On stammering and squinting

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ON

STAMMERING AND SQUINTING,

Ifc.

LONDON :
WILSON AND 06ILVY, PRINTKK*,

Skinner Street, Snowhill.

ON

STAMMERING

AND

SQUINTING,

AND ON

THE METHODS FOR THEIR REMOVAL.

BY

EDWIN LEE, M.R.C.S.

CORRBSPONDINO MEMBER OP THE MEDICAL AND CHIRUROICAL SOCIBTIBS OP

PARIS, BEBLIN, PLOBBNCB, NAPLES, BORDEAUX, LYONS, MABSBILLES,

AND TOULOUSE; AUTHOR OP THE ** BATHS OP GBBMANT,"

** TREATISE ON SOME NERVOUS DISORDERS," &C.

LONDON :
JOHN CHURCHILL, PRINCES STREET, SOHO.

1841.

i4j.

PREFACE.

Among the principal disadvantages attend-
ing the proposal of new remedial measures
may be reckoned, the degree of prejudice
with which they are viewed by some persons,
and their indiscriminate employment by
others : hence several new remedies, in
themselves very efficient, if restricted to the
proper cases, have iallen into unmerited
oblivion of" late years, trom the results not
having corresponded to the exaggerated
expectations which were raised respecting
their efficacy. This is not unlikely to be
the case as i'ar as Stammering is concerned,
different teachers and operators havmg
each their particular method, which is ap-
phed indiscriminately to all the cases which
present themselves to them, notwithstanding
that this complaint does not always depend
upon the same cause, and presents various
complications, which require to be taken

into consideration. The consequence is,
that the failures are numerous in cases which
might admit of relief by a treatment adapted
to the circumstances iu individual instances.

It is tlie chief object of this publication to
endeavour to elucidate these causes and com-
plications, and to point out the treatment
most suitable to particular cases,— my oppor-
tunities of examining the peculiarities of
stanunering in a lai'ge number of individuals,
and of ascertaining the results of tlie opera-
tions for the relief of this intirmity, as per-
formed by different operators both on the
continent and in England, having, 1 trust,
enabled me to take an unbiassed view of the
question, and to suggest such an application
of the means of relief as may lead to a less
indiscriminate employment of them, and
consequently be conducive to a more suc-
cessfiil treatment.

In order to the more general diffusion of
information among the profession upon a
subject which has of late excited so much
interest, the account of Stanunering now
presented to the public was printed in some

Vll

of the late numbers of the Medical Gazette^
with the exception of the conclusions, which
have been subsequently added.

With regard to Squinting, respecting
which so much has been written and said
within the last twelve months, it was un-
necessary that I should enter fully upon its
consideration ; I have, therefore, restricted
myself to giving a brief notice of the opera-
tion for its removal, as performed by dif-
ferent operators in England and on the
Continent, and to offering a few remarks
deduced from the numerous cases which
have fallen under my observation.

London, 38, Golden Square,
May 28, 1841.

STAMMERING,

Previous to entering upon the consideration of
stammering, I shall briefly notice some points
connected with the functions of the voice and
speech.

The first condition necessary for the production
of the voice is that the air contained in the lungs
should be carried, by the action of the muscles of
expiration, against the vocal chords, during its
passage through the larynx ; but as this takes
place in breathing without sound being occa-
sioned, the action of the small muscles which
enter into their composition, under the influence
of the will, is a condition no less essential than
the former. The quantity of the air, the greater
or less rapidity with which it strikes the vocal
chords, and the varying degrees of tension or
contraction of these latter, are the circumstances
which cause the innumerable modulations of
sound in speaking, singing, and other exercises
of the voice.

ON THE VOICE AND SPEECH.

This function may then be considered as inti-
mately connected witli, and as superadded to,
that of respiration ; and its performance depends
entirely upon the lower vocal chords ; as, if the
recuiTent or inferior laryngeal nerve, which sup-
plies them with nervous energy, be divided or
paralysed, the voice is lost, which is not the case
when the upper vocal chords are depri\'ed of
power by the lesion of the superior laryngeal
ner\'es, which, as well as the recurrent, are branches
of the eighth pair. The voice may also be im-
paired or lost by lesions of the brain affecting the
I origin of the nerves, or by moral impressions and
other causes which interfere with the exercise of
volition, of which the nerves are merely the agents
or conductors, as far as muscular action is con-
cerned ; and it is liable, as is well known, to a
variety of alterations, according to the state of
excitement or depression of the cerebral faculties,
as illustrated by the various passions and emotions
— joy, anger, fear, sorrow, &,e.

Of the cerebral nerves, some are exclusively
agents for the transmission of special sensation,
as tile first and second pairs, and a portion of the
seventh (which, however, is essentially a separate
nerve) for smell, sight, and hearing. Others
serve solely for the transmission of volitions, and
the performance of muscular action — as the third,
fourth, sixth, a part of the seventh, and llie ninth
pau-s ; wliile others again, as the fifth and eighth.

ON THE VOICE AND SPEECH.

are agents both of sensation and muscular
motion.

It is scarcely necessary to repeat the obvious
truism, that speech cannot be produced without
the voice ; but the voice may exist, and indeed
does exist in the greater number of animals, with-
out speech, which is peculiar to man, being be-
stowed upon him for the expression of his
thoughts and ideas. Idiot?, who have no ideas to
express, are generally dumb, or can merely arti-
culate a few words or phrases without meaning,
or which they know wUl cause their ordinary
wants to be supplied, but they are incapable of
conversing. Speech, however, is not a natural
gift, but is acquired by education : hence those
born deaf are also dumb : and instances are on
record of individuals who have been found in
solitudes far from the haunts of men, who, though
not deaf, were dumb, and had acquired the voice
of animals with whom they had associated, but
who were afterwards taught to speak. Dumbness,
therefore, does not consist in the absence of voice,
but of speech and the deficiency of ideas, as most
dumb persons can utter a variety of inarticulate
sounds ; but it by no means follows that a
facility in speaking necessarily exists in propor-
tion to the quantity of the ideas or the power of
the mind. Many men of genius and great ima-
ginative powers are but little talkers, and some
not unfrequently experience difficulty in express-

ON THE VOICE ANU SPEECH.

" Talking

Notn

Tlie constant ci

ing their thoughts on sny particular subject;

while empty-headed fellows are frequently very
loquacious, and, like Gratiano, " speak an infinite
deal of nothing;" for —

It always to converse;
e distant from harmony divine,
reaking of a comitry sign :"

And, as has been observed by a powerful writer,
a great fluency of speech is frequently owing to
a scarcity of matter and a scarcity of words, " for
whoever is a master of language, and has a mind
full of ideas, will be apt in speaking to hesitate
upon the choice of both ; whereas common
speakers have only one set of ideas, and one set
of words to clothe them in, and these are always
ready at the mouth : so people come faster out of
a cburcb when it is almost empty, than when a
crowd is at the door*." On the other hand, many
highly intellectual men are great talkers, and not
unfrequently jest or talk nonsense by way of
relaxation ; so that silence and gravity of demea-
nour are not always a proof of superior wisdom,
though they are frequently considered so by the
multitude, and are in consequence sometimes
assumed by persons who either have nothing to
say, or who wish to impress others with a sense
of their superiority! .

• Swift.

f " Reaerve is no more essentially connected with under-
derstandiiig, ihan a church orguu with devotion, or wise with
good nature." — Shenslone's Esmys.

ON THE VOICE AND SPEECH.

" Since silence seema lo carry wisdom's power,

Th" affected rogues, like clocUs, speak once an hour"."

Such individuals are likewise noticed by Shak-
speare, as the sort of men

" Wlioso visages
Do cream and mantle tike a standing pond,
And do a willful stillness enterlainj
With purpose to be dresaed in an opinion
Of wisdom, gravity, profound conceit,"

The immortal bard adds —

" I do know of these
That therefore only are reputed wise
For saying nothing."

A complicated mechanism is required for the
correct articulation of words or speech, in the
production of which various parts are concerned,
which should be in a perfect state, and act in
harmony. If a portion of the upper or lower
jaw, or if the bony palate, be destroyed, if many
of the teeth be lost, the speech will be more or
less affected. A similar effect will ensue if the
soft palate be perforated by ulceration ; if the
passage through which the air has to pass be
narrowed, or its sensibility increased by inflam-
mation or swelled tonsils ; if there be paralysis or
other serious lesion of the muscles of the cheek,
lips, or tongue, though this organ may be in
great part extirpated without speech being lostf .

* Dryden.

+ A case is recorded by Tulpi
which is quoted in tlio Di

(ObsETvationes MedicK),
e de Medecine, of loss of

O ON THE VOICE AND SPEECH.

Now, the pharynx, fauces, the soft palate, the
uvula, the tonsils, derive their ner\'ous influence
from the eighth pair (which we have seen supplies
also the laryngeal muscles), by means of the
glosso-pharyngeal branch (which, however, is
considered by some anatomists. Gall and Bichat,
&c. as a distinct nerve), by means of which their
muscles contract on the application of their appro-
priate stinmU— food for deglutition, the air for
the formation of speech, &c. ; being but partially
under the control of the will as far as other actions
are concerned. This nerve liitewise endows these
parts witli their peculiar sensibility, and also
supplies the muscles of the posterior part of the
tongue, being finally distributed to the papillse
on its surface ; and is in all probabihty not only
the nerve of taste, but is likewise concerned in
some of the movements of the base of the tongue,
the associated action of which is necessary in
speaking, in deglutition, &c.* It forms inoscu-
lations with the respiratory nerves, and with the
sympathetic, participating in then- healthy and
disordered conditions. The tongue is likewise
supplied by the fifth pair for common sensation,
and by the ninth, which, being purely a nerve of

speech after extirpation of one-half of the tongue, but in which
it was restored after an inlei-val ot three years, in conse-
quence of the flight caused by a storm. Here the moral
impression firom l1ie operation doubtless occasioned aphonia.

* Galyanism of the trunk of this nerve, after death, produc
contraction of the muscles of the fauces, &c. which it supplies

ON THE VOICE AND SPEECH.

voluntary motion distributed to the muscles,
brings it more directly under the contiol of the
will thau those parts which are supplied by the
glosso-pharyugeal ; as may be seen on comparing
the flexibility, rapidity, and great variety of the
movements of this organ, with the limited action
of the fauces*. The same remark applies to the
muscles supplied by tlie portio dura, which ia
also exclusively a motor nerve.

In the article Bigaiement, contained in the
" Dictionnaire de Medecine et Chirurgie pratique,"
(which I read two or three days ago), I am happy
to find an opinion which I expressed on the cause
of stammering at the Westminster Medical Society,
corroboratedby thehighauthority ofM.Magendie,
who says, in the above-mentioned article — " Of
the muscles which serve for articulation, some
are subject to the will, as those of the lips and
cheeks ; those which carry the point of the
tongue upwards or forwards, to protrude it out
of the mouth ; and those which di-aw it 'back.
But the other muscles of the tongue, viz. those
which carry its root upwards, downwards, or
backwards ; the muscles of the velum palati,
those of the pharynx and of the larynx, are only

* The size of the lingual nerve has been found to vary in a
direct ralio to ihe quantily ajid rapidity of the movements of
the tongue, either for masticaCion, the prehension of food and
drink, as for the exercise of the voice. It is consequently
larger in dogs anil cats than in the ruminating animals and in
the rodentia. — Sartandiere, Traite du Si/slcmr Nerreux.

I

ON THE VOICE AND SPEECH".

incompletely under the influence of volition ;
thus, what a great difliculty most persons expe-
rience when requested to show the physician
their throat or fauces. We may well tell them
to depress the tongue, because it hides the tonsils ;
they make many efforts, and it is more by chance
than by a true influence of the will that the
desired action is obtained. If they be required to
raise the velum palati, the will is most frequently
powerless : and it would fail entirely in the at-
tempts to contract separately the muscles of the
pharynx or larynx. The muscular organs only
act in a complete manner to attain a certain end
— deglutition. In order for deglutition to be
performed there must be something to swallow,
even if it only be a little water or air. Thus, in
one point of view, the muscles of deglutition are
not subject to the will."

" AVliat has been said of deglutition is applicable
to other phenomena which take place in the
mouth. Nothing is so simple as to gargarise, to
spit, &,c. ; but in these instances, as in swallowing,
we attain the end by means of organs which
serve us, without knowing exactly the part which
each takes in tlie action. It is the same with
respect to the production of sounds in the larynx ;
and in speaking we form the voice, we articulate,
without knowing exactly what movements take
place either in the larynx or in the mouth.
There are numerous vocal phenomena of which

ON THE VOICE AUT) Sl'EECH.

the mechanism is yet far from being known to
the physiologist. We will the end, and we attain
it i that is all."

In other parts of the body, the movements of
which are completely under the influence of
the will, as the trunk and extremities, a certain
degree of harmony, or unity of action, must exist
not only between certain seta of muscles, but
also between musclesand their antagonists. When
the flexors, for example, are employed in the
perfonnance of an action, their antagonists are
not altogether relaxed, but serve to modify the
muscular contraction, in the appreciation of the
degree of tension and resistance, in the preser-
vation of the equilibrium of the body, &c. ; as seen
in the instance of rope-dancing and other feats of
agility, in which tliis harmony is carried by edu-
cation and habit to the highest perfection;
whereas the deficiency or want of it is illustrated
by awkwardness, and in cases of drunkenness
or chorea. Let two boys attempt for the first
lime to slide upon the ice, or to skate ; one will
preserve his equilibrium tolerably well, while the
other wUl probably fall down every two or three
minutes. Or, let them be taught to dance or
fence ; one will acquire easy and graceful move-
ments without difficulty, while the other wiU
probably retain much of his awkwardness, not-
withstanding the instructions of the master.
This greater or less aptitude to acquire perfection

10

ON THE VOICE AND SPEECH.

in muscular exercises, as well as the difference
which is seen in the gait of individuals, depends,
then, upon the greater or less degree in which
this harmony exists between different parts of the
muscular system, which derive their nervous
power from the brain.

