutely sensi- L^ 
tive and alive to the annoyance and to the gaze of l^ 
his schoolfellows. He becomes hot, flustered, and^ 
angry that his difficulty makes him appear to be 
ignorant and unprepared with his work. The self- 
control necessary to apply the rules for speaking 
which he has learnt he is unable to use, and little by 
little the old bad speech habit reasserts itself. In 
these circumstances it is advisable to let the boy 
return from time to time for short courses with the 
teacher who has been successful in curing the 
stammer, or to place him with a tutor who only 
receives a few students at one time. 

Nervous Origin 
Stammerers and their friends often attribute the 
cause of the trouble to *' nerves,** because when the 
patient feels quite at ease with friends, or when at 
play, the difficulty vanishes entirely, while with^-^ 
strangers it is intensified. This sort of nervousness 
is not the origin of the trouble, for the dread and 
apprehension of stammering cannot have existed 
before the patient began to stammer. The mental 
attitude thus created, being once established, be- L- 
comes a powerful contributing cause in the increase 
and continuance of the trouble in children and 
adults ; but when a stammerer obtains the power to 
speak aright, that nervousness goes entirely. 



40 THE TREATMENT OF STAMMERING, 

As soon as a child begins to observe the difference 
in his speech from that of other children, especially 
if grimaces and contortions accompany his efforts 
to speak, he becomes self-conscious, dreads being 
spoken to and having to reply to a question ; and 
the constant fear and apprehension act prejudicially 
on his mind. Mothers who designedly take no 
notice of the defect act in mistaken kindness. 
Children are usually very quick of apprehension, 
and soon perceive the desire to shield their faulty 
speaking from observation. This makes them try 
to do the same, and greatly increases their nervous- 
ness before strangers. It would be wiser to treat 
the stammer as an incorrect pronunciation would be 
treated : kindly and quietly pointing out the correct 
way, and getting the child to repeat the sentence 
slowly and clearly. Although the stammer might 
not be entirely removed thereby, many difficulties 
may be corrected thus, and the children would be 
saved from serious inconvenience afterwards. 

Although nervousness in some instances is the 
result and not the cause of the trouble, stammering 
is undoubtedly of nervous origin in the majority of 
cases. 

As my husband has said (see p. 5) : 

"The causes of stammering, not being local, 
must be sought in disturbed action of the nerve 
centres concerned in the production of speech. If 



CLEFT-PAUATE SPEECH, AND LISPING 41 

speech is to be perfect, there must be harmonious 
co-operation of the several mechanisms of respira- 
tion, phonation, and articulation, all of which are 
under the direct and immediate influence of that 
portion of the brain which is known as the * bulb,' 
or the 'medulla oblongata,' where the centres of 
these mechanisms are situated close together." 

The opinion has been expressed that the seat of 
the disturbances of the nerve centres governing 
speech is not in the medulla but in the cerebral 
cortex. The following quotation from a paper by 
Dr. W. S. Morrow, lecturer on physiology, M'Gill 
University, goes to support my husband's view that 
the medulla is the seat of the disturbance : 

'* There is a respiratory centre in the medulla 
which is divided physiologically into an inspiratory 
and an expiratory centre, so distinct from one 
another that either one may be affected by stimuli 
which fail to influence the other. These centres 
may or may not be able to act automatically, but 
they are in any case profoundly affected by nervous 
impulses reaching them from the brain above, and 
by various paths from below, especially by the 
pneumogastric nerves. The respiratory centres send 
their stimuli to the muscles of respiration by the 
ordinary spinal nerves such as the phrenics and 
intercostals." 

This clear and scientific description enables us to 



42 THE TREATMENT OF STAMMERING, 

understand why control of the expiratory part of 
respiration in speaking is most difficult of acquire- 
ment by all stammerers, viz : because the expira- 
tory centre is not, at the time, influenced by the 
stimuli which have affected the inspiratory centre. 
For this reason explosive speech, difficulties of 
commencement, repetition of vowels and of con- 
sonants may be traceable to spasmodic interruption 
of the stimuli from the nerve centres to the muscles 
of respiration, which, in their turn, act spasmodic- 
ally, without control. This is also an explanation 
of the apparent anomaly noticeable in all stam- 
merers, that at times they speak perfectly and at 
others are scarcely intelligible. We can also readily 
understand the reason why carefully designed and 
regulated breathing exercises react on the nerve 
centres and help to re-establish exact and instan- 
taneous co-ordination with the vocal muscles. A 
similar result accrues in some cases of paralysis, in 
which the medical gymnast effects restoration of 
power by the use of massage and specially localised 
movements. These movements, upon which the 
patient is directed to concentrate, stimulate the brain 
centres, which in turn stimulate the nerves of the 
paralysed muscles, until by repeated stimulation 
normal, healthy action is re-established. 

Even in cases of admittedly nervous origin the 
majority of the stammerers probably failed first in 



CLEFT-PALATE SPEECH, AND LISPING 43 

breathing ; the supply of air becoming less and less 
adequate for the purposes of speech and of health. 
The diminished supply -of breath would cause 
lessening of the physical stimulation of the respira- 
tory nerve centres ; which stimulus would, in normal 
breathing, be conveyed by the action of the respira- 
tory muscles. This diminution in the supply of 
nerve-stimulus soon induces incomplete control of 
the motor power of voice, which is breath ; and 
resulting from these conditions, voice use becomes 
jerky and uncontrolled, and stammering is gradu- 
ally established. 

In an interesting and instructive article on 
'* Defective Nasal Respiration,"* Dr. P. Watson 
Williams argues that ** normal nasal breathing 
stimulates the bulbar respiratory centre*'; and he 
considers that ** abrogation of this physiological 
stimulation is one important factor resulting in 
deficient respiratory exchanges and consequent 
deficient metabolism." Thus the views on this 
subject held by the late Emil Behnke receive con- 
firmation from the writings quoted above. 

Speech Training 

The teaching for cure of speech defect has hitherto 
been mainly based on the assumption that the fault 
lies in the articulating apparatus. Even medical 

* Bristol Medico-Chirurgical Journal, March, 1906. 



44 THE TREATMENT OF STAMMERING, 

writers who have observed that faults of breathing 
are invariably found in all stammerers have failed 
to recognise that these respiratory errors are the 
primary cause of the defect ; and they consequently 
proceed to prescribe treatment for the secondary 
cause — articulation. This occurs in Dr. John 
Wyllie's otherwise admirable work, The Disorders 
of Speech. 

In his opening chapter he gives his opinion as 
follows : 

** 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." 

On p. i6 Dr. Wyllie says : "The starting-point 
of the defect is want of promptitude in the produc- 
tion of the vocal element in the first syllable of 
words, . . . the radical defect in the stammerer 
being the absence or insufficient supply of the vocal 
element . . . the stammerer produces the letter 
voicelessly or with feeble or intermittent voice." 

The above description is perfectly accurate as far 
as it goes; and it is much to be regretted that Dr. 
Wyllie has not gone to the root of the matter, but 
has taken the second position of stammering, the 
laryngeal, as its fundamental cause. We must go 



CLEFT-PALATE SPEECH, AND LISPING 45 

further back in the formation of the voice to dis- 
cover it, and must inquire into the cause of " the 
want of promptitude shown by the vocal mechan- 
ism," as Dr. Wyllie aptly expresses this 
condition. 

What is '* the vocal element " or voice? 

Voice is breath converted into tone by the vibra-\l 
tions of the vocal ligaments or cords in the larynx ; 
and it is in the inco-ordination of the breathing 
muscles with those of the vibrating element, delay- 
ing the production of tone, that the primary cause 
of stammering lies — not, as Dr. Wyllie states, in 
the laryngeal mechanism. 

Stammering is less an articulatory defect than 
a breath and voice defect. The ** silent sticks " of 
laryngeal origin of which Dr. Wyllie speaks are 
impossible of production while the stream of vocal- 
ised air is passing through the vocal gates. The 
stammerer must be taught to acquire control over 
his breathing muscles in speaking as complete as he 
has over the fingers of his hand, so that the con- 
tinuity of the motor power of voice is assured. 

If stammering were a delay of the laryngeal 
mechanism, or a speech defect, Dr. Wyllie 's 
** Physiological Alphabet " would be invaluable in 
the cure of certain forms of the trouble. His study 
of the alphabet and analysis of the pronunciation of 
letters are excellent, and of great assistance where 



46 THE TREATMENT OF STAMMERING, 

articulatory defect exists; but in the majority of 
cases of stammering, the defect being due to wrong 
methods of breathing and of vocalisation, drill of 
the mechanism of articulation alone has very little 
practical use, and had better not be attempted. 
Exercises having as their basis the incessant repeti- 
tion of those syllables and words which present a 
difficulty of pronunciation to the stammerer appear 
very often to increase, rather than to remove, or 
even to diminish, the difficulty, because they do not 
attack the cause of his speech obstruction. If, as is 
held by some writers on this subject, the flow of 
nervous energy lies along the line of consonant 
repetition, and if a man says b-b-b-b-bone, it is 
clearly evident that he is perfectly capable of saying 
the letter b, having repeated it five times. It is not 
j drill on any initial consonant or vowel which will 
j avail him. He gives himself, sorely against his will,y 
/Constant drill in saying initial letters, aggravating) 
)his trouble. Instead, therefore, of encouraging this 
superfluity of nervous energy in a wrong direction, 
by insisting upon the practice of consonant repeti- 
tion, it would surely be advisable to divert the over- 
flow into another channel, as a first step towards 
stopping it. 

