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Full text of "Memoir on the radical cure of stuttering by a surgical operation, tr. by J. Travers"

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600034223K 






SYLLABUS OF THE CONTENTS 



OP 



WOKKS KECENTLY PUBLISHED, 



BY 



SAMUEL HIQHLEY, 32, FLEET STREET. 



ILLUSTRATED BY NUMEROUS PLATES; 



ON THE 



DISEASES OF THE EYE; 

BY JOHN MORGAN, F.L.S. 

SURGEON TO GUY's HOSPITAL. 



THE ANATOMY, PHYSIOliOGY, AND 

DISEASES OF THE TEETH; 

BY THOMAS BELL, F.R.S., &c. 



t , 



PROFESSOR OF ZOOLOGY IN KING 6 COLLEGE^ LONDON 



THE STBUC?rURE, ECONOMY, AND 

DISEASES OF THE EAR; 

BY GEORGE PILCHER, 

LKCTTTBBB ON STTSOBBT AT THB WEBB BTBBET SCHOOL OF MBDICIMB. 



THE ANATOMY, PHYSIOLOGY, AND 

DISEASES OF THE TEETH; 

BY THOMAS BELL, F.R.S., F.L.S., F.G.S. 

LBCTnBEa ON ANATOMY AND DISEASES OF THE TEETH, AT GUY'S HOSPITAL, AND PBOFESSOB 

OF ZOOLOGY IN KING's COLLEGE, LONDON. 

Demy 8vo. Price 145. 

" To the general Practitioner as well as the professed Dentist, we can conscientiously recommend 
Mr. Bell's Book." — Johnsons Medico-Chirurgical Review. 

PART L—ANATOMY, PHYSIOLOGY, &c. 

The Structure, Organization,' and Vitality, of the Teeth. 

Number, Arrangement, and Uses of the Temporary and Adult Teeth. 

Articulation of the Teeth. 

Of Mastication and the Parts concerned therein. 

Formation and Progress of the Temporary and Permanent Teeth. 

Diseases resulting from the irritation of Dentition. 

On temporary irregularity and its prevention. Permanent irregularity. 

Supernumerary Teeth. On the Osseous union of Teeth. 

On the supposed occurrence of a third set of Teeth. &c. &c. &c. 

PART H.— DISEASES, &c. 

On Dental Gangrene (commonly called Caries) — Its origin and progress — Its proxi- 
mate, remote, and exciting causes — Prevention — Method of Treatment — On 
Excision of the Teeth. 

On total Necrosis — ^Abscess in the Bony Structure — Exostosis of the Teeth. 

Injuries produced by Mechanical Violence. 

On the loss of Enamel and wearing dowh of the Teeth. 

On Salivary Calculus — Its formation and effects — Means of prevention and removal. 

Diseases of the internal Membrane. 

Diseases of the Gums and Alveolar Processes. 

Effects of Mercury on the Teeth, Gums, &c. 

Diseases of the Antrum Maxillare. 

On Extraction of the Teeth, and accidents accompanying, or following it. 
• Neuralgia, and Nervous Affections connected with the Teeth. 



THE PLATES, ENGRAVED BY CANTON, EXHIBIT IN UPWARDS OF ONE 

HUNDRED FIGURES, VIEWS OF— 

The Formation, Growth, and Development of the Teeth in the Foetus and Adult. 

Natural and Magnified Sections of the Teeth. 

Production of the permanent Teeth, and their connexion with the temporary ones. 

The upper and lower Alveoli after removal of the Teeth. 

The upper and lower Teeth, with their Articulations. 

Gangrene. Abscess. Fungous Growth, &c., of the Teeth. 

Instruments.— &c., &c., &c. 



A TREATISE ON THE 

STRUCTURE, ECONOMY, AND DISEASES 

OF THE EAR; 

BY GEORGE PILCHER, 

I LECTTJRBB ON ANATOMY AND 8CBGEBT, AT THE WEBB STBEET SCHOOL OV MEDICINE. 

Demy Svo.f Price lOs. 6d. 

" The perusal of this Work has afforded us much pleasure. — A Work was wanted to place the 
whole subject within the grasp of all Surgeons who choose to devote some little exclusive or particular 
study to the Diseases of the Ear, and their treatment, and this has fairly and well supplied the defi- 
ciency." — Johnson's Medico-Chirwrgical Review. 

Anatomy of the Ear — External Ear, Tympanum, Labyrinth, Nerves of the Ear. 

Physiology of Hearing. Sound. Influence of Sound upon the Ear. Influence of the 
External Ear. Influence of the Membrane of the Tympanum. Influence of the 
Ossicula. Influence of Air on the Tympanum. Influence of the Labyrinth. Influence 
of the Nerves. 

Of the Abnormal Condition of the Ear — Development and Malformations. 