Some cases of paralysis, which serve to illus-
trate the destruction or interruption of the har-
mony existing between sets of muscles which
are naturally associated in their at-tious, are thus
referred to by a modern writer on the nervous
system :-—

" C'est ainsi que certaines paralysies partielles,
en detruisant I'liarmonie fonctioneUe, denaturent
les directions et I'equilibre; j'ai vu souvent dans
de telles paralysies les medecins croire, d'apres
M. Flourens, a une lesion du cervelet, parcequ'ils
remarquaient que I'equilibre etoit rompu ; on que
les mouvemens n'etoient pas convenablement
balances ; ou auroit pu croire aussi dans ces cas,
en voyant I'individu manceuvrer autrement qu'il
ne vouloit, que I'orgaue des directions etoit lese ;
mais en observant mieux, il ne reste aucune incer-
titude a ce sujet; on s'aper^oit que les directions
sent appreciees voulues et indiquees, inais que
I'indication n'eSt nuUement snivie, non par inep-
tie, mais par defaut d'ensemble des instrumens
d'execution, dont les uns sent plus ou moins
faibles, on manquent totalement a leur mission,
et dont les autres manquant d'antagouisme ne

ON THE VOICE AND SPEECH. 11

sont pas ponderees ; de la ces mouvemens
brusques, saccades, ou trop energiques sans meaure
ni precision, qui lancent les paralytiquea incom-
plets dans des directions qu'ils n'ont pas resolues,
par la deshamionie d'action, le non-concours
regulier, la non-coordination entre les instrumens
d' execution, dont les uns repondent mal ou meme
ne repondent pas aux direotious imprfevues, et
dont les autres n'etant pas ponderes par leurs
antagonistes, agissent trap vivement j il y a done
bien la non-coordination, mais non pas a la ma-
niere dont I'entend M. Flourena, qui place a tort
la faculte coordinatrice dans le eervelet, au lieu de
la direction des mouvemens en avant*."

We may thus see, from what has preceded, that
speech is dependent upon a variety of move-
ments; and that for its formation, not only is
harmony required between muscles completely
imder the control of the will (as are those of the
lips and tongue), but also between such muscles
and others wliich are but partially so : a free re-
spiration, a regulated contraction of the muscles
of expiration, of those of the larynx, palate,
tongue, cheeks, and lips, in obedience to volitions
conveyed to several of them shnultaneously, or in
rapid succession, being necessary for perfect arti-
culation. It wiU therefore excite no surprise, on
considering these circumstances, that speech
should be so frequently affected in various dis-
* Sarlandiere, op. pit. Paris, 1840.

12

ON THE VOICE AND SPEECH,

eases, and by various conditions of the nervous
system, which destroy or interrupt, for a longer
or shorter period, the harmonious action of these
several parts. Persons labouring under concus-
sion of the brain, apoplectic attacks, in the debility
caused by exhaustion, or which supervenes in the
latter stage of acute disease, can very frequently
put out their tongue, and move their lips, but are
unable to perform the associated actions required
for speech, which inability is likewise fretjuently
a premonitory symptom of paralysis or cerebral
disease. After active exercise, as running, a per-
son will frequently be speechless for some time,
not merely from the want of air, but also from
the temporary disorder or exliaustion of the ner-
vous energies. The same circumstance may occur
from mental emotions, as fear, surprise, agitation,
and may even last for a long period ; as the effect
does not always cease with the action of the
causes v/hich produce it. When these causes act
in an aggravated degree, they may induce loss of
power over the more strictly voluntary muscles,
as those of the extremities, and the individual will
be unable to move*. I have entered more fully

• TLf fascination of some birds by tho aspect of certain ser-
pents rendering tbem unable to escape, or even to keep their
position upon ihe tree, is in consequence of volition being
parulysed by fear. The same cu'cumstance occurs, in a minor
degree, when an individual becomes speechless from strong
mental emotion. — Treatise on some Nervous Disorders,
2d edition, 1838.

ON THE VOICE AXD SPEECH.

13

into the consideration of these points in my work
on Nervous Disorders, and will terminate these
remarks by quoting from it a passage or two
bearing upon the present inquiry. " Those parts
which, though necessary for the performance of
ordinary actions, are not so directly controlled by
the will as some others, and hence require more
exertion of this faculty for ■ the healthy perform-
ance of their functions, appear to be most liable
to be affected by its debility. Thus it has seemed
to me that the muscles of the larynx are more
subject to atony than the muscles of the extremi-
ties, when moral causes have been instrumental
in producing the affection, and that the inferior
extremities are more frequently affected than the
superior."

" Loss of voice, depending on a state of atony
or paralysis of the small muscles of the larynx,
from suspension of their nervous power, is of
frequent occurrence. It may be total or partial,
in which latter case the patient can make himself
understood in a low whisper. The lips and
tongue can be freely moved in tliis variety of
aphonia. It may supervene upon mental emotions,
convulsive or other nervous affections, irritation
of the surface or of viscera ; or it may come on
without any obvious cause. A case is mentioned,
in the Dictionnaire de MSdedne, of a lady who
was deprived of her voice during several years
from excessive joy succeeding a state of great

14

ON THE VOICE AND SPEECH.

anxiety, which resisted all the means employed
for its relief, and disappeared, when least expect-
ed, after strong emotion. In another case, the
patient, during fourteen years, could only speak,
every day, between the hours of twelve and two
or three. Some years ago I saw a young man
who suddenly lost his voice completely, for which
no cause could he assigned. I stated that, al-
though he might not derive relief from medicine,
that the voice was not unlikely to return at some
future period. This has since occurred, after an
interval of twelve years from the attack. M. 01-
livier mentions a case of intermitting aphonia,
which, he says, ' existed more than thirty years,
and was only cured for the time by abstraction
of blood.' He adds, ' what is curious, however,
is, that the voice suddenly returned after one or
two spoonsful of blood had flowed,' In this case
it can hardly be supposed tliat the quantity of
blood lost could have had any influence in the
restoration of the voice ; and I am inclined to be-
lieve that it was in consequence of the impression
on the patient's mind that the voice must neces-
sarily return at the time of the bleeding. The
long duration of the disorder may be ascribed to
the habit of having it recur at stated periods.
These cases also tend to corroborate the opinion
of their nature which I had been led to entertain ;
and there is every reason to believe that, could
the patients' minds have been diverted from the

ON THE VOICE AND SPEECH. 15

expectations of the attacks at the accustomed
period, they would not have occurred,"

I might adduce several other cases illustrative
of the action of mental impressions in the pro-
duction and removal of disorders of the voice
and speech ; but as such would be out of place
on the present occasion, I will merely extract the
following from another of my works, as serving
to exhibit the powerful influence of the imagina-
tion over those disorders :■ —

" APHONIA OF SIX WEEKS' DURATION CURED IN A
FEW HOUBS BY STABCH PILLS GIVEN HOM(EO-
PATHICALLT.

" A girl, !et. 20, was admitted on the 14th of
January, with complete loss of voice, which had
existed since the middle of November. She had
experienced a similar attack in the preceding
year, but had recovered in fifteen days. The
menstruation was regular. A few days rest, and
the usual hospital regimen, producing no effect,
she was consequently placed in the department
where the homceopathic experiments were made,
and was ordered two pills composed of starch, which
she believed to behomceopathicremedies. The first
was to be taken in the presence of the physician,
the other at the expiration of four hours, A few
minutes after the first pill had been swallowed
the following symptoms manil'ested themselves : —
Anxiety, pain, and uneasiness in the region of

16 ON THE VOICE AND SPEECH,

the heart and thorax ; perspiration, with heat and
eruption on the skin. The second pill appeared
to aggravate these symptoms, with the addition
of hiccough. She afterwards fell asleep, and on
awaking she was astonished to find she could
talk in a loud tone. The complaint did not
recur, and she soon quitted the hospital*."

Similar cases to the above will not of course
be confounded, by the discriminating practi-
tioner, with the loss or alterations of the voice
and speech arising from obvious local irritation
reacting upon the spinal cord or nerves, as in the
instances of traumatic tetanus, worms in the
intestines, &c.

* Animal Magnetism and Homoeopathy, with Notes illus-
trative of the Influence of the Mind on the Body. 2d Edition,

1838.

ON STAMMBEING.

This affection has been confounded with the
hesitation, difficulty of expression, or repetition
of words — balbuties, which so commonly occurs
in children in their first attempts to talk, and
which generally ceases as they grow up ; though,
in a few instances, stammering supervenes upon
it, which leads parents, and those who have the
charge of them, sometimes to say, that the stam-
mer has existed from the time they began to
speak, which is not the case. A degree of hesi-
tation, difficulty, or stuttering, may arise from
other causes — as bashfulness, stupidity, confu-
sion of ideas, apprehension, surprise, &c. which
may occasion considerable embarrassment in the
articulation of words ; and, as a foreign author
has observed, " It frequently happens even in
persons highly endowed, and who usually ex-
press themselves with facility, to he wanting, as
it were, to themselves, and to stammer out with
difficulty the most trifling excuse, the most simple
compliment, or the most ordinary answer, to a
question which requires on their part some little
presence of mind *." The imperfect articulation

Ui? Mcdecinc, art. Balbi

18

ON STAMMERING.

in certain states of cerebral congestion, inebriety,
or weakness from disease, must also be distin-
guished from stammering.

Stammering, then, as may be inferred from what
has preceded, may be considered as a spasmodic
affection in the great majority of cases; not,
however, of that kind which is caused by irritation
of the surface, or of internal parts, or by lesions
of the nerves or spinal cord, but of a cerebral origin,
and depending upon a temporary disorder or a
faulty action of the faculty of volition, as far as
certain muscles employed in respiration and
articulation are concerned, which induces a want
of consent or harmony of action between these
muscles and others, which are more directly under
the influence of this faculty*. In the peculiarities
which it presents it has great analogy with other
nervous affections, especially chorea. It seldom
occurs before the age at which children possess
consciousness, and are able to pronounce words
with facility, viz. about four or five years. Like
chorea, it may be acquired by imitation ; is almost
always increased by agitation, or when it is re-
marked by others ; and affects, for the most part,
individuals who are endowed with a high degree
of susceptibility. It may be frequently stopped

• Stammerers, when not atlempting to speak, can, like oiier
people, move their lips and tongue freely iii ail directions, except
in those cases where the tongue is larger, or more hound down,
than naiiira].

ON STAMMERING.

ID

J measured and regulated movements, as speak-
ing slowly after a full inspiration, reciting or
singing j in the same way as the irregular mus-
cular action in chorea may often be suspended
for a time by the patient's playing the piano,
skipping, or performing other actions which re-
quire attention, and a regulated exertion of voli-
tion. Like other nervous affections, stammering
is more common, and usually increases in in-
tensity, about the period of puberty, and the
succeeding years, when the mental sensibilities
are so strongly called into play j but it diminishes
towards the decluie of life, and ceases altogether
when the nervous sensibility is blunted by the
approach of old age. When the stammerer is
alone, or with an intimate friend or relation, he
can usually speak very well, or at all events
better than when he is in company, or in the
presence of strangers. This fact is not invalidated,
but is rather corroborated, by the circumstances
that some persons lose their stanmier after a good
dinner and wine, though in company ; and that
others, having began a speech on a subject which
interests them, in a public assembly, have been
able to go on speaking for a considerable time
without impediment ; as ui point of fact they are
then m much the same condition (with respect to
the stammer) as when alone, having confidence
in their powers, or forgetting their infirmity for
the moment. It has been stated by a French

ON STAMMERING.

author, that stammerere can generally speak very
well when disguised by wearing a mask ; and
M. Itard mentions the case of a boy, eleven years
old, " who was a great stammerer wlienever he
spoke in tlie presence of persons who looked at
him ; but he did not stammer when he knew tliat
he could not be seen, and could speak to people
very well when in the dark. The attempt had
been made to cure him when he was younger by
bandaging his eyes*." These cases are obviously
explicable upon the same principle. Most stam-
merers, again, are made much worse when put in
a passion J though some, by being put in a passion,
become extremely voluble, from their attention
being altogetlier diverted to other matters. Stam-
mering also resembles other ner\'ous affections, in
pi-esenting frequent intermissions at regular or
irregular periods; some stammerers areatiected by
the state of the atmosphere, being frequently worse
in wet than in dry, and warm than in cold weather.
A few find their stammer better or worse accord-
ing as the moon is in its first quarter or at the full.
I have seen two persons in which this was the
case. Some, again, lose their stammer for a few
days, or even for a much longer period, after
which it recurs without theix being able to ascribe
the recurrence to any particular cause ; and as
a further coiroboration (if any be needed) that
stammering is essentitdly a nervous complaint,
* Dictioiiiiairc de Medeciiie, art. Begaieincitf.

ON STAMUERrNG. 21

and of the view which I have expressed respecting
its nature, 1 may allude to the fact, that the
great majority of cases may be cured by systems
of education which have for their object the regu-
lation of respiration, and of the muscular powers
concerned in speech.

