THE LIBRARY OF THE UNIVERSITY OF CALIFORNIA LOS ANGELES UNIVERSITY r.f CALIFORNIA LOS .^.vOEL LIBRARY STUTTERING AND LISPING THE MACMILLAN COMPANY NEW VORK BOSTON CHICAGO DALLAS SAN FRANCISCO MACMILLAN & CO., LIMITKD LONDON BOMBAY CALCUTTA MELBOURNE THE MACMILLAN CO. OF CANADA, LTD. TORONTO STUTTERING AND LISPING BY 2. So Sq- E. W. SCRIPTURE, PH.D. (LEIPZIG), M.D. (MUNICH) ASSOCIATE IN PSYCHIATRY, COLUMBIA UNIVERSITY ; DIRECTOR OF THE RESEARCH LABORATORY OF NEUROLOGY, VAN- DERBILT CLINIC ; FORMERLY ASSISTANT PRO- FESSOR OF EXPERIMENTAL PSYCHOLOGY, YALE UNIVERSITY f|0tfc THE MACMILLAN COMPANY 1912 All rights retervtd COFTKIOHT, 1912, BY THE MACMILLAN COMPANY. Set up and electrotyped. Published November. 1911 S752 IVM 475" PREFACE IT would be difficult to find a group of people more neglected by medicine and pedagogy than that of stutterers and lispers. The stuttering children that encumber the schools are a source of merriment to their comrades, a torment to themselves, and an irri- tating distraction to the teacher. As they grow older, the stutterers suffer tortures and setbacks that only dauntlessness or desperation enable them to survive. The lispers that are so numerous in certain schools are a needless retardation to the classes. In several European countries the state has estab- lished special opportunities for treating children with speech defects, but the matter has not received the full attention justified by its importance. In most medical faculties no place is accorded to speech defects ; the same is true in schools of pedagogy. This was formerly justified on the ground that a scientific study of speech and its defects did not exist. In the last decade, however, the science of phonetics has extended itself to laboratory work and university teaching ; moreover, speech clinics have been established in sev- eral of the foremost medical schools. The treatment of these defects thus stands upon an entirely new basis ; namely, that of a carefully developed science of normal and pathological speech. vi PREFACE The views here expressed as to the nature of stutter- ing and lisping, and the methods of treatment proposed are the results of three lines of work. The fir>t is a long experience in experimental psychology in t lie- laboratory of the University of Leipzig and later in my own laboratory at Yale University. The sen .ml is an almost equally long specialization in experimental phonetics, beginning at Yale and enntinued fur four years in Germany under a grant from the Cam. ^i.- Institution of Washington, D.C. ; some of the results involved were first stated in my lectures at the ('di- versity of Marburg (/Jermuny). Finally, the treat- ment of thousands of patients in the speech department of the Vanderbilt Clinic and in private praetice has developed the methods into forms that produce the maximum result with the minimum expenditure of time. This book has been prepared to meet the needs of physicians and teachers ; both are constantly confronted with the problem of what is to be done with a lisping or a stuttering child. By careful study of the symp- toms as described here and by plentiful experience in a speech clinic a physician may expect within a reason- able time to develop the ability to make a correct diag- nosis. A correct diagnosis by an expert should always be obtained before treatment is begun. The treatment of lisping proceeds along such clearly marked lines that the general practitioner and the regular teacher will have no difficulty in treating the individual cases that come to him in practice or in class. The results are al- ways gratifying ; the parent appreciates the seriousness of the defect, and the cure usually occurs without PREFACE Vll great difficulty. The treatment of stuttering is much more difficult ; it requires great skill and long experi- ence. There should be at least one physician in each town who is able to help the numerous stutterers who must otherwise be neglected. One teacher in a school or in a group of schools may be trained as a special instructor. I have to thank Professor H. Gutzmann, of the Uni- versity of Berlin, for his kindness in specialty modeling the plaster cast shown in Fig. 39, and Mr. Walter Robinson for the suggestion illustrated in Figs. 90, 91. COLLEGE OF PHYSICIANS AND SURGEONS, COLUMBIA UNIVERSITY, NEW YORK, 1912. CONTENTS PAGE PREFACE . . . . Y CONTENTS ix LIST OF ILLUSTRATIONS xi PAET I STUTTERING CHAPTER I. DESCRIPTION. CAUSE 1 -4L SYMPTOMS, FORMS, NATURE 10 III. DIAGNOSIS 42 IV. THERAPY 56 V. METHODS OF TREATMENT 74 PART II LISPING *" I. INTRODUCTION Ill II. NEGLIGENT LISPING 122 III. ORGANIC LISPING ' . 162 IV. NEUROTIC LISPING 173 V. CLUTTERING 18! PART III EXERCISES 8KT I. BREATHING ... 190 IT. MELODY 194 CON T K NTS - ci i \i.r III. I'l I \ ir.ll I I Y ]!l7 IV. SLOWNESS \<,* V. SMOOTHNESS 201 VI. VOICE QUALITY jnj VII. STAKTINO AND ENDING SKMI \< ( , . . . -jo., VIII. KM M'lATION AND Sl'KI.UXi; 207 IX. K\ri:i -VSION X. l'(>NHI>KX( K 21() XI. SniN i \M ..I - M I I < if ^li; XII. THINKING 217 XIII. DESCRIPTION AND RELATION .... i'l!i XIV. TELEPHONING _>_> 1 XV. TALKING WITH PEOPLE __'_ XVI. KM. \XATIOX 224 XVII. Mr-< i I.AK CONTROL j-j: ( XVIII. WORD LISTS 228 SKKKCTED RKFKKKN'CES 245 TECHNICAL TERMS 210 INDEX .... ,249 LIST OF ILLUSTRATIONS 1. Recording the movements of breathing by the graphic method '* . .21 2. Breath record during stuttering ,.': .23 3. Recording the pressure of the lips by the graphic method 23 4. Lip record of a stutterer's attempt to say the first letter in the word " Peter " . . . . . .' ' . 24 5. Recording the movements of the tongue . . . 24 6. Record of a stutterer's cramps of the tongue in attempt- ing to say " Tommy "....... 25 7. Recording the mouth current 26 8. Mouth record of " papa " spoken normally ... 27 9. Mouth record of " papa " with blowy " p's " spoken by a stutterer 28 10. Mouth record of "papa" with an inspiratory "p" spoken by a stutterer 28 11. Mouth record of " sleepy " spoken normally ... 29 12. Mouth record of "sleepy " spoken by a stutterer . . 30 13. Mouth record of " stutter " spoken normally ... 30 14. Mouth record of " stutter " spoken by a stutterer . . 31 15. Mouth record of "Peter Piper's peppers" spoken by a stutterer 32 16. Melody plot for " papa " spoken normally (Fig. 8) . 33 17. Melody plot for " papa " spoken by a stutterer (Fig. 9) . 34 18. Mouth record of " papa " in a case of spastic speech . 50 19. Mouth record of " papa " in a case of motor aphasia . 51 20. Mouth record of " papa " in a case of bulbar paralysis . 53 21. Scheme to illustrate the mechanism of stuttering . . 58 zi xii LIST OF ILLUSTRATIONS no. rxoB _'_'. Notes indicating how the phrase ' H..w .!<> y.m Jl. Line indicating how the normal voice .should rise and fall in speaking the phrase " How do you do?" with a melody similar to that indicated in Fi_'. 21 . . . 76 Line indicating the monotony of the stutterer's voice in speaking the phrase " How do you do?" . . . 7(5 26. Mouth record showing the word " papa " as actually sung 77 .'7. Melody plot to Fig. 26 77 28. Oct;i\<- t\\ Nt in musical notation 78 29. Octave twist indicated by a line 78 30. Mouth record of " papa" spoken with the octavr twist . 78 :>1. M.-lo.ly plot to Ki-. :) 79 :12. Mouth record of "papa "spoken with an unsuccessful attempt at the octave twist 79 3:!. Melody plot to Fig. 32 80 34. Perfect closure of the glottis 81 35. Glottis during a breathy tone 81 36. Vowel curve with normal beginning and ending . . 82 IV7. Vowel curve with glottal catch at beginning and ending 82 38. Mouth record of the stutterer's correction of the inspira- tory " p" in Fig. 10 89 39. Median section of the organs of enunciation and pho- >i at ion 11.'. 10. Artificial palate Ill 11. Palatogram for the vowel " ee " 11~> 42. Candle flame indicator us. -d for the mouth . . . 119 n. Tambour indicator used for the uoae . . . . 1'J" 41. Li p position for "f" aud "v" I'-'J 45. Lip position for " w " !-'' 46. Lip position for correcting " w " into " v " . . . 1 L' 1 LIST OF ILLUSTRATIONS xiii FIG. 1-v.r 47. Palatogram for forward " t " and " d " . . . . 125 48. Palatogram for backward " t " and " d " . . 125 49. Palatogram for " k " and " g " 125 50. Mouth diagram for " t " and " d " . . . .125 51. Mouth diagram for "k" and " g" ..... 125 52. Mouth record of " water " spoken normally . . . 126 53. Mouth record of " water " spoken by a lisper . . . 126 54. Palatogram for " s " and " z " 130 55. Palatogram for occluded " s " and " z " . . . . 130 56. Mouth diagram for " s " and " z " . . . . 131 57. Mouth diagram for occluded " s " and " z " . . . 131 58. Mouth record of " sun " spoken normally . . . 132 59. Mouth record of " sun " spoken by a lisper . . . 132 60. Tongue record for occluded " s " 132 61. Correcting occluded " s " and " z " 133 62. Making the interdental fricative 134 63. Mouth record of the word " Mitchell " . . . .136 64. Mouth record of the word "nutshell" 136 65. Palatogram for "ch" and"j" 137 66. Mouth diagram for " ch " and " j " . . . . 138 67. Mouth diagram for " n " 139 68. Mouth diagram for " ng " 139 69. Palatogram for " sh " 140 70. Mouth diagram f or " sh " 140 71. Palatogram for " th " 141 72. Mouth diagram for "th" . . . . . . 141 73. Mouth record of " thin " spoken normally . . . 142 74. Mouth record of " tin " spoken normally . . . 142 75. Mouth record of " thin " with occluded " th," by a lisper 143 76. Correcting occluded " th " . . . . '. . 143 77. Mouth record of front rolled "r " by an American . 144 78. Palatogram for English " r " . . . . . .145 xiv LIST OF ILLUSTRATIONS no. PAOE 79. Mouth diagram f or " r " 145 80. Mouth record of English " r " 145 81. Mouth record of uvula " r " by a Parisian . . . 148 82. Palatogram f or " 1" * . 146 83. Mouth diagram for " 1 " 14fi 84. Rod for pushing the tongue 147 85. Pushing the tongue into position for " r " . . . 147 86. Recording the nasal current and vibrations . . 151 87. Nasal record of " sun " spoken normally . . . 152 88. Nasal record of " sun " with relaxed velum ... 152 89. Tissue paper indicator . 153 90. Velar hook , . 154 91. Velar hook in position . 155 92. Mouth record of "dog" 156 93. Mouth record of " dok " 150 94. Mouth record of " dogk " 157 95. Mouth record of " apa " with the explosion of " p " well marked 158 96. Mouth record of " apa " with no explosion of " p " . 158 97. Hemiatrophy of the tongue 163 98. Mouth record of " so " spoken normally . . . 175 99. Mouth record of " so " in neurotic lisping . . . 175 100. Mouth record of "silk" spoken normally . .177 101. Mouth record of " silk " in neurotic lisping . . . 177 102. Mouth record of " shoe " in normal speech . . . 178 103. Mouth record of " shoe " in neurotic lisping . . . 179 Plates I, II, III. Mouth diagrams for typical English sounds. Plate IV. Palatograius fur typical English sounds. STUTTERING AND LISPING STUTTERING AND LISPING PART I STUTTERING DESCRIPTION. CAUSE As "stutterers" we designate individuals show- ing certain peculiarities of speech. One stutterer, for example, will make spasmodic contractions of the lips, tongue, etc., whereby a word like "berry" will be pronounced "b-b-b-b-berry." Another will open his mouth wide and produce an "a-a-a-a-" before he can say a word. Another will find himself suddenly unable to speak at all at the beginning or in the middle of something he wants to say. Still others are quite unable to speak certain words. One young man could never speak the name of his town and was obliged always to buy his railway ticket to the next town beyond. One lady would find herself at a ticket office suddenly speechless and unable to 2 STITTERINC! AM) LISPING tell what ticket she wanted while an impatient crowd of commuters gathered behind her. Stuttering is a serious detriment to the person's welfare. One refined stuttering girl of sixteen was studying typewriting and stenography, not realiz- ing that no office would tolerate a secretary who could not answer when suddenly spoken to or who could not use the telephone. But what was she to do for a living ? Even on the lower level of a shop girl she would be impossible. The examiners of immigrants at New York City often refuse admis- sion to stutterers on the ground that they are liable to be unable to make a living and likely to become public charges. A law student felt that on account of his stuttering he must relinquish his ambitions and con- fine himself to uncongenial work. At the best, the stutterer's social life is limited and abnormal. He often retires from social intercourse as much as pos- sible and becomes more or less eccentric. One boy grew up in such isolation that his oddities made him appear feeble-minded, although he was not mentally defective. Excessive stuttering has been made the basis of divorce for cruelty. To most people stutterers seem comical. They DESCRIPTION. CAUSE 3 are the butts of innumerable anecdotes in the news- papers and on the stage. The stutterer learns that people regard him as a kind of involuntary clown and that his family and friends are ashamed of him. Few persons realize how terrible life becomes to a stutterer. A normal person may get a mild idea of it by supposing that every time before he speaks he is obliged to wink one eye or to open his mouth and yawn ; the feeling of embarrassment and shame would soon overpower him. A stutterer is worse off; every time he tries to speak he is obliged to make a fool of himself in such a way as to make other people want to laugh at him. One religious but stuttering lady finally demanded to be " cured or chloroformed." One boy often threw himself on the floor, begging his mother to tell him how to die. Another boy asked for a letter to his father, telling him to keep the other children from laughing at him. Many stutterers become so sensitive that they imagine everybody is constantly making fun of them. The life of a stutterer is usually so full of sorrow that it can hardly be said to be worth living. At school the child is tormented by his fellow mates. He is usually a trial to the busy teacher 4 STUTTERING AND LISPING and a hindrance to the progress of the class. He is often excused from oral recitation, but just as often the teacher constantly corrects him or ridicules him. Sometimes it happens that the child has a cramp that keeps him from starting an answer for a moment, but does not show itself otherwise, such a stutterer prefers to be thought lazy or stupid rather than reveal the true nature of his trouble. Even at home the stutterer is misunderstood and often tortured from the best motives. He is fre- quently reproved or scolded as an inattentive 1 or bad boy because he "could speak properly if he would only try." Many a parent is often sure that this is so because the child will speak properly when reminded to do so. The truth is that no human being can always think of how he is to speak before he speaks ; the stutterer simply cannot stop stutter- ing of his own accord. Stuttering is, indeed, a serious disease. It is not as undesirable as mania or cancer, but most people would prefer to have typhoid or pneumonia for the simple reason that with these diseases a per- son either dies or recovers, whereas stuttering is a lifelong torture. DESCRIPTION. CAUSE 5 A very great injustice to the stutterer is the widely spread notion that stuttering is a bad habit which is to be corrected by reproof, scolding and punishment. The treatment is supposed to con- sist in a kind of schooling, the result depending on the diligence of the pupil. Lack of progress is attributed to inattention or laziness. Parents, friends, and teachers are always alert to test the patient's progress. Of course, all this simply makes the stutterer worse, turns a mild case into a severe one, and drives many a sufferer to despair. Stuttering is a disease ; it can be properly treated only on the principles of any other disease. Just as with all other diseases, some cases get well spon- taneously and some get well no matter how they are treated ; yet so few recover permanently under the treatments in vogue that there is a widespread opinion that stuttering is incurable. The most frequent cause of stuttering is a nervous shock. Ghosts and other practical jokes, and, with very small children, such terrifying experiences as are found at amusement resorts (scenic railways, fire scenes, etc.) are often the causes of fright from which the child never recovers. Severe falls are just 6 STUTTERINC AM) LISIMM! a- often the sources of the mental shock. Surgi- cal operations (for cataract, adenoids, etc.) are occasionally the sources of stuttering. The cause of stuttering in all these cases is evidently the intense fear involved in the shock. In some cases the fear has developed gradually. A boy of twelve relates that at the age of seven, on several occasions in the daylight he thought he heard footsteps of some one following him in the hall, whereas the noise was of his own footsteps; thereafter he began to stutter.. He is still afraid to walk in the dark, to be alone or to go to sleep in the dark. A young man of seventeen relates that he began to stutter in reading at seven years because he knew that he would make mistakes before the class and become nervous about it. Most of the stutterers from shock show a general condition of nervous excitability in which the pre- dominant element is an abnormal state of expectancy toward persons and events. The patient is often on the alert for what is going to happen. He watches other people and replies before they half finish their remarks ; or he is timid to such a degree that conver- sation is painful. The same condition of general over- anxiety I have found in patients who do not stutter. DESCRIPTION. CAUSE 7 It is a typical psychoneurosis, that may, perhaps, be appropriately called the " general anxiety neurosis." In addition to the kinds of nervous shock mentioned above, it is possible that the cause of the general anxiety neurosis may lie in shocks of various kinds occurring in infancy and childhood. This "general anxiety neurosis" differs from the anxiety neurosis of Freud in several ways. In the former the anxiety (or fear) is present at all times ; it is ready to attach itself to any thought or occurrence for which a fairly valid reason can be found ; the patient knows that he is overanxious, but his anxiety always seems fully justified at the moment. In the latter the anxiety attaches itself to one particular thing, for example, the patient cannot cross an open space because he is afraid to do so; although the fear is irresistible, the patient usually realizes fully that it is absurd. A very frequent cause of stuttering is mental contagion by intentional or unintentional imitation. A boy thinks it fun to mock a stutterer, and ulti- mately finds that he himself cannot stop stuttering. A stuttering parent nearly always has one or more stuttering children. Even when the parent had stopped stuttering in youth, there are usually 8 STUTTERING AND LISPING enough traces left in his speech (e.g. hard voice) to start the child stuttering. Stuttering has been known to develop in a child from playing with a deaf-mute who talked with difficulty. Stuttering frequently appears after whooping cough, also after scarlet fever, measles, influenza, intestinal troubles, scrofula, rickets, etc. The cause seems to lie in the condition of exhaustion. One of my cases showed symptoms of spastic infantile paralysis (spasticity of the legs, weakness and athetosis of the hands, weakness of the muscles of speech) with history of difficult birth. The difficulty in using the muscles of speech may be assigned as the cause of the stuttering. A neuropathic disposition or a condition of nerv- ous exhaustion is present in nearly all cases of stuttering. The first suggestion for prophylaxis is that parents and nurses are to avoid stories and scenes that frighten children. Nervous children should re tonic treatment, especially open-air life. If one child in a family begins to stutter, he should be cured immediately in order to save the others. A stutter- ing child in school is a danger to his fellows. DESCRIPTION. CAUSE 9 The statistics show from 1 to 2 per cent of stut- terers among school children. A smaller percentage in the lower classes becomes trebled in the higher ones. Marked increases are found at the periods of second dentition and puberty. The relative fre- quency among boys and girls ranges from 2:1 to 9:1. rilAl'TKH II SYMPTOMS, FORMS, NATURE THE most striking symptoms are cramps or spasms of the muscles connected with speech. Abdominal cramps are nearly always present . The entire abdomen may suddenly become rigid, or it may make irregular contractions. In one case the wall just over the navel was drawn into a deep cuplike cavity. The diaphragm, as seen by the X-rays, may be suddenly fixed or may move down- ward in spasms. The spasms sometime:- propel the abdominal wall outward in jerks. Often both abdominal muscles and diaphragm will become perfectly rigid and immovable. These contrac- tions produce irregular interruptions or expulsions of the breath instead of the steady current necessary for proper speech, or they give no breath at all and render the patient speechless. One patient of mine often beame suddenly speechless in this way for ten to fifteen seconds at a time. A frequent phe- 10 SYMPTOMS, FORMS, NATURE 11 nomenon is the expulsion of the breath just before speaking. The most frequent case is that of con- tinual irregularities of breathing during actual speech. Laryngeal cramps are a never-failing symptom of stuttering. The muscles in and around the larynx become tense and fixed. The tone from the larynx is monotonous, hard, and often husky. It is not un- usual to find a patient who never has any symptom of stuttering in the presence of the physician except the monotonous laryngeal tone. I have never seen a stutterer without this symptom. Cramps and spasms of the muscles of enuncia- tion are the ones most apparent to the observer. The lips may be pressed tightly together for a short or a long time when the patient tries to say "p" or "b." In other cases they will open and shut, producing a series of "p"s or "b"s instead of one. The tongue may be pressed so tightly against the palate that the " t" or the "d" is two, three, or ten times too long. All the sounds may be similarly affected. Less frequent but more striking are the contrac- tions of muscles not ordinarily used in speech. One 12 >TI TTKKIVi AND LISPING patient will t \\i-t hi- head whenever he stutters badly, another will screw up one eye, another will con- tort his whole body, etc. One patient had "pains that did not hurt" in her legs and arms while speak- ing. One boy of seven made horrible grimaces and stuck his tongue like a thick stick far out between his lips. One girl of twenty-two would spend one to two minutes in grunting like a pig and whimper- ing like a dog after which she would say the word or sentence with ease. All the muscles involved in speech are brought into a condition of over-tension or "hypertonicity" whenever the stutterer begins to speak, although there may be no visible cramps or spasms or any stuttering in the popular sense. Hypertonicity is thus a cardinal system of stuttering. 1 The hyper- tonicity is psychic (cerebral) and not spinal ; it appears only when the person intends to speak ; the reflexes are not exaggerated. The trained ear readily detects the hard tone of the voice which results from laryngeal hypertonicity. The expert can thus tell from the first sound that 'Scripture, "Treatment of Hyperphonia," Medical Record, March 21, 1908. SYMPTOMS, FORMS, NATURE 13 the patient makes whether he has started his sentence correctly or has begun with the stuttering tone that will cause him to stumble before he finishes. Another kind of symptom occurs in the "er," "well," etc., that the stutterer uses to get started. Sometimes this "starter" is an inarticulate but complicated grunt. Sometimes the starter is re- peated several times ; one young lady would regu- larly repeat "why" ten to fifteen times before she could get out the first word of what she wanted to say, and even then she sometimes failed and had to begin over again. Often the patient has to make severe contortions of the face or the head or the body before he can begin. An almost constant symptom is excessive rapidity of speech. In some cases this is to be attributed to the desire of the stutterer to get his words out before he is caught or before any one can interrupt him. In most cases it is the expression of nervous anxiety. A never failing symptom is the patient's lack of confidence in his ability to speak correctly. In some cases the mere thought "Will I be able to say that word?" is sufficient to make it absolutely impossible for the person to say it. The stutterer 14 sTI TTKKINC AM) USl'INC always lives with the fear that his speech may "go back on him." Many a one is always thinking a few words ahead of what he is saying, l>eing on the lookout for some word he thinks ho cannot say. When such a word is coming, he avoids it by select- ing another that will serve just as well. One patient practically passed his life in always avoiding words; this mental work, being added to that of a normal man, kept him in a condition of nervous prostration. The fear of being ridiculous is nearly always present. The person does not want to "make a fool of himself." He therefore avoids reciting in school, he refuses invitations to social affairs, he would rather live with his father's employees in a mine than go to college, he shuts himself up with a servant and becomes a queer-mannered hermit, etc. A. condition of mental flurry is usually present. When the patient starts to speak, he ^becomes partly dazed by his emotion and does not know exactly what he wants to say. This condition may be pres- ent even when he does not stutter ; in trying to answer a question, for example, he cannot make up his mind just what he wishes to say. Closely con- nected with this is a habit of hesitating in thought SYMPTOMS, FORMS, NATURE 15 that sometimes arises. The mental flurry perhaps explains why some stutterers have most trouble whenever they are jocular. In some cases they stutter only when jocular. With very rare exceptions the stutterer does not stutter when he knows no one can hear what he says. Almost as rare are the cases where he stutters in singing or in whispering. The embarrassment and sad experiences of the stutterer often lead to an abnormal mental condi- tion. The patient is nervous, shy, easily embar- rassed, retiring, odd in his ways, sad, etc. In some cases the change does not go beyond an increased sensitiveness. Many stutterers, especially young women and schoolboys, acquire a permanent facial expression that is typical of the profoundest sadness. The thought of suicide is frequent. Three forms or stages of stuttering may be dis- tinguished. The simplest form of stuttering is that of "pure habit." Such a case occurs rather frequently where a younger child unintentionally copies the stutter- ing of an older one. If the stuttering does not go beyond the stage of pure habit, the younger child 16 STtTTERINC AND LISI'INC drops his stuttering involuntarily when the older one is removed or cured. The habit stage is often initiated by shock or exhaustion. The person finds himself making inac- curate movements in speaking, and speaking a word or words indistinctly. On account of the excessive nervous irritability in these conditions, he feels that he cannot permit himself to speak in an improper fashion, so he instinctively tries to correct the inaccurate movements by an extra effort at distinct- ness. Such an effort produces excessive muscular tension; his consonants, like "p," "b," "f," "d," etc., are too hard and long. This in turn impresses itself on the memory, so that when he again makes the same sounds he naturally makes excessive muscular movements. The excessive tension readily becomes repetition, so that, for example, instead of a long "p" he says "p-p-p, " etc. Such was the case with a patient two and a quarter years old who stuttered constantly by reduplicating the conso- nants, saying, for example, " strawb-b-b-b-berries " and showing monotony of the laryngeal tone and the usual symptoms. After a few days of correction whereby the stuttered words were repeated correctly SYMPTOMS, FORMS, NATURE 17 with melodious intonation by the father each time after her, she ceased to stutter. A patient two years old, when seen three weeks after the stuttering began, could be induced to speak only with great difficulty on account of the feeling of shame that was evidently present. When she spoke, it was in an abnormally low tone, with stumbling and repetition of consonants. There was no neuropathic history, but a previous exhausting illness. Being told to sing what she wanted to say, she stopped stuttering and spoke naturally after a few