Of the Diseases of the Ear. — Acute Otitis. External Acute Otitis. Inflammation 
of the Membrana Tympani. Internal Otitis. Inflammation of the Labyrinth. 

Chronic Diseases. External Otitis. Inflammation of the Auricle. Chronic Diseases of 

m 

the Meatus. Foreign Bodies in the Ear. Chronic Inflammation of the Membrana 
Tympani — of the Tympanum — of the Eustachian Tube. 

Nervous Diseases. Excited and Torpid Functional Derangements of the Acoustic Nerve. 
Functional Derangement of the Tympanic Nerves. Otalgia. &c. &c. &c. 

The Plates shew the Comparative Anatomy of the Ear in the Lobster , Sturgeon, Thornback, 
and other Fish ; — in the Turkey, Owl, Domestic Fowl, Whale, Porpoise, 8fc. Also the 
Anatomy, Diseases, Malformations, and appearance after injuries of the Human Ear, 
British and Continental Instruments, 8fc., ifc. 



MR. LAWRENCE'S 

ANATOMICO-CHIRURGICAL PLATES, 

THE SIZE OF NATURE, 

I.— THE NOSE, MOUTH, LARYNX, AND FAUCES. 

Anatomico-Cbirurgical Views of the Nose, Mouth, Larynx, and Fa.uces, with explanations 
and references, and an Anatomical Description of the parts. By W. Lawrence, F.R.S., 
Surgeon to St. Bartholomew's Hospital. 

Folio, Price lOs. 6d. plain — ^£1 1*. coloured. 

II.- THE MALE AND FEMALE PELVIS. 

CoMPaiSING — 

Front Views of the Male and Female Pelvis, in which the Bones are seen in their natural 
connection with the principal Ligaments, so as to shew the Construction, Figure, 
Outlines, Boundaries, and Dimensions of the Cavities in question. 

The External Organs of Generation in th& Female. 

Superficial and deeper seated Views of the Muscles of the Male Perineum and Anus. 

Muscles of the Female Perineum and Anus. 

Lateral Views of the Male and Female Pelvic Viscera in their natural situation. 

*«* The Subjects were selected by Mr« Lawrence, who superintended the Dissections, most 
of which he executed himself, and furnished the Descriptions and Explanatory References. 

Folio, Price ]0s. 6d. plain — £1 1*. coloured. 



SA MUEL HIQHLEY. 32, FLEET STREET ^ \-OHO On. 



^t 






i.H \ :';. V 



MEMOIR 



ON THE 



RADICAL CURE OF STUTTERING, 



BY A SURGICAL OPERATION. 



BY J. F. DIEFFENBACH. 



TRANSLATED FROM THE GERMAN, 



BY 



JOSEPH TRAVERS, 

LATB HOUSE SURGEON TO ST. BARTHOLOMBVT'S HOSPITAL. 



LONDON: 
SAMUEL HIGHLEY, 32, FLEET STREET. 

1841. 



/22^S^ 



DEDICATED, BY PERMISSION, 



TO 



EDWARD STANLEY, ESQ. F.R.S, 



fiUBGEON TO ST. BARTHOLOMEW'S HOSPITAL, 



BY 



HIS FRIEND AND LATE PUPIL, 



THE TRANSLATOR. 



TRANSLATOR'S PREFACE, 



In the following Memoir M. Dieffenbach has laid 
before the world another proof of his genius as an 
operative Surgeon. Time alone can show how far 
this operation may be generally applicable ; but the 
success of the first sixteen cases, and the very 
small proportion of untoward circumstances attend- 
ing them, hold out the fairest prospect of its coming 
speedily into general use. 

A daily attendance on M. Dieflfenbach's lectures 
and practice has given me the opportunity of hearing 
his remarks on each case during its progress and 
treatment, and it has been my aim therefore to trans- 
late ideas rather than words ; a mode approved by 
M. Dieflfenbach himself, to whom the revision of tjiis 
Translation has been submitted. 



Vi TRANSLATOR'S PREFACE. 

The occasional generalization of the long accounts 
of the peculiar mode of stuttering, in each indivi- 
dual case, has also received his personal approbation. 

Joseph Travers. 



St. Swithin's Lane^ 

March Ist^ 1841. 



ON THE 



RADICAL CURE OF STUTTERING. 



My attention for some considerable time has been 
directed to the painful condition of the Stutterer 
or Stammerer. The striking ineflficiency of ail the 
means hitherto attempted of cure or palliation, the 
frequent relapse of those who thought themselves 
permanently relieved, the large majority of those who 
have resisted every eflfbrt of the most skilful instruc- 
tors in the art of speaking, and the evident state of 
suffering with which persons thus afflicted have had 
through life to struggle, offered the strongest induce- 
ments to the prosecution of an inquiry into the pos- 
sibility of a quick and radical cure. The idea lately 
suggested itself to me, that an incision carried 
completely through the root of the tongue, might 
possibly be useful, by producing an alteration in the 
condition of its nervous influence, allaying the spasm 



8 RADICAL CURE 

of the Chordae vocales, etc. The brilliant success 
of this new operation more than realized my most 
sanguine expectations. 