Several persons, however, have attributed this
complaint to various physical alterations of the
tongue, fauces, tonsils, &c. ; and, indeed, in a large
proportion of stammerers, some Emormal or peculiar
conditions may be perceived on examination of
these parts ; yet none of them are sufficiently
constant to authorize the supposition that the
disorder is occasioned by them ; though, no
doubt, when existing they tend to aggravate it.
In many individuals the tongue is thicker, its
muscles being more developed than natural ; in
some it is more bound down to the floor of the
mouth, either by the development of the genlo-
glossi muscles, or by the frenum being inserted
too neat the apex. In others, one side of the
tongue (the right) is somewhat larger than the
other, and the organ is drawn to one side on
being protruded from the mouth. In several,
again, the tonsils are swollen, and the arches of
the soft palate are lower than natural; though,
from what I have seen, I cannot concur in the
opinion expressed by Mr. Yearsley, in his pam-
pldet, that, " in the great majority of stammerers,
the tonsils and uvula are in a diseased state."

ON STAMMERING.

I

I

On the contrary, I should say that, in many of
the individuals who experience great difficulty in
speaking, nothing anormal is perceptible in the
appearance of the parts; and that the physical
alteration most frequently met with is the in-
creased size and more energetic contraction of
the muscles of the tongue and beneath it, which
sometimes prevents its being freely protruded
from the mouth, or its tip from being turned over
the lip towards the nose, notwithstanding the
person's efforts, as would be the case with an
individual whose tongue was swollen from the
exhibition of mercury, or any other cause. This
alteration I consider to be a consequence of the
disordered nervous action, which, by inducing
irregular and spasmodic contraction, causes a
greater degree of development of the parts, as
would be the case with any other muscular struc-
ture wliich is unduly exercised. We therefore
see that there is more difficulty and spasmodic
action induced by the attempts to articulate words
which begin with some of the consonants than
with the vowels, the former requiring more the
concurrence of voluntary muscles than do the
latter, the pronunciation of which is of a passive
nature. We also see, in the majority of stam-
merers, that there is more difficulty in beginning a
sentence or speech than in its continuation, as a
more direct effort of volition is required to com-
mence a muscular action than for its repetition ;

ON STAMMEHING.

23

ahd many individuals can pronounce a diJIicult
word with much greater ease if thoy are desired
to repeat it after another person. These physical
alterations may, then, be considered as an acci-
dental coincidence, or as an effect of the disorder.
One or other of them is constantly met with in
tolerably healthy persons, and others who do not
stammer; and it must be obvious that if they
were the cause, the effect must be permanent, and
stammering would always be present, instead of
presenting, as it does, such remarkable variations,
whicli are occasioned by the state of the person's
mind at different times, and by other circum-
stances to which I have alluded. The same may
be said of the opinion which would refer the
complaint to the incident or reflex action on the
sjiinal cord, to which of late years it has been the
fashion to ascribe many diseases, the origin of
which is referrible to a higher source*.

• " The instimt production of several nervous affections from
moral impressions, the variableness of the s^ptouis, their
transient nature and periodicity in many cases, are incompatible
with the existence of organic lesion as their cause ; and, although
there may be some uneijual distribittion in the capillary
bystem of the hraia or sjiiual cord in many instances, yet ihis ia
probably an effect. The immediate cause of the symptoms
most likely conasts in some modificatioa of the nervous action,
with which we are unacquainted," — Treatise on some J^ervcms
Disorders, ^c. p. 22.

" The frequent variation and the cessation and aggravation
of the symptoms at regular or irregular periods, are features
peculiar to disorder of the cerebral functions, serving, in many
instances, to distinguish it from other diseases. These pecu-

24 ON STAMMERING.

I have, however, seen several individtuilB
(though the number is small when compared with
tlie others) in whom the physical alteration in the
size of the tongue, and the energy of the con-
traction of the genio-glossi muscles, appeared to
be the cause of the infirmity, from the manner in
which the tongue is bound down, and the
resistance which is afforded on attempting to
introduce the fingers beneath it. This class of
stammerers differs from the other, inasmuch as
they do not stammer in general, but invariably
upon the same words beginning with a consonant,
as C, B, P, K, or T, or any combination of
syllables resembling them ; they are sometimes
a minute or more before the difficult words can
be articulated, after which they can go on pretty
fluently, and they experience nearly as much
dilficnlty if the word be in the middle of a phrase
as if it be at the commencement. They are not,
like the generality of siammerers, affected by
being in society, as they experience an equal
difficulty when alone ; neither are they influenced
by change of weather, &c. The first individual
with this kind of stammer, whom I noticed, was
a man who presented himself at M. Amussat's,
and who could not pronounce the word courroi/eur.

liarities may be accounted for by the constant succession of im-
pi^saicms to wbich the brain is Gxposed. The disorders of that
organ do not eonsequciitiy follow the definite course pursued by
adeclions ol' other parts." — Ibid, p. 26.

ON STAMMEHING.

25

ajid two or tliree others wJiich resemble it, but
in other respects could articulate tolerably well.
Immediately after the section of the genio-glossi
muscles, he could speak this word, and the others,
without any difficulty ; and when I saw him for
the last time, three weeks after the operation, he
had no further impediment in his speech. I have
little doubt that several of those, whom a long
treatment and education have failed to cure,
would be found to belong to this class*. There
is, again, another class of individuals in whom the
nervous or general stammer (which is sometimes
upon some words, and sometimes upon others,
and to which the preceding remarks principally
apply) is combined with the difficulty in articu-
lating particular words; these persons, though
not free from the stammer when alone, can yet
speak much better, and are much less liable to
gesticulations of the head, neck, or limbs, and to
choreal or spasmodic action of the muscles of the
face or lips, than when in company with strangers.

• A well-marked ease of this permanent or physical slammer
occurred in a man who was a patient in the hospital Beaojon
fur a surgical disease. The tongue was bound down to the
floor of the mouth by an extremely short frenum, which even
turned its tip downwards. As soon as the membrane was
divided, the patient, who previously could scarcely speak a few
words in succession, spoke distinctly and without difficulty ;
hut, as he did not take proper precautions against the part re-
uniting, he duly lost some of the advantages of tlie operation. —
Did. de Med. tl Chir. pratiques, art. Laiifiuc.

ON STAMMEBING.

I

or otherwise excited. In several of those whom
I have seen, there has been nothing remarkable
in the appearance of tlie tongue or mouth, thougli
the majority of them cannot turn the tip of the
tongue upwards over the lip, and the muscles of
the organ contract forcibly on the introduction
of the fingers beneath it. I am inclined to think
tliat in these persons the difficulty in the articu-
lation of particular words is super-induced upon
the nervous stammer ; and that, when in an
aggravated form and of long duration, stammering
would always be found to be connected with
increased muscularity of the tongue.

Females, it is well known, are much more
affected by nervous disorders than men. Stammer-
ing, however, presents this peculiarity — that it is
rarely met with in women or girls. Of the 100
cases mentioned in Mr. Yearsley's pamphlet, not
more than three or four are females. Of 300,
treated by M. Colombat, 386 were males, and
only 14 females. Of between thirty and forty
stammerers who presented themselves at M.
Amussat's, only three were women ; and other
statistical accounts represent the number to be
equally small. This circumstance has never been
satisfactorily accounted for, and perhaps the only
rational explanation that can be given of it is,
that women have naturally a iiner organization
of the parts concerned in speech, with a quicker
apprehension, and that they think quicker than

ON STAMMERING. 27

men ; hence their articulation is more easy and
fluent, they are capable of greater volubility, and
experience less hesitation in speaking. This is
even found to be the case at an early age. When
children are required to appear and speak in
public, as on the stage, girls are almost always
found to be best adapted for the purpose. How
often do we not see a boy become confused,
stammer, and hesitate, on being questioned upon
particular subjects, and how seldom in comparison
does this occur with girls of moderate intelligence*.
Probably, if inquiry had been made of all the

* " Little girls have the organs of speech more supple and
Sexible tlian boys ; they speak sooner and ea^er, and women
speak more agreeably than men. They are accused of speaking
more : such ought to be the case, and I would willingly convert
ihis reproach into praise. The eyes and the mouth have in
them the same mobility. Always occupied in pleasing ;
obson-ing, with the most persevering attention, every thing which
passes around them; always expert to profit by their ad-
vantages, and reduced by the slate of our society and manners,
to shine only by singing, dancing, but especially by conversa-
tion, they give themselves up to these exercises with ardour,
and excel in them more than men. The whole nervous system
is also more developed in them ; the impressions which they
receive are more powerful and multiplied, and hence they have
a greater number of sensations and internal feelings to make
known ; anxious to penetrate the secrets of men, and lo ascertain
the stale of their hearts, speech is for them the most useful in-
strument, and the most indispensable to their happiness."

J. J, ROOSSBAD.

Here we have at once a rational explanation why stammering
aliould be so rare, and otlier nervous afiections ao conunon, in
females.

28

ON STAMMERING.

females who had presented themselves for the
cure of stammering, it would have been ascertained
that in several of them the infirmity had been
acquired by imitation, as it must evidently have
been with the two sisters mentioned by M. Magen-
die, who both stammered badly, and whose
mother was also affected. This appeared likewise
to be the case in a female whom I have recently
seen, and whom I questioned upon this point.
She, as well as her sister, thought her stammer
was owing to her having been accustomed to go
to school with another child who stammered.
At all events, the circumstance of the comparative
infrequency of stammering in females would be
of itself a sufficient refutation of the opinion of
those who regard this affection as dependent upon
physical causes ; as enlarged tonsils, and other
anorraal appearances of the throat and tongue,
are in all probability as commonly to be met
with in the one sex as in the other. With respect
to the comparative facility with which the majority
of stammerers sing, it appears to depend, partly
upon the circmnstance that the attention is con-
centi-ated upon keeping time, and in the variations
of the voice, and partly that, in singing, the words
glide one into another more than in speaking, and
the difficulties may be more easily eluded.

I will now briefly notice the opinions of some
writers on the complaint, and the methods which
have been proposed for its removal. The earliest

ON STAMMERIKX.

instance on record of the cure of stammering is
in the case of Demosthenes, who cured himself
by reciting slowly, in a loud voice, long passages
from the Greek poets, holding, at the same time,
several pebbles in his mouth ; and somewhat
analogous methods have been found successful in
more recent times. M. Itard proposed, in the
year 1817, a sort of fork, with two prongs, which
carried the point of the tongue backwards, com-
bined with the practice of speaking in a foreign
language with which the person was not very
conversant, by which means both the attention
and the memory were exercised during the con-
versation ; and it will generally be observed that
stammerers, if required to read before strangers,
will do 80 much better if they can take an interest
in the book or paper presented to them ; the
attention being thus for the time diverted from
the thought of their being observed. The plan
of Itard, however, was not very successful ; that
of Mrs. Leigh, of New York, was more so, espe-
cially after the improvements of it by M.Malbouche,
who introduced it into France. Mrs. Leigh
considered that the difficulty of articulating
depended on the circumstance of the tongue not
being carried upwards, so as to touch the palate
in speaking ; she therefore made those under her
care persevere in beginning each word by turning
the tongue up to the palate; and between the
years 1838 and 1830 had sent away from her

ON STAMMERING.

establishment 160 persons cured. M. Malbouche
superadded to this plan the drawing the lips
backwards, so as to make the mouth appear
larger, and when the phrase was terminated, the
lips were again drawn back against the teeth, in
order to recommence a fresh one. It was also
required of the pupils to maintain a perfect silence
between the interval of the exercises, and to prac-
tise declamation and reading aloud before attempt-
ing a familiar conversation, which was not
permitted until the cure was considered to be
effected.

M. Malbouche, however, divided stammering
into three kinds, according to the faulty positions
of the tongue in speaking, and varied his method
accordingly ; but it would carry me too far to
enter into the consideration of these varieties,
which subsequent observation has shewn to be
in great measure hypothetical. He says that the
energy of the will is the most essential condition
of success, and " that it is important to con-
centrate it exclusively upon the object to be ob-
tained by the treatment. Children, and that class
of men of the world who are accustomed to dis-
sert upon and discuss every thing, without ever
concluding upon any thing, are incapable of this
concentration of the attention, and for that reason
are difficult to cure : whereas experience has de-
monstrated that peasants, working men, and
uneducated persons in general, are more easily

ON STAMMERING.

31

cured. These individuals having but few ideas,
seize with energy those which they can under-
stand, and in wliich they are deeply interested."
A want of confidence may cause any of the me-
thods of treatment to fail altogether. In general,
those cures which are the most quickly effected
are the least durable.

M. Series divides stammering into two kinds :
the first is characterized by a sort of St. Vitus's
dance of the muscles concerned in articulation ;
the second, by a tetanic stiffness of the muscles of
the voice and of respiration. In the first kind
the will loses its influence over the rapid move-
ments of the lips and tongue ; in the second kind
the breath fails*. His method of treatment con-
sists in making the sufferer breathe regularly, and
combine his breathing with a certain cadence in
speaking, as in declamation and singing. Du-
puytren likewise recommended stammerers to
speak in a manner analogous to the recitative
of operas, by which means much of the difficulty
was obviated.

M. RuUier considers stammering to be a cerebral
affection, and that it is attributable to some modi-
fication of the action of the brain. " But," he
asks, "in what does this modification consist?
Without pretending to explain it, the following
conjecture may be hazarded. In the stammerer,

' Memorial des Hopiiaus An Midi, 1829.

