CLINICAL  REPO^^/^p1
                           ON

ROBERT  BATES'S  CURE FOR STAM
 Clinic of Jefferson Medical College.  Services of Professor Dunglison.
                        February 21st, 1852.    - "^ "" ^ * J?.    m

                 (Reported by J. Aitkek Meigs, M. D.),M LT. ART °


   I am, to-day, gentlemen, enabled, through the kindness irfjMr. Bates,
 of this city, who is present, to bring before you three cases illustrative of
 the nature and treatment of that form of defective or  imperfect speech,
 known  as  "stammering."  It is a subject not often, perhaps, examined
 in a clinic, yet it is  unquestionably a morbid  condition, and  no better
 opportunity than the present could offer itself to explain to you its phe-
 nomena, and to investigate their  causes.  Mr. Bates,  who has the three
 persons now before you under his care, with that  candor and liberality
 which ought to characterize every one  connected directly  or indirectly
 with our noble avocation, had expressed, when I proposed  the matter to
 him, on his calling to explain his views on impediments of speech to me,
 his entire willingness to permit me not only to exhibit some of his cases
 to you, but also to be the expounder of the methods he adopts for its
 rectification; and, after having done so, I shall endeavor to deduce for
 you the  inferences at which I have arrived in regard to the modus ope-
 randi of his means and appliances, and to the great principles of manage-
 ment that flow therefrom.
   To-day,  such an examination and  inquiry are especially appropriate,
 as I have been engaged, during the past week, in another place, in ex-
 pounding to you the physiology of phonation, and the modes in which
 the different vocal sounds are elicited in the glottis, and modified in the
 vocal tube.  The vowels, as you well know, flow without obstacle, and
 consequently demand no consideration.   They are simple modifications
 of the voice formed in the larynx, and are uninterrupted by the organs—
 as the tongue, lips, &c.—in their passage through the  vocal tube ; while
 the consonants require  different, and,  at times, complex  and  delicate
 movements of the tube; and, as their name imports, have  to be sound-
 ed with the vowels.
   Stammering is a temporary inability to enunciate, freely and distinctly,
certain letters  at the  commencement of one or more of the syllables of a
word.  There is a broken or interrupted emission of the voice in the act
of articulation, and a consequent  disconnexion of the  sounds; and you 
2
will understand, that the consonants must  afford great obstacles to the
stammerer, as they do, also, to children learning to talk;  inasmuch as
they are necessarily more  difficult  of  enunciation than the vowels, in
consequence of being dependent upon  an ever-varying disposition  and
arrangement of the parts composing the vocal tube.   Especially is  this
the case with that class of consonants known as explosives—as b, d, t,g,
k, &c.   These letters have  of themselves no sound, or are mutes.  They
do not admit of a continuous pronunciation like the h, m,  n, f, s, r, I,
but require to  be  associated with  a vowel sound, before they can be
enunciated.
  Much difference of sentiment, you will find, has existed in regard to
the essential  cause of stammering;  and views have occasionally been
entertained, which are certainly far  from tenable.  By some of the best
physiologists, all the varieties have been referred  to a spasmodic closure
of the glottis producing a sudden arreslation of the issuing column of air.
That this is not always the  cause of the affection, however, is shown, as
we shall see, by the cases before us. The great fault lies in the spasmodic
action of certain of the  muscles  concerned in the production of the voice,
and in articulation.  Often, as in Chorea  or St. Vitus's dance, the slightest
agitation serves to aggravate, in the most painful degree, the abnormal
action.  Indeed, the affection may not  improperly be—as it has been—
called, "Chorea" or "St. Vitus's dance" of the voice.  The stammerer,
on attempting to enunciate  a word or syllable, experiences  difficulty or
resistance at the commencement, and  having but an imperfect control
over the voluntary muscles of the vocal apparatus, he at once loses all
confidence in his ability to produce the  sound required, and  there conse-
quently results an irregular  or spasmodic action of those muscles, which,
for a longer or  shorter  period and determined by the degree of spasm,
effectually prevents enunciation. In the case of the explosive consonants,
the total interruption of the breath,  and the badly regulated and insuffi-
cient volition, give occasion to the most painful spasmodic efforts on the
part of the muscles more immediately  concerned in articulation.  This
may be even extended to the whole body, which is thrown into a most
distressing state of agitation to overcome the obstacle.  At length the
spasm ceases with the accomplishment  of the act of expiration.  It will
now, therefore, be understood, why the complete interruption to expi-
ration in the enunciation of the explosive consonants should be the most
common phenomenon observed in  stammerers.   In the case, however,
of the continuous consonants, an additional phenomenon occurs, in the
sound being  prolonged by spastic  action for a much longer time than
necessary.
   Mr. Bates, who is an ingenious and liberal mechanic, has been study-
ing, for some time, the nature  and treatment of these distressing impedi-
ments to speech, and, as I remarked, has  been kind enough to bring
here several of the persons now under his care, that you  may see me
examine them,  and hear me explain the mechanical contrivances which
he employs to obviate them.   He was himself,  for a long time, a most
intense  sufferer, and, in consequence,  had his attention earnestly and
assiduously directed to the discovery of some means of relief.  He has
overcome the difficulty in himself, and has happily succeeded in enabling 
others to do the same.   In the three cases now before you, and which
are at present under his guidance, the spasm manifestly affects different
muscles; and hence, although in each person the same amount of diffi-
culty is perhaps experienced in enunciation, the difficulty may concern
different sets of letters.   Thus  the resistance  may more  prominently
affect the labials, dento-labials, linguo-dentals, linguo-palatals, or guttu-
rals; and hence the value of the physiological knowledge which teaches
us the intimate mode of their production.
   [The patients were now brought, seriatim, before the class, and made
to read words and syllables commencing with different consonants, espe-
cially with those of the explosive class.]
   In the first case, (R-----G-----, aet. 26,) the utterance of the explosive
letters is arrested, and accompanied by a singular and sudden spasmodic
protrusion  of  the lower lip.  In the attempt to  articulate such words as
Boston, punch, boat, pill, pant, Pope, &c. an arrestation  of the sounding
breath occurs, accompanied by such protrusion, and the patient is thus
rendered incapable of completing or perfecting the sound.
   In the second case, (R-----S-----, set. 34,) the voice  is arrested, and
there is a sudden and energetic contraction of the lips.   The voice can-
not escape from the mouth, and the difficulty here is with those words
commencing with d, t, st, as doctor, Thomas, stone, &c.
   In the third case, (D-----D-----, aet. 25,) there is spasm of the muscles
that close the glottis, so  that on attempting to pronounce  the gutturals
in such words as grey, goose, great, Icing, court, &c, the glottis is quickly
and spasmodically closed, and the current of air prevented from issuing,
except by  jerks.