In endeavouring to trace back this idea to its 
source, and to give it the form of a systematic con- 
clusion, I am forcibly carried back to a case of Stra- 
bismus concomitans with Nystagmus, in which the 
patient signified his wish to undergo the operation, 
in a well-marked stutter. This awakened me to the 
possibility of an analogy existing between the two 
affections, which was shortly confirmed by the obser- 
vation of many cases in which a spasmodic squint 
was attended by a greater or less degree of stuttering. 
I must here remark, that the momentary inability to 
pronounce a consonant, a syllable, or a word, was at 
times greater than at others — at times the want of 
dexterity in the mechanical use of the tongue under 
certain circumstances was greater or less. 

Pursuing this analogy, and seeing in this disturb- 
ance of the organs of speech a dynamic influence, 
which threw the air passages, and their laryngeal 
aperture in particular, into a state of spasm, in which 
the tongue, the muscles of the face, and often the 
muscles of the throat, participated, I came to the 
conclusion, that the interruption of the stream of 
nervous influence, either forwards or backwards, in 
one of the implicated muscular structures might well 
be followed by an alteration in, and removal of, this 
abnormal condition, inasmuch as an almost invariably 
favourable result followed the division of the muscles 



OF STUTTERING. 9 

of the eye, in Nystagmus bulbi, in spasmodic Stra- 
bismus, or when I attempted a similar operation for 
spasmodic affections of the face. The transverse 
division of the whole muscular substance of the root 
of the tongue seemed to be, on this showing, at least 
worth the trial, and I felt as confident of the result 
in this instance, as I was of the efficacy of the division 
of muscular structures in other essentially spasmodic 
affections. 

To guard myself against the charge of being pre- 
judiced for any one particular method of operation, 
and to avert the self-reproach of having taken a 
limited view of the matter, I determined to perform 
a division of the root of the tongue in various ways, 
and under several modifications — always, however, 
adhering to the general principle of all but total 
division, as, from the interruption thus given to 
the morbid nervous influence I could alone hope for 
a favourable result. 

I have now given a trial to the three following 
methods of operating : they have equally for their 
object total division of the root of the tongue. 

I. The transverse horizontal division of the root of 
the tongue. 

TI. The subcutaneous transverse division, in which 
the mucous covering of the tongue is left inviolate. 

III. The horizontal division, with excision of a 
wedge-shaped portion. 

I was more sanguine as to the success of the latter 



10 RADICAL CURE 

method than of the two preceding, as here some 
shortening of the tongue must necessarily ensue ; and 
forasmuch as the base of the wedge-shaped slice is 
made from the dorsum of the tongue, elevation of 
the tip must take place. This method, then, mecha- 
nically assists that organ to assume the position 
insisted on by those teachers who have been most 
successful in ameliorating this defect. Still, as it 
inflicts a more severe wound than the simple division 
of the tongue, either with or without division of its 
mucous covering, I felt it imperative on me to put 
these apparently more simple operations also to the 
proof. 

The apparatus requisite is very simple : — 

A pair of Miizeux forcep-hooks ; 

An ordinary hare-lip forceps, with teeth ; 

Two retracting hooks, with a handle for the cor- 
ners of the mouth ; 

A narrow and much-curved sharp-pointed bistoury; 
curved strong needles, with thick ligatures of four- 
fold silk ; and a pair of needle-pliers. 

For the sake of brevity I will relate the method of 
operating, together with the other particulars of each 
case. 

The first operation, I performed on the 7th of Jan- 
uary, 1841. I chose for this case the method by 
which a wedge-shaped portion is removed from the 
posterior part of the tongue ; for, as I have remarked, 
I felt more confidence in this than in the other me- 
thods. 