32 ON STAMMF.HTNG.

the cerebral irradiation wliicli follows thought,
and becomes the principle which induces action
in the muscles which are necessary for the ex-
pression of the ideas, rushes out with so much
impetuosity, and is reproduced with so great a
rapidity, that it exceeds the measure of the move-
ments which are practicable by the agents em-
ployed in articulation. Hence, as if suffocated
by this accumulation of the ordinary exciting
cause of their movements, they fall into a state of
spasmodic immobility, and of convulsive shocks,
which characterize stammering*."

This hypothesis is, however, not borne out by
observation. That there is a want of accordance
between the cerebral action which occasions the
muscular movements, and the agents by which
they are effected, wiU, I think, be clear to all who
have paid any attention to tlie subject; and that
this is the essential cause of stammering I have
endeavoured to prove, as well as the manner in
which ittakesplace. M. Magendie justly observes,
in refutation of the above theory, " I have seen
many stammerers; and if I have met with some
in whom the degree of intelligence appeared to
be very great, I have likewise seen others in whom
time was not wanting to the muscles for the
expression of the ideas, which were any tiling but
abundant or vivid. Stammering is evidently a
modification of the contraction of the muscles
R Meilevine, art. B^giiicnioiil.

ON STAMMERING.

33

concerned in speech ; and since by means of
physiology we can give no explanation of this
contraction itself, how can we expect to explain
its various degrees ? Without occupying our-
selves with researches which can lead to no useful
result, let us limit ourselves to remarks on the
kind of contraction of the muscles which take
part in the formation of speech, and of which tlie
action is more or less altered in stammering."
M. Magendie then continues in the words which
J have already quoted in the first part of this
paper.

M. Colombat, whose work is the fullest and
most recent on the subject*, regards stammering
as a nervous affection, the princi|^ml character of
which is a repetition by catches, or convulsive
shocks, of a greater or less number of syllables ;
or a painful and temporary suspension of the
voice before some consonants or vowels which
require a certain effort for their articulation. He
divides the affection into two kinds, which he
terms labio-choreiqne, and ffutturo-tetanic. These
are subdivided into several varieties. The first
kind consists in a sort of chorea of the lips, and
in a succession of movements, more or less rapid,
of the tongue and lower jaw : it chiefly gives rise
to disagreeable repetitions of b, b, b, t, t, t, d, d, d,

* Traile dc lous les vices de la parole, eC particuliereinent
du begaiement, 2 vols. 3d edition, 1840.

S4

ON STAMMERING.

or q, q, q. In the second kind the stammerer
remains with his mouth half open, incapable of
producing any sound ; sometimes, even, when
the word begins with a vowel : the face and neck
become swollen, and the jugular veins distended.
In some individuals the tetanic state predomi-
nates, in others the choreal, though the two kinds
are not unfrequently united in the same person.
Thus a stammerer in beginning to speak is stopped
at the iirst word, if it commence with a consonant
which is difficult to pronounce ; then the fear of
not succeeding renders the breathing hurried, and
he becomes dumb, like a person afiected with the
second kind of stammer. In both kinds the
stammering ceases by making a full inspiration j
but it will soon return if tlie person do not take
care to breathe regularly, and recurs more or less
frequently, or with greater or less intensity,
according as the breathing is more or less agitated,
and according as the moral emotions which he
experiences tend to increase or diminish the act
of the will. " Now," continues the reviewer, " let
us try to teach the stammerer to breathe regularly :
let us connect hia breathing with a certain cadence,
as is the case in singing and declamation, the
stammer will not occur; and if the individual
can subject himself to the same constraint in con-
versation, he will be able to speak without
stammering. To this result the method of treat-

ON STAMMERING.

35

ment of M. Serres directly leads ; whereas the
other methods only attain it indu-ectly*."

It is foreign to my purpose to enter into the
details of these educational methods of treatment :
I therefore refer those who are particularly in-
terested in the matter to the work of M.Colombat.
In order to enable those under his care to keep,
during their exercises, a regular measure, or
cadence, in speaking, this gentleman makes his
pupils use an instrument for counting, termed
the mutkonome, by which the rhythm may be
accelerated, shortened, or kept at the same degree,
at pleasure. After having enumerated several of
the means which he employs, M. Colombat says,
" The combination of the orthophonic means which
have been described, constitutes a vocal exercise
which has the advantage of acting at the same
time physically and morally. It acts physically
upon all the muscles of respiration ; on the lungs,
the larynx, and particularly on the glottis, on the
tongue, and on the lips ; in fact upon the entire
vocal apparatus.

" It also acts morally. Thus the measure
which exerts so beneficially its influence over all
the organs, by regulating their movements, fixes
tlie attention of the stammerers conjointly with
the other parts of my curative method, and be-
comes an accessory idea, which, joined to the
principal one, must necessarily place the nervous
* Gazette Medicaie, 1840, p. 153.

ON STAMMERING.

action which follows thought more m harmony
with the relative mobility of all the vocal organs.".

The followingare the results which M. Colombat
obtained, from the year 1827 to 1833. Of three
hundred stammerers treated at his institution, and
in town practice, two hundred and thirty-two were
cured without relapse, thirty-two relapsed, in
fifteen the complaint returned after a second
treatment, and twenty-one were incurable. The
average duration of the treatment was twenty -five
days. Two hundred and sixty-five were adults ;
twenty, cluldren under twelve years of age ; and
only fourteen, women.

One of the worst cases of stammering which
has fallen under my observation was that of a
Savoyard boy, who presented himself at M.
Amussat's. The difficulty in commencing most
phrases was extreme, and the attempts were
accompanied with strong spasmodic actions of
the face, neck, and upper extremities. M. Colom-
bat took him out of the room, and brought him
back in about a quarter of an hour, when, by
attending to the directions he had received, and
keeping time by striking the fore-finger of his
right hand against the left, he could articulate
with much greater facility. The tongue, and the
muscles beneath it, were very much developed,
and contracted strongly on the introduction of
tlie finger into the mouth. The operation of
dividing the genio-glossi muscles was performed.

ON STAMMERING.

37

which produced a considerable amelioration,
though it did not effect a perfect cure.

After an examination and comparison of the
different methods of the educational treatment of
stammering, MM. RuUier and Itard remark that
every measure which has been advantageously
employed may be reduced to a sort of obstacle or
moderator, which is opposed to the irregular,
anormal, and embarrassed movements of the
organs of speech. This moderator acts physi-
cally or materially ; whether it be the pebbles em-
ployed by Demosthenes, the instrument for fixing
the tongue, of M. Colombat, or the fork of M. Itard.
It acts also upon the tongue, and other parts
employed in articulation morally or mentally, by
means of the attention, the will, the action of the
memory, or the eflbrts at imitation. " The
mechanism of speech," adds M. Itard, " is
then performed under new conditions, associated
as it is with certain voluntary movements, or
with certain positions of the tongue, which are
ordered, and which had previously been uncon-
nected with the action of speaking. Such are,
tlie movements of the thumb upon the forefinger,
or frequently repeated inspirations, as recom-
mended by M. Colombat ; the moveme:its of the
arm, as directed by M. Serres; and the different
positions of the tongue, according to the precepts
of Mrs. Leigh and MM. Malbouche and Colombat,
Such are, likewise, the exercises of the memory

38

OPERATIONS FOB STAMMERING.

and ofimitation, the difficulty the stammerer expe-
riences in endeavouring to learn, and in speaking
only in a foreign language, or to adopt, in his
familiar conversation, the emphasis of theatrical
declamation *.

I now proceed to the consideration of the ope-
rations which have been performed for the cure of
stammering, and of their respective applicability
to particular cases.

The first operation for stammering was per-
formed by Professor DiefFenbach, of Berlin, in
January last, who, in a letter addressed to the
French Institute, thus states the manner in which
he contemplated the removal of the complaint
might be efiected :—'' As I conceived that the
disorder in the mechanism of speech, produced
by stammering, was referrible to a dynamic cause,
which I considered to depend upon a spasmodic
state of the air-passages, especially of the glottis,
which was communicated to the tongue, muscles
of the face, and even of the neck, I was led to
think that, by interrupting the innervation in the
muscular organs which participate in this abnor-
mal state, I should succeed in modifying or
preventing it altogether." Accordingly he pro-
posed the transverse section of the muscles of the
tongue by three different methods; first, trans-
verse horizontal section of the root of the tongue ;
second, transverse subcutaneous section of the root

• Op. cit.

I

OPERATIONS FOB STAMMEBING.

39

of the tongue, or section of the muscles without
division of the mucous membrane ; and, third, the
horizontal section of the root of the tongue, with
the excision of a triangular portion throughout
its whole width and thickness. In performing
these operations, the tongue is seized with forceps
terminating in double hooks to each blade (pinces
de Museaux), and drawn out of the moutii, A
bistoury is then passed through it at its thickest
part, from one side to the other, and iis substance
divided by cutting upwards. The posterior part
is immediately seized with forceps, and held by
an assistant, while the operator passes through it
from behind forwards three short curved needles,
armed with strong ligatures, which are carried to
the bottom of the wound, and brought out on the
upper surface of the anterior portion, when they
are tied together, and approximate the cut surfaces.
The second operation is performed in a similar
manner, with the exception that the mucous
membrane of the dorsum of the tongue is not cut
through. In the third, a piece of the tongue is
cut through, somewhat resembling in shape a
slice of melon, and the ligatures applied as in the
first method. This last operation has entirely
superseded tlie others, which were only performed
at the outset.

The first operation was performed in four cases j
in one, where there was a paralytic state of the
tongue, it was unsuccessful ; in the otlier three

J

40

OPERATIONS FOB STAMMERING.

it was attended with success. The patient firat
operated upon was a boy, whose stammer waa
very bad, and who had been considered to be in-
curable. He experienced more especially a dif-
ficulty upon the gutturalsj g, k, ch, z, and other
consonants. At times he could not speak, and
the presence of strangei's always produced con-
siderable agitation. The tongue was rigid to the
feel, and the action of the muscles of the face
and neck was considerable. On attempting to
speak, the first word always caused the greatest
difficulty : after tliis was overcome he could speak
easier, and the words issued out in quick suc-
cession, till, on his becoming confused, the stam-
mer returned. There was a good deal of hiemor-
rhage during the operation, but it ceased after the
ligatures were tied. The stammering was re-
moved, but the contractions of the lace contmued
when he spoke. Considerable swelling of the
tongue, and fever, supervened, which, however,
subsided, and, on the seventh day from the opera-
tion, no remains of stammering were perceptible ;
the convulsive movements of the face and lips
had disappeared ; his pronunciation was easy ;
the presence of strangers or mental emotion did
not occasion any recurrence of the stammer. In
the case where the second method of operating
was adopted, on the introduction of the bistoury
the blood gushed out with violence on both sides,
and the tongue became very considerably swollen

OPERATIONS FOn STAMMERING.

41

from the extravasation of blood. The third ope-
ration was performed on a boy, ^t. 1 6, wJio had
great difficulty in pronouncing words beginning
with certain consonants, and also occasionally
upon the vowels, attended with considerable
spasmodic action of the muscles. When with his
brother and sister, he could frequently speak very
well ; but the least agitation, or the presence of
strangers, caused a recurrence of the stammering.
A slice of the tongue was cut out, and a good
deal of bleeding ensued. The stammer was,
however, removed, and, on the eighth day, the
cure was complete.

The Paris papers liavmg mentioned that a letter
had been received, on the 9th of February, from
Pi-ofessor Dieffenbach, stating that he had ope-
rated successfully upon the muscles of the tongue
for stammering, though the nature of the operation
was not mentioned, several surgeons began to
operate. M. Phillips first performed the opera-
tion of dividing the genio-glossi muscles below
the tongue in private, and sent a sealed packet to
the Academic des Sciences, descriptive of the
method he had adopted, and the result. I saw
the patient at his house, a few days afterwards ; he
could speak and read with considerable facility.
M, Velpeau, however, first operated in public,
after describing the operation, on the 14th of
February. M. Amussat, who had directed his
attention to the subject (before notice of DiefTen-

43 OPER.VTIONS FOR STAMMEBIKG.

bach's operation had arrived) in consequence of
a patient stammering who presented himself to
have the operation for squinting performed (which
was likewise the case with Professor DiefFenbach)
after having examined the muscles beneath the
tongue in this patient, stated to several persons
present his opinion that their division would be
likely to relieve the slammer. He subsequently
perl'ormed the operation on several patients, some
of whom were presented to the Academie de
Medecine. MM. Baudens and otliers likewise
operated with success in many cases.

M. Phillips' operation is as follows : — ^The
patient being seated on a chair, his head resting on
the breast of an assistant, the operator seizes the
frenum with a small hook near its angle of
reflexion with the tongue. Another hook Is
inserted a little lower down, and an incision with
scissors made between the two, and the membrane
divided to some extent on either side; a sharp-
pointed curved bistoury is then introduced, and
cairied from one side of the symphysis of the
jaw to the other, dividing the attachments of the
muscles. The bleeding is sometimes abundant,
but is salutary. A piece of sponge dipped in
vinegar is placed in the wound to arrest the
bleeding.