   The great object to be accomplished in the treatment of these cases,
is to  overcome the proximate  cause—the neurosis, or irregularity of
innervation, indicated by the spastic condition of the muscular apparatus
brought into play in the process of articulation. To effect this, it appeared
to Mr. Bates, and it was  confirmed  by experiments instituted  on himself
whilst suffering under the infirmity, that if a plan could be imagined to
prevent the total interruption of  expiration, which  occurs in these cases,
the patient would feel confidence in his being able  to elicit the particu-
lar sound, and in this manner the spasmodic efforts might be  prevented.
He  accordingly invented several well devised  instruments and arrange-
ments, adapted to the different varieties of stammering;  either by pre-
venting the spasmodic action of the muscles concerned, or by restraining,
by appropriate pressure,  the irregular contractions  of the muscles.   For
example, when  the  lower lip and chin, in the first case, were  confined by
means of a simple broad bandage,* like the one I show you,  and pressure
was thus exerted upon the spasmodically contracted musculus orbicula-
ris oris of  the lower lip, so as  to prevent the protrusion of the lips, the
letters, which were such stumbling blocks before, could  be distinctly
enunciated, and with a daily decreasing amount of hesitation.
   For the second case, Mr. Bates has contrived,  as  you here see, a small
plate, fitting  closely to  the palate, and affording  attachment to a light
   * In the first case the bandage \s not the instrument that is used for the labials; it is only
used in rvtrnordinarv cases. 
4
narrow tube, the  posterior end of which opens into the mouth, looking
towards the fauces, whilst the anterior projects between the lips.  By this
contrivance the current of air is made to be in part continuous, and the
patient finds, to his surprise and  delight, that he can produce the sound
without any limitation other than his will.
  The subject of the third case has been materially benefited, and is, in-
deed, in a fair way to be entirely cured of his unfortunate habit, by means
of a neckerchief or cravat, in which is a little spring, pressing—as you
observe—directly upon the projection of the thyroid cartilage,  in such a
manner as to relax the rima glottidis, by approximating the thyroid to
the arytenoid cartilages; thus permitting the  exit of air and preventing
the spasmodic action of the muscles that close the glottis.   The spring
is so regulated, that the amount of pressure upon the thyroid  cartilage
can be increased or diminished, as occasion may require.
   [The effects of these different forms of apparatus were exhibited on
the stammerers before  the  class; and the action of each was clearly  man-
ifested.]
   By such contrivances, which are simple, and adapted to the accomplish-
ment of  the  object in view, Mr. Bates succeeds in effecting a  great
desideratum,—the restoration of self-confidence,—the want of which is a
main obstacle to improvement in all such cases; for as soon as the patient
becomes  thoroughly and practically convinced that there is no difference
between his vocal organs and those of his friends, whom he hears speak
without difficulty or hesitation, he becomes inspired with confidence  in
himself,  and  his  exertions are thenceforth the  commencement of his
restoration. 
                   REPORT