days. In both these cases we may assume that the exhausted nervous system led to inaccurate movements. These produced a feeling of uncertainty and insecurity, which in turn aggravated the inaccuracy and led to excessive cramplike efforts. Every incorrectness of action increased the uncertainty of feeling, and vice versa. The parent's correction soon made the child feel that it was doing something reprehensible ; this produced not only embarrassment, but also still greater inaccuracy and uncertainty. The stuttering habit may be initiated by embar- rassment. It sometimes occurs that a lisping child becomes so nervous over his defect and over the way IS STITTKKINC AM) I.ISI'INC other people treat him tliat he brains to stutter. The lisping in such cases i- u>u:lly due to tongue- tie; this is the only case in which stuttering is connected with tongue-tie. Quite a few cases occur where the stuttering hul>it is begun at three or four years of age with no history of shock, exhaustion, or imitation. It i- possible that the child's awkwardness in using his speech organs leads him into blunders over which he becomes nervous. The stutterer nearly always goes beyond the habit stage. People laugh at him, mock him, scold him, threaten him with punishments, or whip him. Usually he is obliged to repeat words he stumbles on. He is made to go through reading and speaking exercises. Extra hard words are given him to practice on. Speaking becomes a torture for him. A new element, the "fear of displeasing and of appearing ridiculous," produces the "fright stage." The stuttering is now a distinct psychoneurosis that may have the most far-reaching consequences. If the question is asked of a patient in the fright stage, "Why do you stutter?" he will answer, "Be- cause I am afraid that I will stutter." Many a one SYMPTOMS, FORMS, NATURE 19 will say that if he could only forget that he had stuttered, he would never stutter again. When the stutterer wishes to speak, the thought of his pre- vious failures occurs to him and he fears or knows that he will appear ridiculous to those before whom he is speaking. This element disturbs his mental condition. He is seized with a violent emotion that may be described as stage fright before a single person. Embarrassment, shame, fear, etc., express themselves in his face and often disturb his mental actions so that he cannot think clearly. The emo- tion may make him absolutely speechless, as in the case of many patients who cannot say a word when introduced to strangers. Or it may make him stumble over his words ; naturally he stumbles in the way he has learned to stumble, namely, with stuttering cramps. The disturbance of mental action during the fright stage may produce a kind of intellectual paralysis. One patient was often unable to answer a question, not because he was afraid of stuttering, but because the requirement of answering actually paralyzed his mind so that he could not think of the answer. This habit had become so thoroughly formed in another 20 STTTTKKINC, AND LI SIMM 5 patient that any excitement might render him unable to think ; on the football field, where the system of signals required him to add numbers, he would, upon hearing the signals "six and four," which had to be added together, have to ask his neighbor how much they amounted to. One st utterer explained the mental paralysis when asked to give his name or any exact information as resulting from the fact that he is overwhelmed by having some one depend on him for information that he alone can give. A third stage occurs not infrequently. The stutterer is no longer embarrassed by his defect. It is obnoxious to him, and he would like to be rid of it, but the fright has disappeared. This may be termed the "stage of indifference." It is usually found in older patients; they stutter because the habit is firmly fixed and not because they are embarrassed. In many cases stuttering seems to be associated with a peculiarity of character. This cannot be attributed entirely to the presence of the stuttering. In one case in my experience the child had previou-ly developed a condition of nervousness which had become very extreme on account of lack of training SYMPTOMS, FORMS, NATURE 21 in self-control. The stuttering habit, engrafted on this, became very violent. In another case the stuttering, was associated with slowness of thought ; FIG. 1. Recording the movements of breathing by the graphic method. Two metal cups with rubber tops are fixed over the chest by a band. Expansion over the chest draws air into the cups. They are connected by a rubber tube to a small recording tambour. This is a metal cup with a rubber top which moves a light recording lever. A line drawn by this lever on a smoked surface moved by clockwork gives a record of the breathing movements. The record- ing arrangements can be attached to the abdomen also. sometimes the hesitation in speech seemed to be a cloak for hesitation in thought. Several previous attempts at cure had failed to be permanent on account of lack of moral backbone. In another 22 STUTTERING AND LIsiMN<; c the stuttering had appeared in a small l><>y who had never been taught any self-control. Very often stutterers are shy and bashful to an extent that can hardly be justified by their painful speech experiences. The stutterer's speech movements may be accu- rately recorded and studied by the methods of experimental phonetics. The movements of the chest during speech may be recorded by the apparatus shown in Fig. 1. The " pneumograph " shown in the figure consi-ts of two metal cups with tops of soft rubber. A tape runs around the body from one rubber top to the other. As the chest expands, the rubber tops are pulled outward. This draws air inward through the tubes which open into the metal cups. As the chest falls, the air passes out again. The "recording tambour" is a metal cup with a rubber top. It is connected with the pneumo- graph by a rubber tube. As the air is drawn into or expelled from the pneumograph, it passes out of, or into, the recording tambour and makes the rubber top bulge inward or outward. A lever is arranged to indicate the movements of the rubber top. SYMPTOMS, FORMS, NATURE 23 The registration occurs on a "recording drum'' consisting of a metal cylinder revolved by clockwork. 111 m 111:1 \ 11:1 nl FIG. 2. Breath record during stuttering. Around the cylinder a sheet of paper has been Fia. 3. Recording the pressure of the lips by the graphic method. A small rubber bulb is placed between the lips and is attached to the recording tambour. stretched and smoked over a flame. The point of the lever of the recording tambour is adjusted to STUTTERING AND Fio. 4. Lip record of a stutterer's attempt to say the first lctt r in tin- wt.nl " lVt np.at-.l ,,,. tract; touch the paper; it draws a white line in tin- -not. The paper is afterwards removed and the record i> fixed in shellac varnish. To record the breath- ing movements the pneu- mograph is hung over the chest or the abdomen by a tape around the neck. The record reproduced in Fig. 2 is from a woman whose abdomen made violent movements out- ward during certain con- sonants. The records show the movements for Fio. 5. Recording the movements of the tongue. A small rul.lM-r Lull, la placed in front <>f (iron tin- torque and ordinary breathing and is connected to the recording tambour. the spasms during the attempt to say "m." SYMPTOMS, FORMS, NATURE 25 The cramps of the lips may be recorded by inserting between them a small rubber bulb (Fig. 3) and con- FIG. 6. Record of a stutterer's cramps of the tongue in attempting to say "Tommy." necting it to a recording tambour as described above. Pressure of the lips makes the line rise. The record of the movement of the lips in an attempt of a stutterer to say " Peter" is given in Fig. 4. In spite of the long series of convulsive movements the patient could not get beyond the letter "p." The cramps of the point of the tongue may be recorded by inserting a similar bulb behind the teeth so that the tip of the tongue rests against it (Fig. 5) ; pressure of the tongue makes the line rise. The result of an effort to say "Tommy" is given in Fig. 6. There is first a violent spasm of the tongue and then a series of smaller ones. Most interesting records are obtained by a mouth recorder. A funnel of rubber (the top of a large 26 .sTI TTKKINi; AM) USI'INC stomach tube) is held over the mouth ; it is connected to a very small and delicate registering tambour. The entire arrangement i> >hmvn in Fig. 7. A record of the word "papa " in normal -perch is shown in Fig. 8. The straight line at the start cor- Fia. 7. Recording the mouth rum-tit. The changes in air pressure and the vibrations of the voice pass to a very small recording tambour and are registered on the smoked surface. responds to the time during which the lips were cl MI 1 for the " p " - the " occlusion." The sudden rise of the line is the result of the puff of air the " explo- sion " - that issued from the mouth as the lips were opened at the end of the " p." The explosion of the SYMPTOMS, FORMS, NATURE 27 " p " shows two large vibrations. This is due to its suddenness, whereby the recording lever receives something like a sharp blow, and vibrates twice in- stead of once. The small vibrations that follow are a record of the first vowel, each vibration correspond- FIG. 8. Mouth record of "papa" spoken normally. It begins with a straight line because the lips are closed to produce the letter "p," and no air can issue from the mouth ; this portion of "p" is called the "occlusion." The sudden rise of the line shows that a sharp puff of air or "explosion" came from the mouth as the lips were opened ; the extra wave in this explosion is due to the vi- brations of the lever, resulting from the sharp explosion. The small waves record the vibrations of the voice for the vowel "a." They are suddenly cut short by a descent of the line ; this is the result of the closing of the lips for the second "p." The extra wave results from the suddenness of this closure. The occlusion is followed by an explosion. The word ends with the vibrations of the final vowel. ing to one vibration of the vocal cords. The vibra- tions end by a sudden fall of the line as the lips are again closed for the second " p." The record of the explosion for this "p " is similar to that for the first one. The word closes with the vibrations of the final vowel. A record of the word " papa " spoken by a stutterer (Fig. 9) shows a very long occlusion for the first " p," followed by a tremendously long blast of air, corre- 28 STUTTKKIV; AND LISPING spending to the explosion of the " p." A -low fall of the line after the first vowel >ho\vs that the lips were Fio. 9. Mouth record of "papa" with blowy " p" 's spoke by a stut- terer. The initial "p" has a very lunn orclu.sion. followed t.y a long :md strong blast of air. The second "p"isan incomplete < -ln-ion fol- lowed by a blast of air. Comparison with Fin. s shows dearly how the stutterer's enunciation differed from the normal one. closed gradually and not suddenly for the second "p." This " p " also has a blowy explosion. A record of the word "papa" spoken by another stutterer is given in Fig. 10. The record shows that FIG. 10. Mouth record of "papa" with an inspiratory "p" spoken by a stutterer. The sudden descent of the line shows that the stutterer drew in his breath to make the " p" instead of closing his lips. The vowel vibrations follow as usual. instead of closing his lips and then opening them for the initial " p," he drew in his breath for a moment and then closed his lips, thus making an inspiration SYMPTOMS, FORMS, NATURE 29 and an occlusion instead of an occlusion and an ex- plosion. A record of the word " sleepy " spoken normally is shown in Fig. 11. There is a gradual rise of the line as the air issues from the mouth during " s." This falls rather suddenly as the tongue changes from the Fia. 11. Mouth record of "sleepy" spoken normally. The gradual rise of the line registers the rush of air during the second "s." The small waves record the vibrations of the voice during "1" and "ee." The occlusion and the explosion for "p" and also the vibrations for the final vowel are similar to those in Fig. 8. " s " position to that for the " 1." There is a second rise with faint vibrations for the "1"; these persist as the line continues to fall. The rather long "1" includes the vibrations along the horizontal line. Suddenly the line rises for the vibrations of " ee," as the tongue moves from the " 1 " position to the more open one for " ee." It is interesting to note that the " 1 " is so much longer than the " ee." The line sud- denly falls as the lips are closed for the " p " ; it sud- denly rises as they are opened with a kind of explo- sion. The final vowel is quite long. 30 STl TTKKIM; AM) LISIMNC In a record (Fig. 12) of the word ".-Irrpy" by a stutterer the sinking of the line shows an initial gasp FIG. 12. M<>uth record of ".sleepy" spoken \,\ :\ -tutterer. There i.- :i Hasp In-fore the '.*." l-'nr file "p" tin -re i.-, iii) complete closing <>f the lips and no explosion. The Miiall vil.rations during tin- "p" show that the larynx continued to vibrate instead of stop- ping. followed by a rush of air for "s." Thereafter come the small vibrations indicating the semivowel "1" Fio. 13. Mouth record of " stutter " spoken normally. There is first a rush of air for the "s," then a sudden fall as the breath is cut off by the tongue in producing the occlusion of the " t." The sharp rise of the line registers the explosion of the "t." The small vibrations belong to the vowel "ti." The closure for the second "t" ("tt") and the explosion arc similar to those of the first. The final vibrations belong to the vowel "er." and the vowel " ee. " A normal " p " would be formed by cutting off the breath at the lips for a moment. In Fig. 12, however, there is no straight line for the SYMPTOMS, FORMS, NATURE 31 "p" ; that is, the stutterer's lips were not completely closed. Naturally there is no sudden rush of air at the end of the "p." The record of the "p" shows small vibrations, indicating that the larynx continued to vibrate instead of stopping as it should have done. FIG. 14. Mouth record of "stutter" spoken by a stutterer. There is an initial gasp followed by a strong "s" and then an immensely prolonged "t." There is then another gasp. The rest of the word is normal. A normal record of the word " stutter " is given in Fig. 13. It registers the rush of air for the " s " by the upward rising line. The line suddenly falls as the lips are closed for the "t." It rises very sud- denly as the lips are opened to let out a puff of air, the explosion of the " t." Then follow the vibrations of the vowel " u." The line falls as the tongue closes the mouth for the second "t "-sound (indicated by " tt "). The word ends with a series of vibrations for the final vowel which is indicated by " er." 32 STtTTKUINc; AM) I.ISIMMO A mouth record . I-'iu. II of the word "stutter" by a patient shows an initial gasp followed by a strong "s." Then conies an immensely ])rolonged " t." At the end of the " t " there is another gasp. The rest of the word shows no marked abnormality. The beginning of a stutterer's attempt to say " Peter Piper's peppers " is given in Fig. 15. A short Fio. 15. Mouth record of "Peter Piper's peppers" spoken by a stut- terer. The stutterer makes a gasp and a vowel sound foUowed by a blowing sound before he can say the first " p." Such sounds are called "starters." The " p"is long and has aviolent explosion. The " t " is so short as to be almost lacking. The " starter " is repeated before each word. gasp is followed by a long vowel that sounds like " u " in " up." Then comes a blo'wing noise made by the lips ; it is the same as the Greek sound " ph " which is similar to the English "f." All this has to be done before he can say the first "p." The "p" is long ; it has such a violent explosion that the large vibrations of the recording lever persist for a con- siderable time. The very short vowel " e " shows no SYMPTOMS, FORMS, NATURE 33 170 v 14C 130 . -- ^ P a p a 95 papa peculiarities. The " t " was made so abnormally short as to almost entirely disappear. The last vowel (indicated by "er") was much prolonged. The " uf "-sound was repeated before each word ; the entire phrase be- 2 ing spoken about as follows: "uf- Peter uf Piper's uf- peppers." The difference between the use of the laryngeal tone by normal speakers and by a stutterer can be illustrated by comparison of the melody of the voice in the two records shown in Figs. 8 and 9. The length of each vowel vibration is measured under a microscope. The number of vibrations of this length that would occur in one second is calculated. This is the pitch of the laryngeal tone at that instant. The result is marked by a dot on cross-section paper. A line connecting these dots shows the rise and fall of the voice. Such a diagram is termed a " melody 100 200 300 400 500 FIG. 16 Melody plot for "papa" spoken normally (Fig. 8). Each wave of the vowels is measured. The pitch of the tone corresponding to each wave is then calculated. The results are indicated by a line, the "melody plot" which shows how the tone rises and falls. The melody plot shows that the voice started at a tone of 170 vibra- tions in the first vowel and descended to 140. In the second vowel it started at 130 and descended to 95. 34 STUTTERING AND LISPING plot." The melody plots for the records in Figs. 8 and 9 are given in Figs. 16 and 17. The monotony of the stutterer's voice is evident. The view of the nature of stuttering that I have pro- posed differs essentially from the prevalent theories. According to Kussmaul the enunciation of each single sound occurs correctly; the trouble is in connecting the consonants with the vowels ; this 200 100 125 55^ 125 P papa a P a 90 300 400 500 700 800 > 9 Fio. 17. Melody plot for " papa " spoken by a stutterer (Fig. 9). The firet vowel maintained a tone of 125 vibrations throughout. The second vowel maintained the same tone for a while and then fell to 90. occurs because the respiratory, laryngeal, and enun- ciatory muscles do not act harmoniously. This is contrary to fact. In the case of a stutterer, every sound without exception is made more or less in- correctly. Even when he is speaking with apparent smoothness, the hypertonicity of the muscles (p. 12) is present, and the strained, monotonous laryngeal tone is heard. The cramps affect the sounds them- selves regardless of how they are followed. A stut- SYMPTOMS, FORMS, NATURE 35 terer does not stick on " t " because a vowel follows it, but because he feels he cannot say that particular word; for example, he may stick on "stove" but not on " sto " or " stone." The statement that stuttering consists purely of a wrong form of breathing simply neglects all the other defects in the stutterer's speech. The theory that it consists essentially in an incoordination of breathing and speech movements quite misrepresents the condition ; such incoordination appears typically in the speech of a person intoxicated with alcohol, whose speech is different in every detail from that in stuttering. The theory that stuttering consists in an exaggera- tion of the consonants in speech merely takes account of the results. Since the stutterer usually has his cramps on initial consonants, these sounds occupy a great deal more time than the following vowels, and also than the following consonants. There are, moreover, cases where the patient stutters on initial vowels, as in " a-a-a-apple." Since in German the initial vowel really begins with a consonant (the glottal catch corresponding to the spiritus lenis in Greek), this might be considered as consonant stutter- 36 STUTTERING ! AM) I.ISIMXO ing. But in English the initial vowels begin clearly. Moreover, the cramped laryngeal tone i> present in every vowel in every case of stuttering. The lengthening and exaggeration of consonants or vowels are the results of the cramps, and t hex- cramps are the results of other conditions. Every one of the above theories neglects just the one vital characteristic of the disease, namely, that the defect is due to the fact that the stutterer thinks some other person is listening to him. As long as he is alone, he can speak perfectly. When a stutterer, who has become so accustomed to me that he speaks perfectly in my presence, is placed at the telephone, he will continue to speak perfectly as long as he sees my finger on the switch that cuts it off ; the moment it is removed he knows that " central " will hear him and he begins to stutter. It has been asserted that stuttering consists essen- tially in the fear of speaking. This is true as an ex- planation of why the person stutters as badly as he does when once the disease is developed. The fear of speaking is perhaps the most prominent symptom in stuttering just as in stage fright, but an underlying cause for this fear must be sought for. SYMPTOMS, FORMS, NATURE 37 The assertion has been made that stuttering is related to tics, to compulsive acts, to the phobias, and to writer's cramp. These conditions are not only utterly different from stuttering, but also from each other. The essential of a tic is a persistently repeated impulse to a special movement that can be suppressed voluntarily for a short time. The tic movement always involves more than one muscle; it is the remainder of a movement that was once purposive, such as sniffing, twisting the head, blinking the eye, etc. The tic, unlike stuttering, does not involve any inaccuracy, uncertainty, or primary embarrass- ment or fear. A compulsive act, like that of touching all the posts as one goes along, or that of never stepping on the cracks in the sidewalk, etc., arises from an al- most irresistible impulse to do a certain compli- cated act. Like the tic, the impulse can be repressed for a while ; but the impulse is to a definite compli- cated act, not to a single movement, as in a tic. Unlike stuttering, the compulsive acts are not pro- duced by any fear, and do not show any inaccuracy or uncertainty. 38 STUTTERINO AND LISPING The phobias arc characterized by inv-i-tiblc fears of objects, acts, or places, as the fear of filth, the fear of committing an act of desecration, the fear of cross- ing open places, etc. The patient with a phobia knows that his fear is absurd. The stutterer's fear is not only reasonable but also thoroughly justified. Writer's cramp is a fatigue of the nerve centers due to overexertion in writing. It is a dull pain or an actual cramp, quite unconnected with any mental disturbance. The cramp is spastic and not clonic. There is no mental compulsion, as in tics, compulsive ideas, and phobias. There is no embarrassment or ' fear, as in stuttering. Penmanship stuttering has been observed in one case. 1 The embarrassment and fear were like those of the stutterer ; the cramplike repeated movements were not like those of writer's cramp, but were the same as those of oral stuttering. According to my view, stuttering is a disease marked by the following cardinal symptoms : 1, psy- chic hypertonicity and spasms of the muscles of speech, 2, anxiety (embarrassment or fear), 3, fixation of these conditions by habit, and 4, the existence of these symptoms only in the presence of other persons. 1 Scripture, " Penmanship Stuttering," Jour. Am. Med. A*soc., May 8, 1909, Vol. LII, p. 1480. SYMPTOMS, FORMS, NATURE 39 The enumeration of the symptoms does not suffice to indicate the nature of stuttering. The fact that one child becomes a stutterer through imitation or fright or an exhaustive disease, while another does not, indicates some deeper difference in the mental or nervous constitution. Analysis of the stutterer's condition of mind always shows a serious disturbance in his attitude toward other people. Most patients are shy and timid ; the boldness or indifference in other cases is only a kind of bravado to cover up timidity. Much of this timidity is undoubtedly due to the effects of the stuttering, but its intensity is often out of all proportion to the occasion. It may well be that timidity is the basis on which stuttering arises. If this is true, stuttering would then be a condition in which timidity shows itself by a peculiarity in speech. Social timidity shows itself in mental symptoms that are approximately the same in stutterers and non-stutterers ; there are the same strained feelings toward other people, the same bashfulness, etc. The bodily symptoms are also similar ; the muscles of the body are more tense than they should be; 40 STTTTKKIM; AND LISPING there is often also the flushing of the face Tin TO are even resemblances in speech. The timid person, who is a non-stutterer, speaks with a tense voice, he often stumbles over his words and some- times can hardly get them out ; he often sticks or reduplicates like a stutterer. If this "stuttery, " timid speech can be supposed to be developed and firmly fixed in a set of habits, the result would be true stuttering. The fact that stuttering arises only in some cases of timidity and not in others indicates that there is some other element in the disease. The following observations may perhaps suggest what it is. In several cases there has been a determined effort to get rid of the trouble and perfect good faith on the part of the patient, yet I have had the feeling that at the bottom of his soul the patient really did not wish to be cured. This reminds one of some forms of hysteria, psychasthenia, and neurasthenia, where the disease is really produced by the patient in order to obtain some end, although he Is absolutely un- conscious of this self-production. It may be sug- gested that stuttering is a defect which tend- t<> oxrlude the person from the society of his fellows. SYMPTOMS, FORMS, NATURE 41 and that persons who already have this unconscious tendency instinctively seize upon such a means of encouraging it. The same mental condition as that underlying stuttering is found in many cases of neurasthenia and psychasthenia where quite other symptoms (head- ache, tremor, anxiety, etc.) appear instead of the speech trouble. It is often a cause of wonder why some neurotic patients are not stutterers. If we assume that the impulse to segregation from society will use the most likely and effective means for its purpose, we understand why it naturally seizes upon the speech function. We also understand that it will more readily disturb the speech when the mechanism of normal speech is less firmly fixed, as after exhausting diseases, fright, or injury by imitation. When the normal speech mechanism is strong, the psychasthenic impulse must find some other outlet. Stuttering is therefore a diseased state of mind which arises from excessive timidity and shows itself in speech peculiarities that tend toward a condition of segregation which will enable the person to avoid oc- casions where he will suffer on account of timidity. CHAPTER III DIAGNOSIS THE mere repetition of a word or of an initial sylla- ble is often termed stuttering. Such repetitions occur to every one at times, especially in embarrassing situations. One stutterer said that every boy in the class stuttered when reciting Latin. Various other conditions, such as hysteria, multiple tics, in- juries to the brain, etc., may produce repetitions in speech. Such repetitions do not have the same cause or the same systematic regularity as the repe- titions due to stuttering in the habit stage; the muscular movements do not have the cramplike stiffness peculiar to stuttering. The symptoms are not the result of embarrassment and fear, as are those due to stuttering in the fright stage. It is quite im- portant to distinguish between the disease called stuttering namely, the disease whose character- istics have been described in the preceding chapters - and the repetitions often called stuttering which 42 DIAGNOSIS 43 are found in various other diseases. These repeti- tions might be called "pseudo-stuttering." ''Organic lisping" is an inaccurate form of speech produced by abnormal conditions of the speech organs. It may be illustrated by the case of the boy who says "sh" for "s" on account of a very high palate. Tongue-tie may cause the child to use "th" for "s." The lisp disappears when the organic defect is corrected. There is no resemblance between the sounds of organic lisping and those of stuttering ; in the former the sounds are incorrect because they are incorrectly made, in the 'latter because they are made with too much force. Tongue-tie never produces stuttering directly. I have had a small boy with tongue-tie who both lisped and stuttered. Upon cutting the tongue band he ceased to lisp immediately, and stopped the stuttering after three days. The tongue-tie caused the lisp, and the embarrassment over the lisp caused the stuttering. A full account