OF STUTTEEING. 11 

Frederick Doenau, a highly intelligent and talented 
boy of thirteen years of age, had stuttered from his 
earliest childhood, and to so painfnl an extent, that 
the defect was thought to be quite incurable. It 
varied, however, much in degree : when at the 
worst, he was unable even to produce a sound. He 
stuttered in Latin and French, as well as in his own 
language — sometimes on one set of words, and some- 
times on others. The pronunciation of the sibilant 
letters ( s, z, ss, ) and of the palatals hard ( g, k, ch, 
and X,) was attended with particular difficulty ; and 
he made no distinction between the hard sounds, p, 
t, k, and the soft ones, b, d, g (German). He re- 
peated the same letter often four times running ; and 
when he whispered, he stuttered as much as when he 
spoke loud or shouted ; often he could either not 
speak at all, or produced only half articulate sounds. 
The presence of a stranger invariably affected him 
in a manner most painful to behold. His face became 
distorted ; the alae of the nose worked convulsively ; 
his lips moved quiveringly up and down ; his eyelids 
were expanded into a wild and eager stare ; the 
tongue was now stiff, now played convulsively within 
the mouth ; and the muscles of the throat, larynx, 
and trachea were sympathetically affected. Thus, 
after terrible efforts, the boy gave utterance to a 
mangled and imperfect word ; — now for a time was 
his speech free, and words chased one another with 
incredible velocity, till confusion ensued amidst the 
thronging sounds ; and the same painfid scene was 




12 RADICAL CURE 

thus again and again renewed. The peculiar physical 
horror which constitutes a stutterer, and which is 
excited by the eflfbrt to speak, is very similar to that 
which gives rise to the excitement and spasm of the 
hydrophobic patient at the sight of water. This 
internal movement might, on that account, be called 
phonophobia. 

The boy's mother caught eagerly at my oflfer to 
make an effort to cure him ; accordingly, with the 
assistance of Drs. Holthoff and Hildebrandt, the ope- 
ration was performed as follows : — The boy sat with 
his head leaned against the breast of an assistant; 
the tongue being protruded as far as possible, was 
grasped on its anterior half with the forceps of 
Miizeux, being thus compressed laterally, and drawn 
forwards by one assistant. The gentleman against 
whose breast the boy's head rested, retracted the 
angles of the mouth with a pair of blunt hooks. 
Grasping now the tongue as near to its root as possi- 
ble, between the thumb and forefinger of the left 
hand, I passed the bistoury through it, and divided 
it completely from below upwards ; a strong ligature 
passed through the posterior edge of the wound, 
served to fix it temporarily, and prevent too great a 
strain upon the slender band which alone connected 
the mass of the tongue to it ; the anterior lip of the 
incision was now grasped, and laterally compressed 
between the modified hare-lip forceps, and a wedge- 
shaped slice excised out of the whole thickness of the 
tongue. It will be found more convenient to make 



OF STUTTERING. 13 

this second incisioii from above downward, and 
with a small straight knife. The posterior edge of 
the wound was now,, by means of the before-men- 
tioned ligature, and a sharp double hook, drawn so 
far forwards that the needles with the ligatures 
could be conveniently passed through it; six strong 
sutures served to bring the edges of the wouud toge- 
ther, and to restrain the hemorrhage. To eflFect the 
latter object, they must include the whole depth of 
the wound within their loop. That the hemorrhage 
was considerable, may be imagined from the nature 
of the operation, which should not be attempted by 
all persons indiscriminately. As soon as the boy's 
mouth was washed out, I desired him to pronounce 
some of those words which he had before found 
especially difficult ; he did so without stuttering or 
hesitation. The distortion of the face, however, 
continued, the patient was put to bed, and a cooling 
plan of treatment ordered. With the exception of a 
slight sympathetic febrile disturbance, the swelling 
of the tongue, that one might anticipate, and the con- 
sequent impeded deglutition, nothing remains to be 
noticed, so far as regards his recovery from the 
operation itself. His features, and his mouth espe- 
cially, were still much distorted when he spoke, but 
the stutter had entirely ceased. On the fifth day I 
removed three of the sutures ; during the next twenty- 
four hours the swelling of the tongue had visibly 
decreased, and I then removed the three remaining 
sutures. On the 7th day the wound was completely 



14 RADICAL CURB 

healed, the back part of the tongue alone was vei^ 
inconsiderably swelled, and the boy quite re-esta- 
blished. At this present time, not the slightest trace 
of stuttering remains, not the slightest vibration of 
the muscles of the face, not the most inconsiderable 
play of the lips. His speech is throughout clear, 
well-toned, even, and flowing. Neither inward emo- 
tions nor unexpected external impressions, produce 
the slightest hesitation ; he can speak, read, and 
entertain himself, indifferently with friends or stran- 
gers. 

On the tenth day after the operation, I had the 
honour to present him to his Excellency the Baron 
Humboldt, who testified the liveliest interest in the 
happy re-establishment of the boy. 

Many physicians of this town can speak personally 
as to the perfect success of this case. Messrs. Schoen- 
lein, Miiller, Lichtenstein, Krause, Romberg, and 
Busse saw him, and the last-mentioned interrupted 
him whilst reading, by desiring him to repeat the 
word " Preobadschenskoy," which he did without the 
slightest hesitation. The members of the Berlin 
Med. Society, have also bestowed their attention on 
this interesting case. 



The operations with excision of a portion of the 
tongue, which, encouraged by the successful issue of 
this case, I have since undertaken, have met with a 
similar succese. 