                       OP THE

COMMITTEE  ON  SCIENCE  AND THE  ARTS,

                       OP THE

  FRANKLIN INSTITUTE OF THE STATE OF PENNSYLVANIA,
ON ROBERT BATES'S INSTRUMENTS FOR THE

              CURE  OF STAMMERING.
               From the Journal of the Franklin Institute, April, 1854.

The Coujmittee on Science and the Arts, constituted by the Franklin Institute of the
  State of Pennsylvania, for the promotion of the Mechanic Arts, to whom were referred
  for examination, "Instruments for the Cure of Stammering," invented by Mr. Robert
  Bates, of Philadelphia, Pennsylvania—Repoet :

  That  much  discrepancy of opinion has prevailed as to the cause and
consequent treatment of stammering.  Many of the earlier writers have
attributed all  the varieties  of this form of defective  speech to  some
organic  affection of the vocal apparatus, or malformation of the parts
that compose the mouth and fauces; as, for example, hypertrophy  of the
tongue,  a too  low position of that organ in the mouth, enlargement  of
the tonsils, uvula, &c.   The  treatment based upon these erroneous and
limited  views  as to the  cause, was  necessarily as various as it was unsuc-
cessful.  Thus  rollers were placed under the tongue, to obviate its fancied
depression, (Mad.  Leigh's  treatment;) the tonsils  and uvula were ex-
cised, deep gashes made in the tongue to lessen  its  size, &c.  Others
again, traced the defect to a want of nervous power in the tongue, occa-
sioned by paralysis of  the ninth nerve, and attempted to overcome it by
the use  of stimulating masticatories, electricity, &c.
  In all these instances it is  obvious that a special was mistaken for  a
general cause.
  A  more accurate knowledge of the anatomy and physiology of the
organs of phonation led to an improvement on the above restricted con-
jectures.  Schulthess,  Arnott, Midler, and several  other  very  eminent
physiologists,  maintained that stammering, in all  its varieties, is depen-
dent for its immediate cause upon  a spasmodic closure of the glottis, pro- 
6
ducing  a sudden  arrestation  of the  issuing column  of air.*   Later
researches, however, have  shown that this is true of the guttural sounds
only.
  Dr. Carpenterf is disposed to consider that the proximate cause, in the
majority of cases, is  a disordered  action  of the nervous centres of a
centric origin.   This is proved by the close analogy which prevails  be-
tween the phenomena of stammering and those of the  general disease,
chorea.   The great difficulty, in by far the largest number of cases, is
to be sought for in the spasmodic action of certain of  the muscles con-
cerned in the production  of voice and  in articulation, which  spasmodic
action impedes or entirely arrests the column of sounding breath.  This
view is  particularly contended for by Dr. Dunglison.J
  Dr. Amott§ proposes, as  a cure for the disease, that the patient should
connect all his words by a vocal intonation, in such a manner that  there
shall be no stoppage of breath.  This is, undoubtedly,  the correct prin-
ciple, although it often fails in consequence of the method advocated,
not being able to carry out the  principle in all  cases.  This was observed
by Miiller, who admits that the plan is  founded on a sound  physiological
view of the nature of the affection, but urges the very proper objection,
that though it may and does afford some benefit, it cannot do everything,
since the  main impediment occurs in the  middle of words themselves.
This is a legitimate objection, as shown by the fact, that the  temporary
inability to enunciate may occur at the commencement of either syllable
of a word, especially those commencing with a consonant; the vowels
being formed  between  the vocal cords,  and issuing without  change,
while the consonants require for their enunciation difficult and often com-
plex and delicate movements of the muscles concerned in articulation.
  Mr. Bates, by an independent course of investigation and observation
upon himself and others laboring under stammering, has arrived at the
same conclusion concerning the difficulty to be overcome  as is entertained
by the modern physiological school.
  The instruments invented by him are all based upon the same princi-
ple, and, in the opinion of the committee, are more efficient in obviating
the vocal defect in question than any other contrivance  or method  with
which they  are acquainted.  As the spastic difficulty obviously accom-
panies different sets of letters  in different  persons, Mr.  B. has invented
three varieties of instruments,  as applicable to all the forms of stammer-
ing, all  having  the same object in view, however—the  maintenance of
an uninterrupted current  of sonorous breath.
  His instruments are as follow :—
  1. A narrow, flattened tube of silver, £ths of an inch in length, very
light, thin, and smooth.  The diameter of the calibre of the tube, mea-
sured from the  inner edge of one side to the inner  edge of the  other, is
|ths of an inch, while the depth, measured from the anterior inner  edge
to the posterior, is igth of  an  inch.   This is applied to  the roof of  the
mouth,  in the median  line, in such a manner that the anterior end is