of organic lisping is given in Part II. "Negligent lisping" is a term that may be applied to those errors of speech that are due to defective perception and execution of sQujids. Thus "w" is used for "r" because the child does not clearly per- 44 STUTTERING AND I.I si -ING Vi-ive the diflVrence and because he does not take the trouble to produce the more difficult muscular adjustments required for the "r. " Most frequently the tongue is pressed a trifle too hard against the palate so that it closes up the small passages re- quired for "s" and "th," thereby turning both of these sounds into "t" and producing "tun," "toap, " etc., for "sun," "soap," etc., or "tick" for "thick." Often "t" is used for "k," as "tandy" for "candy." The defective sounds remain constant, whereas they change in stuttering. The lisper's "s" is always defective, whereas the stutterer may have trouble on initial "s" but not on final " s. " Negligent lisping occurs in normal or phlegmatic or mentally dull children, whereas the stutterer is always nervous ; some lispers, however, become much embarrassed by their defects, and some even become stutterers on account of embarrassment. Negligent lisping is treated in detail in Part II. "Stammering" is a term sometimes applied to the speech defects indicated by the German word "Stammeln" ; these are the same as those just de- scribed under the term "negligent lisping." Often the term "stammering" is applied in a confused DIAGNOSIS 45 way to a case of stuttering where the patient sticks in his speech rather than reduplicates his consonants. Most often the term is used as identical with "stutter- ing." It is better to eliminate the word "stammer" in order to avoid confusion. "Neurotic lisping" is a disease described here for the first time. The person may speak with general indistinctness, appearing to mumble the words, or the incorrectness may be confined to special sounds. One girl of thirteen lisped over all the consonants. She was an excessively nervous child, and she spoke with incredible rapidity. As she was gradually quieted down, the lisping decreased. It became evi- dent that the excessive nervous tension, combined with self-consciousness, produced a tense condition of the vocal organs allied to that of stuttering. She could not produce the smooth and delicately ad- justed movements of normal speech because her muscles were overtense. Another girl of twelve was afflicted with partial deafness, which had made it hard for her to learn to speak. Being a sensitive child, the correction of the parents and the embarrass- ment and fear before them had caused nervousness. She spoke improperly because she over-innervated 46 STUTTERING AND LISIMN*; the speech muscles. Neurotic lisping occasionally occurs in stutterers. The lisping may sometimes ap- pear in only a few sounds, the others being distinct. One case of this kind lisped only on "s" ; the cause was a fright that had left the person excessively nervous. The overtension of the speech muscles, the nervous condition of mind, and the similarity of causation in some cases point to a close relation of nervous lisping to stuttering ; they might perhaps jus- tify the term "spastic stuttering." Neurotic lisping may be distinguished from stuttering proper by the .fact that the overtension of the muscles is a con- stant one ; the mental excitement seems also to be a steady condition, not varying as in stuttering. Fur- ther details are given in Part II. Bad cases of "cluttering" (hasty mumbled speech) are often confused with stuttering. Although the clutterer speaks with excessive rapidity and slurs over the details of his words, and although he breathes improperly and sometimes sticks in the middle of a sentence, yet the defects are the result of over- excitement and eagerness rather than of anxiety and fear, as in the case of the stutterer. The clutterer speaks better the more he is concerned about his DIAGNOSIS 47 speech, the stutterer the less he worries about it (see Part II). "Tic speech" or "choreatic stuttering," or the speech of the "post-choreatic neurosis" (if the terms may be permitted) is characterized by a system of spasmodic movements of constant character that break up the speech in a way somewhat like ordinary stuttering. The ' trouble originates in an attack of acute chorea. After this has passed, the patient may retain various spasmodic movements which are no longer due to the cause of the original disease, but are really "tics" derived from the choreatic movements. Such cases are frequently diagnosed as "chorea," whereas they are really "multiple tics." The patient with this form of speech usually has various other spasmodic movements of the head, arms, etc. The speech itself does not show the regularity of stuttering. The stutterer will stick constantly for a while on certain consonants ; his trouble is nearly always in getting started. The tic-speaker usually begins smoothly and catches and jerks at any mo- ment ; there is no regularity or system in the sounds he stumbles over. The mental attitude of the stutterer is characterized by anxiety and fear ; the 48 STUTTERING AND LISPING lie pcakcr docs not hesitate to speak at any time, and is usually unal>a-hcd ly his defect. The speech defects of "hysteria" have often been confused with >t uttering. In one case the patient upon being asked a question would hesitate a moment, turn her eyes to one side, and make a movement of the head as if she had just waked up to the question, and then answer with a slight difficulty at the start. The symptom was absolutely constant . Corneal and pharyngeal reflexes were lacking ; she was readily hypnotized; all of these pointed to hysteria. Another patient could not say words beginning with "w" because a word beginning with that letter had once shocked his feelings. Sometimes the patient stumbles over all words relating to certain topics. Such patients do not show the cramplike action of the stutterer, and do not have trouble all through their speech ; the laryngeal tone is not monotonous; the mental attitude is quite different. They are cases of hysteria, or of "hysterical pseudo- stuttering," and not of true stuttering. The diagnosis of "hysterical mutism" has been made in cases where the stutterer's fright made him speechless in the doctor's presence. Older persons DIAGNOSIS 49 that complain simply of inability to speak when meeting strangers will be found, on close observation, to stutter more or less perceptibly. " Hysterical aphonia" results in a whispered or faint tone of the voice that is present continuously in a sentence ; there are no cramps in the mouth or face. The stutterer never has the whispered or the faint voice; he nearly always has some cramps in the mouth or face. He may become speechless for a short time, but this does not occur with the hysteri- cal patient. In the " spastic speech" of cases of infantile cere- bral palsy, the characteristic is over-innervation of all the muscles used to express the idea. In speaking a word the patient contracts not only the muscles of breathing, of the larynx, and of the organs of enunciation, as many a stutterer would, but also makes strong contractions of all the facial muscles. The overcontractions are those that would be needed to overcome heaviness of movement, and are often not well coordinated, whereas the stutterer's overcontractions are those that express embarrass- ment and are perfectly coordinated for the purpose. In spastic speech there is none of the stutterer's fear. 50 STI'TTKUINC AND LISPING The over-exertion is continued throughout the sen- tence. The syllables are equal in length, and are laboriously enunciated. A record of the word "papa" made by a patient with "cerebral birth palsy" is shown in Fig. 18. Fio. 18. Mouth record of "papa" in a ease of spastic |H-rrh. Tin occltiMon (straight line) for the "p" is followed by a blowy explosion (upward curve). The v.w<-l vibrations an- blown upward. All the sounds are longer than those of the normal record (Fig. 8). The explosion for each of the " p "s is of the blowing kind, more like those of the stutterer's record (Fig. 9) than those of the normal record (Fig. 8). The vowels are also blown, as shown by the position of the line with the fine vibrations. All the sounds are lengthened, particularly the last vowel. In "motor aphasia" the patient cannot find the words or sounds to express what he wants to say. There is usually a history of trauma or apoplexy. Stuttering nearly always begins in childhood ; aphasia is usually connected with old age or injury. The excessive nervousness of the aphasic person some- times resembles that of the stutterer ; it has partly DIAGNOSIS 51 the same origin in anxiety to get out the words and in fear of being ridiculous. There is no ex- cessive muscular tension or cramp of the speech muscles. The laryngeal tone is normal, and not monotonous. Words or parts of words or letters FIG. 19. Mouth record of "papa" in a case of motor aphasia. The syllable "pa" is spoken gently. A long pause follows. The word is then spoken correctly. may be repeated (pseudo-stuttering), but the cramps of the stutterer do not occur. One aphasic repeated a word or a phrase over and over before he could go on ; for example, " Doctor - doctor doctor Brown told me to come here. I bring I bring I bring what you told me I bring bring bring, yes, bring, bring, I bring, etc;" or "I say to my to my to my I say that to my niece, I have my girl, I have my girl, etc." This is pseudo-stuttering. A stutterer does not repeat a word, but only sounds or syllables ; he would have said " D-d-doctor," "I b-b-bring," etc. A record of " papa " by this patient is reproduced in Fig. 19. The first syllable is spoken normally; 52 STTTTKRINC AM) I.ISIMNC then- ;m> no cramps. Then follows a pau-e. after which the word is spoken nirreetly. This >lmule compared with a record of the same word by a stut- terer in Fig. 9. Sometimes the patient will repeat the first syllable a dozen times with pauses between. He says that he is for a while unable to recollect what the second syllable is. This aphasic syllable or word repetition i- utterly different in its cause and its symptoms from true stuttering. Kussmaul calls it "aphatic stuttering." It is simply one of the phenomena of aphasia. In its early stages "multiple sclerosis" sometime*; produces a kind of pseudo-stuttering ; the later stages are characterized by a scanning speech in which each syllable is brought out with a distinct effort. The characteristic anxiety of the stutterer is absent. In " hereditary ataxia " (Friedreich's) the speech is slowed, clumsy, and often scanning. There may be hesitation, but there is no true stuttering and no stutterer's fear. In "progressive bulbar paralysis" the injury to the nuclei in the pons and bulb produees weak action of the muscles of lips, tongue, pharynx, and DIAGNOSIS 53 larynx. The sounds of speech become mumbled and indistinct. The blurred pronunciation can hardly be confused with stuttering. The weakness of the laryngeal muscles produces hoarseness, dullness, monotony, lowering of pitch, and finally loss of voice. There is no fear of speaking as in stuttering. Fin. 20. Mouth record of "papa" in a case of bulbar paralysis. For " p " the line rises steadily ; this shows that the lips were not closed completely. The strong vibrations for the vowels correspond to the bellowy character of the voice. For the second "p" the lips were closed, but the larynx continued to vibrate. The limits be- tween the sounds are much blurred. A record of " papa " spoken in a case of progressive bulbar paralysis is reproduced in Fig: 20. Instead of an occlusion and an explosion for the initial " p " there is a steady rise of the line, showing that the lips were not closed completely at any moment. For the second " p " there is also only a slight narrowing of the lips instead of a closure ; the larynx does not stop vibrating for a moment as it should. In "pseudo-bulbar paralysis" the speech is im- perfectly enunciated ; it may be nasalized ; it may become an unintelligible mumble; it may even closely resemble stuttering (pseudo-stuttering). The 54 STUTTERING AND LISPING weakness of the muscles shows itself not only in speech, but also in every movement ; e.g. panting, whistling, singing, sticking out the tongue, etc. Similar disturbances occur in swallowing and cough- ing. The eye muscles and the extremities are usually affected. It is characteristic that, although the voluntary control of these muscles is injured, yet they act perfectly in response to emotional, auto- matic, and reflex stimuli ; for example, although the patient cannot move his lips or the facial muscles when talking, yet he laughs and cries and expresses his emotions in an exaggerated manner. In his speech the muscular action is too weak, in contrast to the too strong action in stuttering. There is no anxiety, as in stuttering. In the speech of "general paralysis" the sounds are often slurred over, there are no cramps in enunciation, and single sounds are not repeated. Mistakes occur readily in the combination of the parts of a word. For example, the paralytic patient will say "ar- trallery" or "rartrillery," but it will be said without cramps. A stutterer would say " a-a-a-artillery " or "art-t-tillery." The paralytic can often speak the word correctly by trying very hard ; the stutterer DIAGNOSIS 55 speaks better as he speaks< gently. The paretic "syllable repetition" is quite different from true stuttering; the paralytic will say " hippo-po-po-pot- musmus," the stutterer would never say anything like this, though he might say "hip-pop-p-potamus." The diagnosis of "insanity" with commitment to an asylum occurred in the case of a very bad stutterer. When excited, he would go through the most extreme contortions and gesticulations in the effort to get out a word, and would finally run up and down the room in wild exasperation at his inability to speak. iv THERAPY THE prospect of a permanent cure of stuttering is good, provided the patient is willing and able to keep up the treatment for a sufficiently long time. The length of the treatment is variable. With very young children the cure often succeeds in one, two, or a few more treatments. Somewhat older children require three or four weeks or even months of daily treatment. Older . persons are sometimes cured rapidly, but they are often very difficult to manage. When the patient receives treatment only during visits to the physician two or three times a week, a permanent cure may require six months or a year. When there is weakness of character, a permanent cure can be effected only by remedying the under- lying defect at the same time. The first step in the cure of stuttering is to look after the patient's bodily and mental health. Most stutterers are anemic, all are nervous. Fresh air 56 THERAPY 57 and exercise, proper hygiene of meals, sleep, and moral habits, regulation of school or office work, cod-liver oil, iron, arsenic, etc., are indicated. The treatment of the stuttering is often useless unless the patient is treated for his nervousness ; the two troubles aggravate each other, and they should be treated simultaneously. Nose and throat should be in good condition; turbinates, polyps, septum, ade- noids and tonsils should be treated if necessary. At the outset it is usually necessary to explain to the parents how the stutterer is to be regarded at home, or to the patient himself how he is to regulate his life. The home attitude during the fright stage should be such that the stutterer should be encouraged to forget himself. His attempts at new ways of speaking should not be commented upon. Mistakes and relapses should not be noticed. The patient should never be blamed. With rare exceptions the attempt of a parent to correct or help the stutterer is an added irritation and a direct hindrance. The treatment o^ stuttering is based on the follow- ing principles. The " principle of a new method of speaking" is founded on two facts : first, that the stutterer speaks 58 STUTTERING AND LlsiMNG in an abnormal voice, which we may call the " stut- ter voice"; and, second, that he does not stutter JQUCE* SPEECH THOUGH r TO 'BE EKPP.E33ED EMOTIONAL DISTURBANCE VOCAL ORGANS Flo. 21. Scheme to illustrate the mechanism of stuttering. When the stutterer attempts to express a thoughtin hisuxual voice, he is obliged by the emotions connected with shaking to cramp his vo- cal muscles. If he expresses his thought by singing, by queer modes of speech, or in any other way unusual for him, he has no difficulty. The normal way of speaking differs so much from the stutterer's voice that it is just as unusual to him as the queerest voice can IK-. He cannot stutter in a normal voice. when he expresses his ideas in any other voice, such as the singing voice. The scheme shown in Fig. 21 expresses these two facts. When the stutterer tries to express a thought in the presence of another person, the action of his speech THERAPY 59 is interfered with by the emotional condition (embar- rassment or fear) that is aroused at the same time. He therefore speaks in his stutter voice. If he tries to express the thought in any other way than the usual one, the emotional disturbance does not arise. This explains the familiar fact that a stutterer never has any trouble when he sings what he wants to say. Since the patient does not stutter if he speaks in any unusual way, he can be taught to speak in some kind of an odd voice. The stutterer can at any time speak without stuttering if he will use an abnormally low voice, or an abnormally high one, or if he will drawl the vowels or slur the consonants, or if he will speak in a choppy staccato voice, and so on. These are the methods of the "stammer schools" and " stutter curers." They are objec- tionable because they leave the patient with a queer voice. He is likely to have it told him that the "cure is worse than the disease." He usually gives up the queer voice after a while and becomes a stut- terer again because the queer voice itself produces em- barrassment and he naturally feels like discarding it. The essential point is that the stutterer feels his manner of speech to be different from his stuttering 60 STUTTERING AND UM'ING voice. One patient could never dictate to his stenographer. I found that he could not di>tin- guish one note from another in music. I told him to sing what he wanted to dictate. He did so without the slightest hesitation or difficulty, in what he supposed to be a singing voice ; it did not differ, however, from his stuttering voice, except in being slightly easier and more natural. As long as he thought he was singing, he did not stutter, although he did not sing. The cure was a failure because he refused "to make a fool of himself by singing to his stenographer." To have enlightened him con- cerning the fact that he did not sing would have destroyed the belief that he was singing and would have made him a stutterer again. There was no way out of the dilemma. There is another way of speaking which is unusual to the stutterer, namely, the way in which the nor- mal person speaks. When he speaks in this way, he does not and cannot stutter. The therapeutic pro- cedure on this principle will therefore be to teach him to speak normally. Each of the abnormalities that appear in his speech has to be determined and corrected. The result is perfectly normal speech. THERAPY 61 This is the only method of cure that should be permitted. The " principle of relaxation" is used to aid in overcoming the emotional condition of the stutterer. It is pointed out to him that he speaks in a hard, strained voice. He is taught to speak softly, melo- diously, and pleasantly. It is quite effective to get him to go through various exercises while lying down and trying to doze; a hypnoid or a hypnotic doze aids in relaxation. The "principle of habit formation" implies that the new way of speaking is to be drilled into the patient till it becomes a habit. The greatest diffi- culty lies in the fact that speech is so automatic that we practically never think before we speak. The training requires the patient at first to think how he is to speak each time before he actually speaks. The first steps require him to repeat sentences, poems, etc., after the instructor. This is continued till proper habits are formed. The final result must be a purely automatic system of speech habits. If the treatment falls short of complete automatism in the new form of speech, the patient will probably drop the habit and become a stutterer again. 62 Ml TTKKINC AM) LISIMNC The "principle of spontaneity" is mjui-ito be- cause, when the patient has learned to repeat per- fectly, he will still be unable to do so when he speaks of his own accord. A gradually increasing amount of spontaneous speech is introduced into the treat- ment. A good method is for the instructor to speak declarative sentences and quc-tinn- alter- nately ; each declarative sentence is repeated by the patient, but each question is answered. Ho i* urged to speak the answers in the same tone and manner as the questions Gradually longer answers and then free conversations are introduced. The patient should finally talk freely and perfectly. Another method is to give the patient something to read. At first the instructor reads with him : soon \the instructor drops out for an ever increasing number of words until the patient can read alone. The "principle of increasing embarrassment" arises from the fact that, even when the patient has learned to speak perfectly in the presence of the physician or the instructor, he is unable to do so under other circumstances. The patient is taught to speak properly before a few other persons or before a class. Still more difficulty is introduced by THERAPY 63 making introductions, speaking over the telephone, buying in stores, reciting in school, etc. For the introduction exercise the stutterer practices at first privately and then with gradually increasing num- bers of strangers. The other problems are met by exercises to develop confidence. The "principle of equilibration" responds to the fact that some patients are abnormally lively and expressive while others are retiring and depressed. The former type is quite the usual one among small boys. They are characterized by excessive volubility; their speech runs in a stream, they reply before you have finished your remark, they continually insert remarks in the conversation of others, they often talk and act in a way that is " fresh" or even impertinent. It often happens that the patient stutters only when he gets into such a flippant mood, or when he thinks of something funny. This is the mood expressed in the jokey style of talk of the mining camp, of the swaggering tough, and to a lesser degree of college boys. The very essential of the cure lies in repressing such patients. It is explained to them not only that their manner is improper and offensive, but also that their stuttering 8TUTTKKINC! AND LISPING is due to their lack of self-control. They arc re- quired to keep silent when others speak, to silently count four before speaking, to speak in time to a metronome, to speak no unnecessary word, etc. The other type of stutterer is ashamed to speak. or is dejected and depressed. Such are many of the older boys and the young men and women. They need to be encouraged. It is explained to them that there is a chance for them to escape from their bondage and that life may become bright and happy. Moreover, they are not to take their defect so seri- ously; others have the same trouble. It is useful to accompany such patients to stores, to their homes, etc. ; a helpful word is inserted when needed. It is pointed out to them how much their speech improves from week to week. When a patient has serious trouble on certain occasions, for example, buying in a certain store, it is often stimulating to bet him that he will have the same trouble next time. The "principle of correct thinking" indicates that the abnormal habits of thought, which a stutterer always acquires to a greater or less degree, are to be corrected by appropriate exercises. A frequent abnormality is that of getting into a THERAPY 65 daze at each effort to think. The patient finds that he cannot decide promptly. It was typical of one patient that upon being asked "Which kind of dog do you like best?" he hesitated, and grunted, and finally said, "I really cannot say which I like best." He was cured by being obliged to give some kind of decision quickly, regardless of whether it was correct or not. The trouble was due to the mental flurry or daze that had become a habit. Another patient, when leaving a house, found himself unable to say "Good-by" because some friends were waiting for him. The trouble arose from a conflict between the motive to hurry after the friends and the motive of not offending the host; this produced a mental daze that left the patient speechless. The school exercises of another patient were learned in such a hazy fashion that he had a feeling of uncertainty when reciting ; this made him stutter violently. The habit of hazy knowledge may extend to every topic in life ; the patient must be trained to know perfectly and surely what he does know, and to recognize exactly what he does not know. The " principle of correct enunciation" responds to the fact that some stutterers enunciate indistinctly (ifi STl TTKKINC AND I.ISIMVI or incorrectly. This may he due to confused and incorrect notions concerning sounds ; ,-uch a condition is a form of "negligent lisping" (Part II, ('hap. I). It is sometimes due to a general excess of muscular effort; this is a form of "neurotic lisping" (Part II, Chap. IV). The exercises for general indistinctness (p. 157) are to be employed. An important principle is "belief in the success of the treatment." When the belief is strong, the patient makes his readjustments more eagerly and is bolder in using them in speaking to others; the consequent success encourages him and gives him confidence. This in turn leads to still further success. With a patient who is consciously or un- consciously doubtful of the outcome, the treatment becomes laborious. With such patients and with all who have become doubtful through failures or relapses, a careful psychanalysis (see below) may be needed to remove the doubt. A thorough "correction of character" has to be frequently carried out in order to produce a complete and permanent cure of the stuttering. Whenever possible, the patient should have his entire life studied and regulated by the physician. THERAPY 67 Defects of intellect and morality have to be treated by the appropriate methods. The neglect to reform a person's character frequently results in failure of the cure to be permanent. The "principle of subconscious readjustment" recognizes the fact that only a very small portion of our mental life is conscious. From earliest infancy our characters have been developed by our surround- ings and by the experiences we have passed through. Our past has been mainly forgotten, but its results are present in our traits of character. The last one to have any idea of his character is the person him- self. The cause of the stutterer's trouble is entirely unknown to him. It is purely mental but it is sub- conscious, and a cure is often possible only by a care- ful study of the patient's subconsciousness. This can be done only by the group of methods known as " psychanalysis " (Freud) . Some of these methods are briefly described below. The usual conditions under which the cure is to be achieved include, in the first place, individual treatment at the physician's office. My method is to give the patient a thorough mental and bodily examination. The general anam- liS STITTKKINC AM) LISPING nesis covers the history of the present illness, its presumable cause, heredity >t uttering, nervousness, asthma), past diseases, education, habits (tea, coffee, alcohol, tobacco, drugs, sleep, food, work, sex), appetite, digestion. The general status includes the size, height, weight, general condition (nourish- ment, anemia, exhaustion), general intellectual appearance, urinary analysis (albumen, sugar, in- dican), circulation (heart). Special examination of the organs used in speech includes the nose (septum, turbinates), throat (adenoids, tonsils), larynx (ca- tarrhal conditions), chest (diameter expanded, re- tracted, capacity by spirometer). The special anam- nesis can be obtained only gradually as the patient's friendship is gained. It should furnish all sources of nervous strain in his life. He is asked to give a most careful account of his relations to the other members of his family, to his schoolmates or his friends, to chance acquaintances, to the community, and to mankind. On each of these topics he is to compare his attitude to that of other persons. The object is to relieve him of all feeling