M. Baudens plunges a pair of finely-pointed
scissors, curved almost to an acute angle, with
their blades moderately separated, beneath the

OPERATIONS FOR STAMMERING.

tongue, immediately behind the symphysis of
the jaw, and with one cut divides the attachment
of the genio-glossi muscles. There is generally
little bleeding, as the incision is made close to
the bone. A piece of sponge soaked in vinegar
is put into the wound, and retained for two or
three days, which practice has, in some instances,
given rise to inflammation and suppuration.
M. Baudens likewise divides the genio-hyoidei
in those cases where the muscles of the neck and
throat are implicated in the spasmodic action.
One of the worst cases of M. Baudens was that
of Vincent Zousset, a baker (hoidaiiffer), who
was unable to articulate his name or profession.
Immediately after the operation he conld pro-
nounce these words with great facility.

M. Aroussat divides his operation into two
periods or parts. The mouth being opened wide,
and the tongue turned back, the mucous mem-
brane of the lower part of the frenum, between
the Whartonian ducts, is cut with small scissors,
and the incision is extended on either side, the
tongue being at the s£ime time drawn outwards,
so as to expose the genio-glossi muscles, which
are then divided with large scissors curved on the
flat. " At the point," says M. Amussat, " where
I practise the section of the genio-glossi muscles,
there is less difficulty and danger than at any
other. You act on a double fibrous band
(faisceau) or on the summit of the triangle^

44

OPERATIONS FOK STAMMERING

whilst higher up, as is well known, tiie muscles
spread out In a fan-like form, and are surrounded
by vessels and nerves."

In some Individuals it is found that the mere
section of the frenum and sublingual membrane
on either side of the roof of the mouth is sufficient
to remedy the infirmity. Thus, out of fifty-five
persons who were opemted upon, eigliteen were
relieved in this manner. There is not in general
much bleeding, and in none of the above cases
has it occasioned uneasiness; when more than
usually abundant, it is stopped by Iced water, and
small lumps of ice beneath the tongue.

One of the first patients operated on was
Alexis Beyeuval, a man, aet. 48, who had stam-
mered from bis childhood, and had had the
frenum divided at two different periods without
any advantage. The stammer was of the worst
kind. The movements of the tongue were very
limited. It was turned towards the right side,
and the patient could not protrude it over the
upper lip. After the division of the frenum and
the sublingual membrane on either side, he could
speak some words plainer than before, but
experienced great difficulty upou others. The
genio-glossi muscles were then divided, which
was followed by considerable amelioration, though
the stammer was not altogether removed. Some
muscular fibres which were felt to be still attached
to the bone were cut through, and pronunciation

OPERATIONS FOR STAMMERING.

became free and easy, with scarcely any remains
of the stammering. The deviation of the tongue
was likewise rectifiefl. Two months afterwards
(18th April) there had been no relapse; the
patient spoke as well as immediately after the
operation.

Victoire Courgeot, ait. 16, has stammered since
her childhood ; her elder sister likewise stammered
till she attained the age of fourteen, when it
ceased. The father of these girls was a stam-
merer, which strongly corroborates the opinion
I have already advanced ; viz. that the majority
of cases of stammering m females would be found
to arise from imitation. We see, in Ibis instance,
that the sister, when appi-oaching to puberty,
being probably less under the control of her
father, and associating less with him, lost her
stammer ; whereas, in the majority of cases, the
complaint increases at this period of life. In
Victoire'a case the division of the membrane was
auflficient to cure her. Two months afterwards
there had been no relapse.

An operation of a different kind was performed
by M. Velpeau a few days before I left Paris.
In this patient the tongue was longer than natural.
He could touch the lower part of his nose and
chin. A small triangular portion was cut out
of the apex of the tongue, without dividing the
mucous membrane beneath. The edges of the
wound were brought together with points of

46

OPERATIONS FOR STAMMERING.

I

I

suture. This was attended with some degree of
amelioration at the time ; but I hear that as the
wound healed the stammering returned, though
not so bad as before.

Another method, which I saw described a few
days ago in the Gazette des Hupitaux, hajs lately ,
been tried, as it would appear with success, by I
the same eminent surgeon. The patient was a J
young man from whom scarcely a word could be 1
obtained, insomuch that he would have been I
considered dumb, were it not that the movements
of the lips, and the violent efforts which he made j
to articulate, indicated his actual condition. The J
tongue in this case was also very long, and he
could touch with it the lower part of his nose. ,
Previous to operating, M. Velpeau tried the J
experiment of raising the tongue with a pair of I
ordinary forceps, when the patient was able to f
pronounce some words ; from which it was -]
anticipated the operation would be attended with J
fiuceess. The operator then drew the tongue out ]
of the mouth with his left hand, furnished with. |
a piece of linen rag, and with the right passed |
transversely through its substance, at the j unction |
of the posterior and middle thirds, a needle armed J
with four ligatures. Two of the ligatures were 1
tied as far back as possible ; the other two were
tied anteriorly, thus circumscribing a portion of
the tongue, which, after it had sloughed away,
would entail a similar loss of substance as in

OPERATIONS FOR STAMMERING.

Dieffenbach's operation. The patient did not
appear to sufier much, and immediately after the
operation was able to pronounce some words
distinctly. He would not remain in the hospital,
but promised to return every second day. During
the first four days the size of the tongue was
considerably enlarged, and the neighbouring parts
were swollen, but no serious accident ensued :
a few leeches, with the use of gargles, sufficed to
allay the above symptoms. A week after the
operation there was only some slight incon-
venience felt in the throat. The stammer was in
great part removed, so that he could speak with
tolerable facility.

About the same time M. Velpeau tied the tem-
poral and facial arteries on a man, Eet.36, affected
wilh epilepsy durmg the last seven years.
The disease was first induced by a fright, and the
attacks had continued eight or ten times a month j
but within the last three months he had attacks
almost daily. The temporal arteries were first
tied : the patient had only a slight attack on the
same day, and the following day passed without
any. On the 6th of April the external maxillary
arteries were tied at the point where they pass
over the jaws, and the attacks did not recur.

The operation on the genio-glossi, as performed
by Mr. Lucas, does not differ materially from the
other methods
tioned, except
removed

which have been already men-
that a portion of the m'

a different mode of divid

48

OPEBATIONS FOH STAMMERING.

muscles, viz. the subcutaneous, has more recaitly
been practised by M. Bonnet, of Lyons. A
puncture is made in the skin, a few lines behind
the symphysis of the jaw : a blunt-pointed teno-
tome is tlien introduced, with its sliarp edge turned
towards the bone, and passed upwards till its
point is felt by tlie finger through the mucous
membmne beneath the tongue. The attachments
of the muscle are then divided right and left ; the
cutting edge of the tenotome being kept close to
the bone, and acting only on the superior part of
its concavity, the genio-glossi are alone cut, and
the genio-hyoidei avoided. Scarcely any bleed-
ing ensued. M. Bonnet had performed this ope-
ration in five cases ; the two last patients, though
labouring under a bad form of stammering, and
who even stammered in reciting verses, were im-
mediately relieved, without preserving the least
trace of their infirmity. On the other three
patients the relief was not so decided, though a
considerable degree of amelioration resulted;
which circumstance M. Bonnet ascribed to the
mode of operating not being so perfect in the
first case as in the last ; though I should think it
depended on the former being more strictly cases
of nervous stammer than the latter, and that the
operation would not be so likely to be perma-
nently successful.

The following cases will serve to illustrate the
two varieties of stajnmering.

Purely nervous stammer. — A young man, who

OPERATION'S FOR STAMMERING.

49

has stammered since his childhood, states him-
self to be very nervous. When alone, or when
with persons with wliom he is very intimate, he
can talk very well, but almost always stammers
before strangers ; sometimes more than at others ;
especially if he thinks the infirmity is remarked,
or if he be questioned respecting it. The stammer
is not, however, very bad. There is no particular
tension of the muscles of the tongue, which can be
turned upwards towards the nose, nor is there
any thing anormal perceptible about the mouth
or throat. He has two cousins similarly affected.

Physical stammer. — This man always ex-
periences difficulty in pronouncing certain words,
especially those beginning with a q or n, as
qualorze, navet ; considerable spasmodic action of
the muscles of the face and lips being induced by
the attempts to articulate these or other words
upon which the difficulty exists. He has as
much difficulty when alone as when in company,
or before strangers : cannot protrude the tongue
far, or turn it upwards over the lip. After the
division of the sublingual membrane, and cellular
texture on the floor of the mouth, he was able to
protrude the tongue, and could speak the above
and other words with facility.

Mr. Yearsley's operation consists in the ex-
cision of the entire uvula, and also of the tonsils,
when these bodies are enlarged or diseased. The
part to be removed is seized with an Assalini's

50

OPERATIONS FOR STAMMEItlNG.

tenaculum, and cut oft', scissors being employed
for the uvula, and a knife for the tonsils, which
being frequently hardened, present considerable
resistance, and could not, in all probability, be
cut through by the new instrument, or guillotine
as it has been termed, recently invented for this
purpose, on the supposition of the likelihood of
hfemorrhage from this operation ; which occur-
rence, though it might happen when the tonsils
are enlarged and soft, is not likely to take place,
and I believe never has happened, when they are
indurated. The extirpation of these parts is
attended with scaredy any pain in most instances,
and the pain from the excision of the uvula is but
slight. Nor has any particular inconvenience,
as far as I know, attended the loss of this part ;
though it is said that singers and others, who
have had this operation performed, were more
liable to sore-throat and coughs. Mr. Yearsley,
however, states that this is not the case when the
entire uvula is removed ; but that when only a
portion of it is snipped off the pain is much
greater, and subse(|uent irritation is not uncom-
mon, which may be very easily conceived. In
some cases, when the palatine arch descends
lower than natural, it is snipped on each side
previous to the removal of the uvula.

One of the most successful cases of this opera-
tion which has fallen under my observation is
that of Crawley (the seventh case in Mr. Yearsley's

OPERATIONS FOR STAMMERING.

pamphlet), who was affected with one of the
worst kinds of stammer ; in whom the tonsils and
uvula were enlarged, and who derived immediate
relief, which has continued to the present time
(two months from the operation). He can now
apeak with facility and without stammering.

In the boy Wright the stammer came on when
he was between three and four years of age : there
were occasionally remissions of a few weeks at a
time ; and as he had not stammered for a long
time, his mother supposed that he had got rid of
it altogether. Three months ago, however, his
father died, which occasioned a recurrence of the
stammer. Nothing anormal was perceptible
about the mouth or throat. On the uvula being
removed he immediately spoke freely, and with-
out impediment. I am unable to say whether, in
this case, the relief was permanent.

A man, a-t. 40, sailmaker, when alone speaks
" as well as any body ;" and when with his com-
rades does not stammer so much as when with
strangers, when the inconvenience is sometimes
lery great. Does not stammer when he speaks
in a singing voice. The uvula was removed, but
he still stammered, though not so much as before.

A man named Partridge has a difficulty espe-
cially upon the p's, and can scarcely articulate
his own name ; but if he says it without fore-
thought, or if his attention be diverted, can speak
it very well.

OPERATIONS FOR STAMMERING.

Snelling, a young man who was in the room
when the boy Wright underwent the operation,
on seeing its effects, and that the boy spoke
without difficulty, was likewise able to speak
without stammering. At my suggestion he was
sent back to wait a little, and on returning into
the room, at the expiration of about an hour,
stammered a good deal while being questioned
respecting it. There was a warty excrescence on
the left tonsil : while he was asked about its origin
he spoke fluently, and without the least stammer.
This was also the case when questioned about
other things which diverted his attention from
the complaint. After the wart was removed he
thought he spoke better, but still stammered.
After removal of the uvula he spoke better, and
on reading experienced every now and then some
difficulty.

A boy, who had more especially a difficulty on
letters begining with p and 1, experienced con-
siderable hesitation when told to say love-child or
loUypop ; but after a full inspiration he could pro-
nounce these words tolerably well during the act
of expiration. After the removal of the uvula he
could articulate them with facility, and without
dmwing in his breath.

A ymitit/ Koman whose uvula was removed with-
out any perceptible advantage. — The muscles be-
neath the tongue were a good deal developed,
and this organ appeared to be limited in its move-

OPEHATIONS FOR STAMMERING.

53

ments. She is not free from stammering even
when alone, but is always much worse when
with strangers.

A man in whom the palate had hem extermvely
divided by another surgeon, without any advantage
resultiny. — ^Theuvula was excised by Mr. Yearsley,
but did not produce any amelioration at the time.

Henry Gee, a had stammerer.— ^\ie palate was
divided on one side, after which he spoke better.
Desired to return in a week. At the expiration
of this period he still stammered, though not so
badly as before. His mother says that he spoke
better the two days succeeding the operation than
the three subsequent days. After the uvula was
removed, he was able to articulate much easier
than before.

Wilkinson (mentioned in Mr. Yearsley's pam-
phlet), a man in whom the tongue was of large size.
—Uvula removed without any advantage.

Henry iSmith, a boy who stammered. — The tou-
sils were enlarged. After their excision was able
to speak without much difficulty. The uvula
was next removed, but it did not appear that he
spoke any better tfian after the operation on tiie
tonsils.

The above are a few of the cases of whiclj I
made a memorandum, anti to which I sliaJI liave
to allude. It now remains that I ithoi '
to explain in what manner tliese
and operations were succeesfuJ

UPEltATIONS FOR STAMMEKING.

mering, and the causes of their failure in some
instances ; and to what cases the one or the other
are more particularly applicable.