Dr. Wyllie frequently refers to the necessity of 
attention to the production of the vocal element in 
speech, or, to quote exactly, *' the vocal mechanism, 



CLEFT-PALATE SPEECH, AND LISPING 47 

whose want of promptitude is the primary cause of 
the difficulty." It is matter for surprise that so 
accurate an observer should have overlooked the 
first and basic element in the production of voice — 
breath. He speaks of two mechanisms only — the 
laryngeal and the oral ; whereas, in all speech three 
mechanisms are employed : 

1st, That of breathing. 

2nd. That of tone production in the larynx. 

;^rd. That of the oral or word-making. 

Of these three mechanisms, faults of breathing /(/ 
are the primary cause of stammering, the laryngeal 
faults being secondary. 

The following quotation from an article of mine 
which appeared in Guy's Hospital Gazette puts the 
matter clearly : 

"The primary cause of stammering is want ofC 
co-ordination between the breath muscles and the 
vocal muscles ; the one or the other lags behind. 
The harmonious working together of the mechanism 
of the voice being thereby interrupted, the nerve 
centres in the brain, which govern their movements, 
spasmodically fail to control them. The conditions 
are frequently aggravated, perhaps sometimes in- 
duced, by blockage of the post-nasal passages, im- 
peding free intake of air. Such cases require 
medical aid before elocutionary treatment can be 
commenced. Exercises designed to re-establish the 



48 THE TREATMENT OF STAMMERING, 

exact and instantaneous co-ordination of the muscles 
are given ; their continual practice reacts on the 
motor nerve centres in somewhat the same way 
in which gymnastics and massage act in certain 
cases of paralysis. But, as no two persons stammer 
alike, it is necessary carefully to study the idiosyn- 
crasies of each case and to conquer individual dif- 
ferences before applying general principles. The 
various forms of speech obstruction appear to be 
reflex action, rarely requiring special attention, and 
disappearing as control is obtained over breath and 
voice."* 

The opinion that laryngeal spasm is not the cause 
but the effect of the antagonism in the mechanisms l_^ 
of speech, is amply proved by the experience of 
many years of practical work in the cure of this 
complaint ; the results having been attained mainly 
by giving attention to correct respiratory move- 
ments. 

Spirometer Records 

I have for many years kept records of the age, 
stature, vital capacity, and power of chest expan- 
sion before and after treatment. These records 
show that the vital capacity of stammerers is, in 
varying degree, always below their average; the 
chest girth and chest expansion being less by some 

* Mrs. Behnke : Guy's Hospital Gazette, July, 1897. 



CLEFT-PALATE SPEECH, AND LISPING 49 

inches than they should be for the age and height 
of each person ; the breathing being markedly 
** high chest," or clavicular. This invariable in- 
feriority of lung capacity and of chest girth in all 
cases of stammering, in patients of both sexes, of 
all ages, and of different nationalities, is a strong 
proof that errors of breathing are at the foundation 
of the trouble. 

In order that my readers may judge this im- 
portant point for themselves, I give below the 
records of the age, stature, lung capacity, and 
chest girth of one hundred patients, taken before 
and after treatment, in the order in which they 
came to me ; fifty being women and girls, and fifty 
men and boys. 



50 THE TREATMENT OF STAMMERING, 

WOMEN AND GIRLS. 





Age. 


( 


i 


Breathing Capacity. 










a V Q 


u 

5 ^ 


1 










.J 


J 














Ft. 


In. 


Cubic In 


Cubic In. 


Cubic In. 


Inches. 


Inches. 


Inches. 


' 


i6| 




31 


195 


235 


40 


33 


37 


4 


2 


34 




3 


91 


no 


29 


30 


3ii 


li 


3 


i5i 




4 


74 


i34i 


6oi 


26i 


30 


3i 


4 


28 




7 


60 


203 


143 


34 


37 


3 


5 


16 




4 


132 


146 


14 


3ii 


33i 


2i 


6 


18 




10 


154 


172 


18 


33 


38 


5 


7 


40 




9i 


113 


159 


49 


28 


3ii 


3i 


8 


22 




3h 


100 


114 


14 


3ih 


34i 


3 


9 


35 




n 


80 


lOl 


21 


29i 


32 


2i 


lO 


20 




9 


66 


148 


82 


3i| 


321 


I 


u 


26 






167 


183 


16 


34 


36 


2 


12 


30 




% 


91 


131 


40 


29^ 


3ii 


2 


13 


27 




9 


100 


ISO 


50 


33i 


34 


1 


14 


17 




5^ 


117 


156 


39 


3ii 


36i 


5 


15 


20 




6^ 


131 


143 


12 


31^ 


33i 


2 


i6 


16 




6| 


108 


160 


52 


27i 


30 


2| 


17 


I3i 




3i 


105 


175 


70 


294 


32 


2i 


i8 


15 




3i 


74 


121 


47 


26 


28i 


24 


19 


30 




5i 


107 


169 


62 


28 


29 


I 


20 


29 




3 


64 


IIO 


46 


29 


291 


1 


21 


24 




8 


no 


140 


30 


25 


29 


4 


22 


12 




I 


81 


123 


42 


25i 


27i 


2 


23 


14 




7i 


150 


176 


26 


30 


32i 


25 


24 


30 




8i 


65 


121 


56 


30 


3ii 


li 


25 


21 




oi 


57 


139 


88 


28 


30 


2 


26 


23 




71 




175 


44 


30 


33 


3 


27 


29 




9i 


81 


122 


41 


29i 


32^ 


3 


28 


18 




6 


90 


118 


28 


29 


31 


2 


29 


32 




I 


57 


98 


41 


32f 


35 


2i 


30 


22 




7 


113 


156 


43 


29 


3ih 


2i 


31 


24 




lOi 


149 


203 


U 


32 


34 


2 


32 


25 




3 


55 


123 


29 


32 


3 


33 


4b 




II 


61 


93 


32 


27 


51 


4 


34 


36 




4i 


180 


226 


46 


33 


351 


2| 


35 


18 




5 


112 


130 


18 


29 


3if 


2f 


36 


20 




6i 


8ii 


150^ 


69 


3i 


34 


3 


37 


16 




71 


40 


172 


132 


28I 


34 


5i 


38 


21 




6i 


136 


170 


34 


32i 


35i 


3 


39 


19 




4i 


135 


180 


30 


30 


32i 


2i 



CLEFT-PALATE SPEECH, AND LISPING 51 
WOMEN AND GIRLS— continued. 









Breathing Capacity. 


„ 


u 
















Ic" 




« 


>> 


>« 






Age. 


5 

C/2 


hi 


g Capacit 
after 
eatment. 


crease in 

Lung 

apacity. 


g 

2^ 


•S «J 


u 
a 








§ H 


§ H 


a ^ 


6 


U 










J 
















Ft. In. 


Cubic In. 


Cubic In. 


Cubic In. 


Inches. 


Inches. 


Inches. 


40 


28 


5 10 


130 


164 


34 


29 


30 


I 


41 


16 


5 H 


131 


190 


59 


30 


32i 


2i 


42 


24 


5 5 


134 


160 


26 


33 


33i 


4 


43 


31 


5 7 


«o 


144 


64 


314 


34 


3i 


44 


24 


— 


100 


143 


43 


29 


33 


4 


45 


28 


5 3 


160 


210 


50 


34i 


37 


24 


46 


13 


4 9 


'°^ 


140 


33 


28i 


30i 


2 


47 


32 


— 


98 


131 


33 


— 


— 


— 


48 


54 


— 


145 


160 


si 


33i 


34i 


I 


49 


22 


5 10 


122 


180 


34 


36i 


2i 


50 


30 


5 74 


117 


165 


48 


29 


32i 


3i 



MEN AND BOYS. 





Age. 




Breathing Capacity. 










IJ 


irt 

5 <-> 








ij 


h] 














Ft. In. 


Cubic In. 


Cubic In. 


Cubic In. 


Inches. 


Inches. 


Inches. 


I 


16 


S 5 


194 


351 


57 


31 


35 


4 


2 


I2i 


4 " 


80 


143 


^3 


29 


3oi 


i| 


3 


15 


5 6i 


151 


179 


28 


29 


31^ 


2i 


4 


17 


5 94 


129 


181 


52 


304 


344 


4 


S 


21 


5 "4 


205 


235 


30 


35 


38 


3 


6 


20 


5 H 


180 


225 


45 


33 


36 


3 


7 


17 


5 2| 


154 


184 


IS 


28I 


32 


3i 


8 


18 


6 2i 


170 


230 


26i 


294 


3 


9 


21 


5 5 


151 


172 


21 


30 


32 


2 


10 


18 


5 94 


137 


164 


27 


26i 


294 


3J 


II 


22 


5 8 


121 


ISO 


^ 


27 


294 


24 



52 THE TREATMENT OF STAMMERING, 

MEN AND -QOYS— continued. 





Age. 




Breathing Capacity. 


lest Girth before 
Treatment. 


SI 


si 




'hi 


g Capacity 
after 
eatment. 


crease in 

Lung 

apacity. 








§ H 


§ H 


a ^ 




U 










a 


-) 














Ft. In. 


Cubic In. 


Cubic In. 


Cubic In. 


Inches. 


Inches. 


Inches. 


12 


I? 