of strain by mak- ing him realize that all human beings are built on the same principles as he is, and that they are not strun- THERAPY 69 gers before whom he should have any feeling of fear or distance. Since the patient stutters least before persons who have the most sympathy with him and notice his trouble least, he is brought to feel that the whole world is much more friendly than he supposed. Without waiting to get a detailed special anam- nesis, work may be begun with exercises, and, in some cases, with psychanalysis. The exercises are prescribed at each sitting as the various faults show themselves. If the patient speaks too fast, one or more slowness exercises are ordered ; if too stiffly, melody and flexibility are indicated ; if the breathing is incorrect or the tone is husky, the appropriate exercises are noted, etc. An attendant, who has been listening to the physi- cian's criticisms and explanations, then carries out the exercises with the patient. Psychanalysis is begun by association tests and the analysis of dreams, as described below. This immediately brings physician and patient into the closest personal relations ; the latter will discuss matters that he would not mention otherwise ; the special anamnesis is obtained rapidly. Moreover, 70 STITTKHINC AND USl'INT, it brings to his mind many important events of the past and calls his attention to many conditions in the present otherwise overlooked. Finally, it is used for a study of the patient's subconscious con- dition. The distinction between the conscious and the subconscious elements of his mental life are ex- plained. As he learns to realize the points in which his mind works differently from what it should, he involuntarily proceeds to a gradual correction. The physician should gain the patient's friend- ship and devotion. His ability to develop the pa- tient's confidence is one of the chief factors of the cure. The patient should be willing to devote a large amount of time to the exercises with the at- tendant. Office treatment has the advantage that it does not remove the patient from his business or school and also that it enables a cure to be gradually worked out in the environment in which the pa- tient must live. The final success or failure of the treatment de- pends largely on the patient's determination to persist until the cure is complete. Sometimes a patient will spend many months with only gradual improvement ; finally the resistances and ancient THERAPY 71 habits suddenly break down and the patient is cured rapidly. He should make up his mind that at any cost he will continue treatment until he speaks per- fectly. When he does speak perfectly, he should not drop the treatment. He should return at steadily increasing intervals for examination and for any needed revision. When he reaches a six-months in- terval, he should make a permanent arrangement to return at such an interval ; this is not too much to ask, even a dentist makes that demand. It is true that some cases get well in a few treatments, and that most cases do not have relapses ; but no one can tell beforehand how any one case will turn out. Another form of treatment is that at an institu- tion. The patient lives with the physician and attendants in a special house. He suddenly breaks off all connection with his past life and enters upon a novel series of experiences in strange surroundings where people constantly supervise his speech. His entire manner of life bodily and mental is subject to regulation. This form is very effective when it can be carried out. The separation from the family is often absolutely necessary for a cure. 72 STITTKKI.VG AND LISPING Treatment by class work has a great advantage in the feeling of solidarity it awakens and in the inspiration of being cured together with others. It is used in the office and institutional forms of treat- ment by holding daily classes for the various exer- cises. The interest and enthusiasm that can be awakened by the various exercises, by the tele- phoning, by the ticket selling, by the impromptu vaudeville, by the debates, etc., are most beneficial. In the speech clinic the treatment must be mainly in small groups or classes. So far as possible, the physician should attend to the patients individually also. In connection with the public schools a careful examination should be made by a competent phy- sician of every child who does not speak perfectly. Stuttering must be carefully distinguished from the other nervous defects. In all cases of defective enun- ciation (Part II) there should be tests of intellectual development also. Many of the stutterers and some of the lispers can be treated in special classes con- ducted by trained experts under direction of the specialist. Whether these classes are held during school hours, after school hours, or in vacation is a THERAPY 73 matter that must depend on local conditions. Quite a number of the stutterers and lispers must receive special individual treatment. The other speech de- fects can be treated only on directions from the specialist. CHAPTER V METHODS OF TREATMENT THE object of the treatment is to give the stutterer a normal voice and a normal state of mind. The following methods of treatment are those that will be found most efficacious : Training in Melody and Flexibility The tone of the voice, which rises and falls as we speak, is produced by the vibrations of the vocal cords in the larynx ; it may properly be termed the "laryngeal tone." The stutterer cramps the muscles of the larynx so that he speaks in a monotone. The cure con-i-t- in putting melody and flexibility into his laryn- geal tone. By "melody" we mean the rise and fall of pitch for successive syllables. Melody may be indicated by notes on a staff or by the rise and fall of a line. The tones on which the words "How do you do?" 74 METHODS OF TREATMENT 75 may be sung are indicated by the notes in Fig. 22 or by the line in Fig. 23. In speech each syllable has a rise and fall in pitch, as indicated in Fig. 24. The speech of the stutterer FIG. 22. .Notes indicating is monotonous and Stiff, haV- how the phrase "How do you do?" is to be ing neither melody nor nexi- S un g . bility (Fig. 25). A record of the word " papa " as actually sung is reproduced in Fig. 26 ; its melody plot is given in How do you. FIG. 23. Line indicating how the phrase "How do you do?" is to be ming according to the notes in Fig. 22. Fig. 27. Comparison of Fig. 27 with Figs. 16 and 17 show vividly the differences in melody among the three forms of expression. The pitch of the laryngeal tone is determined by 76 STUTTERING AND LIsPlKQ the degree of tension of the vocal cords. To vary the pitch constantly, as in Fig. 27, the cords must change their adjustment at every in-taut ; that is, the laryngeal muscles must be freely and delicately do? How do you Fio. 24. Line indicating how the normal voice should rise and fall in speaking the phrase "How do you do?" with a melody similar to that indicated in Fig. 23. poised and must act readily and accurately. The stutterer, however, cramps them up so that they can How do you do? Fio. 25. Line indicating the monotony of the stutterer's voice in speak- ing the phrase "How do you do?" move only with difficulty. He sticks to one tone as much as possible. His action resembles that of a child who cramps a pencil tightly in his hand ; he can draw a straight line with a ruler to guide him, but he cannot write or draw gracefully. METHODS OF TREATMENT 77 The laryngeal cramp may be broken up by the "melody cure." The stutterer is first taught to sing a song or a phrase while accompanied by the FIG. 26. Mouth record showing the word "papa" as actually sung. The vibrations of each vowel are of the same length throughout. piano or another voice. His voice will rise and fall, as indicated in Fig. 23, and he will have no stiffness or cramps. Then he must speak the word on the 200 100 250 125 A papa a " a ) 100 200 300 400 500 600 700 800 9( FIG. 27. Melody plot to Fig. 26. same notes, first with and then without musical accompaniment. This gives him the idea that he must put melody in place of monotony. The patient now learns to make his voice "flexi- ble." The instructor pronounces various words in such a way that the laryngeal tone passes over an octave in the first important vowel ; this may be 78 STUTTKKIM; AND I.ISI-IN<; called the " octave twist." Fig. 28 indicates the method in musical notation. In Fig. 29 the general change is shown by u line. X^ x<* HP In going over the octave in this way the voice passes from FIQ. 28. Octave twist the chest register to the head in musical notation. . _, . register, ror these registers the laryngeal adjustments are quite different. The stut- terer always speaks in the chest register. If he leaves this register, he must relax the muscles, that is, he must drop the cramp and rq start a new adjustment. An an- Rrr alogy may be found in raising a Flo 29.-o.-tav,- twin weight by the arms from below ""'-^1 by .line. the waist to over the head One set of muscles pulls it up to the shoulder, but an entirely different set nui-t Fio. 30. M<>:ith rr.-ord of "papa" spoken with the octave twist. Tho waves of the first vowel Income shorter and shorter ; this indicates that the voice rises steadily. be used to get it up any farther. The stutterer will try to raise his voice while keeping to the rhe-t register ; he will usually stop at the fifth (c to g) in- METHODS OF TREATMENT 79 stead of going over the whole octave (c to c')- As long as he does this, the exercises do him no good whatever ; he must be persistently trained until the full octave becomes easy. 300 10L 125 a papa 500 600 700 800 100 200 300 400 FIG. 31. Melody plot to Fig. 30. The voice rises through an octave in the first vowel. A record of the word "papa" spoken with the octave twist is shown in Fig. 30. The waves of the first vowel become shorter and shorter. The melody 900 FIG. 32. Mouth record of "papa" spoken with an unsuccessful at- tempt at the octave twist. Although the vowel waves become shorter in the first vowel, they do not become as short as in Fig. 30. plot (Fig. 31) shows that the voice rose through an exact octave. The word spoken in this way was much longer than when spoken normally. This is usually so at the beginning of the treatment, but as so STUTTERING AND LISIMNC the patient becomes more skillful no more time is required when the octave twist is used. The common fault of the beginner who sticks to the chest register and fails to rise a full octave is shown in Fig. 32. Although the waves of the first vowel become shorter, it is very evident that they did not 200 100 125 n 800 100 200 300 400 500 600 700 Fio. 33. Melody plot to Fig. 32. The voice fails to reach an octave on the first vowel. become short enough. The melody plot is given in Fig. 33. The melodization of the voice goes on day after day until the stutterer can do it perfectly. Usually all the other kinds of stiffness and cramps disappear together with the laryngeal stiffness, be- cause the stutterer has learned to speak with a new voice, that is, to use a new set of habits free from the stuttering impulse. The object of the melodiza- tion and the octave twist is relaxation of the muscles 900 METHODS OF TREATMENT 81 of speech. When this has been accomplished per- fectly and permanently, the person may speak in any way he pleases. Correcting the Vocal Quality The stutterer's voice usually sounds hoarse and breathy. This is due to improper action of the laryn- geal muscles whereby the vocal lips are not brought closely together. Perfect closure is shown in Fig. 34 ; one condition for the breathy tone is shown in Fig. 35. FIG. 34. Perfect This ' ' stutterer's hoarseness " can closure of the glot- tis. be readily corrected by exercises in The vocal cords .... . . close tightly to- which the patient sings and speaks ge ther in produc- "ah" with the glottal catch (coup de glotte) at beginning and end of the sound. The breath is held back by closing the glottis ; the vowel begins suddenly with strong F i G. 3 5^0 1 o 1 1 i s vibrations ; it is ended by snapping during a breathy ,, jrlnttiq oVmt no-ain Fiffs 3fi .. MM LOLL1& OllvlL (tL-,.,1111. J. !;-,> *J\J The cords do and 37 iye recor d s of a normal not come together completely and English vowel and a vowel marked the tone sounds husky or breathy. o ff b y glottal catches \ they were 82 8T1 TTKKING AND USIMV; made by the apparatus shown in Fig. 7. Such a vowel begins like an initial vowel in German. It is usually not difficult to teach this to the patient. In a similar way the patient learns also t<> - Fia. 36. Vowel curve with normal beginning :mting, etc. These and gymna-t it- exercises (chest weights, running, and the like) aid METHODS OF TREATMENT 85 in giving command of the breathing organs and produce a feeling of confidence in them. The ab- normality in breathing usually disappears when the stutterer speaks with the octave twist (p. 78). Developing Slowness Almost without exception stutterers talk too rapidly. They do not realize this fact, and they often refuse to believe that they talk as fast as another person who imitates them. They have two different measures of rapidity, one for themselves, the other for other persons. The correction of the fault is most difficult ; it can be accomplished only by frequently repeated exercises and continual remind- ers. Many stutterers are cured in a relatively short time of everything but excessive rapidity ; owing to its persistence they repeatedly relapse. Others seem able to speak slowly only with the utmost difficulty ; in such cases a cure of the stuttering is often impossible as long as the excessive rapidity is not overcome. Exercises in slowness are given by having the patient read and repeat poems and sentences in time to a metronome beating 54 times a minute. Conversa- tion is carried on likewise. Later the conversation is carried on just as slowly, but without the metronome. S(, STUTTERING AND LISPING Speaking with the metronome usually makes the voice hard, unless special attention is given to soft- ness. Some kind of pendulum, such as a weight on a string, may be used instead of the metronome. Quite useful is persistent drill in speaking with lengthened vowels, for example, "The su-u-u-u-un is se-e-e-etting." The voice must be kept soft and melodious. , A stutterer often thinks he gains slowness by putting pauses between words, whereas each single word is spoken as quickly as before. This produces jerky speech. Training in Proper Thinking A common trouble is the inability to say a certain word that the patient wants to use. He may be unable to read the names of a list because he may stick at any one. Or he is constantly looking ahead in his conversation for words he may not be able to say, and he spends much of his mental energy in substituting other words for them. Exercises are instituted wherein the patient gives the names of objects pointed to. This he does first by singing them and then by speaking them melodiously. METHODS OF TREATMENT 87 The most common defect is the inability to go di- rectly to the point to be brought out in speech. A series of graded exercises is to be used. A word is called out, to which the person is to respond with the first thing he thinks of. For example, when the in- structor says "rose," he may answer " flower." This "simple association of ideas" is to be made as quickly as possible. Measuring the "association time" with a stop watch in fifths of a second is an effective stimulus. In a somewhat more difficult exercise the patient is required to make such associations in a series, starting from a given word and making as many as possible in ten seconds. For example, on hearing the word "shoe" the patient may associate ' ' lace-black-mourning-death-skeleton-medicine-doctor -cravat-etc." Somewhat greater difficulty is in- volved when all the associations must be connected with the given word. Considerable more difficulty is introduced by requiring each association to refer to the preceding one in the relation of (a) part to whole or (6) whole to part. For example, to "room" the association might be "floor" (6), "board" (6), "house" (a), "city" (a), "street" (6), "sidewalk" (6), "stones" (6), "hills" (a), etc. 88 STUTTERING AND IJSI'INC The indefinite or dazed condition of mind of the stutterer applies specially to his notions of words. It is frequently accompanied by inability to spell correctly ; in such a case exercises in spelling are to be used. Some stutterers develop the habit of frequently breaking off a sentence and repeating it with a changed construction. In such cases this may not be due to the desire to avoid certain words, but to a hesitating habit of mind. The patient should be required to stick to his original sentences. Exercises in conversation carried on entirely hi short declara- tive sentences can be readily devised. Correcting Enunciation The excessive muscular tension of the stutterer is to be combated by training him to keep his muscles relaxed. To correct individual sounds he repeats words with that sound, first with the sound omitted and then with the sound much weakened. If the stutterer is troubled by initial "b," he reads or re- peats words beginning with " b " but omitting that letter, for example, "-utter" instead of "butter"; then he pronounces the same word with a very faint METHODS OF TREATMENT 89 "b," thus, "butter." This can be done for all sounds with which he has trouble. Words may be found in a dictionary or in the lists in Part III. The stutterer often places his tongue or lips in- correctly while stuttering. He may learn the correct positions for any sounds that trouble him and may Fio. 38. Mouth record of the stutterer's correction of the inspiratory "p" in Fig. 10. A correct occlusion is followed by a fairly successful attempt at an explosion. try to get these positions. On the principle of a new method of speaking (p. 57) this is often effective. For many stutterers it is of great benefit to study the positions of the vocal organs for the vowel sounds, as shown in the Plates at the end of this volume. The stutterer's incorrect enunciation, however, usu- ally does not arise from the placing of the organs, but from abnormal use of them. The incorrectness in use can be accurately and strikingly shown by the graphic method. The record of a stutterer's inspiratory " p " is given in Fig. 10. After the nature of the defect had been explained to 90 STUTTERING AND LISPING him, he tried to correct his mistake ; with the eighth attempt he was able to change the inspiratory " p " into an explosive one, as shown in Fig. 38. The result was not a very good "p," but the essential fault had been overcome. Developing Confidence The most serious disturbance in the stutterer's emotional condition is lack of confidence in his ability to speak when he wants to. The following procedure is serviceable when confidence in the voice is utterly gone ; it can be abbreviated as may be necessary. A tone is produced on a piano, organ, or some other musical instrument. The instructor sings "ah" at the same time. The patient then sings it with the instructor while the piano sounds. This is repeated until the patient declares confidently that he is sure he can at any time sing a tone with the instructor and the piano. Then the patient is to sing the tone without the instructor. If he hesitates, the instructor sings also. This is repeated until he declares that he can at any time sing a tone with the piano. Thereafter two, three, and more tones are used in the same way ; a declaration of confidence METHODS OF TREATMENT 91 is made at each step. Often it is convenient to begin at once with the arpeggio c-e-g-c' instead of single tones. The preceding steps are generally unnecessary, as it is usually possible to begin at once either with singing or with repeating sentences. Children are usually ready to sing without hesita- tion or diffidence, and it is often best to begin the treatment with simple songs, because the child knows that it never stutters when it sings. If the child is at all diffident, the instructor sings a line of it first alone ; then the instructor and the patient sing it to- gether ; then, if necessary, both start together, but the instructor drops out while the patient keeps on ; finally the patient sings the line alone. In this way he learns to sing various songs with the fullest con- fidence. Other words are now substituted for those of the first line of the song. Sentences like "This is a very fine day," "My name is Jack Robinson," etc., are sung to the notes of the piano. Then the instructor sings a question and the patient sings the answer; for example, "What is your name?" "My name is Jack Robinson." The patient becomes fully convinced that he can sing anything he wants to say. 92 STUTTKRINd AM) LISPING Having gained so much confidence the patient is now to learn that he can always speak properly in a singsong tone. With most older patients the preceding practice in singing may be omitted and the singsong may be started at once. The best form of singsong is a frequently repeated "octave twist" (p. 57). The patient reads or repeats with the in- structor a sentence or a poem whereby the voice is made to go over the octave several times; for example, in the lines "A wee little boy has opened a store" the octave twist would be used in "wee," "boy," "o" of "opened," and "store." Then he repeats such material after the instructor, and finally says it alone. He practices till he is quite confident that he can do this perfectly. The instructor reads a series of sentences and questions (as in a traveler's manual) in a like way. Whenever a statement occurs, the patient repeats it. When a question occurs, he answers it spontaneously, striving to keep the flexible intonation. The nm-t careful watch is kept on the octave twist. Some patients persist in raising the voice only a fifth (c to g) instead of an octave (c to c') when repeating a sentence. In answering questions all patients at METHODS OF TREATMENT 93 once drop back to the stiff stutterer's tone, and fail at first to get the octave twist. The patient's answer should be used as a sentence for repetition whenever it does not have the proper intonation. By gradually developing the melodious speaking during answers to questions, the patient ultimately finds that he can always speak independently with the octave twist. It is pointed out to him that it is impossible to stutter and to use the octave twist at the same time ; the instructor tells him, and he will agree, that he need never stutter again if he can only remember to use the octave twist always. Of course, it is im- possible for any one to always think of this before he speaks; therefore this way of speaking must be persistently drilled till it becomes automatic. It is also true that, even though he forms the habit while at work in the office, he will at once drop it as soon as he becomes worried by the presence of another person ; further development is thus necessary, as follows : When the patient has gained confidence in this work with the instructor, another person is brought in to listen to him. This should be done in such a way as not to embarrass him. If the patient is a child, t>4 8TI TTKKING AND LISPING he should first be praised for his progress, and then asked if he would not like to let his mother or sister see how well he is doing ; the other person should be instructed beforehand to praise the patient's success. With older people it is well to begin with the presence of the doctor's assistant or with some one whom he feels not to be a critic. It may be necessary to go over the whole routine again in order to develop confidence before a third person. When this is accomplished, still more people are brought in. It is often very inspiring for the patient to go through these exercises in company with other stutterers. Strangers are gradually added to the group. If the patient stutters when reading, a similar method is pursued. He first reads in unison with the instructor. The latter stops for a few words at a time, leaving the patient to read independ- ently. Gradually the stops are longer, until the patient can read alone perfectly. He is to learn in a similar way in the presence of a third person, etc. Further steps in developing confidence in spon- taneous speech are taken by assigning topics con- cerning which the patient must say a few words. METHODS OP TREATMENT 95 For example, he is to make a few remarks about the furniture in the room, the weather this morning, the fine time he had last summer, the best way to reach his home, etc. For a somewhat more difficult exercise the instructor relates or reads an anecdote, a short story, a newspaper item, etc., and the patient is then required to give the gist in his own words. As a variation he may first read the material, and then tell about it. He may be required to give short accounts of what he has learned in school. Still further confidence is developed by requiring the patient to stand up and deliver speeches, either those that have been memorized, or spontaneous ones on topics that are suggested. This is best accomplished with a group of stutterers. The group is said to represent, for example, a dinner at which each guest has to respond to a toast. Again, the group is a party of tourists on an automobile; one of the patients is the chauffeur; they all make remarks on the events of the journey. Again, the group is in a restaurant; one of the patients is the waiter, the others are guests, etc. Entire scenes are acted out, whereby spontaneous speech is constantly required. The inspiration of such a class is a potent factor in developing confidence. ST1 TTKKIXC AND I.ISIMNC More difficult situations arc approached by imi- tating them first in the office. A table with objects represents a store. The patient buys and sells in the presence of people. When he can do this perfectly, the instructor goes with him to stores and helps in the buying. In like manner a ticket booth is ar- ranged. For classroom work a class is organized and lessons in arithmetic, geometry, Latin, etc., are assigned, as may be appropriate. The patients are called up to recite, to demonstrate at the board, etc. Later the class is transferred to an actual da mom ; still later outside instructors are brought in, older patients are appointed instructors, etc. The special difficulty hi telephoning is met by practicing at first on a private line between two rooms. The person at the other end represents " central" and the people called up. The stutterer should also practice the part of "central " in order that the real central may not appear so strange. When the patient no longer gets excited, the main line telephone is given to him, but the switch is held down so that there is no connection. Some one near by speaks as if he were "central." When the patient feels quite confident at such "dry telephoning," METHODS OF TREATMENT 97 the switch is released and an actual call is sent. The instructor keeps close to the transmitter, so that at the slightest hesitation he finishes what the pa- tient wants to say. The outside situations are in general to be met by an attempt to get the patient's mind directed to the interest of the thing and not the manner of presenting it. For school it is desirable to go over the exercises with him beforehand, explaining and illustrating them in such a way that he becomes fascinated with the subject. The appointment of stutterers as teachers of other stutterers in the office or in the clinic is very effica- sious in developing confidence. A very difficult abnormality of feeling that occurs in many stutterers is the mental cramp that occurs when they are suddenly called upon. The cramp of expectation in a mild degree is perfectly normal ; for example, while waiting for cards or for dice to be shown, a normal person usually feels a slight flurry and holds his breath for a moment. With the stutterer this goes so far that at a knock on the door he will be struck absolutely speechless and be unable to call out. To meet with such a condition 98 STITTKKINC AND LISPING games with dice, counters, etc., may be practiced ; thereafter exercises arc instituted in suddenly answer- ing knocks, and in other situations that the patient describes as troublesome. Confidence is also developed by increasing the loudness and carrying power of the patient's voice. He learns to speak in a full, resonant tone. Then he is removed to a distant room and forced to speak more loudly. The loud, resonant voice cannot be produced unless the speaker has a feeling of self- confidence; the cultivation of the voice thus de- velops the feeling directly. Moreover, a decisive, commanding voice causes those who hear it to attend in a more respectful way than they do to a hesitating, timid voice; this in turn produces more self-confi- dence