With regard to the methods of education, the
object of which is to regularise the respiration and
the action of the different parts concerned in
speech, and thus bring them to act in harmony
together, there is no doubt that they are calculated
to effect tlie removal of the complaint in a large
proportion of cases ; but when we consider the
length of time required, the subsequent attention
necessary to prevent a recurrence, and the power
of habit, we cannot be surprised that many persons
should be unwilling to have recourse to them, and
that relapses should frequently occur ; for the
statistical accounts of teachers and practitioners
of these methods cannot always be relied upon,
on account of the difficulty which must exist
in keeping the patients in view for a sufficient
time after the termination of the treatment; and
if the opinions which I have expressed of the
varieties of stammering be correct, there are ob-
viously cases in which these means would be
attended with no advantageous result, though
all are undertaken indiscriminately. This mode
of treatment I should conceive to be the most
likely to be attended with success in the nervous
kind of stammer, particularly when it has arisen
from imitation, and in those cases where there
exists little or no physical alteration of the

OPERATIONS FOR STAMMERING. 5o

tongue or thioat : but even in these it will fail
in a certain proportion, and relapses must not
unfrequently occur : so that, as stammerers now
have other means within their reach by which they
might frequently be relieved, it becomes a matter
of choice for them to wliich they would prefer
having recourse ; but " Cun liempechepas Cautre,"
and many individuals whom treatment had failed
to relieve, may still be cured by operations which
are not particularly serious, and in the vast
majority of cases entail no unpleasant conse-
quences. And again, in some of those who have
undergone operations, educational methods may
be had recourse to with advantage when the
operation has not succeeded in removing the
infirmity, or has been attended with only a
partial success. Having just said that the
operations are not generally serious, or followed
by unpleasant consequences, I of course do not
include that of Professor Diefienbach, which I
consider to be attended with considerable danger,
and only to be thought of in extreme cases,
when the patient is willing to run the risk ; and
I have no doubt that many, if not the great
majority, of the patients so operated upon would
have been relieved by the other operations. It
lias, I believe, only been performed once in
this country, by Mr. Lucas — after the failure of
the other operations — with success ; and
seen that the operation by the I

0PEBATJ0N8 FOB STAMMEBING.

M. Velpeau, appeared to be equally efficacious ;
though this also is a proceeding by no mean*
to be reeommeuded. Indeed, the haemorrhage
is almost always profuse, and has occasioned the
death of one patient, a medical student. Even
Professor Diefienbach speaks of it in such a
manner as not to recommend its adoption, unless
by very skilful operators. He says, " The
importance of so serious an operation, the dangers
which may result from it, the loss of the tongue
by mortification, a too abundant suppuration,
or even the unskilfulness of an assistant, which
may cause it to be torn, are so many considerations
which require to be taken fully into the account,
and which, joined to the difficulty of its per-
formance, wUl prevent its being undertaken by
unskilful operators." The cases in which it
might be admissible, and most likely to be
attended with relief, are those in which the tongue
is of very large size, which impedes the
harmonious action of this organ with the other
parts concerned in speech.

The division of the genio-glossi muscles, or of
the frenum and sublingual mucous membranej
on either side, is the operation which I have seen
most successful ; and in which the success has
been the most permanent in bad cases of stam-
mering. I consider that the method of perform-
ing by the mouth is preferable to the sub-
cutaneous operation, not only because it is more \

OPERATIONS FOB STAMMEBISG. 57

easv", and because it may be ascertained by the
finger whether all the fibres are divided, but
likewise because in a certain number of cases the
division of the membrane is sufficient, and the
patient is spared the pain and inconvenience
of the second part of the operation. It may be
that the three first patients, on whom M. Bonnet
operated, were not completely relieved of the
stammer, because the muscular fibres were not
completely divided, as in the last two patients ;
or it may be, that being of the purely nervous
kind, the division of the muscles is not so well
calculated to remove the stammer as in the
physical kind, where the movements of the tongue
are limited, or this organ is more fixed than
natural to the floor of the mouth, so as to prevent
its being duly protruded. The section of the
membrane or muscles by the mouth I conceive
to be also best adapted to the third kind of
stammer, when there is a combination of the
nervous and physical varieties. The chief
objections to this operation are the bleeding and
inflammation sometimes occasioned by it. In
the great majority of cases these accidents do not
occur to any prejudicial extent; and by keeping
the edge of the kjiife or the blades of the scissors
near to the bone, the risk of bleeding is greatly
obviated, as there are only small vessels at this
part, though they may in some cases become
anormally enlarged, in proportion as the mu8»

ftS OPERATIONS FOB STAMMERING.

themselves are enlarged. Several of the patients
at M. AniuBsat's lost a few ounces of blood
before the bleeding ceased by the appbcation of
ice. Hsemoirhage to a considerable extent
occurred in one case of M. Phillips, but was not
followed by any bad consequences. A case
likewise happened to myself, in which at least
ten or twelve ounces of blood were lost before
the bleeding ceased. The muscles of the tongue,
and beneath it, were very much developed in
this case. The patient's pulse was quick and full,
and the bleeding did not induce faintness, so that
I consider it was rather beneficial than otherwise.
This was a bad case of mixed stammer; the
patient being of a very nervous temperament.
The stammer was a good deal relieved, but he
still stammers much when excited.

A case of alarming haemorrhage recently occurred
to M. Guersant, but it was not attributable entirely
to the operation, as there existed in the boy a
haemorrhagic diathesis, of which the operator was
not previously aware. He was subject to repeated
bleedings from the nose, and only a few days
before, the extraction of a tooth had given rise to
troublesome bleeding. There was very little loss
of blood at the time of the operation, but it took
place subsequently, and the greatest quantity of
blood was lostthree days after the operation, so that
it did not occur from the division of any particular
artery. The actual cautery was twice apphed,

I

OPEBATIOKS FOR STAMMERING.

ice and other means having been previously found
ineffectual ; but the hfemorrhage ultimately ceased,
and the boy's pulae was not particularly depressed*.
M. Guersant had peribnned the operation on nine
other individuals, who considered themselves re-
lieved by it, but the amelioration was not so
apparent to M. Guersant. In one of the patients,
who experienced the greatest benefit immediately
after the operation, the stammer gradually returned
as bad as ever. In that case also, where M.
Velpeau excised a triangular portion from the
apex of the tongue^ the advantage resulting from
the operation vras not permanent : so that in
these cases the mental impression must be con-
sidered as the cause of the immediate advantage,
as it is evident from M. Velpeau's account that
there was no physical alteration of the tongue
itself; and I purposely mentioned the case of
epilepsy, in which he tied the facial and temporal
arteries, (as well as those of aphonia cured by
mental impressions, in the begining of this paper),
in order to illustrate the power of similar agenciei
over nervous diseases. Almost every practitioner
is aware that the attacks of epilepsy may fre-
quently be suspended for a longer or iihorter
period by any means in which the patient can be
induced to have confidence : hence the hi»torieg

* The last accounts state that the ble)
ihe boy was in a »eiy exhftiuted Mate,

scribed.

60 OPERATIONS FOB STAMMERING.

of cures of this disease from animal magnetisin,
as weii as from the host of drugs which have in
turns been cried up as specifics, but which have
only enjoyed an ephemeral reputation. Any
thing tending to break the chain of habitual
recurrence will also very frequently produce a
similar effect ; as a bum or other accident. And
there is not the slightest doubt that in a great
many of the cases of stammering which have been
cured by operation, the advantage may be satis-
factorily accounted for in this manner ; but, on
the other hand, there is no doubt that the opera-
tions act in many cases by lemovlng physical
impedirflents to the associated and harmonious
action of the parts concerned in speech, as in
many of the individuals whom I have observed,
especially in Paris, where in almost all those
persons whom I saw, some degree of shortening,
thickening, or other anormal condition of the
tongue existed, (which has led M. Amussat to
conclude that stammering depends invariably
upon these anormal states, but which, I have no
doubt, are, in the majority of cases, consecutive on
the nervous kind of stammer, as I have already
said), and almost all of whom were either cured,
or derived more or less permanent advantage from
the operation.* In one patient, whoml examined,
where it failed to afford any relief, the tonsils
• In a series of cases where this operation was performed
with success hy M. Dufresse, of Angoul^me, the tongue n-as, in
almost all the patients, thicker or shorter than natural

OPERATIONS FOR STAMMERING.

were conaiderabl}' enlarged, wliich shews the
necessity of discrimination. The nine cases ope-
rated by M. Guersant, in which he did not think
any very marked benefit was produced, were
likewise in all probability not so well suited to
this kind of operation. The circumstance, which
I witnessed several limes, of the stammer being
pjirtly remedied on the section of the sublingual
membrane, still more so when the muscles were
partially divided, and altogether removed after
the division of the muscular fibres which remained
attached to the bone, suffices to show the material
action of the operation in some cases. Even when
the movements of the tongue are not pajticularly
limited, yet, in a large proportion of cases, its
muscles are unduly developed, and contract ener-
getically on the introduction of the finger, and
consequently, on attempting to articulate par-
ticular letters or words which require their active
concurrence : here, I conceive, the operation pro-
duces a beneficial effect by removing this etate of
anormal contraction and rigidity, producing a
degree of relaxation (to which likewise the loss
of blood is favourable) which enables this organ
the better to act in unison with the muscles of
the throat and of respiration. Dieltenbach's ope-
ration tends to pro ' ' nilar result. Hence
we may perceive -tioiis of
the face
after thei

OPERATION'S FDR STAMMERINO.

uvula and tonsUs should fail when there is con-
siderable enlargement of the tongue, or when the
motions of this organ are particularly restricted.

With respect to this latter mode of operating,
I am convinced that it likewise acts in many
cases, though not in all, by the moral impression
produced upon the patient: this will be evident
on referring to two or three of the cases which I
have noted, and also to those reported by
Mr. Yearsley. We see in the case of Henry Gee,
that he spoke much better when the palate was
incised on one side ; that he continued to speak
tolerably well the first two days, but afterwards
he began to lose the advantage, till the uvula was
removed, when he again experienced a decided
improvement. On the other hand, the man on
whom the extensive division of the palate had
been made without any benefit resulting, had
also his uvula removed without any advantage.
In some patients the excision of a portion of the
tonsil relieved the stammer, as in the case of
Henry Smith. I think it not improbable that
the presence of these bodies when enlarged may
in some cases produce stammering (not, as
Mr. Yearsley imagines, by narrowing the throat,
or preventing the free egress of air, but in a
similar manner as when the muscles of the tongue
are enlarged, and consequently limited in their
movements, or when this organ is more bound down
than natural), by interfering with the harmonious

OPERATIONS FOR STAMMERING.

and associated action of the muscles of the palate
with other parts concerned in speech. But
these cases are rare when compared with others.
The presence of enlarged tonsils must then be
looked upon as an accidental coincidence, though
when existing this enlargement doubtless tends
to aggravate the stammer. In the ease I have
mentioned, at M. Amussat's, when the section
of the genio-glossi failed to afford relief, and the
tonsils were a good deal enlarged, it is very likelj
their removal would have been productive of
benefit. This I suggested to M. Amussat, and he
promised to perform the operation ; but as I left
Paris on the next day, I am not aware whether
or not it was done. In Mr. Yearsley's case,
to which I have already alluded (Crawley), it
may be questioned whether the extirpation of
tlie tonsils would not have been attended with
considerable relief to the stammer, even if the
uvula had not been excised : I say this, not to
call in question the propriety of excision of
the uvula in this case, but as a hint for future
investigations, which may serve to elucidate
the complications of stammering. When,
therefore, in stammerers, the tonsils are enlarged,
the removal of these bodies may relieve the
stammer, by allowing a freer play to the muscles
of the throat, by which means their action can
be better associated with that of the respiratory
and lingual muscles. In corroboration of what

04 OPERATIOKS FOR STAMMERING.

I have now stated, I may refer to the case of
Charles Geyer, (in Mr. Yearsley's pamphlet),
IB which the tonsils were enlarged, and the mere
excision of the uvula produced no advantage ;
of J. Topliss, whom the excision of the tonsilB
sufficed to cure; and also of James Carter, set. 12,
a "bad case of stammer from early childhood, in
which the tonsils only were excised, with relief
at the time, and progressive subsequent improve-
ment, terminating in complete cure. I think,
therefore, that in stammerers, when the tonsils
are enlarged, there will often be found, in addition
to the nervous stammer, a difficulty upon
particular letters (the gutturals), and that the
removal of the enlarged tonsils would generally
be productive of as much benefit as when the
uvula is also excised. The excision of this
substance, or the division of the palate, may likewise
act in some cases by diminishing the state of
tension, or tendency to anormal contraction of
the palatine arch, which occasions the impediment
in articulating, when the person is in a nervous
or excited state; but in many, ifnot in the majority
of these instances, the moral impression from
the operation is principally instrumental in
producing the amelioration, which may be only
temporary, or it may be of a permanent nature ;
but in which ever way it acts it is unquestionable
that several persons have been cured, and many
have experienced decided relief ; so that in certain

OPERATIONS FOE STAMMERINr,.

cases, when thedivision of thegenio-glossimuscles,
or of the membrane covering them, does not
appear to be more especially indicated, I see no
reason why the uvula should not be removed:
for, even supposing the effect to be merely mental,
that is no reason against its adoption, if the
complaint can be by this means removed or
mitigated, particularly if it be clear that no incon-
venience results from the loss of the uvula in
those cases where it is not attended with success.
In cases of purely nervous stammer it is perhaps
as likely to be successful as the more severe
operation of tiie section of the genio-glossi,
which, however, I consider better adapted to the
physical or mixed cases (unless when there is
enlargement of the tonsils), and to those of bad
stammerers, where a difficulty exists upon particular
letters or words. This operation, as well as the
others, no doubt also acts in some cases where
nothing anormal is perceptible, purely by the
mental effect which is produced.