5 6 


107 


163 


56 


27i 


29i 


2 


13 


18 


5 7 


148 


180 


68 


3'f 


35 


3i 


14 


9 


4 2 


80 


lot 


21 


25i 


28i 


3 


IS 


25 


5 11 


123 


146 


23 


30 


32 


2 


16 


15 


5 7i 


102 


162 


60 


30I 


3.3i 


3i 


17 


21 


6 3 


19s 


290 


95 


32i 


34i 


2i 


18 


i3f 


5 6i 


139 


172 


33 


29 


32i 


3i 


19 


17 


5 7 


160 


190 


30 


29i 


3'i 


2 


20 


26 


5 11 


230 


285 


55 


36 


2>H 


2i 


21 


15 


5 4 


144 


166 


22 


29I 


3if 


2 


22 


18 


6 


158 


208 


50 


34 


36i 


2i 


23 


15 


4 8f 


84 


116 


32 


26i 


38i 


2 


24 


12 


4 8| 


96 


128 


32 


27 


30 


3^ 


25 


12 


4 10^ 


82 


145 


63 


27i 


30 


2i 


26 


12 


4 Si 


58 


84 


26 


26i 


27i 


I 


27 


24 


5 II 


48 


211 


163 


29 


33 


4^ 


28 


15 


5 li 


141 


i62i 


2il 


30 


35i 


5i 


29 


22 


5 Hi 


160 


204 


44 


39 


4ii 


2i 


30 


22 


5 9 


210 


234 


24 


29 


34 


5 


31 


33 


5 II 


150 


255 


los 


33 


37 


4 


32 


48 


5 II 


213 


270 


57 






4^ 


33 


24 


6 oi 


210 


279 


69 


— 


— 


3i 


34 


25 


5 4i 


184 


207 


1 


37 


38 


X 


35 


19 


6 i\ 


194 


230 


28 


32 


4^ 


36 


12 


4 7i 


81 


116 




26I 


27i 


li 


37 


17 


5 II 


138 


207 


69 


32 


33i 


li 


38 


21 


5 8i 


182 


20Si 


2li 


31 


33 


2 


39 


IS 


5 6i 


124 


201^ 


77i 


29 


31* 


2i 


40 


26 


5 8i 


200 


253 


53 


32 


35 


3 


41 


42 


6 


254 


262 


8 


29f 


32i 


3i 


42 


29 


6 3 


294 


304 


10 


32 


34 


2 


43 


39 


5 4 


179 


191 


12 


31 


34, 


3 


44 


41 


5 9i 


160 


209 


49 


3ii 


34l 


3i 


45 


22 


5 6i 


145 


155 


10 


29 


3ii 


2* 


46 


20 


5 9 


190 


220 


30 


29i 


32 


2I 


47 


21 


6 


206 


224 


18 


30 


33 


3 


48 


21 


6 oi 


126 


249 


123 


33 


3Sf 


2| 


49 


19 


6 I 


72 


188 


116 


33 


35 


2 


50 


24 


6 


136 


200 


64 


33i 


35i 


2 



CLEFT-PALATE SPEECH, AND LISPING 53 

In the first table the ages of the female patients 
were from 9 years to 54 years old. 

Breathing capacity was from 51 cubic inches, the 
lowest, to 195, the highest. 

The gain in lung capacity was from 12 cubic 
inches to 143 cubic inches. 

The increase in chest girth was from |-inch to 
5J inches. 

In the second table the ages of males when com- 
mencing treatment were from 9 years, to 48 years old. 

Breathing capacity Avas from 48 cubic inches, the 
lowest, to 294, the highest. 

The gain in lung capacity was from 8 cubic 
inches to 163 cubic inches. 

The increase in chest girth was from i inch to 
5 J inches. The patient who made the largest 
increase of lung capacity was a medical man, who 
stammered so badly that it was impossible for him 
to take a practice. When he commenced studying 
with me his lung capacity was only 48 cubic inches, 
but in a few weeks it had increased to 211 cubic 
inches. His chest girth also increased 4 inches. 
Before coming to me he had practised articulation 
drill for two years, with no good results to his speech . 

All the measurements of breathing were taken on 
the same instrument, and the chest girth with a 
surgical tape measure. 

The comparison of lung capacity on commence- 



54 THE TREATMENT OF STAMMERING, 

ment of treatment with the increase at the end of it, 
shows undoubtedly that the breathing of stammerers '> 
is very deficient. Their difficulties of speaking dis- 
appear as the breath capacity and control increase; 
another proof that the primary cause of the stammer !/^ 
lies in the respiratory mechanism, and not in the 
vocal or oral mechanism. 

The increase in chest girth in every patient is 
worthy of attention for reasons other than stammer- 
ing. The improvement was not confined to the 
youth of both sexes; for in males the ages of the 
recorded cases were from 9 years to 48 years, and 
in females from 9 years to 54 years. The results 
were obtained, for the most part, in about eight 
weeks, and in a few cases in a fortnight, the 
improvement in physique and in general health 
being marked. Army officers have frequently 
observed that the use of similar exercises would be 
an invaluable assistance in drilling their men. 

There is no doubt of their value for all classes 
and for all ages, if given by an experienced and 
judicious teacher. 

The correctness of the opinion that the primary 
cause of the stammer lies in the respiratory 
mechanism, and not in the vocal or the oral<^ 
mechanism, is further demonstrated by the tracings 
of the pneumograph. For the use of this instrument 
I am indebted to one of my pupils, Dr. Worthington, 



CLEFT-PALATE SPEECH, AND LISPING 55 

who kindly endeavoured to find me some means by 
which I could test the amount of contraction requisite 
for the large breathing-muscle — the diaphragm — for 
the purpose of my work. The instrument showed 
the extent of the movement, and also recorded 
irregularities and stoppages of the respiratory 
mechanism, giving a diaphragmatic picture of the 
checks and stops of voice which actually take place 
in a stammerer. 

Action of Breathing Musoles as shown by the 
X-Rays 

A few years ago, being desirous of obtaining 
some ocular demonstration of the actual movements 
of the great breathing muscle — the diaphragm — and 
of the intercostal muscles, my daughter and I made 
observations with the X-rays : * 

ist. In ordinary passive, automatic, natural 
breathing. 

2nd. In the larger requirements of voluntary 
active breathing for tone-making, for use in speak- 
ing and reciting, and in the greater effort to fill a 
large hall. 

3rd. In singing simple tones and phrases, in long 
sustained notes, in rapid passages of different dura- 
tion, and in staccato passages. 

^th. In stammering. 
* The Speaking Voice, Behnke. Curwen and Sons. 



S6 THE TREATMENT OF STAMMERING, 

The main object of the investigation was to 
ascertain if any fresh light or new fact could be 
deduced from it which would be of assistance in 
voice training; or, on the other hand, whether the 
accepted scientific views on the all-important matter 
of breath-taking and breath-control were contra- 
dicted in any particular. The result showed their 
entire correctness. 

It was quite easy to see the raising and widening 
of the lower part of the thorax corresponding to the 
expansion of the lungs as the air gradually filled 
them, more or less, according to the amount of air 
inhaled. If the air was exhaled slowly, as in normal 
breathing, the diaphragm gently ascended, the 
thorax slowly returned to its former position, and 
the lungs to their former size. 

When voice use was commenced the wonderful 
regulating and controlling power of the breathing 
muscles, the diaphragm and lower costals, was 
evident; at times, by will of the demonstrator, 
giving out the air column so slowly and gently that 
the muscles seemed hardly to move at all, while in 
a forte passage the return action was much stronger 
and the muscle tension greater. 

When the demonstrator, instead of controlling the 
exit of the breath by the great breathing muscles, 
used the muscles of the upper chest and throat, the C 
voice, whether in speaking or in singing, at once 



CLEFT-PALATE SPEECH, AND LISPING 57 

became ** breathy " with occasional false intonation, ^ 
and the tones became thinner and poorer in quality. 

In the production of staccato tones a short, dis- ^ 
tinct upward jerk of the diaphragm, with a corre- 
sponding abrupt movement in the lower thoracic 
walls, was seen. 

Passing on to the examination of stammerers — 
proceeding thus to the comparison of normal with 
abnormal breathing — we found that the X-rays fully 
confirmed the accuracy of our view that stammering 
is mainly due to faulty action and failure of co- 
ordination of the breathing and voice muscles. 

Diaphragmatic spasm and irregularities of the 
respiratory mechanism were clearly seen, thus 
corroborating the results of the pneumograph 
described in the previous pages. 

The Curability of Stammering 

Is stammering curable ? 

Undoubtedly it is curable under right conditions 
in all but a very few cases, such as those in which 
there is idiocy, lunacy, or epilepsy. ^ 

It must be clearly understood that the carrying^ 
of the cure of this distressful complaint to a suc- 
cessful issue lies in the hands of the stammerer 
himself. The teacher's work is to show him what 
to do, and to train him until he is thoroughly and 
practically acquainted with the method necessary 



58 THE TREATMENT OF STAMMERING, 

for his special case. This training should always 
be continued until there is no more difficulty in 
reading or talking under any circumstances. When 
this has been achieved and lessons are discontinued, 
the rest of the work lies with the stammerer himself. 
If he is negligent in carrying out the rules for con-L 
trolling his speech which he has been taught, he 
will, sooner or later, have a relapse, however per- 
fectly he may have spoken before leaving his 
instructor. It will be well if this fact is recognised, 
not only by all persons so afflicted, but also by their,:; 
relatives and friends. The patient will then fully 
understand that continued success in speaking 
depends upon the continuation of the method in 
which he has been trained, together with the control 
he voluntarily exerts over himself. 