in the speaker. Readjustment to Environment A. very obstinate abnormality of feeling is the stutterer's altered appreciation of the relation of himself to his environment. It arises not only be- cause he knows that he is abnormal in his speech, but also because the abnormality makes other people treat him differently. His feelings toward METHODS OF TREATMENT 99 other people are therefore very different from those of normal persons. This leads to an abnormal kind of life. With some patients this condition has to be attended to from the start, because they make no progress and cannnot be cured except as the abnor- mality is mitigated. My method is as follows : I first attempt to establish intimate personal rela- tions in the ordinary ways of acquaintanceship, so that the patient feels me to be his personal friend. As various incidents occur or as topics arise in conversa- tion, we discuss the rules of conduct of the average man, and we condemn extremes. For example, a patient fears to go to a post office window because he stuttered when he was there before and he feels that the clerk expects him to stutter and will be im- patient. It is pointed out that many hundreds of people have been to that window since he was last there, and that it is most improbable that the clerk would remember him. Again, the business of the clerk is to wait on all customers politely and pa- tiently; he is trained to allow for the peculiarities of customers, some of which are more trying than stuttering. Again, he is not allowed by his em- 100 STriTKRlNC AM) I.ISIMVJ plovers to show the slight ot impatience or discour- tesy. Again, the postal clerk is in the sen-ice of the government of which the stutterer is a member; he i- therefore the stutterer's employee. In this way the stutterer is brought to a correct understanding of the relations between himself and the clerk. The other situations in life are met similarly. Readjusting the Subconscious Recent psychological work has shown that the instincts and desires with which we are born are gradually modified and suppressed until they have become to a considerable extent unconscious. Moreover, our minds are trained to think along certain grooves and not to permit thoughts along other ones. Such a " censorship " makes it quite impossible, for example, fcr certain thoughts of love to arise in a European or an American girl that wculd be only the most natural thoughts for the negress in Africa. The person knows nothing about this " censorship " ; it has been drilled into the mind until it governs without being realized. The difference in censorship permits certain thought^ to be perfectly natural in the one case and keeps METHODS OF TREATMENT 101 them entirely absent in the other. Yet, although absent from consciousness, the original natural forces persist with undiminished energy. When properly directed they produce the normal successful indi- viduals; when improperly, they produce the group of diseases known as neurasthenia, psychasthenia, hysteria, some forms of insanity, etc. Our thoughts and emotions are controlled largely by the sup- pressed natural instincts. In a stutterer some of these instincts have gone wrong, and it is necessary to readjust them. A minute analysis of the patient's mind, including the subconscious, is often necessary to a cure. The methods of psychanalysis furnish an outline of the patient's subconscious life. These methods may be applied to the stutterer in somewhat the following way:- The patient is alone with the physician. The latter explains that the mind is an extremely complicated organ whose ways of action have to be learned by the most careful study. Since stuttering is ac- companied by a somewhat incorrect action of the mind, it is necessary for the stutterer to carefully analyze his mental condition. The physician will 102 STITTKKI\<; AND LISPING train him to do this. The training may take a long time. We judge other persons and interpret their actions on the basis of our own ideas ; our notions of other people are "egomorphic." The physician there- fore asks the patient to note down from time to time any thoughts or criticisms that may occur to him concerning the physician personally. The patient may reply, for example, that just a moment ago he had said to himself that in spite of his age and calm- ness he couldn't help thinking that the doctor was really shy and bashful. It is pointed out to him that, utterly regardless of whether his judgment was correct or not, such a thought would probably not have occurred to a man of fearless disposition ; the patient had sought out in the physician some signs of his own trouble. Of course this was not done consciously; the thought was merely the re- sult of many past experiences and habits which he had forgotten, but whose traces remained to make up his character. The patient is warned not to try to produce the thoughts concerning the physician, but to note only what comes unpremeditatedly. The next day perhaps he says, with many apologies, that METHODS OF TREATMENT 103 the thought had occurred to him that the doctor was not always perfectly frank and honest with him; the reply is, "It is you who are not perfectly open and honest in your dealings ; you have a tend- ency to get out of embarrassing situations even at the cost of some truth. Let your thoughts wander as they will, and see if you do not recollect a number of cases where you have acted in this way." These spontaneous revelations of traits of character strike the patient with great force and automatically start a readjustment. During the day the restraints of life do not let our personalities come freely into play ; we automati- cally suppress most of our thoughts and emotions and permit only a certain narrowly limited group to develop. Moreover, the " censorship " of the un- conscious does not permit the suppressed instincts and desires to become known to us. In sleep, how- ever, the censorship is somewhat relaxed, and our innermost ideas and feelings come forward in dreams. A study of the patient's dreams is, there- fore, a most important source of information. The patient receives instructions to have paper and pencil beside the bed and to wake up and write BT1 TTKIxIXC AND USIMNCJ down immediately one dream each ni^lit. The ac- count is read off by him to the physician. The interpretation of some parts is immediately clear. When more information on any point is desired, the patient allows his mind to wander through a series of associations starting from the part of the dream involved ; usually the explanation is forth- coming during such "running associations." The following analysis of a patient's dream will illustrate the method. The record of the dream was:- "I buy a ticket to some place, a single ticket because I am not coming back. At a certain sta- tion on the way I get off. I go to the manager's office, where I find two men at work over papers. I stand at attention, heels together in the German fashion. The man has an American military cap of dark blue. I say to myself, 'Shall I give a mili- tary salute or take off my hat ? ' When the manager turns around, I ask for the return of my money because I have found a patient on the train. The manager, who has now become a younger man, says 'Yes, but it will be dear; it will cost one fare plus a hemorrhage, plus an infarct.' I reply, METHODS OF TREATMENT 105 'Never mind, the expense is nothing to me.' The assistant reckons out what I am to get, and says it will be about fifty per cent." The patient had originally been in doubt whether he should stop for treatment in this town or go to a physician farther off. Stopping at the nearer place, he had a few days before seen the doctor and his assistant (manager and clerk) at a scientific meeting. The doctor had told him he could not be- gin treatment till next week (he stands at attention waiting). The patient holds the doctor in great re- spect (the. dream clothes him in a military costume, and makes him manager of the station). The doc- tor is, however, a personal friend ; the two feelings are present at the same time and the patient doesn't quite know how to act (shall I give a formal mili- tary salute or take off my hat in a friendly manner ?) . The patient naturally expects the doctor to do him enough good to compensate him for what he loses by not going to the other place (I ask for return of my money for the part of the journey not taken). It is characteristic of dreams that the personalities are often changed. The patient now represents himself as a doctor who has found a patient on the train. 106 STfTTKUIXG AND LISPINd Instead of remaining the inferior (the patient), he for a moment gratifies himself by feeling that he is the superior (the doctor), who is about to treat a patient. The dream now notes that the doctor is younger than the patient (manager is now younger). The patient had been somewhat worried over the probable expense, and feared what the dream de- clares (it will cost you dear). On the previous evening the patient had discussed the matter with a friend, and had remarked that the journey was not entirely for the sake of the treatment (one fare), but also to learn the method ; he had also complained that the treatment cost him part of the time he wished to give to some anatomical work (hemorrhage plus infarct). He had finally concluded that he was ready to pay any price if he could be cured (never mi ml. the expense is nothing to me). The fifty per cent seems to refer to the fact that the treatment was taking about half the time from some other work. The further interpretation was made in connec- tion with the rest of the treatment. A vitally important defect of the patient's character was an inability to properly and promptly understand his relations to other persons; the uncertainty as to METHODS OF TREATMENT 107 how he should approach another person expressed itself in the dream as the doubt concerning how he should greet the doctor. Another defect was a con- stant conflict between a naturally spendthrift nature and an acquired but annoying and ill-judged penuri- ousness ; the whole dream consisted of questions of expense. This dream, as well as many others, ex- pressed the patient's thoroughly egocentric view of the events of life. These defects of character were the sources of the patient's trouble, yet he had never suspected the existence of any one of them. As they were revealed by psychanalysis, a correc- tion took place automatically. The fundamental principles in interpreting dreams are (1) that the material of the dream is taken mainly from recent events, (2) that every dream expresses the fulfillment of a wish that has remained unful- filled, and (3) that the language of the dream in adults is usually symbolical and not direct. In children the language is not symbolical, and the dream shows itself at once as the expression of a wish . My niece, twelve years of age, had received some chickens which rather disappointed her on account of their smallness ; the next morning she related a IDS >TI TTKIM\(i AND l.lsl'l\(; dream of having a lot of fine, large Cochin-Chinas. Her dream had fulfilled her unsatisfied wish of the day before. In adults the language of the dream is sometimes also direct. It is not unusual for my patients to report that they dream of losing the paper given them to record dreams on, of seeing me tell them not to record dreams, etc. Upon being told that these are really wishes, they confess that the task of recording dreams is irksome to them. Nearly always, however, the language of the dream is symbolic, and the patient sees no meaning in it. Many of the dreams of stutterers, however, have a common type. One stutterer dreamed repeatedly that he was ft great social success at parties, that he was a friend of the King of England, etc. Another one thought that he and a friend, playing with great exhilaration, had won a football game against an entire college eleven, whereby he had made brilliant runs and kicks that had brought applause from the grand stand. In all such dreams the stutterer represents himself as pos- sessing an excess of coolness and self-confidence ; that is, he puts himself into possession of just the qualities he lacks. It is also typical of stutterers' METHODS OF TREATMKXT 1C9 dreams that they refer to their relations to other persons. The method of "running associations" referred to above is intended to give the subconscious an oppor- tunity to present its material. Why should my niece, in the dream related above, have thought of Cochin- Chinas ? She was induced to talk about chickens ; before long she came out with the memory of a former home where she had seen such chickens. The stutterer who won the football game was asked to let his thoughts wander freely. He gave the asso- ciations : " football game crowd class Medi- cal School -- professor Roosevelt campaign," all of which referred to incidents where he had had difficulty in speaking. The friend who played with him was indistinctly seen ; when asked what he thought of when the word "friend" was spoken, he replied, "doctor." The meaning of the dream was at once clear. With his friend the doctor to help his speech he was able to face a formidable crowd or a difficult situation and achieve success and applause. The wish that realized itself in the dream was that with the doctor's help he might get over his stuttering and be able to conduct himself 110 STUTTKKIM; AND LISIMV; in his speech so brilliantly that he could success- fully face his class and all other situations that might present themselves. As the peculiarities and deformities of character of the stutterer present themselves spontaneously in the dreams and in the discussions, he learns to see them himself and gradually to correct them. This is usually more efficacious than any attempt of the physician to directly point out the defects. The psychanalysis need not go so far as in the treat- ment of hysteria ; it has, moreover, the distinct ad- vantage that every such revelation of his own charac- ter to himself produces greater ease in the stutterer's speech. The results of the treatment show them- selves gradually and steadily. PART II LISPING CHAPTER I INTRODUCTION OWING to the fact that the symptoms are so often the same or similar, it is convenient to include under " lisping" several different speech disorders whose characteristics lie essentially in defects of enuncia- tion. We may distinguish four different lisping disorders ; namely, negligent lisping, organic lisp- ing, neurotic lisping, and cluttering. The use of the word "lisp" in this larger sense is in accord with the original Anglo-Saxon "wlisp" and with the use in literature. "To lisp in num- bers" (Pope) refers to baby talk, of which negligent lisping is the survival. In discussing individual sounds it is desirable to have an alphabet. The following list gives the chief sounds of English with a phonetic alphabet in paren- theses ( ) to indicate them, and with examples in ill 112 STITTKKIV; AND USIMN<; ordinary >prHing. In the -i 1 debt Z zone. t m^nts also differ for thr various vowels. Scripture, Researches in Kx|x'rimental Phonetics, 116, Carnegie Institution Publication No. 44. INTRODUCTION 117 The "occlusives " (p, b; t, d; k, g) are made by clos- ing the mouth passage at some place. The closure occurs at the lips for the " labial occlusives" (p, b). The closure at the front of the tongue for (t, d) and at the back of it for (k, g) causes them to be called " front" and "rear lingual occlusives," respectively. In English an occlusive usually ends with release of the contact before the breath ceases, producing a sharp puff of air. The English occlusives are there- fore termed "explosives." For the sounds (f, v; s, z; J, 3; 6, 5) a channel per- mits a current of air to issue with a rushing or hissing effect ; they are called ' ' fricatives." The sounds (f , v) are "labial fricatives"; (s, z; J, 3; 8, S) are "front lingual fricatives"; there are no rear lingual frica- tives in English. For (j) the tongue leaves a moderately large opening at the front ; for (1) the opening is at the sides ; for (w) the small opening is at the lips ; the opening is not so large as in the vowels and not so small as in the fricatives; no term for grouping these sounds has yet been introduced. For (h) there is a narrow opening at the glottis. For the sounds (5, j) there is occlusion by the front IIS STITTKKINC AND LISPING of tin 1 tongue during the lii>t portion and a rush of air through a narrow channel for the second portion. It has been proposed to consider them as double sounds (tj, d3), but experimental records show vital differences; the two elements of occlusion and fric- tion are so closely united in (c, j) as to make them single sounds. Moreover, the positions of the tongue, jaw, and lips are different from those of (t, d) and (I, 3), as may be seen in Plate I. During (m, n, q) the nasal passage is open, hence the term "nasal." During (p, f, t, k, s, J, 8) the larynx does not vi- brate; these consonants are called "surds." Dur- ing (b, v, d, g, z, 3, 5) the larynx vibrates ; they are called "sonants." The sounds (m, n, q, J, w) are nearly always sonants. The sound (h) is usually surd, but sometimes sonant. All whispered sounds are surd. The vertical diagrams and palatograms for the consonants are given in Plates I, II, and III at the end of this volume. The dotted line over the larynx indicates that it does not vibrate for the surds; the heavy line indicates that it does for the sonants. The breath indicator shown in Fig. 42 may be used INTRODUCTION 119 FIG. 42. Candle flame indicator used for the mouth. According as air issues or does not issue from the mouth, the candle flame bends or stands upright. to illustrate the properties of many sounds. The tube from the mouth is directed against a candle flame. When the vowels are spoken into the mouth- 120 BT1 TTBRING A\I> 1 ii. (.5. TumlMiur indicator us:-d for the nose. The indicator is made from a thistle funnel coven d with ruhlxT. A piece of card hangs in front of the rul>l>er ami is fastened t.i it l>y glue or wax. Air issuing from the nose moves the card flap. A mouthpiece may l>e used, its in Fig. 4_'. piece, the flame is deflected. The same is true of the fricatives. During the occlusives the flame is up- right, but it is sharply deflected by the explosions at the ends of the occlusions. INTRODUCTION 121 The breath indicator shown in Fig. 43 consists of a thistle funnel over the top of which thin rubber is stretched and tied. A strip of visiting card is cut across and joined with tissue paper to make a hinge. A piece of wax holds one piece of the card to the fun- nel, while the other one hangs in front of the rubber membrane. A drop of paste connects the hanging flap to the membrane. The funnel is connected by a rubber tube to a nasal tip. When any air issues from the nose, it goes into the funnel and moves the rubber membrane ; the movement is indicated by the flap. This indicator can be used with a mouth- piece like the one in Fig. 42. The examination cf a person with incorrect enun- ciation should cover the typical sounds. Each con- sonant may be spoken with the vowel " ah " after it or in some typical word; the list on p. 112 may be used. Although the patient may be able to speak the separate sounds correctly, he may mumble and con- fuse them in ordinary talking. CIIAITKR II NEGLIGENT LISPING IN order to produce speech sounds like those of other people an individual must hear correctly what other persons say; in . order to move his speech organs correctly he must feel their __ movements and hear the sounds he himself produce-. By long ex- perimentation the in- fant acquires the art of talking like other people. If, however, the child is careless or Fio. 44. Lip position for "f" and negligent in his obser- The lower lip is brought against the upper teeth. vation of the speech of other people or himself, he fails to produce the sounds properly and he does not even notice his errors. 122 NEGLIGENT LISPING 123 These are the characteristics of "negligent lisping," or "functional lisping." The essential pathological fact is mental carelessness. The cure consists in teaching the patient to carefully correct his faults. If the cure is neg- lected, some children may become nervous about their speech and turn into neurotic lisp- ers (see Chapter IV) ; as this trouble is a much more serious one, it is not safe to neglect negligent lisping. In other children the ridi- cule of their comrades , , . FIG. 45. Lip position for "w." and the reprOOI at The lips are projected slightly i i forward with a small opening. home may produce a true hysteria with symptoms of disturbance of mind (emotional complexes) and body (loss of pharyn- geal and corneal reflexes, etc.). Occasionally a defective speech organ produces a defective sound (organic lisping), which so confuses 121 STUTTERING AND USIMNC the child that all his sounds become incorrect (negli- gent lisping). Lip Defects Some persons use "v" for "w," as in "Samivel Veller" for "Samuel Weller." For "v" the lower lip should be against the upper teeth (Fig. 44) ; for "w" the two lips are brought near each other (Fig. 45). To correct the fault, the patient is told to say "well, word, wind," etc. Just as he starts to say "veil, vord, vind," etc., his lower lip is pressed down with a finger or a stick ; he is thus FIG. 46. Lip position for correcting "w" into "v." The lower lip is caught between the teeth when a "w" is to be forced to Say "w" in- spoken. stead of "v." The opposite defect may occur. The patient says werry" for "very," "wote" for "vote," etc. He NEGLIGENT LISPING 125 is told to bite his lower lip when trying to say words beginning with "v" (Fig. 46). The use of "p" for "f and "b" for "v" arises from pressing the lips too tightly together. A thick . 47. Palato- gram for for- ward "t" and "d." . 48. Palato- gram for back- ward "t" and "d." FIG. 49. Palato- gram for "k" and "g." stick or a finger is stuck between the lips so that they cannot close tightly. This produces the fricative FIG. 50. Mouth dia- gram for "t" and "d." The front of the tongue is raised against the hard palate just behind the teeth. FIG. 51. Mouth dia- gram for "k" and "g." The back of the tongue is raised against the velum at the rear of the hard palate. 126 STUTTERING AND LISPING sound. The differences are also learned by observa- tion of the instructor and looking at one's self in Fiu. 52. Mouth record of "water" spoken normally. The sudden and complete cutting off of the breath during the "t" and the strong explosion at its end arc evident. a mirror. The differences may be made apparent b / a breath indicator (p. 119). The substitution of "s" and^z" for "f" and "v" upon the likeness in the fricative sound. Atten Fiu. 63. Mouth record of "water" spoken by a lispcr. Iii-t-ad of the breath being cut off for the "t," there is only a faint diminution ; the sound is like " th " instead of " t." The laryngcal vibrations are continued from "a" without stopping through the "th" into the vowel "er." A correct "t" has no laryngeal vibra- tion is called to the fact that in words with "f" and "v" the lips are closed, while in the words with "s" and "z" they are open. NEGLIGENT LISPING 127 Defects o/'%" "d," "k," and "g" (t, d, k, g) For "t" and "d" the front of the tongue is raised against the palate just behind the teeth (Figs. 47, 48, 50); for "k" and "g" the rear part is raised (Figs. 49-51). For "t" and "d" it is usual to turn the tip of the tongue upward as in Fig 47. Many persons form the "t" and "d" by putting the tip farther back against the palate (Fig. 48). One defect in "t" and "d" is failure to completely close the air passage by the tongue. An additional defect for "t" is failure to stop the laryngeal vibra- tions when the sound occurs between vowels. The two defects are illustrated by graphic records taken with the mouth recorder (Fig. 7). A normal curve of "water" as recorded by the graphic method is given in Fig. 52. A slight rush of the breath is followed by a nearly straight line indi- cating the faint sound of "w." The mouth opens rather suddenly and the line rises as the vibrations of "a" rush out. The breath is cut off completely during the "t." As the tongue releases the "t," a strong puff of air occurs and the line goes sharply upward. The record ends with the final vowel. The record for a lisper is shown in Fig. 53. Where there 128 WTTTKKINC AND LISIMNC should Ix? a straight line with an explosion |Or the "t," there are strong vibrations with only a slight sinking of the line. This shows that the larynx did not stop during "t" and that the tongue did not close the air passage. The patient says "wather" (woSa) instead of "water" (wota). The chief fault b the failure to close the tongue tightly at the front. Ordinarily it is sufficient to explain to the patient that there are t\vo classes of sounds calle 1 "occlusivcs" and "fricatives." For the occlusives the current of air passing throuf h the mouth must be cut off at some point ; for the occlusives "t" and "d" the tip of the tongue must close firmly against the palate. When it does not do so, it produces the fricative sound " th." The other defect, namely, keeping the larynx vibrating, disappears when the "t" is carefully made. A frequent defect among children is the use of "t 1 ' for "k," as in "tandy" for "candy." Sometimes this substitution occurs regularly; usually it is only in some words. The patient who says "tandy" will usually say "car" correctly. That is, although he is able to make the sound of "k," he replaces it by "t" in some words through pure negligence. NEGLIGENT LISPING 129 Both "t" and "k" are occlusives, that is, the cur- rent of air is shut off entirely during the sound ; the patient does not take the trouble to distinguish be- tween them. A similar substitution is made of "d" for "g" (hard "g" as in "go"). The child says"Div me sum tandy." The cure ma} r begin by having him open his mouth wide and say "ca-ca-ca-candy." He looks into the mouth of the instructor and sees that the tongue rises in the back ; looking into a mirror, he learns how his own tongue is to move. It is sometimes useful to push the point of the tongue back and down by a stick (tongue depressor) when a word beginning with "k" or "g" is used. The child cannot say "t" or "d," and he is forced to raise the tongue at the back. Similar procedures are used if "k" and u g" are replaced by other sounds. Defects of "s" and "z" (s, z) To produce "s" or "z" the front of the tongue is raised against the hard palate behind the teeth, while a small channel is left in the middle so that a jet of air is blown through. A palatogram is shown in Fig. 54, a mouth diagram in Fig. 56. Every modi' 130 STI TTKKINO AND LISPING fication in the shape of this channel changes the character of the hissing sound. For "z" the vocal cords vibrate ; for "s" they do not. The hiss for the "s" is frequently too weak, the channel being too wide. The defect is corrected by using greater FIQ. 54. Paiato- pressure of the tongue. When the hiss gram for "9" and "." is too sharp, relaxation is taught. The most frequent defect is that whereby the patient says "toap," "toup," "tun," etc., for "soap," "soup," "sun," etc., or "dink" for "zinc." Instead of a rush of air dur- ing "s" there is complete stoppage; the "fricative" sound is turned into an "occluslve." Through negligence r FIG. 55. Palato- the person presses his tongue against gram for oc " eluded "" the palate a trifle too hard when and "" The tongue saying "s" or "z." This closes the touches the palate over a opening that is necessary for "s" larger area ,_,. N . than in Fig. (Figs. 54, 56), and makes an occlusive 54. Theeban- /T rr fr\ J.L j i-i A > nelifldoaedby (Figs. 55, 57) that sounds like "t. too much This may be shown by graphic records (p. 22) by means of the mouth recorder (Fig. 7). A normal record for "sun" is shown in Fig. 58; a NEGLIGENT LISPING 131 record with the occlusive instead of the "s" is given in Fig. 59. With a small rubber bulb placed bctv/cen the front of the tongue and the palate (Fie;. 5), and connected to a registering appa- ratus (Fig. 3), the force of the pressure of the tongue can be recorded. For an FIG. 57. Mouth FIG. 56. Mouth dia- gram for "s" and occ i u ded "s" it is "z." The front of the greater than for the tongue rises so as to form a narrow ordinary "s" or for channel at the front of the palate, "t" (Fig. 60). The occluded "s" is thus not the same as a "t"; it may be defined as an " s " made with excessive tongue pressure resulting in a sound like "t." Treatment by having the patient imitate the "s" of a normal person usually aggravates the defect; he is already making too much effort with his tongue, and the more he tries, the greater the effort he makes. Sometimes he can be taught directly to relax the tongue, but this rarely succeeds. diagram for oc- cluded "s'' and "z." The channel of Fig. 56 is closed by too much pressure. 