No one can have a greater abhorrence of
charlatanism, or be less likely to countenance it,
thanmyself; Itherefore think itduetoMr.Yearaley
(though not agreeing with him as to the nature
of stanmiering, or the manner in which excision
of the tonsils and uvula afford relief) to state my
belief tliat he has acted with good faith in
giving the correct results of his cases, as far as
he was able to ascertain them ; and I think that

66

GENERAL CONCLUSIONS.

if his operation were performed with more
discrimination, he would be enabled to record
a greater amount of success.

From a consideration of what has preceded, I
think we are justified in deducing the following
conclusions ;- —

1. That stammering is, in the great majority
of eases, originally a nervous affection.

3. That in a comparatively small number of
persons it arises from physical causes, which in-
terfere with the associated action of the parta
necessary for the formation of speech ; and that
the tongue is most frequently the organ in which
anormal conditions are observed.

3. That the nervous kind of stammer is some-
times superinduced upon the physical kind, but
that more frequently the physical alterations
supervene upon the disordered nervous action, and
that, when existing, they add considerably to the
severity of the complaint.

4. That the physical alterations most fre-
quently perceived, as the tongue being more
bound down, larger or shorter than natural, en-
largement of the tonsils, &c. are not necessarily a
cause of stammering, as all these alterations are
frequently seen in persons who do not stammer,
and they exist permajiently, though many stam-
merers are at times comparatively free from the com-
plaint: but they may give rise to, or increase
stammering, whenever they present obstacles to

M

GENERAL CONCLUSIONS.

67

the associated muscular actions required for
speech, being sometimes constant in their ope-
ration, at other times depending, in a great
measure, upon the person's state of mind.

5. That in the purely or principally physical
kind, there is always a difficulty upon certain
letters or words, which is generally as great when
the person is alone as when in company ; but
that, on the other hand, the nervous stammer is
always aggravated by society, unless when cir-
cumstances arise to divert the individual's atten-
tion from it ; and that, when alone, or with an
intimate friend and relative, the stammer is fre-
quently absent, or greatly mitigated, but that
these two kinds are often combined in the same
person,

6. That stammering presents, in many respects,
great analogy with other nervous affections, but
that it differs from them in the circumstance of its
being but rarely met with in females, which may
be accounted for by the explanation which has
been given in the text.

7. That the reason why stammerers can gene-
rally sing without the infirmity being perceptible
is, that, in singing, the inspirations are taken at
longer intervals, the air issues from the lungs in a
more continued stream than in speaking, and
consequently less frequent efforts of volition are
required : the words gliding more one into
another, the difficulties upon particular letters

GENEBAL CONCLOSIONS.

can be belter avoided, but that where the stammer
is pmely physical, if it do not prevent singing, it
is present, though generally in a less degree than
in speaking.

8. That the complaint is capable of being
cured, in many cases, by methods of education
which tend to regularise and associate the respira-
tion and the muscles concerned in speech, but
that this treatment is not applicable to all ctises of
stammering, and that relapses not unfrequently
occur.

9. That the operation of Dieffenbach should
only be had recourse to in extreme cases, after the
failure of other means, and that it is most appli-
cable to cases where the tongue is unwieldy
from its increased size.

10. That the division of the sublingual mem-
brane of the mouth, and of the genio-glossi mus-
cles, is the operation most generally applicable,
especially to bad cases, and when the tongue
cannot be properly protruded or turned up ; and
that this operation is, in a great many cases,
successful in producing a permanent cure, or con-
siderable amelioration .

11. That when, in stammerers, the tonsils are
enlarged or diseased, the extirpation of these
bodies is advisable, as it may suffice to remove
the stammer, without the necessity of having
recourse to other means.

That the excision of the uvula is followed by

GENERAL CONCLUSIONS. 69

a cure in some, and is attended with benefit in
many cases ; and that there appears no ground
for apprehending inconvenience from its removal.
12. That when stammerers are disinclined to
go through a prolonged course of educational
treatment, or when this has failed, a cure, or con-
siderable amelioration, may often be obtained by
operation ; and that the kind of operation most
likely to afford relief can be best determined by
an examination of the peculiarities in individual
cases.

ON SQUINTING.

From the success which attended the diviaicm I
of muscles and tendons, by a small aperture in ■
the skin, for the cure of club-foot and other
deformities of the body, the originator of this
method, in recent times. Professor Stromeyer i
(whom I had the pleasure of meeting last spring J
at Erlangen, when he shewed me several cases,.!
cured and in progress of cure, but who has since]
been removed to replace Graefe, at Berlin), waa 1
led to entertain the opinion that a similar operation J
might be equally applicable to the cure of squint- J
ing ; and he accordingly described the method J
of operating which he recommended for the J
purpose in 1838*. One or two other practitioners,
however, put forward a prior claim to the meriC'l
of having proposed this operation. M. Guerin^l
wlio is well known to the British medical public I
as one of the most eminent practitioners of Parisi ,'
and as the director of the orthopedic establish-]
ment, La Muette, in the Bois de Boulogne, stateBl
that, so far backas 1837, he proposed the division \
of the muscle in cases of squint, which he con-
sidered to be an affection of an analogous nature
• BeiUage zur operative Onhopcedie.

ON SQUINTING.

71

to club-foot ; but that he was deterred from per-
forming the operation by the apprehension of
serious inflammation of the eye. Be this as it
may, the first public announcement of the per-
formance of this operation was made by Professor
DiefFenbach, of Berlin, from whom a letter
was read in the sitting of the Academie des
Sciences of February 3, ] 840, stating that he had
divided, with success, the internal rectus muscle
in two cases of convergent strabismus ; and on
the 25th of the following May he further
announced that he had operated on 118 cases.
These announcements excited considerable inte-
rest throughout Europe ; the attention of the
profession became strongly directed to the sub-
ject, and numerous operations were performed in
other countries ; the firet in England having been
performed by Mr. Guthrie, Jun., in April, 1840.
Several of the first operations, however, were not
very successful ; and some of the failures have
been attended with very serious consequences,
though these are now of very rare occurrence.
This operation now ranks among the most simple
and successful in surgery, in the majority of
cases. The failures which have occurred are, in
some cases, attributable to an improper mode of
performance of the operation ; in others, to com-
plications which should have counterindicated
it, and which rendered it nugatory : for as
squinting depends upon a variety of causes, the

72

ON SQUINTING.

operation is not universally applicable ; though
this circumstance has not been sufficiently attended
to by some operators, who have undertaken every
case which presented itself to them.

According to the opinion of Buffon, squinting
was, till lately, supposed by the majority of
persons to be the result of a congenital or
acquired inequality in the powers of vision of the
two eyes ; but it is now admitted to depend, in
the majority of cases, on the want of liarmony
or irregular action of the muscles destined to
move the eye, and that the weakness of vision is
secondary to the squint, being generally removed
after the position of the organ is rectified.

Six muscles move the eyeball in different
directions : the four recti or straight muscles
rise from the bottom of the orbit, and pass
forwards to be attached to its surface. The
tendons of the superior and inferior muscles
are inserted at aboat equal distance from the
margin of the cornea, so that their antagonising
powers are pretty equal ; the inner rectus, how-
ever, passes more directly to its insertion than
the external, and is likewise attached nearer to
the cornea than its antagonist. When one
muscle alone acts it necessarily turns the eye
in its direction ; the four muscles acting at the
same time draw back the eye within the orbit
(and there is reason to believe that this action
though imperceptibly exercised, is Instrumental

ON SQUINTING. 73

in adapting the powers of vision to different
distances) ; the action of the recti muscles is
antagonized by that of the superior and inferior
oblique, which tend to keep the eye forward, in
which they are assisted by the elasticity of the
cellular texture and fat in which it is lodged,
and which, when partially absorbed in emaciated
persons, after lingering illness or long abstinence,
imparts to the organ its sunken appearance.
The two oblique muscles acting together, concur
with the internal rectus in turning the axis of the
eye inwards ; to which likewise the inner fibres
of ine superior and inferior recti contribute;
while the external fibres of these muscles tend to
cause eversion of the cornea, and act in concert
with the external rectus, which draws the eye
directly outwards, and is employed when we look
at an object sideways. Thus, from the preponde-
rance of muscular power on one side, we may see
the reason why people can so easily turn the eyes
inwards, or squint towards the nose, whereas it is
impossible for any one, by an effort of volition, to
squint outwardly with both eyes, and why conver-
gent strabismus, or inward squinting, should be so
frequent in proportion to the divergent kind j which
I think would be found, in most cases, to depend
more upon a want of power, or faulty condition of
the internal rectus, than upon an increased power
of its antagonist ; which opinion is corroborated
by the circumstitnce thai division of the external

74

ON SQUINTING.

rectus only partially succeeds, in many cases of
divergent etrabisraus, in rectifying the position
of the eye, whereas, when properly performed,
the section of the internal rectus, in convergent
squint, rarely fails to effect this object. In a few
instances, however, after the operation for
external squinting, a convergent squint has
supervened, thus proving that the internal rectus
was in its normal condition : the reverse also
occasionally takes place, to a certain extent, after
the operation for convergent strabismus : indeed,
it was at first apprehended that this would almost
invariably be the case, but experience iias anl^jly
demonstrated that the influence of the oblique, and
of the inner fibres of the superior and inferior recti,
is sufficient to counteract that of the external
rectus.

M. Guerin divides squinting into two kinds,
which he slates comprise all the varieties of this
infirmity. The first is the mechanical or active
muscular squint, the other the optic or passive
muscular, the characters of which are perfectly
distinct from the former; the one being almost
always capable of being cured, or at all events
greatly ameliorated, by the division of the muscles,
whilst in the other the operation should never be
performed. In the first kind, from the muscle
being shorter, tlie axis of the eye is turned in
that direction, and the movements of the two
eyes do not hannonise together. The second

ON SQmKTtNG. 75

kind is mostly consequent upon obstacles which
prevent the rays of light from being received in
the direct visual axis, as in the healthy eye : such
as cataract, opacities of tlie cornea, &c. Mecha-
nical squint generally arises during the period of
childhood (which is so prolific in convulsive
affections), in consequence of convulsion or
other affections of the nervous centres ; and once
existing, it usually persists, increasing with the
development of the organ and the growth of the
individual, and becomes more and more permanent.
Mental emotion generally increases it for the
time, and when once the spasmodic action has
passed into a state of pennanent contraction, the
affection is incurable except by operation. The
sphericity of the eyeball becomes altered, the
organ being frequently flattened on the side
corresponding to tlie muscular retraction, and
the portion between the eyelids on the opposite
side being more prominent tlian natural. The
pupil is, in most cases, more dilated in the
squinting eye, which is likewise smaller than the
healthy one. The degree of movement possessed
by the organ varies from almost complete immo-
bility, or fixed squint — in which the patient feels
the eye tied, as it were, to one side — to nearly
the perfect motion of health ; which M. Guerin
terms the rudimentary squint. In the efforts to
rectify the position of the squinting eye, the
spund eye participates so as not unfrequently to

76 OK SQUINTING.

induce squinting on that side. When the patient
attempts to look at any thing with the squinting
eye, its position becomes rectified, and the power
of rectification is always in an inverse ratio to
the degree of muscular shortening ; so that in
incomplete strabismus the deformity only exists
when the individual is not looking at any thing
particular; constituting what has been termed by
Buffon and others the faux regard. When
there is a double squint, equal in degree in both
eyes, the position of each eye is rectified alter-
nately, when the patient looks at objects ; and
the squint thus appears to travel from one eye to
the other. In rudimentary squint the patient
looks with both eyes ; in the double squint, which
is equal on both sides, he looks alternately with
one eye and the other. Many patients, on look-
ing from both eyes, see double, from the want
of correspondeuce between the visual powers.

It may, however, be questioned whether, in
those cases where the patient possesses the power
of rectifying the position of the eye, there be any
actual shortening of the muscle ; this doubtless
exists in those cases where the eye is more or
less fixed to one side ; and the muscle is not
unfrequently seen during the operation to be
considerably increased in bulk*. It is likewise

* " The active ghoriening having the effect of occasioning
conaiderable tension of the retracted muscles, these progressively
acquire a, texture dependent upon their continued tension ; that

ON SQUINTING.

77

now admitted that in some of the passive kinds
of squinting advantage may be derived from the
operation. No reflecting surgeon would think
of operating, when, from opacity of the cornea,
or other irremediable physical obstacle to the
passage of the rays of light through its centre,
the eye is turned inwards, so as to allow the light
to pass through its lucid part to the retina ;
though this has been done by some of those who
operate on all cases indiscriminately, with the
obvious consequence that though the squint was
removed the eye was rendered useless for vision.
But when squinting co-exists with cataract which
admits of operation with a probability of success,
it becomes a question whether it would not be
better to perform the operation for squinting in
the first place. Again, when squiniing is induced
by paralysis of the antagonist muscle, as the
rectus externus, the internal rectus may often be
divided with advantage, provided the sight be not
impaired ; for even if the eye were afterwards
to be motionless, it would have a better appear-
ance in the centre of the orbit, and be more useful
for vision, than if drawn to one side.

In the largest proportion of cases the squint
is confined to one eye, most frequently the right ;
probably from the circumstance of the muscles of

is to say, they become fibrous, whilst the muscles passively con-
tracied lose somewhat of their consistenc;, and lend to pa^s to
Ihe fattv state." — Guerin, in Gazriie Medkalr.