Age is no bar to cure. I have had patients from 
the age of five — the youngest — to the age of eighty- 
one — the eldest. Very young children, if bad 
stammerers, have not sufficient determination or 
self-control to be able to help themselves; and as 
the cure requires the active, intelligent co-operation 
of the patients, it is usually better to defer treatment 
until they can themselves apply the rules given for 
their assistance. Some children are much more 
advanced than others ; these may begin quite young, 
especially if they have become conscious of the 
drawback their difficulty is to them, and ar^ 



CLEFT-PALATE SPEECH, AND LISPING 59 

desirous of getting rid of it. Some of the quickest 
cures have been effected in people of middle age, 
and in some who were considerably beyond it. 
Patience, perseverance, and conscientiousness in 
following the directions given are essential ; for- 
tunately these qualities can be commanded, or can 
be acquired, by every adult. 

Cleft-Palate Speech 

Next in importance to stammering comes the 
distressing, imperfect vocalisation and articulation 
caused by the deformity called Cleft Palate. 

The elocutionary treatment in these cases is the 
most difficult of all work for the correction of speech 
disorders. The difficulties are mainly due to the 
conditions which exist in the nasal passages above 
the palate, after the fissure in the hard palate has 
been united ; they also greatly interfere with the 
resonance of the voice as well as with articulation. 
One contributory cause is the high position of the 
hard palate in the mouth ; it encroaches upon and 
crowds the lower part of the air passages, of which 
it forms the floor, where the largest portion of breath 
passes; narrowing the air-space, and reducing to a 
minimum the co-vibration of the air in these 
chambers with the vocalised air in the mouth. It 
is probable that a considerable amount of feebleness 
and want of development remains in the upper air- 



6o THE TREATMENT OF STAMMERING, 

ways and in the naso-pharynx after the operation 
for closure of the palate, interfering greatly with 
the timbre of the voice and with the articulation of 
many letters and syllables, causing the snuffling, 
hollow sound which is so marked a feature in cleft- 
palate speech. 

Great improvement is effected by breathing exer- 
cises, which are specially devised to reach these 
parts via the nose; the repeated passage of large 
amounts of air through these partially blocked 
upper airways exerts a favourable stimulus on the 
respiratory tract, and helps to establish a healthy 
state of the nasal and pharyngeal passages. It is 
absolutely necessary to insist on breath being taken 
only through the nose. This is somewhat difficult 
at first to many of these patients ; but a little perse- 
verance will soon make it easy. 

Another prominent feature in cleft-palate speech 
is nasality of tone. It is distinct from snuffling, but 
both are usually present, although sometimes the 
one defective sound, sometimes the other, may pre- 
dominate. The nasality is caused by an imperfect 
and immobile soft palate ; and to the same cause we 
may, in a measure, attribute some of the poor 
quality of voice which is generally to be noticed in 
these cases. The fissure usually extends from the 
hard palate through the soft palate, completely 
dividing it ; but sometimes it is confined to the 



CLEFT-PALATE SPEECH, AND LISPING 6i 

latter part only, and the operation of uniting it 
often causes some amount of thickening and a 
resulting want of elasticity. Even when there is 
no thickening, the soft palate becomes semiparetic, 
through loss of the influence which nasal breathing 
exerts on its mobility. 

Sufferers from this trouble are as seriously handi- 
capped by the disagreeable vocal and articulatory 
difficulties following on cleft palate as are stam- 
merers by their difficulties of speech, perhaps even 
more so ; but they usually show very little nervous- 
ness or disinclination to talk, and appear not to 
realise the unpleasantness of their speech ; while 
stammerers generally dread to talk, and remain 
silent as much as possible. 

From experience with the speech education of a 
number of these patients, I find that the best results 
are obtained with those in whom the operative treat-' 
ment for closing the palates is performed as early 
as possible. Very much depends on the complete- 
ness of the closure in both palates, not only for 
success in articulation, but also in voice. 

A girl who was sent to me by her doctor was not 
operated on for closure of the cleft palate until she 
was fifteen years old; and she was not brought to 
me for treatment of the speech difficulty until she 
was nineteen years old. It had been impossible 
entirely to close the hard palate; an aperture as 



62 THE TREATMENT OF STAMMERING, 

large as a pea had been left in the centre of the roof 
of the mouth, through which the air taken into the 
nose came into the mouth, thence finding its way 
through the larynx and windpipe into the lungs. 
This was not only a serious hindrance to aeration 
of the naso-pharynx by breathing exercises, but also 
to the correct pronunciation of several letters; and 
it was impossible entirely to overcome the nasality 
which is one of the characteristics of these cases. 
By the careful employment of various devices for 
obtaining control over the articulatory processes, 
much improvement was effected; but if the opera- 
tion on the palate had been performed in early 
childhood, it would probably have been possible to 
close the cleft completely, and the speech would 
have greatly benefited thereby. 

In contrast to this is the case of another girl, now 
in her nineteenth year, who can speak so well that 
no one can detect the slightest abnormality in voice 
or in articulation. The palate was beautifully united 
in childhood, and she was sent to me by her doctor 
when about eight years old. She took lessons 
regularly for a year, afterwards coming again 
occasionally if her parents thought there was a 
little falling-off in her speaking. 

There is great difficulty in speech education 
whenever the cleft is left unclosed until the patient 



CLEFT-PALATE SPEECH, AND LISPING 63 

has reached thirteen or fourteen years of age; the 
best resuhs being obtainable if the closure is effected 
quite early in childhood, and the elocutionary work 
commenced at about eight years of age. 

The surgical treatment of cleft palate has made 
great advances of late years. The symmetry of the 
mouth is rendered more nearly perfect than formerly 
by the greater skill and experience of the operators. 
This makes it possible to do much more on the 
elocutionary side of the work. The teacher must, 
however, carefully notice all divergences from the 
normal in the internal configuration of the mouth ; 
and when these divergences are such as to interfere 
with clear speech careful study is required in order 
to suggest adaptations of mouth positions for the 
correct pronunciations of those letters and words 
which are unintelligibly pronounced owing to the 
malformations. 

Occasionally, in closing the upper jaw, a space is 
unavoidably left where a tooth should have come, 
making it impossible to get the true sound of certain 
letters, as 5, c soft, sh, and z. A single artificial 
tooth can sometimes be inserted to fill the vacant 
space, with excellent results on the pronunciation 
of those letters. It happens occasionally that the 
missing tooth comes through into the middle of the 
hard palate, interfering greatly with almost every 



64 THE TREATMENT OF STAMMERING, 

word the patient says, making the tongue rough 
and sore, and the speech quite unintelligible to 
strangers. In some recent cases of mine this 
happened ; and I had a little difficulty in persuading 
the parents to allow a dentist accustomed to such 
cases to extract the tooth. After its removal each 
child made excellent progress in speaking clearly 
and distinctly. 

When there is entire absence of the soft palate, 
it is advisable to have an artificial one of thin, 
pliable gutta-percha, attached to a small dental 
plate. This arrangement has answered very well, 
with some of my patients, for nearly all letters but 
hard g, the closure for that letter taking place a 
little lower down in the throat than the artificial 
velum can reach. When there is only a portion of 
the soft palate — also when it is slightly paretic, stiff, 
and immovable — exercises must be given to over- 
come the difficulties of these conditions, care being 
taken never to continue the practice to the point of 
local fatigue. 

If there has been hare-lip as well as cleft palate — 
the fissure extending along the whole of the hard 
palate, severing the upper jaw and also the upper 
lip — the lip is sometimes a little shortened by the 
operation for closing it ; or the muscles are inelastic 
and stiff. In this condition the pronunciation of 
labials, 6, />, and m, is the most unfavourably 



CLEFT-PALATE SPEECH, AND LISPING 65 

affected; w and y, as pronounced in the alphabet, 
are difficult in a lesser degree. 

But the greatest difficulties to overcome are the 
snuffling, the nasality, the absence of nasal 
resonance, and the pronunciation of the throatal 
letters fe, q, and c and g hard. All of these troubles 
are the result of the undeveloped condition of the 
upper respiratory passages, and in particular of the 
naso-pharynx ; and also of an imperfect soft palate 
and uvula, which latter are not sufficiently mobile 
to fulfil their work of closing off the nasal passages 
from the mouth, and of assisting in the articulation 
of the letters mentioned above. 

Nasal tone is caused by the vocalised air going 
out through the nose instead of through the mouth. 
I am aware that many persons hold a precisely 
opposite opinion ; but the truth is so easily demon- 
strated that anyone can satisfy himself on the 
subject without special knowledge. For example : 

** Close the nostrils completely, and sing ah, 
when you will find you can produce pure vocal tone. 
Or try this experiment : Take a thin mirror and 
hold it flat against the upper lip with the glass 
upwards. Sing a pure vocal tone, and the mirror 
will remain perfectly bright. Sing, on the contrary, 
with nasal quality, and the mirror will at once be 
completely dimmed. This shows conclusively that 
nasal sound is produced by singing through the 

5 



66 THE TREATMENT OF STAMMERING, 

nose, and this cannot be done without lowering the 
soft palate."* 

In cleft-palate cases the soft palate is always more 
or less inelastic and immovable. In its normal state 
this little movable partition acts like a curtain. We 
can drop it on the back of the tongue, thereby com- 
pelling the tone to pass through the nose, and thus 
giving it nasal quality. This nasal quality increases 
the more the passages through which the tone has 
to travel are impeded. Raise the soft palate, and 
you may completely shut the nostrils and vet pro- 
duce a pure vocal tone ; because with the soft palate 
up, the nose is shut off from the throat, thereby 
compelling the tone to pass through the mouth. 