132 STITTKRINT, AND LISPING Fio. 58. Mouth record of "sun" spoken normally. The record was made as shown in Fig. 7. The rising line register* the air issuing during "a"; this is followed by the vibrations for "u" and "11." Fio. 59. Mouth record of " sun" spoken by a lisper. The record was made as shown in Fig. 7. The straight portion of the line shows that no air issued during the attempt at "s." Fio. 60. Tongue record for occluded "s." A record by the method of Fig. 5 shows that the pressure of the front of the tongue against the palate is small for " s," larger for " t," and largest for occluded " s." One cure consists in inserting a probe, an appli- cator, a toothpick, or a pencil just over the middle of the tongue and pressing it down as the person NEGLIGENT LISPING 133 begins to speak a word beginning with "s" (Fig. 61). He cannot close the passage completely, and instead of saying "t" he is forced to say "'s." This catches his ear, and he notices the difference in sound. Constant repetition enables him to train his tongue in the new way. Another cure con- sists in practicing the patient in making a sound with a sharp hiss. For other cases a breath indicator (Figs. 42, 43) is ef- fective. Frequently the "s" and "z" are made with channels at the sides instead of the front. The hiss sounds like an "1" ; instead of "soap," "soup," the patient seems to say "sloap" and "sloup." The defect is corrected by teaching a correct "s," either by imitation of the sound as FIG. 61. Correcting occluded "s" and "z." The small stick over the front of the tongue produces the channel necessary for " s " and " z." 134 STUTTERING AND LISPING heard by the ear or by using a stick ovor thr middle of the tongue, as in the case of occlusive "s" and "z"; the patient will close up the side channel as soon as one is made in the middle. Sometimes the "s" and "z" are made in a way that produces sounds like "sh." For "sh" the channel in the middle of the tongue is seen to be broader and differ- ently formed when compared to that for "s." The cure is often brought about Fio. 62. -Making the interdental fricar by usmR a pro b e or tivr. The tongue is pushed out be- a 8 tj c k ag j n the pre- tween the teeth. The sound re- sembles that of "th." vious case ; the irrita- tion makes the patient narrow the channel. Some- times it is necessary to train the patient to use "t" instead of "s," and then to correct this fault as previously described. Sometimes a "th" sound is used for "s" and "z." NEGLIGENT LISPING 135 The patient who has this fault usually sticks his tongue between the teeth for "s" (Fig. 62), mak- ing an interdental fricative not used in English. Sometimes it is sufficient to show him that people do not stick their tongues out that way. He then watches his own tongue in a mirror. He also learns to make "s" with the teeth tightly closed. A small stick can also be used, as in "t" for "s." The patient who uses "f " for "s" is satisfied with the fact that he is producing a fricative sound; he notices no difference. He must be taught to dis- tinguish between the two kinds. He is to watch his lips in a mirror ; he sees that the lower lip does not close against the teeth for "s." His lips may be held open while he is obliged to say "s." A similar case is that where a guttural fricative (like the German "ch" in "ich") is used for "s." The formation of "s" is to be explained and taught. Occasionally an utterly different sound, such as "k," is used. If the correct "s" cannot be taught directly, the "t" is taught and then this corrected to "s" as described above. 136 STl TTKKIXr, AM) USIMXG Defects of "ch" and "j" (c,j) The sounds "ch" and "j," as in "church" and "judge," have been considered as consonantal diph- thongs, each made up of two sounds, "t" with "sh" !. Mouth record of the word " Mitchell.' The faint vibrations for "m" are followed by stronger ones for the vowel "i." The air current is cut off entirely for a abort time then- after; this is the occlusion for the sound "ch" ("tch"). Then-after the rather quick and strong rise of the line indicates an explosion of special form. The record ends with the vibrations for "e" and "11." and "d" with "sh." Graphic records of the sounds "ch" and "j" have proven that they are two indc- Fio. 64. Mouth record of the word "nutshell." The faint vibrations for "n" are followed by stronger ones for the vowel "u." The air current is cut off for "t," which has no explo- sion here. This is followed by gradual rise of the line for the- frica- tive sound "sh." The word ends with the vibrations for "e" and "11." pendent sounds. 1 A record of the word "Mitchell" (Fig. 63) shows the sound "ch" spelled "tch" here - to be an occlusion followed by an explosion of a 'Winifred Scripture, "The sounds of 'ch' and *j,'" Popular Science Monthly, October, 1911. NEGLIGENT LISPING 137 special form that is never seen in any other typical sound. A record of the word "nutshell" (Fig. 64) shows an occlusion for the "t" without any explo- sion, followed by a long rush of air for the "sh." The sound "ch" (6) is thus quite different from the combination of the sounds "tsh" (tj). The difference between the two sounds can be shown in another way. A palatogram for "ch" or "j" shows that the tongue touches the palate FlG - 65 - for "ch" farther back than for "t" or "d," and "j." The tongue and that it covers a bigger space touchesthe palate over a (Fig. 65). larger area than for "t" The mouth diagram is given in and "d." Fig. 66. The front of the tongue touches the palate rather far back ; the lips are somewhat pro- truded. The differences from "t," "d" are marked (Fig. 50). The establishment of the fact that "ch" and "j" are individual sounds is analogous to the proof fur- nished long ago that the two forms of "sh" (J, 3) are individual sounds, and not compounds of "s" and "h." The typical defects are of two kinds. In one the 138 STUTTKUIN'i AND LISPING tongue presses too tightly against the palate, in a way similar to that for an occluded " s " (p. 130). The sound is likea"t" for "ch"anda"d" for "j." In the other the tongue is not pressed tightly enough. This produces a sound resembling " sh." The treatment for the former is similar to that for the occluded "s" (p. 132), the purpose being to obtain relaxation of the tongue. For the latter the patient is told to press the tongue more strongly. W*> of "n " and "ng" (n, ) and "j." The tongue For "n" the tongue takes the touches the palate over a larger area same position as for "t" and "d" than for "t" and "d"; the lips arc (Fig. 50), but the velum is not projected forward, . and the teeth are raised (Fig. 67). For "ng," as in rather close. . . ,, , . . . ... sing, the tongue position is like that for "k" (Figs. 49, 51) with the velum not raised (Fig. 68). The use of "m" for "n" (the lip nasal for the front tongue nasal) is corrected by observation in a mirror, by making the patient open his lips while saying "n," etc. Tne use of "t" or "d" for "n" NEGLIGENT LISPING 139 is a velar defect; it is corrected by exercises in raising the velum as described under Velum Defects below. The sound "n," namely, the nasal with forward contact of the tongue, is sometimes used for "ng," the nasal with rear contact, as in "good FIG. 67. - Mouth dia- FlQ 6g _ Mouth di& . 8 r mfor n - gram for "ng." Thetongue , , ,, The velum is touches the palate . ,. lowered and the at the same place as for "t" and back of the tongue "d." The velum is raised slightly to . , meet it. is lowered. mornin" instead of "good morning." The confu- sion is aided by the lack of any English letter for the sound "ng." The correction is made by calling the patient's attention to the difference and by making him open his mouth widely while making the "ng" in such words as "sing," "ring," "bring," "calling," etc. The "ng" hi words like "finger" consists Ill) 8TUTTKKINC! AND L IS! 'INC of the two sounds "n" and "g" and not of the single sound "ng" (q). Defects of the Two Forms of "sh" (f, 3) The two sounds indicated by "sh" are made by raising the front of the tongue so as to cut off all breath except through a small channel (Figs. 69, 70). For (J) ("sh" FIG. 69.-Paiato- as in "azure") the gram for "sh." The tongue larynx vibrates ; for touches the pal- ate along the (3) ("sh" a s in idea and leaves . a.ar f eropening "show ) it in front than for .. 8 .. not. .. . ' 8h< The tongue is ****** t the palate over a broad area further back than for "s." The channel is longer. Sometimes the pressure of the tongue is too weak ; the channel is tOO large, and the "sh" SOUnds faint and hollow. The defect can be corrected by emphasizing the tongue pressure. Sometimes the contact is so weak and incorrect that the resulting sound is more like "th." The tongue is to be pressed with more force. When the sound "s" is made instead of "sh," it NEGLIGENT LISPING 141 indicates that the child does not properly distin- r^^i^i guish between them. ^f ^^L He is to be drilled in careful pronunci- ^p. ^^^ ation of words with FIG. 71. Palato- such SOUnds. gram for "th." The tongue It occasionally touches the palate in front happens that "f" is over a broad space so lightly USed f or " sh . " Just that air cs- capes. as with f for s (p. 135), he is taught to distinguish them, and his lips may be held apart. For the rare " t " f or " sh " a procedure like that of "t" for "s" may be tried. FIG. 72. Mouth dia- gram for "th." The front of the tongue is raised against the palate, but a very wide channel is left. Defects of the Two Forms of'tk" (6, S) In producing the two sounds indicated by "th" the front of the tongue is raised against the palate (Figs. 71, 72), the tip touching so lightly that the air escapes over it. For "th" as in "thin" the larynx is silent; for "th" as in "thine" it pro- duces a tone. It is very common for children to use "t" and "d" for "th"; thus, they say "tin," "tree," "tumb" STUTTERING AND LLSI'INC for "thin," "three," "thumb," and "dfc," "dough," "dee" for "this," "though," "the." It is like the language of the !<; i r or the tough: Ar<> you \vi /5, tne nrs the sharp upward movement evidently an occlusion i- lh " r,-,it f it. pioon. The small vibrations are from with an explosion similar th, vuw.iand-n." to the first sound in "tin" (Fig. 74). The cure consists in inserting a probe or a stick at NEGLIGENT LISPING FIG. 75. Mouth record of "thin" with occluded "th," by a lisper. The sudden depression of the line at the start indicates a strong jerk of the tongue whereby air is drawn in for an instant. The straight line indicates that the tongue is held tightly against the palate. The sudden upward jerk is the explosion of the occluded "th." The occluded "th" is longer than the normal "th" or "t"; this is a result of the excessive effort. Its explosion is stronger than that of "t." the side of the mouth above the tongue (Fig. 76) . When the patient tries to say "t," his tongue is pressed down across the tip and he is forced to say "th." It is also useful to teach the use of the interdental fricative (p. 134) as a substitute for the defective "th." FIG. 76. Correcting occluded "th." The breath indicator is A stick is held across the front of f fe /TT \ *^e t n 6u e ' 8 t na t it cannot be Ot ten effective (b Ig. 42) . presscd tightly against the palate. 144 STTTTKUINC AND LISPING Children often use "f" and "v" f.,r "th," sub- stituting one fricative for another. The defect is explained to the patient. He is to observe in a mirror that for words like "thin," "thimble," "this," "though," etc., the lips remain apart. If necessary, Fi 77. Mouth record of front rolled "r" by an American. 'I'd'- larger vibrations result from the flapping of the tip of the tongue ; the very fine vibrations are the record of the luryngcal vibrations, that is, of the tone of the voice. the lower lip may be held down by a stick or the finger. Defects of "r" and "I" (i, 1) The original sound from which English derives ttfl r," as in "run," was the rolled or trilled "r," which is indicated phonetically by (r). The rolled "r," which is no longer used in English, is the only one in German, French, Italian, and most other languages. To produce the rolled "r" with the point of the tongue, its front portion is pressed against the palate tightly except at the point. The pressure of NEGLIGENT LISPING 145 the breath causes the point to flap. A mouth record by the apparatus shown in Fig. 7 is given in Fig. 77. a In English "r" the tongue position is the same, but the point is held away FIG. 78. Palato- gram for Eng- from the palate front of the g fl ap pi n g or tongue are raised; the rolling. A HlOllth ric - 79. Mouth dia- channel in the gram for "r." middle is wider record of " SO1TOW " The front of the than for "sh," tongue is raised but not so wide (Fig. 80) shoWS Small against the palate, as for the DUt the tip does vowels. vibrations for the not quite touch it. r" like those of a vowel. The phonetic letter is (j). In large cities like Berlin and Paris, and regularly FIG. 80. Mouth record of English "r." The record is of the word "sorrow." The rising line at the start indicates the air issuing during the "s." The small vibrations are those of two vowels with "r" between them. The vibrations for "r" do not differ from those for the vowels except in minor details. in Yiddish, the rolled "r" is produced by forming a groove in the rear of the tongue in which the 1 If. STITTKUIM; AND USIMM; uvula is allowed to rest. The breath causes the uvula to vibrate. A mouth record is shown in Fig. 81. The phonetic letter is (R). Fio. 81. Mouth record of uvula "r" by a Parisian. The larger vibrations result from the flapping of the uvula ; the finer ones are the record of the laryngeal vibrations, that is, of the tone of the voice. For "1" the tongue is tight in front and open along the sides (Figs. 82, 83). The most com- mon defect in Eng- lish is the use of the easy sound "w" for FIO. 82. Paiato- the difficult sound gram for "1." The tongue touches the . , . ... palate at the S1S * S m getting the Fio. 83. Mouth dia- in the ri S ht The front'. .f th- tongue touches the palate. method is to teach the rolled "r" place for "u." One the rolling is to be done with the tip of the tongue. When the patient can talk with the rolled "r," he simply NEGLIGENT LISPING 147 drops the roll while using the same tongue position. When the person cannot get the tongue right for the rolled "r," it is useful to use an- other sound that requires the point FIG. 84. Rod fo* pushing the tongue. The rod is made of an aluminum applicator OI the tongue (twice the size of the figure). against the palate. For example, he is told to repeat . FIG. 85. Pushing the tongue into position for "r." The rod pushes the front of the tongue up and back. sun, run, sun, run, etc., or "tun, run, tun, run," etc. In more difficult cases the patient ob- serves the tongue of another person say- ing "r." He finds that it touches the teeth along the sides, but is free in front ; this is particularly clear when the "r" is rolled. With a mirror he tries to get the same position. The instrument shown in Fig. 84 is made by 148 STUTTKKIV; AM) LISI'INC bending a light wire (aluminum applicator). With it the front of the tongue can be pushed upward and backward into the position for "r" (Fig. 85). Sometimes "1" is used for "r." It is like the Mongolian lisp used by the Chinaman, who says "Melican man here light away." The patient is shown that for "1" the tongue is open along the sides while tight at the tip. The action is thus the reverse of that for "r." For the correction of this obstinate defect the tongue is drawn back into the mouth so that it cannot be released at the sides ; the point is turned up. A flat stick or a small rod (aluminum applicator) bent to the form shown in Fig. 84 may be put under the tongue to push it back and up. Children of foreign-born parents sometimes use the lingual or u\ ? ular rolled "r" instead of thesmooth English "r." Their peculiarity may be illustrated as follows: "Rrrobert makes a rrring arrround it" or "RRRobert makes a RRRing aRRRound it" instead of "Robert," etc. It is usually sufficient to teach the difference by ear between the English "r" and the rolled "r." For more difficult cases a breath recorder (Fig. 7) may be used ; the indicator makes NEGLIGENT LISPING 149 a steady movement for the English "r," while it vibrates heavily for the rolled "r." The "r" may be omitted or replaced by other sounds, as "n," "t," "w," etc. The use of "w" for 11 r" is very frequent; the child is sometimes en- couraged to say "vewy," "pwetty," etc., because it sounds "cute." Both tongue and lips take the posi- tions for "w" instead of those for "r" (Plate II). Even when the tongue is in the position proper for "r," the lips may have the position for "w." This makes a peculiar "r" with a " w " tinge. These defects are to be corrected by teaching the patient to make exaggerated or rolled "r"s. Words are recited with exaggerated "r"s, rolled and not rolled. The lower lip may be held down to hinder the "w" move- ment. The usual defect for "1" consists in the use of an "r" or in dropping the "1." In both cases the cure consists in imitation or in explanation with observa- tion of the tongue. In order to enforce the fact that the tongue must touch at the tip for "1," it is useful to draw the tongue back and then throw the tip sharply into place against the palate as an initial "1" is to be pronounced. 150 8Trm-:m\<; AND LISPING If a nasal xmud is used for " 1. " the correction is to be made by pinching the nose, by the n;t>al indicator, etc., as described under "Velum Defects." Velum Defects For all English sounds except the nasals "m, n, ng," the velum, or soft palate, must rise so as to close more or less completely the passage from throat to nose. When this is not done, the speech has a dull, nasal snorting character. The vowels may be tested by the following li-t : for "ah" (a), "ah, arm, art"; for (SB), "at, after, am"; for "aye" (e), "aid, ate, ale"; for "eh" (c), "ebb, effort, egg" ; for "ee" (i), "eel, eat, easy" ; for (i) "it, in, ill"; for "oh" (o), "old, owe, oak"; for "awe" (o), "awe, awful, ought"; for "oo" (u), "fool, boor, tool" ; for (u), "full, pull, bull." The occlusives may be tested by the words "ape, pa, upper ; able, bee, obey ; at, tar, utter ; add, do, odor ; oak, caw, ochre ; egg, go, ago." The fricatives may be tested by the words "eff, fare, offer; eave, veal, ever ; ess, see, essay ; ease, zee, easy; shoe, ash, usher; azure, pleasure; thin, oath, ether; though, bathe, either." NEGLIGENT LISPING 151 The sounds of "r" and "1" may be tested by the words "run, arrow, law, ell, fellow." If the velum does not rise during the vowels, they have a nasal character reminding one of the FIG. 86. Recording the nasal current and vibrations. A small glass tip is inserted into one of the nostrils. Currents of air and vibrations from the nose pass down the rubber tube to the small recording tambour, whose lever traces a line on the recording surface. French nasal vowels. If it does not rise during "s," that sound appears like a nasal snort. For the oc- clusives (p, b, t, d, k, g) the lips or the tongue close the air passage in front and the velum closes the nasal passage; the air, which accumulates under some 152 STITTKKINC AM) LISIMNC pressure, is released by the lips or the tongue; this causes a slight puff or explosion from the mouth. If the velum is dropped before the release, the explosion Fio. 87. Nasal record of "sun" gpokrn normally. occurs through the nose, producing peculiar snorting sounds for "p," "b," "t," "d," "k," and "g." Graphic records may be obtained by the arrange- ment shown in Fig. 86. For example, the nasal rec- I'nj. 88. Nasal record of "sun" with n-l:ix-J and half "k," NEGLIGENT LISPING 157 and he said "dogk." Mouth records of the three cases are given in Figs. 92, 93, 94. The trouble can usually be corrected by training the ear. General Indistinctness The negligence may go so far that the patient speaks in a generally slurred manner. Ordinarily FIG. 94. Mouth record of "dogk." There are faint vibrations after the vowel, showing that the sound began as "g" and not as "k" ; these die away and none are found at the time of the explosion, showing that the sound ended in "k." this is corrected by having him repeat sounds, words, and sentences after a careful speaker. The following points are to be especially noticed. The sounds "p, b, t, d, k, g" are produced with the lips or tongue stopping the air passage. When the stoppage is released, the air comes out with a slight puff or explosion. When the air pressure is allowed to fall before release of the lips or the tongue no explosion occurs. This is the normal pronunciation in French ; in English it indicates negligence. i:>X STUTTERING AND LlSlMNd A graphic record(Fig. 7)of the normal " p " (Fig. 95) shows the sharp explosion at the end of the occlusion. Fio. 95. Mouth record of "apa" with the explosion of "p" well marked. The record was taken with the apparatus shown in I in. 7. The waves at the beginning are those of the first vowel. Then follows the straight line for the occlusion of "p." The sharp upward move- ment of the line is the result of the explosion of "p." Thereafter follow the vowel waves. A record where the explosion is omitted is shown in Fig. 96. The cure consists in training the patient to ex- plode his "p"s, "t"s, etc., so that the explosion is Fio. 96. Mouth record of "apa" with no explosion of "p." The record is the same as in Fig. 95 without the sharp upward movement of the line. The "p" had no explosion. quite audible. The breath indicators shown in Figs. 42, 43 with a mouthpiece are most effective. The patient must learn to make all his occlusivcs with marked explosions. NEGLIGENT LISPING 159 The "s" and other sounds are often made too weakly. The patient must learn to hiss the "s" strongly and to make each sound with sufficient energy to cause it to be heard distinctly. Some- times the nasal sound "n" is systematically too weak. It is corrected by speaking and reading with prolonged "n"s. Vowels or consonants are often slurred over too briefly. The training consists in reading and speak- ing with the vowels exaggerated in length. For general indistinctness it is useful to speak and spell Words backward over a private telephone wire or to a person so far away that there is diffi- culty in understanding. The patient may prac- tice repeating words from a dictionary, making, for example, at one time all the "s"s prominent, at another all the "t"s, etc.; such combinations as "tw," "tr," "str," etc., require special attention. Such sentences as "Peter Piper picked a peck of pickled peppers," "Round the rough and rugged rock the ragged rascal ran," "Shall she sell sea shells by the seashore," "Tired Tommy tripped his toes," etc., are useful. The higher degrees of indistinctness found where 160 STfTTF.mNC AND LISP1NC the intellectual development begins to ho slightly de- fective are to bo treated 1>\ the following system: Tongue gymnastics are introduced. They include, (1) putting out and pulling in tongue ; (2) moving it from side to side ; (3) holding it out while 2, 3, etc., are counted ; (4) turning up the tip of the tongue to the palate (with fingers if necessary). Similar exercises are performed in advancing the lips, bit- ing them, pouting, grinning, and moving the lower jaw. Respiration exercises may include blowing up bags, blowing out candles, blowing bubbles, etc. The articulation exercises are to be based on the principle that the child is to see how the teacher makes each sound ; he hears the sound and is then to feel his own movements and see them in a mirror while he hears himself make the same sound. Thus, after seeing the action of the teacher's lips for "f" and "v" he watches his own lips in a mirror. To distinguish between "f" and "v" he puts his hand over the teacher's larynx and feels that the vibrations are lacking in "f" and present in "v"; then he feels his own larynx. The lip and tongue positions for the other consonants are taught similarly. The NEGLIGENT LISPING 161 emission of the breath during "h" and the fricatives may be felt by the hand held in front of the mouth. Careful drill in pronouncing words and sentences can be carried out in connection with reading exer- cises. The training of the intellect should be carried on at the same time. As speech is most closely con- nected with thinking, the most efficacious method is to make the speech training the center of the entire instruction. CHAPTER III ORGANIC LISPING ''ORGANIC lisping" is the term that may be ap- plied to such speech defects as arise from anatomi- cal defects of the vocal organs. The defective speech is usually a great drawback to the patient's career. It sometimes leads to fur- ther troubles. One boy whose enunciation of "s" and "z" was defective on account of overshot jaw had his ideas of speech so confused that he had failed to correct the infantile " t " for " k " (" tandy " for "candy"), although he could make such sounds perfectly. Moreover, the defect had caused him so much mental distress and strain that he enunciated his sounds with strongly contracted muscles, whereby they were indistinct. He thus had all three kinds of lisping : organic, negligent, and neu- rotic (Chapter IV). Lisping from Hare Lip or from Feeble Lips The former requires the surgeon. The latter may, in some cases, be aided by massage, electricity, and lip 162 ORGANIC LISPING 163 gymnastics. The lip gymnastics include specially pressing them tightly together, holding them tightly while the breath is pressed against them, pouting, puckering, etc. If the lips are weak on account of muscular dystrophy, all such treatment must be avoided. Lisping from Tongue Defects When the tongue is too thick, too small, too clumsy, or injured, the resulting inaccuracies may be mitigated by careful gymnastics (p. 160) and training by means of mir- ror, palatograms (p. 114), etc. FIG. 97. Hemiatrophy of the tongue. Degeneration of the nerve centers had caused one side of the tongue to become much smaller and weaker. This caused the patient to lisp. The lisping had produced such a condition of embar- rassment and fear that she was considered back- ward, although really per- fectly normal mentally. Hemiatrophy of the tongue (Fig. 97) shows itself in smallness of one side of the tongue, in grooves in the surface and in fibrillary twitchings. The speech is usually correct, but not always so. The speech of 164 STUTTKKINC AND Us|'|\r, one girl of fifteen was so indistinct that she could not get along in school and was considered mentally dull. The correction and scolding at school and by the mother had produced intense depression. The cause was a hitherto unobserved hemiatrophy of the tongue which made it difficult to use the tongue properly (organic lisping) ; this had so confused her that she made all sounds indistinctly (negligent lisping). A stuttering boy of eight years was found to have imperfect enunciation, due to confused habits of enunciation arising from weakness of one side of the tongue. The physical defect had thus produced organic lisping, which had in turn produced negli- gent lisping. The embarrassment and shame had produced not only severe stuttering, but also a serious deformity of character. Lisping from Tongue-Tie When the frenum of the tongue is too short, it prevents the tongue from rising sufficiently in front to cut off all the air except what passes through a small channel to make the "s" sound (Fig. 56). The sound actually produced is more like "th"; ORGANIC LISPING 165 e.g. "people thay I lithp, but I don't pertheive it." If the person can project the tip of the tongue beyond the teeth, the tongue is free enough for cor- rect speech. To cut the frenum the region is thoroughly co- cainized ; an incision is made with aseptic scis- sors ; the membranes are then torn slightly further by the fingers wrapped in gauze. A too deep in- cision risks cutting large blood vessels. In older people the lisp may still remain as a habit. It should then be treated as in the case of "t" for "a" (p. 130). There is an antiquated belief that tongue-tie causes stuttering. It cannot do so directly, but I have had cases where the lisping due to tongue-tie had made the person so nervous that he had become a stutterer (p. 43). Lisping from Jaw and Tooth Defects Overshot and undershot jaws are due mainly to irregular development of the teeth. The undershot jaw occurs also with the disease akromegaly. In ex- cessive cases of overshot or undershot jaw the pro- jection may be so great that the lips do not close 166 STUTTERING AND LISIMM! properly for "f," "v,""p," "b," "m," and several of the vowels. In these and similar cases it is frequently difficult to adjust the tongue quite