OF STUTTERING. 

Frederick Kiel, son of a schoolmaster at Potsdam, 
sixteen years of age, tall, slender, and intelligent, had 
stuttered from the age of six years. This affection 
followed his recovery from a smart inflammatory 
affectiou of the lungs. He suffered from a similar 
attack on the lungs, after the interval of about a 
year. The impediment appeared from this time to 
be much increased. " 

He has nine brothers and sisters. The two eldest 
sisters do not stutter ; the next brother stutters at 
times ; the two next brothers also do not stutter; but 
the younger sister, a child of three years of age, 
stutters in a very aggravated manner. The father 
himself stuttered till in his sixth year, when he 
suddenly ceased to do so. In my patient, the 
pronunciation of those words in the formation of 
which the lips are employed, or the tip of the tongue 
approximated to the upper teeth, or to the roof 
of the palate, was attended with particular difficulty, 
as for example in the letters b, p, d, t ; the sibilant 
sounds s, z, ss, &c. 

He pronounced the palatal sounds, the German g, 
k, ch, by themselves well enough, but in the hurry 
of a sentence he stuttered over even them. The pro- 
nunciation of the vowels deserves particular notice. 
When he slowly and attentively repeated them, he 
was able to go through them without hesitation ; this 
was the effect of education I When he did so hur- 
riedly or inattentively, one distinctly heard the aspi- 
rate prefixed, with the stuttering repetition h, h, a — 
h, h, e — h, i, i, etc. 



16 RADICAL CURE. 

The same thing took place with those consonants 
of which the written sounds require a prefixed vowel. 
Besides abnormal articulation of isolated sounds, 
both as connected with the cavity of the mouth and 
the larynx, there were many curious circumstances 
attending the mode of expiration. During speech the 
stream of air was often driven out involuntarily from 
the lungs, without assisting in the production of any 
tone. The cause of this appears to be, that the 
organs in the mouth which are destined to shape the 
rude sound produced in the larynx, and in particular 
those muscles of the tongue which are connected 
with the larynx, are prevented by a species of involun- 
tary contraction from performing the motions necessary 
to distinct articulation, and thus the undefined sound 
escapes. The patient, then, by a powerful exertion, 
raises the whole chest and diaphragm, places his 
tongue in the requisite position, and brings forth the 
at length articulate word. The whole appearance of 
this young man betrayed suffering and melancholy ; at 
each attempt to speak, his thorax and trachea were 
convulsively agitated ; his stuttering might be said 
to be of intermittent or of irregular type, increased 
by anything that caused him anxiety. With his 
brothers and sisters he often spoke with little difl&- 
culty, but the slightest strangeness increased the 
impediment, and the ready thought in vain sought 
words in which to express itself; certain muscular 
structures being rendered incapable, by a sudden 
spasm^ of executing the impulse of the will. The 



OF STUTTERING. I? 

operation in this case took place on the I !)th January, 
1841, in the presence of Messrs. Jiinkgen, Romberg, 
Baum, J. Siebold, Keil, Trettenbacher, Hauck, Biih- 
ring, and Hildebrandt, I followed nearly the same 
plan of operation as in the case before related, by 
which a portion of the tongue near the root was 
removed. The tongue being drawn forward with 
Muzeux forceps, a strong ligature was passed through 
it at its most posterior part, and then pushing the bis- 
toury through the tongue, the incision was completed 
from below upwards. The anterior lip of the wound, as 
before, was held between the forceps, (Plate No. II,) 
and a wedge-shaped slice of three-fourths of an inch 
in breadth at its top taken away in the whole thick- 
ness of the tongue ; the edges of the wound were 
brought together by means of six strong sutures ; the 
bleeding was not inconsiderable, but it ceased after the 
application of the sutures. Immediately after the 
operation, I made the young man repeat a few words, 
which he did without any stutter whatever, with the 
^ene only that might be expected after an operation 
on the tongue. 

Strict quiet was ordered for him, and frequent 
rinsing of the mouth. No particular constitutional 
disturbance followed the operation ; and except the 
swelling of the tongue, the symptoms did not differ 
from a severe catarrhal inflammatory sore throat. 
He had some difficulty in deglutition, and his tongue 
was coated. On the third day after the operation 
he had already quitted his bed, and pronounced 



L 



RADICAL CUBE. 

single words without difficulty. On tiie fourth day 
the tongue was scarcely swollen at all ; its motions 
were free, aiid the patient could already pronounce a 
short sentence ; he neither grimaced nor stuttered. 
On the 5th day I drew out one suture, and the others 
in the course of the two foUowing days. On the 
eighth day the wound was healed, and the patient 
completely cured of his former most painful defect. 
Many physicians who have seen him since that time, 
can speak as to the complete success of this opera- 
tion. 