It is this absence of the action of the soft palate 
in cases of cleft palate which causes the nasality. 
Sometimes there is very little of the soft palate left 
after the operation, and it is too short completely to 
shut off the nose from the throat. In others the 
edges are very thick, and occasionally the closing 
seam has destroyed its power of movement; but it 
is astonishing what can be done by educative 
measures to restore its functions. 

In the educational work for voice and speech in 
cleft-palate cases, it must always be remembered 
that "use brings function"; therefore no pains 

* Mechanism of the Human Voice, i8th edition, p. 60, 
Behnke. 



CLEFT-PALATE SPEECH, AND LISPING 67 

should be spared to devise exercises which shall 
bring about the power of using the various muscles 
employed in voice and speech in a manner as nearly 
as possible approaching to that which is natural to 
persons unafflicted with cleft palate and its results. 
The sort and degree of movement requisite will 
probably vary with each patient — at least, this has 
been my own experience ; but it is extremely interest- 
ing to watch the growth of facility in using the 
different muscles, and their adaptability for un- 
accustomed use. Nature is wonderfully accommo- 
dating if we know how to manage her. 

LaUing 

Lalling is the name given to the unintelligible, 
imperfectly formed efforts at speaking of little 
children. It is also used to designate the imperfect 
speech of imbeciles. Sometimes these imperfections 
of speech are retained long after the time when the 
child should have spoken the words in its limited 
vocabulary clearly. It is then the duty of its parents 
to ascertain the cause of this delay in speech develop- 
ment. It may be the result of malformation of the 
throat, tongue, or mouth, or of word-deafness, 
which latter trouble would prevent the child from 
hearing the pronunciations of some words with 
sufficient clearness to imitate them. 

Grown-up people who are much with the child 



68 THE TREATMENT OF STAMMERING, 

should invariably speak with accuracy and distinct- 
ness, employing simple words as far as possible; 
and they should use every endeavour to teach the 
little one to speak correctly, never imitating its 
*' baby talk." Why should the poor child be put 
to the trouble of first learning this " baby talk " and 
afterwards having to learn entirely different words 
for the same object ? For instance, gee-gee for 
horse ; moo-cow for cow ; baa-lamb for lamb ; bow- 
wow for dog, and so on. Each of those "baby- 
words " is a dissyllable, requiring two movements 
of the voice and of the articulatory processes to 
produce it; yet, when learnt, the child finds that 
the animal he has been taught to call a gee-gee is a 
horse, and so on, to the confusion of his little brain. 
When lalling proceeds from imbecility, the child 
should be placed under the care of a medical prac- 
titioner who specialises in such cases. 

Lisping 

Lisping is an imperfect way of pronouncing the 
letter s, usually occasioned by wrong position of 
the tongue; sometimes also by defective shape of 
the hard palate. In the simple and commonest form 
of lisping the sound th is substituted for s, because 
the tip of the tongue is put either between the upper 
and lower teeth or against them. In a few cases, 
the fraenum, or muscle of attachment of the tongue 



CLEFT-PAL'ATE SPEECH, AND LISPING 69 

to the bottom of the mouth, is too short to permit of 
raising the tip of the tongue sufficiently high to 
reach the proper position against the roof of the 
mouth for s. If exercises for stretching the cartilage 
and making it pliant fail in their object, it will then 
be necessary to call in the aid of a surgeon to snip 
the muscle so as to allow freer movement of the 
tongue. When this little cut has quite healed, daily 
practice in the right pronunciation of the letter will 
overcome the habit. It is easy to correct this sort 
of lisp in childhood; but some parents think the 
child "will grow out of it," and they take no 
trouble in the matter ; therefore the habit increases, 
and gives much trouble in after years. The lisp 
frequently commences at the time of shedding the 
first teeth, when a gap is left in front of the mouth, 
through which the tip of the tongue protrudes in 
the endeavour to say s; it becomes almost impos- 
sible not to substitute th for s, as thay for say, yeth 
for yes, etc. The habit being thus formed, it is neces- 
sary to watch the effect of the second teeth on the 
mispronunciation. Sometimes the lisp rights itself, 
but it often remains, unless definitely corrected. 

The tip of the tongue should not touch the teeth 
or gums in saying a pure s. The front of the 
tongue becomes spoon-shaped, with the tip a little 
depressed, and the edges at the sides slightly turned 
up, just as in a dessert-spoon. These turned-up edges 



70 THE TREATMENT OF STAMMERING, 

touch the upper gum close against the teeth; the 
breath is thus forced into the narrow groove between 
the turned-up edges of the tongue, and the hissing 
sound of s is made. It is more or less acute and 
sharp, or dull and muffled, according to the extent 
of approximation of the edges of the tongue against 
the gums. The s sound can be made peculiarly 
aggressive and unpleasant; and as it is constantly 
recurrent in our language, it is worth taking trouble 
to learn to say it well. A very little patience and 
perseverance will enable anyone to conquer this sort 
of lisp, unless it is caused by malformation of the 
mouth, such as abnormal height of the palate, or 
its narrowness, or to faulty position or absence of 
teeth. Even with these drawbacks, it is often pos- 
sible to acquire correct pronunciation of the letter. 

The other form of lisping is caused by sending 
the breath forcibly through the side teeth, causing 
a disagreeable, bubbling sound. The tongue, in 
these cases, is generally too thick and too large for 
the mouth. Various exercises which I have devised 
for acquiring control of the tongue and for reducing 
its size are described in The Speaking Voice* and 
have proved very useful ; but this sort of lisp takes 
much longer to eradicate than the first one described, 
and can seldom be overcome without special exer- 
cises. 

* Mrs. Emil-Behnke, loth edition, Curwen and Sons. 



CLEFT-PALATE SPEECH, AND LISPING 71 

One of our bishops refused ordination to a can- 
didate on account of this aggressive, bubbling lisp. 
The Principal of the young man's college asked 
me to see what I could do to remove the trouble. 
Fortunately the lisper was most intelligent and 
persevering in carrying out instructions, and in 
three weeks could pronounce every s perfectly. He 
has since been ordained, and has had no recurrence 
of the difficulty. 

There are many minor forms of speech disorders, 
such as the substitution of w for r, or forming the r 
with the root of the tongue instead of with the tip ; 
the substitution of v for th, as farver for father, wiv 
for with; dropping the final g — as lazy and bad a 
habit as dropping the h — and so on. But the worst 
of all is the horrible mispronunciation of the vowels 
heard amongst the populace of our large towns, as 
disagreeable to hear as cleft-palate speech. These 
being faults of careless pronunciation rather than 
defects of speech, do not require detailed explana- 
tion, and, moreover, are fully dealt with in The 
Speaking Voice, 



PART III 
BY KATE EMIL-BEHNKE 



PART III 

From a lifetime of intimate association with the 
treatment of stammering emerges the unmistakable 
fact that, be the contributory factors in stammering 
what they may, its root cause, in all except such as 
is acquired by imitation, is to be found in some 
nervous derangement. This may be a matter of 
inherited neuropathic tendency; or of definite ner- 
vous instability ; or it may have been caused by 
some shock to the nervous system. But it is im- 
probable that such shock would have induced stam- 
mering had not the sufferer been of a neuropathic 
constitution ; and it is equally improbable that any 
of the factors mentioned in the foregoing pages — 
bars though they are to cure, and essential as is 
their removal to ensure a successful issue of speech 
treatment — would have contributed to stammering 
without the nervous diathesis. 

Thus stammering must be regarded as a nervous 
disorder, and every effort must be made to reach 
the psychic causes, tranquillise and stabilise the 
nervous system, and treat the stammer by breathing 
exercises and re-education of the muscles of speech. 
No greater mistake could be made than, on the one 
hand, to treat the stammerers with harshness or 

75 



76 THE TREATMENT OF STAMMERING, 

severity, or, on the other hand, to ignore the trouble 
and expect that the sufferer will grow out of it. 
For one who does so there will be ninety-nine who 
do not, and for whom life will be little short of 
misery in consequence. Systematic treatment must 
be carried out, hygienic conditions of life insisted 
upon and the general health carefully watched and 
any departure from the normal attended to without 
delay. It is extraordinary what a variety of causes 
not seeming to have the least connection with stam- 
mering may act as contributory or exciting factors, 
either in starting it in the first place, or tending to a 
return of it if the general health be not kept up to 
the mark. 

In many cases that have come under my notice 
stammering has commenced in childhood after an 
illness, such as whooping-cough or measles, and in 
some instances asthma is stated to have caused it, 
The association of asthma and stammering con- 
stitutes the most difficult class of case to deal with. 
Much depends of course on how bad the nervous 
factor is, and also upon the degree of emphysema 
and spasm which exists. In many such cases, how- 
ever, not only has the stammer been entirely over- 
come, but the asthma has also benefited materially 
through the breathing exercises and treatment of 
the general nervous conditions. 