correctly, especially for "s." With strongly undershot jaw the "s" sound may be produced as the tongue moves to its posi- tion to make a "t"; "tool" sounds like "stool." When the upper front teeth project much beyond the lower ones it is frequently difficult to adjust the tongue so that the jet of air strikes the lower teeth correctly for "s" (Fig. 56) ; the sound is rather like "sh." The procedure is like that for the similar cases in negligent speech. The gaps left by extracted teeth often affect the "s" in ways difficult to remedy except by insert- ing artificial teeth. Sometimes a canine tooth is bent inward in such a way as to hinder the tongue in making "t"; a slight "s" sound precedes the "t." For many jaw and tooth defects the most impor- tant therapeutic procedure is orthodontism. If the child is under sixteen years old, he should be put in the care of an orthodontist. Older cases are usually hopeless. ORGANIC LISPING 167 Lisping from High. Palatal Arch The defect mainly affects the "s" ; the person has difficulty in getting the tongue properly again t the palate to produce the small channel. Sometimes he lets the air escape at the sides. Sometimes the at- tempt to press the tongue up tightly leads to a strong spasmodic pressure at every "s." One such pa- tient with the "s" spasm was often supposed to be a person who stuttered only on "s." In one case the patient, eleven years old, had given up all effort at us- ing the tongue for "s," replacing it by a pause filled by a cramp in the larynx. He pronounced "sink" apparently like "ink" ; in reality the pronunciation was ('ink), where (') indicates the glottal catch. The distortion of speech caused by the omission of the "s" had produced so much trouble that the boy had acquired the strained, hoarse voice and the sad face of a stutterer. The defect can be cured or alleviated by careful attempts to get the proper position. The spasmodic cases are helped by train- ing in soft and relaxed speaking. With the patient just mentioned who always omitted the "s," the cure consisted in teaching him to use "ts" for "s," His STUTTERING AND l.lsi'INC whereby he would say "tsoup" for"up." As soon as the habit was formed, he dropped the "t" and retained the "s." Lisping from Cleft Palate When the velum cannot close the rear passage through the nose, all the sounds except nasals are modified. All the explosives become nasal sounds, thus "p" and "b" become "m," "d" becomes "n," "g" becomes "ng," "t" and "k" become surd "n" and "ng," "s" becomes a snort, etc. The vowels are all nasal. After the velum has been closed by operation, there may be little or no ability to raise it into place across the pharynx. Its muscles can be strengthened by the velar hook (p. 154). Exercises can be devised for teaching the use of the velum, such as blowing out a candle, playing a mouth harmonica, etc. The pa- tient does them at first while holding his nose closed with his fingers ; he gradually lessens the finger pres- sure and tries to substitute velar action. With a light illuminating the interior of the mouth, the patient observes his velum in a mirror as he sings "ah" on a low note and then on a high note. The ORGANIC LISPING 169 velum should rise for both notes, more for the higher ones. Exercises with a nasal indicator, tissue paper flag, etc., as described for negligent speech (p. 153), aid in giving the proper control. Electrical stimula- tion (p. 154) is often very effective. To make the velum rise during the occlusives "p, b, t, d, k, g" they are pronounced singly and in words with much prolonged occlusions and sharp explosions at the end. This cannot be done unless the velum is properly raised. Occasionally some of the velar associations are very firmly fixed ; special devices must be tried to break them up. Thus, if the velum persists in remaining down for "s," rods of various sizes may be placed over the tongue (p. 143, Fig. 76). The loss of air during speech with a cleft palate naturally leads the patient to take breath repeatedly within a sentence. The habit may persist after the operation ; in such a case systematic breath exer- cises are to be performed. The great effort involved in speaking with a cleft palate may lead the patient to overexertion of all his speech muscles; this produces a grimacing speech; that is, the muscles of the face overact. This is 170 STUTTKHINC. AND LISIMNC liable to persist after operation. Relaxation is taught by speaking with no lip motion (as in ven- triloquism), by singing, by exercises in melodious speech (p. 74), etc. The nervous rapidity of speech requires exercise in slowness (p. 85). Lisping from Relaxed Palate after Adenoids When a person has large bunches of adenoids, the closure of the velum is made against them. After they have been removed, the velum sometimes makes the same amount of movement as before. This leaves a gap between it and the rear wall of the pharynx whereby all sounds become nasal. The treatment is the same as for negligent lisping (p. 150). Lisping from Obstructed Nasal Passages The obstruction deprives the nasal sounds more or less of their peculiar ring. Thus "m" sounds like "b,""n" like "d," etc. This condition is found temporarily in severe colds ; the turbinates in the nostrils become swollen and the nasal cavities are more or less closed. Per- manently enlarged turbinates or a deflected septum may cause a similar result. With large adenoids tin- ORGANIC LISPING 171 passage through the upper pharynx is also more or less obstructed. In regard to speech this condition is the opposite of that with cleft palate. The nasalization from cleft palate, etc., consists in adding nasal tones to sounds where they do not belong. The denasaliza- tion from obstruction consists in eliminating nasal tones when they should be present. No special voice treatment can improve this condi- tion. For colds the treatment comprises a laxative (Seidlitz powder, citrate of magnesia), cleansing with antiseptic sprays, menthol, coryza wool, etc. Tur- binates, adenoids, and tonsils are referred to special- ists. Lisping from Defective Hearing When the hearing is diminished, the child may fail to grasp the finer essentials of the sounds. In mild cases the words may be spoken loudly into his ear. Each incorrect sound may also be treated separately as described in the chapter on Negligent Lisping. Hearing tubes are often useful. In more severe cases lip reading should be taught in a way somewhat similar to that for deaf children. By feeling the teacher's larynx and his own larynx 172 STUTTERING AND LIsiMMJ and by listening to loud tones from a musical in- strument the child gets a definite idea of pitch and of the adjustment he must make in his larynx in order to produce musical sounds. Then by watch- ing the instructor's face and by looking in the mirror he learns the positions of the lips for the individual sounds. In a similar way he learns the positions of the tongue for "t," "d," "k," "g," etc. The positions are explained by the diagrams in the plates at the end of this book. The tongue posi- tions for the vowels and consonants can be taught in this way. To show the various amounts of breath that issue during the vowels, during "h," during the frica- tives, and for the explosions in the occlusives, the patient's hand is put before the instructor's mouth and then before his own. A slate, a cold piece of metal, or the breath indicators described on pages 119-121 can be used for the same purpose. The presence or the absence of nasality can be shown in a simlar way. As much as possible the child should be made to hear all the sounds. When such children are spoken to, they should be able to see the face of the instructor. CHAPTER IV NEUROTIC LISPING PATIENTS with this trouble often enunciate sounds in ways that resemble negligent speech. The failure of the methods of treatment for negligent speech first made it clear to me that this disorder was of an entirely different nature. One patient used "t" for "s," "d" for "z," and "t" and "d" for the two forms of "th," the tongue action being the same as that described on pp. 130, 141. The patient also said "tsoe" instead of "shoe." The occlusives (t, d, k, g) were used correctly, but they had no explosions (p. 157). This was quite in contrast to the false occlusives "t" and "d" used for "s," "z," "th," as these had strong explosions. The patient had learned to talk clearly, but at four years of age she fell, striking her head ; she remained unconscious for several hours. A few days afterwards she had convulsions ; they were frequently repeated till the age of six. The 173 174 >'i i TTEBINQ AND USIMM; defect in speech appeared shortly after the fall. She now has a tremor of the entire body when she attempts to speak. There is also a tremor of the lips during "p" and "b" and a tremor of the laryn- geal tone when a vowel is sung. It is hard to get her to produce any loud or long sound ; every sound, even a simple hiss, is produced in a manner indica- tive of excessive timidity and almost of fright. These conditions never occur in cases of negligent lisping; the patients are always perfectly cool and deliberate ; they are sluggish and phlegmatic instead of nervous. The similarity of her mental condition to that of the stutterer is evident. Graphic records were made of the air current for the mouth while she pronounced some sounds. The arrangement was that shown in Fig. 7. When a current of air issues from the mouth, the recording lever rises and the white line bends upward. A de- scent of the line indicates that the air current is diminished or cut off. The decrease of the air current may be due to some adjustment of the tongue or lips or to a cessation of the pressure from the chest. The record for "so" in Fig. 98, spoken by a normal person, shows that the air current steadily NEUROTIC LISPING 175 increased during the first part of the "s" and then fell somewhat. The small waves in the record are due to the laryngeal vibrations; in "so" they indi- FIG. 98. Mouth record of "so" spoken normally. The first part of the line registers the emission of the air during the "s" ; it rises and falls smoothly. The small vibrations indicate the waves of the vowel. cate the vowel. A record of "so" spoken by the patient is given in Fig. 99. Instead of the gradually increasing and diminishing air current for "s," the FIG. 99. Mouth record of "so" in neurotic lisping. There is very little emission of the air for the "s" ; it is suddenly cut short by complete stoppage. The sudden descent of the line at the beginning indicates that the tongue was drawn sharply back. The larger waves after the step show the explosion as the "t"-like sound is completed by the release of the tongue. The small vibra- tions are those of the vowel. patient merely starts the current, and then not only cuts it off, but actually causes the line to fall below zero. For the normal "s" the tongue is placed against the roof of the mouth in such a way as to leave a 176 STI TTKUI.M; AND USI-INC small channel in the middle, through which a jet of air is directed against the lower teeth. A palato- gram for normal "s" is shown in Fig. 54 ; a mouth diagram of the position of the tongue is shown in Fig. 56. During the normal "s" a current of air passes to the recording apparatus and causes tho line to rise steadily. The record in Fig. 99 indicates that the patient pressed the tongue so hard against the top of the mouth that she closed up the small channel ; more- over, in doing this she made such a forcible move- ment of the tongue that air was actually drawn into the mouth for an instant. The sudden rise of the line indicates that, as the tongue was released from its place, the air burst from behind it in the form of a sharp puff, or explosion, that acted like a blow on the recording membrane. The sound produced by such action is like that of "t." Apparently the patient substituted "t" for "s." In like manner for "z" she used a sound like "d." The mechanism for the defective "s" is like that for occluded "s" (p. 130), as indicated by the palato- gram in Fig. 55 and the mouth diagram in Fig. 57. The tongue is pressed against the palate harder NEUROTIC LISPING 177 than it should be ; the small channel is thereby closed. The graphic record of "silk" (Fig. 100) in normal speech shows a rather long emission of air for "s," FIG. 100. Mouth record of "silk" spoken normally. The "s" and the vowel are indicated as in Fig. 98. The "1" is represented by some small vibrations at the end of the vowel. The "k" begins as a fall in the line due to cutting off the breath by the tongue ; it ends in a strong upward movement due to the ex- plosion as the tongue is released. ' followed by waves for the vowel and "1." The "k" begins as the vowel waves cease ; the line falls be- FIG. 101. Mouth record of "silk" in neurotic lisping. There is first a brief intake of breath, then an emission of breath corresponding to a normal "s." This is followed by an occlusion with an explosion. The sound is thus partly a normal "s," as in Fig. 98, but mainly an occlusion with an irregular explosion. The following fine vibrations belong to the vowel and "1." The "k" is represented by a straight line due to the stoppage of the breath by the tongue ; the abnorm ality is shown by the lack of an explosion wave for the "k," the breath being stopped before the tongue is released. cause the current of air is cut off by the tongue ; the explosion of the "k" is marked by the sudden rise of the line at the close. 17S STlTTKRINd AND LISPIV; The record of "silk" (Fig. 101) by the patient shows a sharp inrush of air followed by a sudden rise of the line with some emission of air thereafter. The inrush of air indicates presumably an extremely brief gasp as she starts the tongue movement. The sudden rise shows that the sound "s" is begun. This sound is at first a true though faint "s," some air being emitted. There follows, however, a sudden FIG. 102. Mouth record of "shoe" in normal speech. The emission of air during the "sh" is similar to that of "s" in Fig. 98. The record ends with the vowel vibrations. drop of the line ; this shows that the breath has been stopped and that the sound has become an occlusive. The sudden rise of the line thereafter shows that this sound, like most occlusives in English, ended with an explosion. The first part of the sound was thus a true "s," while the second was an occlusive "s" with an explosion. The remainder of the record shows the waves for the vowel and "I" followed by a straight line for the occlusive "k." The "k" is abnormal, having no explosion. The record of "shoe" in Fig. 102 is that for normal NEUROTIC LISPING 179 speech. It shows an emission of breath during u sh" similar to that for "s" in Fig. 98. The action of the tongue for u sh" is like that for "s" in forming a channel through which the air is directed. A palatogram for normal "sh" is given in Fig. 69; a mouth diagram in Fig. 70. A record of neurotically lisped "shoe" is given FIG. 103. Mouth record of "shoe" in neurotic lisping. The straight line, the sudden fall, and the strong waves show that the tongue closed the mouth, was sharply drawn back, and was then released with a strong explosion. Then followed a faint breathy sound like a weak "s." The record ends with the vowel vibrations. To the ear the word sounded somewhat like "tsoe." in Fig. 103. There is a sudden intake of breath ; this is abruptly released. This indicates that at the start the tongue was placed tightly against the palate. As it was released to form u sh," it permitted a slight puff of air to pass. This would produce a short "t." The "t" was followed by a rather faint emis- sion throughout the "sh." There was no occlusion during or after the emission ; otherwise the line would have descended at some point as in the "s" of Fig. 99. That the passage was not wide open, however, is ISO STITTKK1N<; AND USl'INC shown by the slight elevation of the HIM- during the emission of the breath and by the sudden rise (slight explosion) in the line at the end of the "sh" just before the vowel begins. The sound is not so open as in the normal "sh." The impression on the ear was that of "tsoe" rather than "shoe." For the two forms of "th" as in "thick" and "this," she used sounds resembling "t" and "d." For "th" the tongue is pressed against the palate at the sides, but the contact in front is so light that the air escapes (Fig. 71). The patient pressed the tongue too tightly and cut off the air entirely. The condition for "k" noted in Fig. 101 is typical for all her occlusives, i.e. sounds involving a complete closure of the mouth passage; namely, "p," "b," "t," "d," "k," hard "g." In these she regularly weakens the breath pressure before they end, so that they have no explosions when the tongue or the lips release the tension. This is quite in contrast to the incorrect occlusives that she makes out of the frica- tives "s" and "sh," etc., to which she gives strong explosions. The case seems at the first view to be one of what has been termed "negligent lisping" (p. 122) . Children NEUROTIC LISPING 181 with this trouble regularly substitute "t" for "s," "d" for "z," and "t" and "d" for the two forms of "th," just as this person does. The defect arises from the same cause, namely, pressing the tongue too tightly against the palate. The excessive tongue action in negligent lispers arises from negligent observation and careless action. The children with negligent speech are usually those that have grown up in surroundings unfavorable to careful enunciation, as among the poorer classes or where baby talk has been encouraged. This patient, however, had learned to talk clearly. Moreover, she is not careless about her speech, but overanxious. Her tongue touches her palate not simply because she is too negligent to take the pains to leave a small open- ing, but because it is seized by an uncontrollable spasm. It is evident that we have here a form of speech characterized by quick nervous muscular action in- stead of the deliberate smooth action required for nor- mal sounds. In trying to make the "s," for example, the patient is too nervous to carry out the fine adjustment requisite; she presses the tongue too tightly and thus makes a "t." The result for the 182 STl TTKKINC AND hearer is the same as in negligent li-pinp;. but the nervous processes in the two diseases are quite dif- ferent. Can this be a form of stuttering where the exces- sive contractions are quite limited ? A never-failing symptom in stuttering is the excessive contraction of the laryngeal muscles whereby the laryngeal tone becomes hard and monotonous; here the laryngeal tone is rather soft and timid. Moreover, the stut- tering cramps are never confined exclusively and constantly to just a few sounds. They frequently vary from time to time, the trouble being on "p," for example, during one month and on "s" during another month. Again, the stutterer will have trouble not on a single consonant wherever it occurs, but on consonants in a certain position, generally initial ones. Facial and bodily contortions often oc- cur with stuttering, but I have never found tremor present. We must conclude, I think, that this is not a case in any way resembling stuttering, although the cause may be the same. Another case was that of a girl of thirteen who lisped over all the consonants. Her speech was at times almost unintelligible. Treatment along the lines NEUROTIC LISPING 183 of muscular and mental education indicated for negligent lisping produced no result. She was an excessively nervous child, and she spoke with in- credible rapidity. As she was gradually quieted down, the lisping decreased. It became evident that the excessive nervous tension, combined with self-con- sciousness, produced a tense condition of the vocal organs allied to that of stuttering. She could not produce the smooth and delicately adjusted move- ments of normal speech because her muscles were overtense. Another case of nervous lisping was that of a girl of twelve whose speech was mumbled. Her mother thought her tongue was too long; her father thought there was something the matter with her intelligence. The methods for curing negligent lisping were fruitless. It became evident that partial deafness had made it ; hard for her to learn to speak. Being a sensitive child, the con- stant correction by the parents and the embarrass- ment and fear before them had produced a condition of nervousness much as in the previous case. She spoke improperly because she overinnervated the speech muscles. She began to improve under 1X1 STUTTERING AND LISIMNC quieting treatment. Unfortunately the parents did not trust the diagnosis, and preferred to regard the defect as one of intellect. Neurotic lisping is rather frequently found combined with stuttering. A patient twenty-eight years old was a typical stutterer. At the same time his speech was, aside from his stuttering, so indistinct that he was frequently asked to repeat a word. For example, he would say that he had been to Hartford in such a way as to leave it in doubt if he had said " Harwood," "Harvard," " Havre," or something similar. The "s"s and "n"s were weak and often inaudible. The explosions of the occlusives "p," "b," ' V " <> <> <> D. Sing "ma" upward and downward on the notes c, e, g, c r . SET III FLEXIBILITY (p. 74) 12. Singing A. Sing the vowel "ah, ' .hrough the notes of the octave. B. Strike the lowest note of the octave, then the highest; sing the vowel "ah," half on the lowest note, half on the highest. C. Sing the vowel continuously (portamento) over the octave (octave twist). I'.IS STCTTKKINC AND LIM'INC D. Practice singing the different vowels over the octave in this way. E. Sing a series of one-syllable words with long vowels, running the vowels up in the same way. 13. Speaking A. The instructor speaks a word with the octave twist. The pupil repeats it. B. Same with sentences, putting the octave twist on the first important vowel (the first important vowel is not necessarily the first vowel). C. Same with poems, putting the octave twist on the first important vowel in each line. D. Same with prose, putting the octave twist on the first important vowel in each phrase. E. Statement and question exercise (see note to Exercise 6) with the octave twist. SET IV SLOWNESS (p. 85) (It is advisable to give the "octave twist" to the first important vowel in each sentence, as under Flexibility, Exercise 13, B.) EXERCISES 199 14. Speaking wiih Lengthened Vowels A. Repeat, after the instructor, single monosyl- lables, making the vowel three times as long as nor- mally. B. Repeat words of more than one syllable, lengthening the chief vowel likewise. C. Repeat short sentences likewise. D. Read words from a book likewise. E. Read poems likewise. F. Read prose likewise. G. Answer questions likewise. H. Tell a short story likewise. 15. Speaking Together (pp. 62, 94) A. Repeat or read a poem in unison with another person speaking slowly. B. Repeat or read it alone slowly. C. Repeat or read a prose piece with another person slowly. D. Repeat or read it alone slowly. E. Alternate C and D, a few sentences of each. F. Read conversation (dramas, traveler's manual, etc.) slowly with another person. G. Free conversation, question and answer. 200 STITTKKING AND I.lsl'INC 16. Metronome Exercise (p. 85) A. Speak sentences to a metronome beating 54 to a minute, with one syllable to each beat. B. Statement and question exercise likewise (see note to Exercise 6). C. Tell a connected story likewise, such as what you had for breakfast, how you spent last summer, etc. D. Repeat A, B, C while some one holds the finger on the metronome ready to act whenever you speak too fast. E. Repeat A, B, C, D without the metronome. F. Repeat A, B, C, D without the metronome, taking care to eliminate all jerkiness of speech. 17. Speaking with, Sticks A. Repeat sentences, striking the stick to each em- phatic vowel and keeping time with the metronome at 54 a minute. B. Same without the metronome. C. Question and answer likewise (see note to Exercise 6). D. Same without the metronome. E. Tell a story about breakfast, etc., keeping time to the metronome. EXERCISES 201 SET V SMOOTHNESS 18. Linking A. Repeat and read sentences, linking all the words together, that is, making no pause or interruption between the different words. The whole sentence should be spoken as if it were one word, or just as in French. "Thecoverofthebookisred." "Thecarpet- onthefloorisgreen." " Theelectriclightisveryconven- ient." " TheturkeycomesonThanksgivingDay." B. Repeat and read short stories likewise. C. Repeat sentences and answer questions likewise. 19. Vowel Start A. Read sentences, making the first important vowel in each sentence at least three times as long as usual. Speak it with the octave twist. Speak the rest of the sentence as described in the exercise on "Linking." B. Read likewise. C. Repeat sentences and answer questions like- wise. D. Conversation likewise. 202 >T UTTERING AND LISPING SET VI VOICE QUALITY (p. 81) 20. Tone Placing by Chanting A. Chant one line of a poem or a prose statement on one note. B. Repeat this on other notes. C. Same, dropping to a lower note on the last word. D. Same, short story. E. Same, statements, question and answer. 21. Tone Placing vnth "Bee-bee-bee" A. Strike middle c and sing "bee-bee-bee," mak- ing the vowel sharp as in the French word "pique" ; this is far more sharp than the English word "peek." Go up the scale for an octave in the same way. B. Same with "bee-ah." C. Same with "bee-ay." D. Same with "bee-oh." E. Same with "bee-you." F. Same with "bah." G. Same with "bay." H. Same with "boh." 7. Same with "bou." EXERCISES 203 All these vowels should, be sung in a ringing, very slightly nasal tone, that is, in what is termed a " for- ward tone." 22. Tone Placing with "Ma" A . Strike middle c and sing ' ' mmmmmmaaaaaah . ' ' Hold "m" until the vibrations are felt strongly on the lips; then simply open the mouth to let the "ah" out, being careful to keep the same quality of tone as in "m." For a high voice begin above middle c. B. Repeat up the scale for an octave. C. Same with "mee" ; same with "moh" ; same with "moo." D. Repeat on arpeggios of three and four notes. Ma ma ma ma ma Ca * -V- -M J J m 3= F=^=H Ma ma ma ma ma ma ma 204 STl TTI.KIMJ AND 23. Husky Tone A. Strike middle c and sing "ah," beginning and ending it with the glottal catch (p. 81). Continue up the scale. B. Sing arpeggios likewise. C. Sing "ah" to the notes of a song likewise. D. Sing a song, cutting all the words sharply apart. 