The method employed in these two cases, viz, the 
excision of a wedge-shaped portion of the root of the 
tongue, may be thus modified by those less practised 
in operating : In performing the first incision, a por- 
tion of the superior border of the laterally com- 
pressed tongue may be left undivided, until a suture 
has been passed through the posterior edge of the 
wound, to prevent the possibility of its premature 
retraction, and the incision afterwards completed. 
The foUowing operation accomplished neither more 
nor less than I expected from it. 

SIMPLE TRANSVERSO-HOBIZONTAL DIVISION OF 
THE ROOT OF THE TONGUE. 

This method of operating I have only tried in one 
case. The case was one of much difficulty being 
complicated with an otherwise incompetent state of 
the tongue. The excision of a portion was here 



OP STUTTRBING. W 

perhaps more strongly indicated, were it only to have 
abridged the unusual length of that member. 

Carl Stephen, thirteen years of age, of weakly ap- 
pearance, and slender intellect, had been, since hia 
second year, the subject of Strabismus concoraitans. 
At six years of age he lost the faculty of speech, 
apparently in consequence of an apoplectic attack, 
and laboured under this deprivation for three months, 
during which time he gave utterance only to inarti- 
culate sounds. By slow degrees, and with great 
difficulty, he learned to pronounce isolated words, 
and, up to the date of the operation, his speech was 
so imperfect, that he was unable to frequent the 
school. At the sight of a stranger his face expressed 
the most painful anxiety, the squint increased, and 
the eyes moved about wildly ; every endeavour to 
speak was attended by hideous grimaces, his colour 
came and went, the muscles of the throat worked 
powerfully, and his head vibrated here and there, his 
lips quivered when speech should have commenced, 
and saliva flowed copiously from his mouth. He 
grimaced most over the labials, and the pronuncia- 
tion of the word voter, in which the v and the t so 
quickly follow one another, was attended with con- 
siderable difficulty. 

tThe tongue being fixed, as in the foregoing cases, 
and its root cut transversely through, six strong 
Sutures were applied, which brought the wound 
effectually together. As in the preceding cases the 



20 RADICAL CliRE 

bleeding was considerable at the time, but completely 
stopped by the application of the sutures. 

The stuttering disappeared for a short time imme- 
diately after the operation, and the contractions of 
the countenance were materially diminished ; single 
letters and even the letter p and the word voter were 
pronounced without difficulty. The after treatment 
was here of a cooling nature ; the reaction was but 
slight, and the swelling of the tongue unimportant ; 
the flow of saliva was, however, particularly distress- 
ing to the patient. On the fourth day three sutures 
were removed, the others on the fifth day ; and the 
boy was then, as far as the operation was concerned, 
completely established. I was assisted by Dr. Holt- 
hoff, and Messrs. Buehring and Hildebrandt. In 
this case the hoped for improvement in speech did 
not take place, but the grimaces are not so bad as 
before. 

In the following case subcutaneous division of 
the root of the tongue was tried ; as I wished to 
ascertain its value, and its relative difficulty or ease 
of performance. 



Hermann Hirschberg, of Berlin, seventeen years of 
age, painter, of slender make of body, and limited 
intelligence, had stuttered from his earliest child- 
hood, to such a degree, that he was unable to avail 
himself of any public school instruction, and could 
only attain to the most superficial acquirements. 



To enter into a minute description of the mode in 
which he stuttered would he superfluous ; suffice it 
to say, that it was ordinarily almost impossible, and 
sometimes quite impossible to understand the young 
man. I myself hoped but little from an operation, 
and the triumphant result was, therefore, the more 
gratifying to me. 1 determined to try, in this case, 
the subcutaneous division of the tongue, not be- 
cause I hoped to gain any material advantages by 
this method of operating, but because it seemed to 
me necessary to try the worth of this method before 
giving a preference to either one of the others. I 
thought it possible also, that the introduction of the 
sutures might be rendered easier, as the tongue 
would be unable to retract as after the total division. 
On the other hand, I doubted whether the blood 
might not collect in so considerable a subcutaneous 
wound, and thus prevent the application of a con- 
tinued pressure ; and also, I thought, that this me- 
thod must be a less certain one, inasmuch as no 
shortening of the tongue could take place, a condi- 
tion which seemed to me to be necessary to success ; 
nevertheless, the result quite exceeded my expecta- 
tions. Dr. Trettenbacher, and Messrs. Buehringand 
Hildebrandt, assisted me at this operation. 