             •Miiller.—Elements of Physiology,
             fCarpenter's Principles of Human Physiology.
             tMedical Examiner, July, 1*52
              -Elements of Phy i'"5- Vol.  I. 
7
lodged just behind the teeth, while the posterior  opens into the mouth,
looking upwards and backwards towards the fauces. In this position it is
maintained by a delicate piece  of wire or thin slip of india rubber fas-
tened to one end of the tube, the other passing between the incisor teeth
of the upper jaw.                               .
  This tube is intended  to overcome the difficulty in the  pronunciation
of the linguo-palatal letters, which are formed by the application of the
tongue to the palate. This it accomplishes by preserving a  continuous
current of air, thereby preventing spasm, allowing the letter in fault to be
properly elicited, and thus restoring the self-confidence of the sufferer.
  2.  For the explosive  consonants, the  labials,  dento-labials, &c, the
contrivance consists of a hollow, bi-convex disk,  from one end of which
projects a silver tube, which, passing out between the  lips, keeps up
the communication between the atmosphere and the oral cavity.  The
current of air  from the glottis enters by means of a small hole at one
side of the disE,  and escapes through the silver tube.   Finding that the
saliva was apt to accumulate in the disk, and thus obstruct the entrance
and exit of air, the inventor has recently substituted for this lateral open-
ing a small tube, passing from the upper  edge of the disk, and bent at an
acute angle upon itself.
   3.  For the accurate elimination of the guttural sounds,  Mr. B. has
contrived a belt, made of patent or glazed leather, or  any  other strong
material,  and lined with morocco.  This belt is concealed in  an ordinary
stock or cravat, and in this manner  secured around the  neck.   In the
middle and on the anterior surface of this belt is fitted a metallic plate
through which passes  a regulating  screw.  On the inner  side of the
belt, and just opposite the  plate, is a metallic spring  covered with kid
or  any other soft material, and firmly sewed by both ends to the strap.
When this apparatus is adjusted about the neck, the  regulating screw
resting upon the spring causes the latter to be forced inward, so as to
press  more or less  strongly upon the thyroid cartilage, thus relaxing the
rima-glottidis by approximating the  thyroid to the arytenoid cartilages.
In  this manner the  exit of air is provided for, and the spasmodic action
of  the muscles that close the glottis is overcome.   The  pressure upon
the larynx can be increased or diminished, as may be  required.
   From the above  description it will be  seen that the efficiency of these
 instruments is entirely dependent upon the unobstructed  channel which
they preserve for the egress of the  vibrating column of breath from the
larynx, through the mouth,  into the open air.  Muscular spasm is neces-
sarily removed, and the self-confidence of the stammerer restored—un-
doubtedly the  great desideratum in this  affection.  When the  patient is
fully convinced that he can really enunciate the opposing letters as  dis-
 tinctly as his friends, he rapidly overcomes the disease, by the judicious
 and effective exertions which renewed confidence begets.
   An advantage of some importance possessed by this apparatus is, that
 it can be worn without attracting notice, two of the pieces—the tube for
 the palatal  and the belt for the guttural sounds—being entirely concealed;
 while the tube which projects externally from the silver disk may be dis-
 guised by slipping  over it the barrel of a quill, cut like a tooth-pick. 
8
Moreover, each of the pieces can be most easily and expeditiously ap-
plied, as occasion may require.
  In  consideration of the  advantages here set forth, the committee
would, recommend that the first premium be awarded to Mr.  Bates, for
the instruments deposited by him at the last Exhibition of the Institute;
and1 furthermore, that the Scott legacy premium be awarded him for his
ingenious and  useful invention.

                      By order of the Committee,
January 12th, 1854.
William Hamilton, Actuary.