In a recent case of mine, that of a girl of sixteen, 



CLEFT-PALATE SPEECH, AND LISPING 77 

a bad stammer commenced in childhood after acute 
colitis. Diaphragmatic spasm and tremor were 
very marked, with great difficulty in words begin- 
ning with consonants. Speech, even when the 
patient spoke without stammering, was extremely 
jerky, and the stammer was accompanied by con- 
siderable grimacing, the tongue frequently being 
rolled out in a condition of spasm and contortion. 
A curious feature of the case was that there was 
little or no apparent nervous factor, the stammering 
seeming to have been caused solely by the upset to 
the system of unusually acute colitis. There was 
also a slight lateral spinal curvature with marked 
rigidity in the lower dorsal and upper lumbar 
regions, and considerable lack of balance and mus- 
cular co-ordination. These physical irregularities 
were attended to by a medical gymnast while the 
speech treatment was being carried out, and the 
results were in every way most excellent. 

Spinal Irregularities 

I find some form of spinal curvature in 80 per 
cent, of my cases, very frequently accompanied by 
knock knees and flat feet; and even when there is 
no lateral curvature there is more often than not a 
marked lordosis with rigidity in the lower dorsal 
and upper lumbar vertebrae. I am quite convinced 
by long observation of such cases that this rigidity 



78 THE TREATMENT OF STAMMERING, 

has a bearing on nerve tension and irritation in 
relation to stammering which it is impossible to 
over-estimate, and my view is confirmed by the gain 
in ease and freedom, with corresponding benefit to 
the speech, when this is corrected. Knock knees 
and flat feet, with their concomitant of faulty dis- 
tribution of weight, also contribute materially to, 
and in some cases are the primary cause of, the 
faulty balance and general lack of co-ordination so 
frequently found in stammerers ; while the flattened 
ribs in scoliosis, impeding as they do expansion of 
one lung, and bringing about torsion of the dia- 
phragm, are amongst the causes of the characteristic 
spasmodic irregular breathing of the stammerer. In 
some cases I have found that a depressed sternum 
has been a serious factor in the stammer. 

An instance of this was the child of a medical 
man, a boy of nine and a half, who stammered so 
badly as to be absolutely unintelligible to all but his 
own people, and whose efforts to speak were so 
great as to leave him completely exhausted. The 
sternum was so much depressed that a good-sized 
walnut could be placed in the cavity — great pressure 
was caused on the heart, with consequent consider- 
able degree of cyanosis. By means of carefully 
graded breathing exercises the depressed sternum 
was gradually corrected, and as the respiratory 
power developed and spasm ceased the stammer was 



CLEFT-PALATE SPEECH, AND LISPING 79 

overcome. The boy, who was undersized and poorly 
developed, then commenced to make normal growth. 
I find it more satisfactory to have any medical 
gymnastic treatment that may be required for such 
cases carried out under my immediate supervision, 
in close co-operation with my treatment of the speech 
defect, and I have for some time had a medical 
gymnast working in conjunction with me for this 
purpose. Even where there is nothing in the nature 
of spinal or other definite physical irregularity I 
find that in most cases medical gymnastics are of 
great value in combination with the speech treat- 
ment. Balance and general co-ordination of move- 
ments are usually faulty in stammerers ; the jerkiness 
and lack of rhythm which are characteristic of their 
speech being more often than not also found in all 
their physical activities ; and the establishing of 
correct speech habits — the result of delicate complex 
co-ordination of many different types of muscle 
actions, which we are practically unconscious of 
when they are functioning normally — is materially 
assisted by graded resistive movements and training 
in co-ordination and balance. 

Mental Shook of Fright 

I Stammering is more frequently the result of 
( shock or fright in childhood than is usually recog- 
nised, and is the most difficult type to overcome. 



8o THE TREATMENT OF STAMMERING, 

Parents are often unaware that any shock has 
occurred, the fact only coming to light after a lapse 
of time; and they are therefore completely at a loss 
to understand the sudden development of a stammer. 
Under these circumstances the tendency is to expect 
the stammer to depart as suddenly as it came, 
whereas the longer treatment is deferred the more 
deeply rooted does the trouble become. Moreover, 
where it has been caused by a shock of any kind 
an apprehensive habit of mind in the sufferer be- 
comes established, and not only does this exist in 
relation to the stammering itself, but apprehension 
of disaster of any kind, of bodily injury, acute 
distress at sudden noise, are also frequently present, 
and any mischance that may befall the stammerer 
will cause bad fits of stammering. 

An interesting case of stammering that developed 
after an accident was that of a boy who fell out of 
a window, a drop of some thirty feet, on to hard 
ground. He had concussion of the brain, was for 
a considerable time unconscious, and on recovering 
consciousness commenced to stammer violently. 
The stammer became habitual, though varying in 
intensity, always being worse under any conditions 
of nervousness. 

Before the accident he was apparently quite 
normal in every way, and in the opinion of his rela- 
tives not of a nervous disposition. This view, how- 



CLEFT-PALATE SPEECH, AND LISPING 8i 

ever, must be accepted with reserve, as in early 
childhood a nervous diathesis is not always recog- 
nised unless circumstances arise which bring the 
child under expert observation. 

In this case not only was the action of the muscles 
of respiration and articulation spasmodic in the 
extreme, but muscle action in general was spas- 
modic, balance and co-ordination were very poor, 
and he was quite incapable of carrying out any 
smooth slow movements. 

Had the psychic factor been treated when the 
stammer first developed after the accident, on the 
lines of the psychotherapy which has been so suc- 
cessful in shell shock, the trouble would probably 
have been overcome ; but the too prevalent idea was 
acted upon that the boy would grow out of it, 
instead of which by the time he was brought to me, 
some four years later, he had grown into it : nervous 
apprehension in general had assumed formidable 
proportions, and incorrect, jerky muscle action had 
become firmly established. One or two attempts 
had been made by ordinary elocution lessons to 
improve the speech as the boy grew older, when the 
relatives realised that he was not '* growing out of ** 
the stammer, attempts foredoomed to failure unless 
the psychic factors were also treated and certain 
adverse physical conditions attended to. The latter 
I found to be not inconsiderable, consisting of a 

6 



82 THE TREATMENT OF STAMMERING, 

deflected nasal septum, latent spinal curvature, wing 
scapula, a bad rigid lordosis, knock knees and 
flat feet. 

The nasal obstruction was by my advice surgic- 
ally corrected, and the boy found considerable relief 
in his speech therefrom, but the relatives did not 
see their way to having the other matters attended 
to while he was under me for his stammer, taking 
the view, against my advice, that it would be time 
enough for this to be corrected by the school medical 
gymnast when he left me. Subsequent events fully 
demonstrated the unwisdom of this decision. All 
the muscular movements of ordinary daily activities 
were so jerky and erratic as to render very difficult, 
if not actually impossible, acquirement of the con- 
trolled breathing, and co-ordinated rhythmic action 
of the finer muscle work that go to produce speech. 

This was proved by the fact that, whereas he was 
able to speak perfectly when lying down, or when 
sitting in a correct position with the weight sup- 
ported in a reclining chair, he stammered violently 
when attempting to talk whilst walking or standing. 

His treatment with me was brought to a prema- 
ture close by the sudden death of a near relative, 
and he went to public school still under the handi- 
cap of his stammer. 

There is little doubt that, had medical gymnastic 
treatment been combined with the speech training. 



CLEFT-PALATE SPEECH, AND LISPING 83 

as I advised, the trouble would have been com- 
pletely eradicated even in the much reduced time 
he was with me. 

I mention this case because I do not think it is 
sufficiently realised how many possible contributory 
factors there may be in stammering which must be 
attended to, either before or during the speech 
training (according to the nature of the particular 
factor) in order to ensure success. 

Another case of stammering following nervous 
shock was that of a girl of sixteen who had de- 
veloped the trouble after fright occasioned at the 
age of five and a half by a tramp snatching a locket 
from her neck. She stammered badly to strangers, 
and to her own people in moments of excitement. 
I found here a slight nasal obstruction, so slight 
that I did not anticipate it would be any factor in 
the stammer, and as her parents feared the effect of 
a visit to a surgeon on her extremely nervous 
temperament, I decided to commence speech treat- 
ment without seeking medical aid first — as is my 
custom in such cases. Her progress, however, did not 
satisfy me and my advice was then followed and the 
nasal obstruction removed, after which the stammer 
yielded satisfactorily to the speech treatment. 

It is certainly extraordinary how slight a patho- 
logical condition may hinder success, but my ex- 
perience confirms this time after time. Even an 



84 THE TREATMENT OF STAMMERING, 

elongated uvula may be a sufficient adverse factor, 
and frequently when it has been thought unneces- 
sary to have it shortened and subsequently it has 
been decided during the course of treatment with 
me to have it attended to, the gain in freedom of 
speech and ability to respond to the exercises has 
been immediate and unmistakable. 

The EflPect of the War 

The effect of the war upon children is common 
knowledge. Even here in England, where the 
privations were infinitesimal compared with those 
endured on the Continent, the results physically 
from insufficient vitamines, fats, sugars, etc., were 
obvious; but who shall estimate the effects on the 
nervous system of a child, of the anxiety and 
anguish of its mother, and of actual nerve shock 
from air raids ? 

Who can estimate how far-reaching may be the 
effect upon young children roused from sleep again 
and again, often many nights in succession, and 
taken downstairs to shiver with anticipation of the 
deadly shattering terror that approached : to say 
nothing of the hundreds who nightly slept hour 
after hour in the foetid atmosphere of the Tubes? 
Who that saw this can doubt that the results ner- 
vously must be incalculable and possibly inefface- 
able? 