The tongue being drawn as much forward as 
possible, I pushed a curved bistoury through it, as 
near its root as I could, and cut through its whole 
muscular thickness, leaving the mucous membrane 
inviolate ; on the withdrawal of the knife the open- 



Ik 



^ 



RADICAL CURE 



ing appeared only of the breadth of the blade. The 
substance of the organ was so completely cut through, 
that a slight additional poll with the forceps would 
probably have torn it off. The blood streamed from 
the apertures made by the knife as vehemently as 
from a large artery, whilst at the same time the ca- 
vity of the wound became exceedingly distended with 
the rapidly flowiug blood. This cavity I sought to di- 
minish by introducing a strong suture from behind for- 
wards, through the tongue, and with other sutures I 
closed the openings made by the bistoury on each side, 
The succeeding day passed without any circumstances 
worthy of observation Deglutition, as may be sup- 
posed, was impeded ; but he managed to swallow 
some thick soup. His tongue was furred, and he had 
a slight accession of fever in the evening. Complete 
reunion soon took place in the deep parts of the 
wound; on the seventh day the swelling had dis- 
appeared, and on the eighth he left his room. He 
stuttered no more ; but some few particular words 
still give him a little difficulty, and he delivers him- 
self of certain tones with a slight hesitation of 
manner. However beautiful the result of this oper- 
ation, as having so ameliorated the highest degree of 
stuttering, still it is not so fully satisfactory as those 
cases iu which a portion of the tongue was actually 
excised ; and this subcutaneous method cannot be 
recommended as being at all easier of performance. 



OF STUTTERING. 



ON THE TREATMENT OF THE WOUND OF THE 
TONGUE. 

Wounds of the tongue, united by suture, heal with 
^reat rapidity, provided only the edges are kept 
1 strict contact. Forasmuch as deep wounds of the 
Irposterior part of the tongue are complicated with 
■considerable hemorrhage, it becomes necessary that 
■these sutures should not only hold the edges in con- 
act, but by embracing within the circle of their 
lOops the whole depth of the incision, act at the 
ame time as a means of restraint on the hemorr- 
thage, which would otherwise be dangerous. They 
fclDust on this account be more tightly draw:i than 
1 usual in ordinary external wounds. Taking up 
I'the arteries singly would here interfere too materially 
f with the process of union, and would be as highly in- 
admissible as in the operation for hare-lip. The 
union of the wound is for the most part complete on 
the third day, sometimes it is tolerably firm at the 
Lend of twenty-four hours ; but as no disadvantage 
Sattends the presence of the ligatures at that period, 
ad the wound might be torn asunder by the move- 
ments of the tongue, thus giving rise to dangerous 
Jiemorrhage, they should not be disturbed till the 
■fourth day ; one, two, or three, may then be re- 
moved according to circumstances. Should they come 
away easily, the remainder may be taken away ou 
the fifth and sixth days ; to leave them longer than 
iuiir presence is actually required, might cause sup- 



RADICAL CURE 

pnration, or the formation of fistulous passages. 
Should the withdrawal of the first ligature be at- 
tended by the flow of even a few drops of blood, it 
is a sign that the plastic process has not made suffi- 
cient progress to allow of the removal of more — that 
the union is not as yet firm, and nothing further 
should be attempted that day. 

The drawing out of the sutures should be per- 
formed with great care and without any force. The 
patient must thrust his tongue a little forward, the 
loose end of one of the ligatures being then seized 
between the forceps, it is to be gently drawn forward, 
till the loop of the ligature comes into view, which 
may then be cut through; the ligatures being re- 
moved, the mouth should be rinsed with luke-wann 
water. The process of cicatrization, as I have re- 
marked, takes place quickly ; the scar presents a 
smooth surface, which dififers greatly from the cover- 
ing of the tongue itself, giving it the appearance of 
having an elevated edge. 

The sutures leave some slightly marked depressions, 
each pair of which is connected by a shallow fur- 
row, grooved by the ligature. These disappear at a 
later period, unless the suture is allowed to remain 
till ulceration takes place. Longitudiual wounds 
of the tongue leave a less evident scar than transverse 
ones ; the scar consequent on the present operation 
divides the superficies of the tongue into two very 
distinct portions. When a portion of the tongue is 
removed, that member ever afterwards looks as 



B^ 



OF STUTTERING. 25 

though the tip and body of a small tongue were 
grafted into the root of a larger one ; as might be 
naturally expected where so large a portion of a gra- 
dually taperiug organ is removed. The scar serves to 
make this peculiarity still more evident. In couse- 
quence of the removal of a portion of the tongue, 
the posterior part with its large papillae presents 
itself more anteriorly in the mouth than is usual. 

The wound when healed after either of these 
methods of operation, affords to the patient the sen- 
sation of a hard resistant elevation, which, however, 
softens by degrees, and possibly at a later period 
disappears. The movements of the tongue are firee 
in every direction, and in those cases where a portion 
is removed, the patient experiences a sensation of 
shortening, and the tip of the tongue seems to be 
approximated to the palate. 