ON SQUINTING.

the right side of the body being naturally more
developed than the left ; and being but little
used foT vision, it is almost constantly drawn to
one side. When, however, it is recent, and not
very decided, as m children, it not unfrequently
disappears as the child grows up ; and may like-
wise frequently be removed by means which tend
to exercise the eye, as bandaging the sound eye,
&c., but these means frequently fail, from not
being persevered in for a sufficient length of time.
When both eyes are affected, it does not fre-
quently happen that they are both affected in the
same degree, tJiough it is not always easy for a
casual observer to determine in which eye the
squint is the most marked. This, however, may
be readily ascertained by holding up, at a certain
distance from the patient, some small object, as a
pen or pencil, and requesting him to look at it,
when the eye which is most affected will be
turned inwards, and the object will be perceived
with the best eye, which likewise will be able to
distinguish the letters on a book, or the effigy on
a coin, at a greater distance*.

* Montaigne, in the chapter of his Essays headed De ne
contrefaire U malade, alludes to the disuse of one eye causing
it lo become weaker, and lending to nlrengthen the other, in
mentioning the case of an individual who, in order to disguisB
hiuifielf, wore a pMch over one eye, and who, on removing il,
when no longer under the necessity of wearing it, found that the
sight of the eye was lost. He says, " II est possible que I'action
de la veue s'eioist affahlie, ponr aToir esie ri longtems i
exercice, el que t& force virave s'estoit tout rejectee en I'aultn

on SQUINTING. 79

The operation is performed, in many cases,
within a minute, though sometimes a few minutes
are required. It is attended with but little pain,
and scarcely any effusion of blood; and very
rarely gives rise to inflammatory symptoms which
require active treatment. Several methods have
been proposed by different operators, which,
however, with the exception of the sub-conjunc-
tival method of M. Guerin, all consist in exposing
the tendon of the muscle before dividing it.

In Professor Dieffenbach's operation, the pa-
tient is seated in a chair, his head resting on the
breast of an assistant, who, with an elevator,
raises the upper eyelid ; the lower eyelid is in
like manner depressed by a second a'^sistant : the
operator then takes hold of the conjunctiva,
about three or four lines from the margin of the
cornea, with two small hooks, one being held by
himself, the other by the assistant: the raised fold
of membrane is then divided with small scissors,
and dissected from before backwards, by w'lich
means the muscle is exposed, and a blunt hook,
or director, being passed beneath it, is divided
with the scissors, or a bistoury.

The method of M. Phillips does not materially
differ from that of Dieffenbach, except that a
portion of the muscle is removed.

M. Amus&at, after directing the patient to look

tei], car nous senloos evidemment que I'cei] que nana tenons
eouvert ranvoye A son compagnon quelqiie partie de son effect;
en maniere que cefui qui reste a'en grossit et s'en enfle. "

ON SQUINTING.

outwards (in the convergent squint), seizes the
conjunctiva near the caruncula lacrymalis with
small forceps having sharp teeth ; the elevators
are then applied by assistanta, to hold the eyelids
apart; the conjunctiva is taken up with another
pair of forceps near the former, and is divided
with scissors between the two to some extent, so
as completely to lay bare the tendon, which is cut
through with blunt-pointed scissors, curved on
the flat, after a blunt hook has been passed beneath
it. If the squint be removed, the operation is
considered to be satisfactory ; but if any degree
of convergence remain, the hook is again passed
upwards and downwards along the surface of the
sclerotic, in order to ascertain whether any fibres
or portions of cellular texture exist which tend
to keep the eye inverted. In fact, it not unfre-
qnently happens that the "fascia which extends
from one muscle to the other, and forms attach-
ments between them and the sclerotic, requires to
be extensively divided before the squint is removed.
M. Baudens, after directing the patient to look
outwards, passes a sharp hook through the con-
junctiva, which he divides with a falciform knife,
slightly curved on the flat, and sometimes the
muscle is seized and divided at the same time as
the conjunctiva; a blunt hook is then passed
beneath the muscle, or any remaining fibres or
bands of fascia which may draw the eye inwards,
and these are cut through with scissors.

ON SQUINTING. 81

Mr. Guthrie, Jun. has an assistant to raise the
upper eyelid with an elevator, and depresses the
inferior one with his fore finger ; the assistant
likewise seizes the conjunctiva with a double
hook, with short thick points, to prevent their
entering the sclerotic, and draws the eye outwards ;
the operator then incises the conjunctiva, near the
edge of the semilunar fold, to an extent of three
quarters of an inch, with a curved knife ; the ten-
don being exposed, a curved director is passed
beneath it, previous to its division with the
knife.

Mr. Lucas previously binds up the unaffected
eye, and after the eyelids have been separated by
an assistant, seizes the conjunctiva with a small
hook, and divides it with scissors, to the extent
of from four to six lines, near the cornea ; he then
waits for a few moments, allomng the eye to
repose. The eyelids being again separated, a
blunt hook is passed beneath the muscle, which ia
cut with scissors.

M. Sichel likewise allows the eye to repose
for a short period after the section of the conjunc-
tiva, previous to completing the operation.

M. Guerin places the patient in the recumbent
position on a table, and, after the eyelids are
separated by an assistant with elevators, directs
the patient to look outwards ; he then seizes the
conjunctiva with a sharp hook, and holds it till
he has implanted a small short double hook in

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ON BQUlNTlNli

the sclerotica, after which the first is withdrawn ;
the eye being drawn outwards, the assistant next
raises the conjunctiva near the semilunar fold,
and, consequently, over the insertion of the mus-
cle ; a puncture is then made in a direction parallel
with the muscle, with a narrow spear-shaped
knife, curved on the flat, its concavity being
turned upwards : this is then withdrawn, and
the tenotome is introduced into the aperture, and,
by a movement of the hand, is passed beneath
the muscle: it is then turned round, and the
sharp convex edge being brought in contact with
the muscle, cuts through it, without dividing the
conjunctiva, a noise or crack being generally
heard at the moment of division : the instrument ,
is then withdrawn through the minute apertm
and, in almost every instance, the position of t
eye is found to be rectified.

This operation has a similar advantage to thosofl
performed for the division of tendons in othal
parts of the body, viz. that it prevents exposure
to the air, and consequently is not attended with
the inflammatory accidents which occasionally
supervene on the other methods : at least I have
never seen an instance, during the period of my
late sojourn in Paris, when I saw M. Guerin ope-
rate on several patient^ every week. Neither is
it followed by the unnatural prominence of the
eye which sometimes occurs, or by the fleshy
excrescences which so commonly arise after the

ON SQUINTING. 83

oUien), and require to be excised ; but, on the
other hand, there is always a certain degree of
chemosis and ecchymosis of the palpebra, which
gives the patient the appearance of having received
a blow ou the eye, or what is vulgarly called a
black eye. This generally lasts from a week to
a fortnight, or even three weeks, before the blood
is entirely absorbed, but it occasions no further
inconvenience than the unpleasantness of its ap-
pearance. This operation, likewise, requires more
practice and dexterity than the others, but from
what I have seen I think the results are more
generally successful, though they would, in all
probability, be less so, in less skilful hands.
M, Guerin, however, does not perform this ope-
ration in all cases. In divergent strabismus he
generally prefers exposingthemuscle, and dividing
it in the usual way.

With regard to the other methods, I should say
that sharp small hooks are preferable to forceps
in seizing the conjunctiva, as they occasion less
pain ; that the excision of a portion of the muscle,
as practised by MM. Phillips and Baudeus, is un-
necessary, and often prejudicial; that it is not ma-
terial whether or not the sound eye be bandaged;
whether the blunt liook or Uie director be passed
beneath the muscle, though the former is, perhaps,
the most convenient ; or whether the muscle be
divided with the knife or scissors : division of the
conjunctiva, and exposure of the sclerotic, are to

84

ON SQUINTING.

be avoided when poasible, as tending to occafflori
Berioiis infiammation and prominence of the eyei
Different circumstances may prevent tlie BquiiU
from being removed, or even lessened, after th*
section of the muscle. One of these causes -I
have already alluded to, viz, the adhesion of
gmall bands of cellular texture, which require to be
divided; this, however, is sometimes not suf-
ficient, and the squint, though perhaps partially
remedied by the operation, is not altogether re-
moved. The division of the inner fibres of the ,
rectus superior, and, if this be not sufficient, ot I
those of the inferior rectus, will not unfrequentlijs
be attended with success, these fibres appearing
to have acquired an increased power from thp 1
altered position of the eye, especially in those |
cases where part of the cornea is hidden within i
the inner angle of the orbit. When the eye catt
scareely be moved from this position, or is anehy*
losi'd, as it is termed, it is often at the same time
atrophied, and the operation would probably not
be attended with any advantageous results, as the
division of the rectus and of the inner fibres of
the su]>erior or inferior recti would frequently not
be sufficient, and these two muscles would require
to be divided altogether, but then the eye would
be considerably protruded from the orbit, and ita
visual power would not correspond with that of
the other eye. M. Baudens, indeed, practises in
these cases the section of four muscles, viz. the

ON SQUINTING. 85

internal, superior, and mferior recti, and the supe-
rior oblique. I have, however, never seen any
good result from the division of this latter muscle.
In one case of this kind the internal rectus was
strongly fibrous, and nearly half an inch broad :
its division only partially rectified the position of
the eye, which, from its prominence after the
section of the superior and inferior recti, presented
a much greater deformity than before. In some
cases squinting is produced, and the eye retains
its faulty position after division of the muscle,
from the antagonist muscle having lost its power,
or having become elongated ; and this I consider
to be the reason why divergent strabismus is fre-
quently not rectified by the section of the external
rectus. In this case, also, the further division of
the parts would not be likely to produce much
amelioration ; but means should be had recourse
to, in order to excite the muscle to contraction :
as electro-puncture, Ike. Sometimes, after the
operation, a degree of obliquity of the eye re-
mains, depending upon sympathy with the com-
paratively sound eye, which, on proper examina-
tion, win often be found inverted, though so
slightly as to be scarcely perceptible, and is
curable by division of the other internal rectus,
as recommended by Mr. Guthrie.

In order to prevent the divided muscle from
attaching itself to the sclerotic too far forwards,
and thus causing a recurrence of the squinting.

the jiatient is recommended to exercise the an-
tagonist muscle, by frequently looking outward
(in convergent strabismus). Thesame efiectmay
be produced by wearing glasses the inner half of
which is darkened, so that the light can only paSa
through their external half, and the patient, in
order to see, is obliged to turn the eye in that
direction. This plan will likewiHe frequently
succeed in removing the slight convergence which
sometimes remains, without the necessity of having
recourse to a second operation.

Opinions are divived as to the propriety of
operating on both eyes, in cases of double squint.
M. Baudens only operates on one eye, unless when
the squint is very decided in both, in which case he
operates on the second eye a few days afterwards.
M. Phillips has likewise found that the operating
ou one eye is frequently sufficient ; the position of
the other becoming subsequently rectified. This,
it is true, is sometimes the case, where the squint
of one eye is slight, and of a purely symjiathetic
nature : but, on the other hand, it not unfre-
quently happens that, in the eye which previously
squinted only occasionally, or slightly, the squint
becomes more marked after the operation on the
other eye ; of which I have had occasion to ob-
serve several instances. I think, therefore, that
when the squint of both eyes is at all decided,
especially if there be a difficulty as to which eye
squints the most, that it is better to adopt the

ON SQUINTING.

87

phm of M. Guerin, and to operate on both at the
aome time, by which means a future operation will
not be required, and the education for both eyes
can be conducted simultaneously*.

Unusual prominence of the operated eye,
dependent on the action of the oblique muscles
after division of the internal or external rectus, is
not of frequent occurrence, unless the superior or
inferior rectus have been also divided, though ex-
tensive division of the conjunctiva, and exposure
of the sclerotic, may, in some instances, give rise
to this accident. In order to remedy it, Mr. Lucas
has rec6mmended a division of the corresponding
muscle of the opposite eye, in order to render it
equally prominent. Having never seen a case in
which this was performed, I am unable to give a
positive opinion as to the results it is calculated
to produce, though I should apprehend that it
would be likely to occasion a double instead of a
single deformity. The prominence of the eye
might doubtless be diminished by the recumbent
position, and by gentle pressure made upon it, by
means of wetted compresses and bandage, in order
to allow the divided muscles to attach themselves
more forward upon the sclerotica.

With regard to the squinting which depends
upon accidental and obvious causes, as blows on

■'• "The section of the muscle does not complete the cure j
there yel remains the consecutive treatment, and the orthopedic
enercise of the eye."^Von Ammon, Monatsschrifl, June 1840.

88 ON SQUINTING.

the head, apoplectic attacks, teething, intestinal
irritation, from worms, &c., it is to be treated by
endeavouring to remove the causes which pro-
duced it, and can only be made the subject of
operation after it has become permanent, and
these causes have ceased to operate. When de-
pending upon greater weakness of vision in one
eye than the other, either congenital or acquired,
and also where there exists divergent strabismus,
in consequence of the muscle supplied by the
third nerve being paralysed, the operation is
counter-indicated, though it has been performed
under these circumstances, with the effect of in-
ducing double vision, which also notunfrequently
exists for a short time after the operation, in ordi-
nary cases, but is seldom of a permanent nature.
But little is required, in most cases, in the way
of regiminal and medical treatment, beyond
quiet for a day or two, application of cold water
immediately after the operation, and attention to
the state of the bowels.

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