CLEFT-PALATE SPEECH. AND LISPING 85 

) I had many cases of stammer in children directly 
caused by air raid shock, and found them always 
accompanied by a high degree of nervousness and 
nervous apprehension. 

Apart from actual causation of stammer, there is 
no doubt that even outside the air raid areas the 
anguish and nervous tension that the whole nation [ 
was living under reacted on the children, and I \ 
think we are far from having lived it down yet. ' 
Certainly in my work in connection with the treat- 
ment of speech defects, I find a much higher degree--^ 
of nervousness than formerly. 

Hopes have been entertained that the psycho- 
therapy which was found so successful in the treat- 
ment of shell shock would be equally successful in 
the treatment of stammering in general, but in 
the main these hopes have not, I think, been 
realised. 

Where a stammer, caused by shock, can be treated 
soon after it manifests itself, before wrong muscle 
action has become established, this would clearly 
be the right method to adopt, but where breathing 
is insufficient or spasmodic, and where co-ordination 
is faulty, muscle re-education and patient training 
in rhythmic co-ordination will be necessary. 
Naturally psychic re-education will be equally 
necessary, but cure cannot be expected from this 
alone where wrpng muscle action has become a 



86 THE TREATMENT OF STAMMERING, 

habit. It is a mistake, in my opinion, to deduce 
that only the psychic element requires treatment 
because in so many cases a person who stammers 
badly at times will speak on other occasions with- 
out stammering. If the speech of a stammerer be 
analysed, it will be found in most cases, even when 
he is at his best, always to have in it the elements 
of the defect; that is, faulty respiration, jerky 
delivery, and unduly short vowels. It only requires 
the spark to the magazine of nervousness or excite- 
ment to convert this into a stammer. 

Influence of Prevailing Habits of Speech 

It is, therefore, not sufficient to be satisfied with 
removing the stammer; really good speech habits 
must be acquired and the stammerer's tone per- 
ceptions must be awakened. He must aim not 
merely to speak as well as most normal persons 
but a great deal better. He must take a pride in 
speaking his own language beautifully and must 
not be content with the slipshod clipped mutilation 
of our noble English that prevails. 

The Auto-suggestion of the New Nancy School 
must without doubt be materially assisted in its 
application to stammering by the high standard of 
speech that obtains in France. Continuity of tone — 
that sine qua non for the stammerer — is automatic- 
ally ensured by the liaison, and further reinforced 



CLEFT-PALATE SPEECH, AND LISPING 87 

by nasal resonance, which is absolutely inherent in 
the French language, and conspicuous by its absence 
from the English language, or rather, from the 
English language ** as she is spoke.'* 

The subconscious mind of the Frenchman has 
registered good speech, and, moreover, speech of 
the kind most calculated to assist in overcoming a 
stammer. This fact should be borne in mind when 
results obtained by the New Nancy School in this 
respect are being considered. 

Undoubtedly the careless, slovenly speech which 
is heard on all sides in England makes it much 
more difficult for a stammerer to conquer his defect 
than it need be. All those associated with him 
should do their best to speak deliberately, smoothly, 
and distinctly. They can in this way render great 
assistance. 

It is further very wise that after the speech defect 
has been overcome the stammerer should -take up 
the study of singing or elocution, preferably, if 
possible, under the same teacher who has treated 
the stammer. In this way control is obtained of 
the muscles used in the production of the voice 
which will be invaluable and which will give him 
the confidence born of knowledge and the sureness 
arising from trained muscles which by systematic 
exercise have been brought under the control of the 
brain ^nd consequently will no longer be liable to 



88 THE TREATMENT OF STAMMERING, 

be upset in their correct functioning by any assaults 
of nervousnesss. 

Confidence will still further be established as the 
pupil progresses in his study of normal voice use 
by discovering that he can give pleasure by per- 
formance — which the teacher will encourage him to 
do — a change in his whole attitude towards life in 
association with his fellow-men the psychic bearing 
of which is impossible to over-estimate. 

General Health 

It is essential to attend to the general health of 
a stammerer. ** Coddling '* or fussing should be 
avoided, but healthy conditions of life must be 
insisted on. Plenty of exercise in the open air, 
plenty of sleep, avoidance of late hours, crowded 
rooms and excitement, these are all essential. A 
careful diet should be carried out. Rich foods 
should be avoided and meat should be taken in 
moderation ; indeed, some stammerers do better on 
fish in place of meat. '* Sloppy '* foods, rich pud- 
dings and pastry should be avoided, and starch 
food in general should be cut down as much as pos- 
sible. Sweets — particularly chocolates — should not 
be permitted; condiments, pickles, sauces and the 
like are better avoided altogether. Wine and spirits 
should never be taken ; tea and coffee sparingly, and 
not strong. Mastication should be thorough. 



I 



CLEFT-PALATE SPEECH, AND LISPING 89 

Stammerers, as is so frequently the case with ner-r^ 
vous persons, are inclined to bolt their food, and 
the resultant indigestion upsets breath control. A 
bad attack of indigestion has frequently caused a 
relapse in a stammerer. 

A diet rich in vitamines is essential, and a good 
plan is to make one meal a day as far as possible of 
uncooked foods such as wholemeal bread and cheese, 
salad — with good olive oil and lemon juice instead 
of vinegar — and plenty of fresh fruit. Raisins or 
honey can be taken at this meal. These give the 
necessary sugar in an easily assimilable form, and are 
valuable nerve foods. For adults such a meal would 
be best at midday, and it will be found that it is 
much easier to work after than after a meal of 
cooked foods. For children, whose chief meal is 
usually the midday one, it will probably be best as 
the last meal of the day. Nervous children will 
sleep more quietly and be less likely to dream after 
a meal of ** raw '* foods such as these than after one 
of cooked foods. 

Hurry and worry should be avoided. Stammerers 
should not lie in bed in the morning till the last 
minute and then dress in violent haste, go to break- 
fast late and discomposed, bolt their meal, and rush 
off to work. The whole day goes wrong, and many 
a bout of bad stammering has its origin in an early 
morning scramble. -"A stammerer should always 



90 THE TREATMENT OF STAMMERING, 

feel that he has ample time for everything that he 
has to do. Few things are more likely to upset his ( 
self-control than the feeling that he is keeping { 
others waiting, either in speech or action. 

Undoubtedly an outdoor life is best, and where 
this is not possible, recreation should be in the form 
of outdoor amusements. Exercise should be taken 
in all weathers, and not only should Saturdays and 
Sundays be spent in the open air, but a daily walk 
throughout the week should be insisted upon. 
Young people who go into business on leaving 
school, or take up work of a sedentary nature, 
frequently suffer very much from the cessation of 
regular outdoor games, and a great deal might be 
done to counteract this by forming the habit of 
walking part of the way to and from work. When- 
ever possible the walk should be through park or 
recreation grounds, or along the Embankment, or 
where no such open spaces are available, quiet by- 
streets should be chosen rather than the crowded, 
noisy main streets. 

Influence of Noise upon the Nervous System 
I have long been convinced that noise has a very 
prejudicial effect on the nervous system, and T have 
frequently noted its adverse influence on stammerers 
of a nervous type. It is, therefore, of interest to 
mention that this view has recently been corroborated 



CLEFT-PAUATE SPEECH, AND LISPING 91 

scientifically. It used to be thought that people 
became accustomed to noise, but it has now been 
demonstrated that we actually expend nervous 
energy in ** refusing to hear." Instruments have 
been devised which give approximate values for the 
energy expended in not hearing noises of various 
kinds, from which it is clear that dwellers in large 
towns are perpetually expending nerve force in this 
way unnecessarily. This naturally reacts seriously 
on those who are of a nervous disposition, added 
to which, in the case of stammerers, is the actual 
expenditure of physical effort in trying to speak 
against noise. Some idea will be formed of this 
wastage of energy when it is recalled how loudly 
people coming to the country from towns are 
noticed to be speaking when they first arrive. It is 
also noticed that they cannot at first rest. They 
rush about feverishly, making excursions, seeing 
sights, and so forth, and frequently only after 
several days can they relax and rest. 

The noise of the screeching shell and the thunder 
of the big guns were as great a factor in the shatter- 
ing of the morale as the fear of bodily injury. 

So we see that where stammering is of nervous 
origin, everything in the daily life of the individual 
which has an adverse influence on the nervous con- 
dition must be legislated for. 



92 THE TREATMENT OF STAMMERING, 

Importance of Establishing Good Conditions 
of Life 

It by no means follows that this necessarily means 
a life of deprivation, still less that it implies a 
constant "fuss,'* or conscious arrangement, of what 
is or is not permissible. Where the patient is a 
child, or in early youth, the parents or guardians 
can for the most part control, or at least improve 
materially, the conditions of life ; and in the case of 
an adult, or one old enough to realise the drawback 
of stammering, there will be every incentive to co- 
operate in avoiding everything which may be preju- 
dicial to cure, and reward soon comes, not only in 
overcoming the stammer, but in the increase of 
well-being, of capacity for enjoyment, of self- 
control and competence due to a higher degree of 
nervous stability. 

Treatment 

There is nothing to add to what has been said in 
Parts I. and II. on the matter of the treatment of 
stammering. It is not possible to give more than 
an outline of the general principles. Their applica- 
tion must necessarily vary in accordance with the 
history, nature of the trouble, and nervous condition 
of the individual, and it is useless to expect that 
directions for cure can be given in a book or by 



CLEFT-PALATE SPEECH, AND LISPING 93 

correspondence. It is essentially a matter for 
personal instruction, and in many cases the close 
co-operation will be required of medical man, 
medical gymnast, and speech specialist. 