No permanent alteration takes place in the sense 
of taste, but for a few days it seems to be somewhat 

N blunted. 
It cannot be supposed that an operation on the tip 
of the tongue would prove of benefit to stutterers, 
as then no alteration or breaking off of the abnormal 
nervous influence is effected. The shortening of the 
tongue, by amputation of its tip, and the excision of 
a portion of the anterior parts have, as might k priori 

I be expected, no influence in diminishing stuttering. 
The division of the frcenum I have certainly seen 
useful in some impediments of speech, but not in 
stuttering. 



^6 RADICAL CURE 

lu this operation it is more difficult to prescribe 
for the iudividual modifications of each particular 
case, than in the operation for Strabismus, and it 
can never be performed by one who has not the 
temperament of an operator ; the hBemorrhage must 
hold all others at a respectful distance. The ex- 
tent and importance of the operation, the possible 
danger to life, or loss of the tongue, either through 
the want of skill in the assistants who may tear 
it off when so nearly separated, or through mor- 
tification or ulceration of its connecting isthmus ; 
these are contingencies rationally to be feared, and 
which must be carefully weighed before-hand. 

During the last few days I have again operated on 
six stutterers, and removed from them portions out 
of the root of the tongue. In all the stuttering is 
completely cured. 

The total number of stutterers that 1 have relieved 
np to this time is sixteen, and those who are as yet 
under treatment appear to promise equally favourable 
results. 

Professor Midler, who has been kind enough to 
examine the excised portion of the tongue, found 
that it consisted of a portion of the genio-glossus, 
some of the proper fibres of the tongue, and small 
portions of the stylo and hypo-glossus. 

Amidst the prevaiUng rage for modifying opera- 
tions, I foresee that my having described the three 
principal available methods, cannot fail to open to 
Surgeons a vast field for the discovery of modifica- 



OF STUTTERING. 27 

tions^ and the creation of instruments. We shall 
have conical and oblique incisions, from the surface 
and under the skin ! Actual and potential cautery ! 
We shall have knives and scissars with improved 
curves, and a thousand variously fashioned forceps 
and hooks. They will set the blades at angles with 
the handles to allow of a better light falling into the 
mouth. Opportunity is likewise afforded to pro- 
fessional antiquarians to hunt after a name for this 
operation. To them I freely make oyer the right of 
baptism. 

For the best researches into the nature of stutter- 
ing, we have to thank the following distinguished 
men in Germany, J. Frank, Burdach, Keil, Schulthess, 
Wolfgang von Kempelen, Chladni, T. Mueller, &c., in 
England, Arnott ; in France, Magendie, Serres, Itard, 
Voisin, Hervez, Chegoin, Colombat, and RuUien : 



DiEFFENBACH. 



Berlin f 3lst. January , 1841. 



PLATE I. 
Fig. 1. — Side View of the Tongue. 

a. Museux Forceps, used by M. Dieffenbach, by which the tongue 

is drawn forwards in the first step of the (operation. 

b. The wedge-shaped portion to be removed : the posterior or 

first incision akeady completed. 

c. c, c. Situations of the Sutures. 

Fig. 2. — ^Another form of Museux Forceps, suggested by Mr. Weiss. 



PLATE 11. 
Fig. 1. — An ordinary sharp-pointed bistoury. 

Fig. 2. — ^The forceps used to compress the tongue laterally during 
the excision of the wedge-shaped portion. 

Fig. 3 and 4. — ^The needles and ligatures. 



«■•♦■ - 



MOftiFhed ly S.Bghl&^MtetSP 




AW«A«/ hrS.mghley.neH St 






'I. t : : 









■ XT. .. ■--/% ' j:w:.. !-^ i v!' 



*:.. 



J 1 I ' ■. ■ ' • ■ " . ■ 



. • l\ , 



' *• . • 






-I". t. 



, 1 • 



., Wii:.-. .'• 



» ■ »»r' '»■■■• I ... .1 



■ ' ■ i« . 



n* 



PLATE III. 

Fig. 1. — ^A Tongue, (in which a wedge slice of three-quarters inch 
broad at its base was removed) in the fourth week after the 
operation. 

Fig. 2. — A Tongue, (where simple division of the root was performed) 
three weeks after the operation. 

Fig. 3. — A Tongue,' (in which the subcutaneous division was per- 
formed) three weeks after the operation. 



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1 & 3. HUMMING BIRDS, 68 Coloured 
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and as valuable as pretty." — Llterarg Oagett*. 

" The book is perhaps the most interesting, the most beautiful, and the cheapest series yet offered to the pablic." — 
jithenteum. 

*^*A large paper Edition of the Humming Birds handsomely printed in 8vo, is also published, in 
which a characteristic coloured landscape is given with each plate. Price £2 28. el^antly l)ound in 
Morocco. 



I.