Stress has purposely been laid on the bearing of 
the nervous condition, and of any adverse health 
conditions, upon stammering in order to combat 
the still too prevalent view that the patient will 
" grow out " of the trouble, or that he could speak 
properly if he were not " careless." It is incredible 
to anyone who, like myself, is concerned with the 
treatment of this distressing malady that either 
view should be entertained, particularly where the 
position and education of the parents are such as to 
warrant the expectation of better judgment, as in 
two cases which recently came under my notice. 

The first was the son of a medical man, an 
intelligent boy of 12 J years of age. His father, 
medical man though he was, took the view that 
because at times the lad spoke without stammering, 
he could, if he exercised care, do so always, and he 
had only been deterred by his wife's entreaties from 
attempting to '* thrash it out of him." It was due 
to her insistence that my opinion was sought. The 
child's highly nervous condition was to me so 
patent that it was difficult to believe that it could 
escape lay observation, much less that of the father 
who was a medical man . Despite everything I could 



94 THE TREATMENT OF STAMMERING, 

say, however, the boy was not placed under treat- 
ment, the father adhering to his view and maintain- 
ing that the boy was merely careless and could 
speak properly if he chose. 

The result of such an attitude is shown in the 
second case. 

A lad of about 17, who had just left school, 
had wished to enter a civil employment (an employ- 
ment of his own choice for which he had been 
keenly desirous for several years). A medical 
examination was necessary, and he was '* turned 
down " on account of his stammer. His parents 
then got him into an office in the City, where they 
thought his speech trouble would be no bar. 

At the conclusion of his first week there he was 
"sacked," his employer stating that there was no 
fault whatever to be found with him in the carrying 
out of his duties, but that his stammer made it 
impossible to keep him. In this case the opinion 
had been expressed in childhood that the boy would 
"grow out" of the trouble. It probably could 
have been quite easily dealt with then, whereas in\ 
the meantime wrong speech habits had been estab- 
lished, nervousness had increased, and self-con- 
fidence fatally wrecked at the onset of entry into the 
world by two such knock-down blows. It will 
readily be understood what long and patient work 
would be needed for the joint business of speech ' 



CLEFT-PALATE SPEECH, AND LISPING 95 

re-education and establishment of nervous equi- 
librium and confidence in such a case. 

Age in Relation to Treatment 

This brings us to the consideration of what is the 
best age for treatment, the conditions necessary for 
success, and the time it is likely to take. 
* The first thing to be realised is that no hard and 
fast rules can be laid down. Individual circum- 
stances vary so widely that each case must be con- 
sidered on its own merits. 

Undoubtedly expert advice should be sought the 
moment stammering shows itself. If dealt with at 
once it may at once be eliminated. In early child- 
hood, while control of the body is still being 
acquired, and its habits are not yet fully auto- 
matic — habits which later in life give us so much 
trouble to alter — the matter may be fairly simple. 
Particularly important is it that it shall be attended 
to without delay if the stammer has been induced 
by any nerve shock. A wise psychic handling 
when the trouble first arises may not only prevent 
the stammer from becoming established, but may 
prevent the development of nerve trouble, the 
ramifications of which may be incalculable. 

If advice can be obtained at once the trouble may 
be arrested. On the other hand, treatment in child- 
hood may have to be carried over a very con- 



96 THE TREATMENT OF STAMMERING, 

siderable period of time, or short courses may be 
needed at intervals. In some cases, when the matter 
has not been attended to in the first place, it may 
be wiser to defer treatment till the child is old 
enough to realise the drawback of stammering, and 
will, therefore, bring active will-power and co- 
operation to the treatment. This is a factor of the 
highest importance in overcoming the trouble, and 
can only be considered negligible in earliest child- 
hood. Cure may be accomplished in a compara- 
tively short time in adult life by reason of the 
greater degree of concentration and determination 
which is brought to bear by the stammerer, but 
this is no argument for omitting to treat the trouble 
in childhood. 

Education is obviously hindered by such a 
handicap, not to mention the fact that there is a 
growing tendency on the part of school authorities 
to decline to take a stammerer into the school at all. 
It is to be hoped in the interest of stammerers that 
this tendency will become universal, for the trouble 
will then of necessity be treated, as would any other 
remediable illness or physical disability. And this 
brings me to a very important point. 

Conditions Necessary for Cure 
When treatment is decided upon a stammerer's 
whole time should be given up to it and to the 



CLEFT-PALATE SPEECH, AND LISPING 97 

establishing of the necessary health conditions. 
Parents must realise that the success and happiness 
of the whole future may depend on the complete 
eradication of the trouble, and to talk about " sacri- 
ficing education " by withdrawing a child from 
school for this purpose is sheer nonsense. Educa- 
tion will proceed very differently when the handicap 
of the stammer is removed. The laments I hear 
from adult stammerers on the hiatuses in their 
education, owing to their trouble, would surprise 
many who take this view. 

A child must either be withdrawn from school till 
the trouble is overcome, or it must be treated in the 
holidays. It is easy to see that there are practical 
objections to both these courses, and it may be 
expedient to adopt a compromise — viz., to withdraw 
the child from school for a term on first commencing 
treatment, and then to take holiday courses until 
the trouble is completely overcome. In most cases 
the school authorities must be asked to arrange for 
practice to be carried on at school, and, where time 
and distance permit, it may be desirable that the 
pupil should visit the speech specialist once or twice 
weekly during the term, an arrangement which will 
help to prevent a relapse under the rather adverse 
conditions for a stammerer of school life. It is also 
very wise for the school authorities thus to be in 
touch with the speech specialist, for relapse can in 

7 



98 THE TREATMENT OF STAMMERING, 

this way frequently be prevented. To give an 
illustration of my meaning, a public-school bov 
commenced to stammer again after being rather 
badly damaged in a football '* scrum." In another 
case the nerve shock of an injury in the carpenter's 
workshop brought about a return of the trouble, 
which in short holiday courses I was able com- 
pletely to remove. 

There are two fixed points in a boy's career when, 
if stammering has not already been treated, a pro- 
longed course should be undertaken ; or when, if it 
has already been treated, a course should again be 
taken if there be the least trace still existing — viz., 
between leaving the preparatory school and going 
to public school, and on leaving public school 
before going to University or embarking on his 
career. 

Nevertheless, should adult years have been 
reached without the stammerer having been treated, 
no one need think it is too late. In my experience 
the trouble is curable at any age, and always with 
great gain in general health and happiness. 

Undoubtedly it is best, not only in childhood but 
also in adult life, for the stammerer's whole time to 
be devoted absolutely to the lessons and practice. 
No one would expect to carry on education, pro- 
fession, or business while undergoing treatment for, 
say, gout at Harrogate. Why should such a thing 



CLEFT-PALATE SPEECH, AND LISPING 99 

be expected in regard to stammering, particularly 
when it has been long established ? 

Daily lessons give the best results, and though 
the trouble may be — and is — curable where these are 
not possible, I find that cure is almost invariably 
accomplished in a considerably smaller number of 
lessons when they can be taken daily. Co-operation 
at home in the practice and application of the rules 
is most desirable, and will materially speed up the 
cure. In the case of children it is essential, and 
even in adults such assistance is of great value. 
One young man who was working in London and 
had little opportunity for practice in talking owing 
to his being in lodgings, brought at my request a 
friend with him to his lessons who devoted all his 
spare time to helping him in his practice and 
reminding him of the rules in talking, with 
admirable and speedy results. 

Stammering in Several Members of a Family 

When more than one member of a family 
stammers each should be treated, either separately 
or together as seems the more desirable. 

A child whose father or mother stammers will 
find it very difficult to overcome the trouble unless 
the parent's stammer is also treated, and I have had 
most excellent results in several instances by taking 
parent and child together. 



loo THE TREATMENT OF STAMMERING, 

Conolusion 

In the foregoing pages the most serious of the 
disorders of speech have been considered and their 
treatment indicated. As has been stated, it is not 
possible to give rules for every patient, because no 
two persons are alike in their defects, whether of 
stammering, cleft-palate speech, or lisping. Each 
case must be treated individually according to its 
special requirements. In all cases patient perse- 
verance is a necessity in order to remove bad 
muscle habits and to form new and correct ones. 
Exercises must be systematised and regularly per- 
formed every day until the spasmodic, irregular 
movements of the various muscles involved in 
breathing and vocalisation have been entirely over- 
come. No efforts can be too great to make for the 
purpose of conquering the serious drawback to 
success in life which stammering causes; and 
sufferers from this trouble should be much 
encouraged by the knowledge that it is extremely 
rare to meet with an incurable case. 

No one need despair, and even if cure takes some 
considerable time it is best to make the effort. 
Moreover, great mental relief is experienced from 
the moment treatment is commenced from ihe mere 
fact that something is being done to alleviate such 
a terrible nerve strain. 



CLEFT-PALATE SPEECri, ANE)' LIS'FmG loi 

Let no one take a pessimistic view of the possi- 
bilities of cure from the difficulties enumerated in 
the preceding pages, or the time that may be needed 
to overcome them. 

That they can be overcome in the majority of 
cases is certain, and that the attempt should be 
made is equally certain, for the sake of the sufferer, 
for the sake of those with whom he is associated, 
and last, but not least, for the sake of his or her 
possible descendants. 



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