24. Trumpet and Megaphone A. Hold a small trumpet to your lips. Shout through it the phrase "Pie-apples, ten cents a water pail," using the sharp tones that would be used by a peddler calling out on the street. Use other phrases in the same way, for example, "Nice fresh straw- berries." B. Call out railway stations in a similar way. C. Same with a small megaphone. Note that you have to make somewhat more of an effort to get the sharpness with the megaphone. D. Repeat all the preceding without anything before the mouth. Make a special effort to get the sharp ringing tone. EXERCISES 205 SET VII STARTING AND ENDING SENTENCES 25. Strengthening the First Word A. Sing short sentences, striking a note on the piano as you sing the first syllable. Instead of using the piano you may strike a bell or a table or you may hit your knee or make a gesture as in beat- ing time. B. Repeat the same sentences, with the same accompaniment in the same way, but singing only the first word. C. Speak them with the same accompaniment on the first syllable. D. Question and answer are sung with the ac- companiment on the first syllable. E. As before, but only the first syllable sung, the rest being spoken. F. As before, but all spoken. G. Tell a story, singing the first word of each sentence with the accompaniment. H. Tell a story without singing, but accompany- ing each first syllable. JIM, STTTTKKIMi AND LIS1MNC 26. Emphasizing Periods A. Read short sentence-, striking :i hell or a piano note at the period. B. Read a story likewise. C. Question and answer likewise. D. Tell a story likewise. E. Raise a heavy weight in the hand and hold it till a period is reached. Read and speak sentences, stories, etc. 27. Lowering Tones at the End A. Chant sentences on one note, but drop by a fifth sol to do on the last syllable. Use the piano at first, but gradually omit it. B. Speak sentences on a rather high tone, and drop on the last word. 28. Clear Endings A. Sing sentences, cutting the last word short with the glottal catch. B. Speak sentences, singing the last word sharply. C. Speak sentences, making sure that the last syllable is sharp. EXERCISES 207 SET VIII ENUNCIATION AND SPELLING (p. 88) 29. Typical Sounds (p. 117) A. Indicate by printed or written letters on paper, blackboard, or chart the typical explosives "p, b, d, t, k, g"; show their explosions by paper flags or the breath indicator (pp. 153, 119). B. Indicate the typical fricatives " f, v, s, z, sh, fch." C. Indicate the occlusive-fricatives "ch and j." D. Indicate the nasals "m, n, ng, " showing that air issues through the nose. E. Indicate the liquids "1, r." F. Indicate the semi- vowels "w, y. " 30. Combination of Sounds into Syllables A. Combine each of the explosives "p, b, t, d, k, g" with various vowels; indicate the result on paper, blackboard, or chart and speak it at the same time ; thus, "pa, pay, pee, po, pu, ba, bay, bee, bo, boo," etc. B. Same with fricatives and the other sounds of the previous exercise; thus "fa, fay, fee, fo, foo, va, vay, vee, vo, voo," etc. 208 STUTTERIXO AND LISPIXO C. Form syllables with explosives followed by "r" and the vowels: thus, "pray, pree, pro, proo, bray, bree, bro, broo," etc. D. Same with "1" instead of "r"; thus, "play, plee, plo, ploo, blay, blee, bio, bloo," etc. 31. Division of Words into Syllables (p. 88) A. Learn to spell words, dividing them into syl- lables according to the dictionary. Pronounce each syllable separately, for example, "a-c, ac, c-e-1, eel, e-r, er, a-t-e, ate, accelerate." SET IX EXPRESSION 32. Giving the Idea of Emphasis A. Sing "ah" with notes on the piano as indicated. B This gives an idea of emphasis by change in pitch. B. Sing "ah" on one note but with different lengths as indicated. Q * EXERCISES 209 This gives the idea of emphasis by change of length. C. Sing a ah" on the same note and with the same length, making the first one of each group of three louder than the others. This gives the idea of emphasis by change in loud- ness. 33. Developing Expression In each of the following exercises the instructor first shows the pupil just what he is to do. He criticizes the pupil's deficiency, and imitates him where he fails to get the proper expression. A. Repeat a poem with expression. B. State a certain fact in a very melodious and expressive way. C. When the instructor gives a question in a very melodious and expressive voice, answer it by taking a few words from the question. D. As before, but answer freely with the same melody and expression as in the question. E. Recite poems and prose pieces with proper expression. p 210 MTTTKKING AND LISIMNC F. Read dialogues with the proper change of ex- pression for each character. G. Read and speak jokes with an effort to give the most effective expression. SET X CONFIDENCE (p. 90) 34. Reading Together (pp. 62, 94) A. Read a poem together with the instructor. Read alternate lines together and alone. B. Same with sentences. C. Read a prose speech together; the instructor is to remain silent occasionally. D. Read a prose piece; the instructor is to join in at the first intimation of difficulty. E. Read statements and questions sometimes to- gether, sometimes alone (see note to Exercise 6). F. Read parts in a drama; the instructor joins in whenever the pupil has difficulty. G. Read a paragraph, and then tell its contents in your own language ; the instructor joins in wherever there is any difficulty. EXERCISES 211 35. Speaking Together (p. 62) A. Repeat a poem in unison with another person, speaking slowly. B. Repeat it alone slowly. C. Repeat a prose piece with another person slowly. D. Repeat it alone slowly. 36. Reading with Decided Voice (p. 98) A. Call off the railroad stations from a time-table through the megaphone. The voice must ring out clearly and decidedly. B. Same without the megaphone. C. Read headlines from a newspaper in a similar way. D. Read short sentences likewise. E. Read short poems likewise. F. Read short prose pieces likewise. G. Read jokes likewise. Speaking with Confidence (pp. 94, 95) A. Call out railroad stations with the megaphone ; the voice must be clear and decided. B. Same without the megaphone. C. Make geographical statements with and without 212 STUTTERING AND LISPINC the megaphone; for example, "The Atlantic Ocean is east of the United States." D. Make historical statements likewise (that is, with and without the megaphone) ; for example, "George Washington was the first president of the United States." E. Question and answer likewise. F. Relate a story of an incident likewise. G. Make a speech likewise. H. Take part in a debate likewise. /. Take part in a continuous story which is ar- ranged as follows : One person tells a story which he makes up as he goes along; he suddenly stops, and the next person is immediately to continue the story according to his own ideas ; he, in turn, sud- denly stops and the following person continues. This is kept up until the story reaches the first person. 38. Buying (p. 96) A. You are supposed to be a storekeeper with a number of objects before you ; other people go to the store, inquire about articles, discuss the prices and buy. This must all be done with proper attention to slowness and melody of speech. EXERCISES 213 B. Take the part of the buyer. C. The store is turned into a railroad ticket office with yourself alternately as ticket agent and as trav- eler. Various questions concerning trains, accommo- dations, etc., are to be asked. D. The ticket office becomes the box office at the theater ; the questions are to include location and seats, exchange of tickets, etc. 39. Introducing (p. 63) A . The instructor introduces himself to you ; you reply, "I am glad to meet you." B. Introduce yourself to the instructor. C. The instructor introduces some other person to you, you reply "I am glad to meet you" or "How do you do?" D. The instructor introduces you to another per- son ; you say "How do you do ? " E. Introduce yourself to another person. F. Introduce the instructor to different persons. G. Introduce different persons to the instructor. H. Introduce two familiar persons to each other. 7. Introduce strangers to each other. As much as possible the stutterer should feel that 214 STUTTERING AND LISPING the instructor is at hand to speak for him in case of any difficulty. 40. Public Speaking (p. 95) A . Prepare a short speech to make on an assigned topic, and deliver it in the presence of the instructor. B. Same in the presence of several people. C. Make an impromptu speech on a given topic in the presence of the instructor. D. Same in the presence of other people. The number of the people is to be gradually in- creased until the stutterer feels ready to get up at any moment and make a short speech on any topic. 41. Scenes from Life (p. 95) A. A group of people is supposed to be in some familiar situation ; for example, eating at a restau- rant, riding in an automobile, forming a box party at the theater, etc. The instructor works out the situa- tion by description, while the persons, including the pupil, make the appropriate remarks. For example, if the scene is at the restaurant, the instructor takes the part of the waiter, while the other persons order what they wish to eat, discuss the bill of fare, etc. If the scene is at the theater, the instructor tells a EXERCISES 215 story of the play while the persons discuss the inci- dent, the house, their neighbors etc. In the auto- mobile party, the instructor takes the part of the chauffeur while the party travels to various places and discusses what he has seen. B. Similar scenes are worked out, the patient tak- ing the leading part. C. The group of persons is supposed to represent a club, the instructor occupying the chair. Various members are to make motions and discuss them, officers are to be elected, etc. D. The stutterer is made chairman of the club. 42. School Work (p. 96) A. The stutterer is to prepare and recite to the instructor some of his school exercises. B. He is to do the same before several people. (7. The group is to be gradually increased till it forms quite a class. The instructor is to be the teacher and is to call on the patient or patients to recite. D. The exercise is transferred to a schoolroom. E. Outside teachers are called in to conduct the class. 216 STl TTKKING AND LISPING SET XI SPONTANEOUS SPEECH 43. Collection of Ideas (pp. 14, 19, 62) A. Say some word referring to an object placed before you or pointed out ; the word must have some application to or connection with the object. You may say "large" referring to its size, or "black" referring to its color, or "read" referring to its use, or "table" referring to its position, or "yesterday" referring to something it reminded you of, etc. B. Make a statement slowly and melodiously con- cerning some object placed before you or pointed out to you. C. Name the objects you see on one side of the room, proceeding systematically from left to right and speaking slowly and melodiously. D. Describe an object placed in front of you, us- ing single words and proceeding systematically ; for example, if a telephone is placed before you, you will first use words referring to its appearance, then to its use, then to its faults, then to its history, etc. Always adopt some such system in selecting words. EXERCISES 217 E. Same as D, but complete sentences are to be used instead of single words. F. Short sentences are to be spoken concerning objects not seen but more or less familiar; for example, breakfast, a distant city, George Washing- ton, Atlantic Ocean, etc. G. A more extended account is required concerning similar objects, as in F< 44. Increasing the Embarrassment (p. 62) A. Part or all of the preceding exercise is to be carried out in the presence of additional people. B. When this can be done perfectly, you are to be called on to make short speeches on topics that have been given you before. C. You are to make speeches on topics of your own choosing. SET XII THINKING (p. 86) 45. Single Associations of Ideas A. The name of an object is called out. You call out the name of some other object that suggests itself to your mind. If you are in doubt what to say, 218 STUTTERING AND I.ISPINC choose some object that is often seen together with the one mentioned. For example, on hearing the word " horse" you reply "cart." This process is called "association of ideas." For the present you are to associate slowly, taking as much time as you wish. Practice for several times with the following list of words ; then add other words. hand shoe coat tooth boat sail rope pump lamp theater piano street school foot glove sock nose canoe pin seat lake bell hotel gun head collar hair eye motor water whip wheel road ticket dance ring bell muscle pencil B. Upon hearing each of the words just used, make a sentence about it. It does not matter what the sentence states. EXERCISES 219 C. Upon hearing each of the words make a sen- tence defining it. D. Upon hearing each of the words state some fact about the object implying something in regard to its location or its use, or something that preceded it, or caused it, or followed it, or resulted from it, or had some relation to it. 46. Running Associations Starting with any given word, let the mind bring up a long series of thoughts. These thoughts should not revolve around the original word, but should pass away into other subjects. If necessary, the rule may be adopted of obliging the mind to leave the original word within three associations. SET XIII DESCRIPTION AND RELATION 47. Description (p. 19) A. Describe an object placed before you; if you have any difficulty, you are to adopt some system, such as proceeding from top to bottom or according to cause and effect, etc. B. Same with simple pictures. 220 STUTTERIXC AXD LISPINd C. Same with complicated pictures. D. Same with what you see in the room or out of the window. E. Same with a simple topic from memory, such as breakfast this morning, house where you live, school, well-known buildings, etc. F. Same with a longer experience, such as a journey, a visit to a theater, the plot of a story, etc. G. All the preceding exercises are to be performed in the presence of one other person, then two, and so on. 48. Relation A. Read aloud a short story, for example, one of jEsop's fables ; then with the book open before you relate the contents of the story. B. Same with the book closed. C. Relate some story that you have previously read, for example, Robinson Crusoe, Cinderella, etc. D. Same with some previous experiences, such as last summer, last Christmas, etc. E. Read a joke and then tell it. F. Tell some funny story that you read some time ago. EXERCISES 221 G. Tell what you would like to do next summer, next Christmas, etc. H. All these exercises are to be done in the presence of one additional person, then two persons, etc. /. Pretend that you are conducting a scene in vaudeville. SET XIV TELEPHONING (p. 96) 49. Private Line A. Call up some one on the private telephone, using the system of your town as nearly as possible. First call " central," and then speak with the person desired. You are to speak slowly and melodiously. B. Take the part of "central" and then of the person called up. C. Repeat A and B in the presence of other people. D. Do some of the most difficult exercises over the telephone with the instructor or some other person at the other end. 50. Main Line A. Put your finger on the telephone switch so that when you take the receiver off the hook, the ._>_>_> STUTTERING AND LISIMNC telephone is not connected with " central." Some one sit t ing beside you takes the part of " central " and the person to whom you wish to speak. Carry out exer- cises as on the private line. B. With the instructor close beside you, call up "central" and then some friends; if you have the slightest hesitation, the instructor will speak for you. C. When you succeed perfectly as in B, try the telephone independently. The instructor is to criti- cize your success. SET XV TALKING WITH PEOPLE (p. 90) 51. General Conversation A. In a group of two people, talk on assigned topics of conversation, with material prepared be- forehand. B. Then with three people, and so on, gradually increasing the number in the group. C. Gradually bring in strangers. D. Same as A, with topics not prepared beforehand (impromptu conversation). EXERCISES 223 E. Same with three or more people. F. Same with strangers. 52. Coolness in Argument A. Argue a question with the instructor. B. Argue a question with somebody else. C. Argue a question in a group of three. D. Debate a topic with some person before a small group. E. Debate a political question with interruptions from the audience. 53. Transacting Business A. Sitting at a desk, you ring a bell as a signal for a person to enter. As he approaches your desk, you greet him and ask him what he wants. If he is applying for a position, inquire into his qualifications and then dismiss him ; if he wants to buy or sell or transact some other business, you are to promptly settle the matter, speaking very slowly and melodi- ously. A series of persons is interviewed in like manner. B. You are to take the part of the person entering the office for business. 224 STUTTERING AND LISPING SET XVI RELAXATION (p. 61) 54. General Relaxation A. Lie on a couch, close your eyes, and purposely try to relax every limb. B. Some one passes his hands over the various limbs, feeling that the muscles are all relaxed. This is repeated four or five times at intervals of about fifteen minutes. C. Get your mind fixed on the thought of relaxa- tion and quietness. Lie perfectly quiet in this way for five minutes on the first occasion, for ten minutes on the next, and so on for an increasing length of time up to a half hour. 55. Speaking A. You are to lie on a couch in a relaxed condition. Some one speaks a sentence to you very slowly and melodiously ; you are to repeat it likewise. B. Repeat sentences and reply to questions in the usual way (p. 92). C. Exercises in description and relation (p. 219) are carried out in this relaxed condition. EXERCISES 225 SET XVII MUSCULAR CONTROL 56. Tongue Gymnastics (p. 160) A. Thrust the tongue out and draw it back quickly ; do the same slowly. B. Move the tongue from side to side outside of the mouth, first slowly, then quickly. C. Same inside of the mouth. D. Touch the point of the tongue to the upper lip. E. Touch the point of the tongue to the roof of mouth, keeping the mouth open; same with the mouth shut. F. Touch the point of the tongue to the upper front teeth. G. Place the thumb and finger on each side of the tongue ; broaden and narrow the tongue by use of the muscles within the tongue ; this is felt by the fingers. H. Place the thumb and finger below and above the tongue; repeatedly thicken the tongue; this is felt by the fingers. 226 STUTTERING AND Llsi'INC 57. Lip Gymnastics A. Without projecting the lips, alternately con- tract them to a round circle while saying "oh," and draw the corners back while saying "eh." B. Same, on different tones. C. Same, speaking sentences. 58. Relaxing the Jaw (p. 83) A. Place the hands at the back of the cheeks; notice the swelling of the masseter muscles during speech ; relax them by dropping the jaw. B. Speak the vowels, dropping the jaw at the same time. C. Speak sentences, dropping the jaw as much as possible. D. Leave the mouth open for long periods of time. 59. Fixation of the Larynx (p. 83) A. With the fingers, press backward and down- ward on the hyoid bone ; resist its rising while you pretend to swallow. B. Sing "ah," pressing the hyoid bone backward ; alternate in singing "ah" with and without pressing. EXERCISES 227 Try to make the " ah " without pressing sound like the " ah " with pressing. C. Speak vowels, words, and phrases as in B. 60. Jaw Position A. Insert two fingers vertically between the teeth ; speak the vowels in this position; speak sentences also. B. While looking in a mirror, speak all the vowels, keeping the mouth as widely open as before, or nearly so. C. With the mirror, speak sentences, opening the mouth as widely as before on the broad vowels, such as "ah" and "oh." 61. Rear Palatal Arch (p. 84) A. Look in the mirror; observe the rear palatal arch; whisper "ah" softly and loudly alternately; observe that the arch is narrow for the loud whisper. B. Try to narrow the arch by a voluntary effort without whispering. C. When the ability to narrow the arch is obtained, sing out a loud "ah" at the moment of narrowing. D. Same with other vowels. E. Same, speaking the vowels. J'JS STUTTERING AM) SET XVIII WORD LISTS 62. Words beginning with "p" pack pay .pie play post pad peel piece plum pound paint pear pink point pour pair pen plain pole preach 63. Words ending with "p" ape deep help loop rope cape drape keep map stop cap grape lap mop tape cheap hope leap nape top 64. Words with "p" in the middle appeal approach dipper lisping reply appear apron dripping repeat report apple chapel happen repel reproach appoint clapper helping repent ripple 65. Words beginning with "6" bad band bead bend bite bag bank bear bet black bake bark bed bill blank ball bat bee bind bloom EXERCISES 229 66. Words ending with "b" Arab crab drab sob tub babe crib garb stab tube bribe cube grab stub verb cab daub probe tab web 67. Words with "b" in the middle cable lobster obey obtain rubber dribble marble object rabbit stumble fable medal obscure ribbon tumble labor nibble observe robbin warble 68. Words beginning with "t" table tame tell town trust tack tape test trade tune take taste toe train twist talk tea top trunk twine 69. Words ending with "t" at boat fat not rate ate cat fit nut rust bat coat get ought what bit eat hit put wet 230 STUTTERING AND LISPING 70. Words with "t" in the middle attach attire fatal mutter tattle attack battle fitting outer utter attain bitter letter patter vital attend butter matter rattle water 71. Words beginning with "d" dance date debt desk dive dare day deep dew dog dark dead dell dim doll dash deaf depth dine draft 72. Words ending with "d" add fed lid mud road bad glad load odd rude bed had mad pad sad bid lead made raid sled 73. Words with "d" in the middle address bondage childish endless fiddle adept boulder conduct fading gladden binding cadet cradle federal harden bundle cedar edition feeding widen EXERCISES 231 74. Words beginning with "k" cab crop cuff keep kind catch cross cup key king care cry cure kick kiss creep cube cut kill kite 75. Words ending with "k" ache bleak flake neck pick bake cake kick oak pluck beak duck like pack risk beck drake make peck stick 76. Words with "k" in the middle aching flicker looking occur raking baker knuckle market package scrape barking leaking masker picture scream drinking locket milky picnic screw 77. Words beginning with "g" gain gay girl glance globe game get give glare glow gas gift glad glass go gate gild glade gleam gold STl TTKRING AND LISI'IXC beg big bug 78. Words ending with "g" clog egg pig tag dig fog rag tongue dog frog rug tug drag mug sting wig 79. Words with "g" in the middle again agony aggrieve agree aghast anger aglow angle argue bungle longer baggage digging organ braggart dragging program bugle laggard rugged 80. Words beginning with "ch" chain chap cheer chill chisel chair cheap chicken chimney chocolate chalk cheat chief chin choke change check child chip chop 81. Words ending with "ch" batch crutch much pitch Scotch beach grouch notch pouch screech botch latch peach preach smirch church lurch perch reach such EXERCISES 233 82. Words with "ch " in the middle bleaching hitching perching Scotchman twitching butcher itching pitcher screeching urchin etcher latching preacher searching watcher fetching lurching scorching teacher witching 83. Words beginning with "j" Jack jaw jig joint jug jail jerk job joke jump jam jet jockey jury joy jar jewel John judge justice 84. Words ending with " j " age dodge bridge dredge budge edge courage fringe hedge judge lodge marriage porridge purge rage sage sledge smudge stage urge 85. Words with " j" in the middle adjoin engaging language regent Roger arranging enjoy luggage reject stranger baggage ginger manger rejoice tinged conjurer injury prodigious religious unjust STUTTERING AND LISPING 86. Wards beginning with-"/" face fair fame fast fight fact faith fan fault fine fail fall fare feel fire faint false farm fell fish 87. Wards ending with "f" bluff elf hoof life rough chafe grief if muff safe cliff gruff laugh off snuff cuff half leaf puff stuff 88. Wards with "/" in the middle affair buffet effect lofty puffy affect coffee effort offer roughen afford differ laughter office stuffy afraid efface lifting often toughen 89. Words beginning with "v" vague van vain voice value vain vast verb void vapor vale vault vest vote very valve veil vine valley vigor EXERCISES 90. Words ending with "v" above dive glove live save brave drive groove move valve cave five grove pave wave crave give have rave weave 91. Words with "v" in the middle braver event evince having never diving ever favor level over evade every fever lever river even evil flavor movement silver 92. Words beginning with " s " sack same seed sin slate sad school sell since slave safe scrub set sit sleep sail sea silk skate slice 93. Words ending with "s" base dress kiss loose race brass face lace miss rice case grease lease moss slice crease hiss loss place us 235 236 STUTTERING AND LISI'IM; 94. Wards with "s" in the middle ascent assign astray dresser listen aside assist basket essay loosen asleep assure biscuit essence master assay astir casket fasten tasty 95. Words beginning with "z" zeal zone zenith zither zoology zest zoo zero Zion Zeus zinc zebra zigzag zouave Zulu zodiac zephyr zounds 96. Words ending with"z" bees daze his maze seize breeze freeze has nose size cries graze haze praise tease craze hers lose rise trees 97. Words with "z" in the middle busy dizzy grisly losing result breezy dozen hazy nasal resume bruising fuzzy lazy prison scissors cozy freezing lizard prize weasel EXERCISES 237 98. Words beginning with "sh" (surd) shade shame shed ship shore shaft shape sheet shock short shake share shelf shoot show shall sharp shell shop shut 99. Words ending with "sh" (surd) ash dish lash rash trash bush fish mash sash thrush cash flash push slash wash dash fresh plush smash wish 100. Words with "sh" (surd) in the middle ashes bushel crashing flashing rashly bashful bushy crushing flushing rushing blushing cashier dashing hushing washing brushes clinching fishy freshness pushing 101. Words with "sh" (sonant) adhesion delusion evasion Parisian seizure azure derision invasion pervasion treasure cohesion division leisure pleasure vision decision elision measure precision visual STUTTERING AND LISPING 102. Wards beginning with "th" (surd) thank thin thirst three throb thaw thing thorn thrift throw thick think thought thrill thrust thief third thread throat thud 103. Wards ending with "th" (surd) bath broth faith month tooth blithe death fourth moth width both depth fifth mouth wrath breath earth lithe path wroth 104. Wards with "th" (surd) in the middle athirst bathos ethereal monthly southerly athlete earthly . lengthen pathway strengthen athwart Ethel Matthew pathetic youth author ether method pathos zither 105. Words beginning with "th" (sonant) than them they this thus that then these thou they the there thine though therefore EXERCISES 239 106. Words ending with "th" (sonant) bathe clothe lathe soothe breathe swathe smooth loathe 107. Words with "th" (sonant} in the middle another brother further lather panther bathing either gather leather rather bother father heather neither together breathing feather mother other weather 108. Words beginning with " w " wad weak wish willow wafer wag wealth wit wily wager waif wear wolf wince wagon wail wax worn wife waffle 109. Words with "w" in the middle awake bower jewel rower towel aware cower lower sewer tower bewail dowry mowing slower trowel bewitch fewer power sowing vowel 240 STUTTERING AND LISPING 110. Words beginning with "y" yacht yawn yeast yes yoke yard ye yell yesterday you yarn year yellow yet young yawl yearn yelp yield youth 111. Words beginning with " r" race rasp rid rob rule rack rat ride robe run raft rate ridge rock rung rag rave rig rod rush 112. Words with "r" between vowels arrow errand marry narrow terrace berry ferry merry parrot terror current garret mirror pirate turret direct hurry moral sorry worry 113. Words with "r " after a consonant braid bread drive dry fruit branch break droop fraud fry brass crab drop free grape brave drip drum frost grease EXERCISES 241 a 7 >> 114. Words beginning with " I lad leaf let lion long lake leak lick lip loose lame lean lie live lot lamp left limp loaf low 115. Words ending with " I " animal avail bell call deal annual owl bewail camel dial appal bail bill cereal eel appeal bawl boil chill fool 116. Words with "I" between vowels alarm along elegant eleven illegal alert aloud element elope illumine allow alum elephant eloquent illusion alley elect elevate island olive 117. Words beginning with "m" machine magnet major man milk mad maiden maker measure monkey made mail malice meat move magic mane mama meal must STUTTERING AM) Lisi'ixr, 118. Words ending with " m " aim gleam beam gloom comb gum come home jam ream some lamb rim swim limb room thumb ram seam Tom 119. Words with "m" in the middle amaze company limit amount dreamer mama bemoan former mimic murmur summer plumber summit roomy swimmer comma hammer moment steamer trimming 120. Words beginning with "n" name niece no north nudge neck niche nod not number nest night noon note nurse nice nine noose now nutshell 121. Words ending with " n alone dawn John pine balloon fine moan pint bean gone moon prune brine gun pan rain run ruin sun win EXERCISES 243 122. Words with " n" in the middle Annie corner honor panel tender banner counter lining render whining bonny dinner money running winner briney fountain only sooner wonder 123. Words with " ng " ailing covering having nothing ringing bending caring killing pudding singer being counting laughing remaining willing bringer crawling living ring wringer PLATE I. Mouth Diagrams for Typical English Sounds. PIRATE II. Mouth DinKrnm for Typir-jil Enjtli.sh Sounds PLATE III. Mouth Diagrams for Typical English Sounds Q,D,A,. 162. Hemiatrophy of the tongue, 163. Hereditary :it:i\; IliKh palatal an-h, 167. Hoarw voice, si. Hoarseness, 81. He. me, the .stutterer at, 4, 57. Husky tune. -'nt. H\ perphonia, 12. Hypertoiiieity, 1L'. H\ -teria, 48. Il\ M'-ri'-al aphonia, 49. :>-nl mutism, 48. Ideas, collection of, 216. Imitation as a cause of stuttering, 7. Increasing embarrassment, 62. Indifferent stage in stuttering, 10. Infantile cerebral palsy, 49. Insanity, 55. Institutional treatment, 71. Intellectual disturbance in stutter- ing. 65, 119. Introducing, 213. Jaw defects, 165. Jaw position, 227. Kussmaul, 34, 52. Laryngcal tone, 11, 23, 74. Larynx, fixation of, 226. Larynx defects, 155. Lengthened vowels, 199. Linking, 201. Lip defects, 124. Lip gymnastics. 163, 226. Li| iveinents recorded, 25. Lip reading, 172. I.ips in connection with lisping, 162. Lisping, as a cause of stuttering. 17. Hit ; .Mined. Ill ; negligent. 122; organic, 162; neurotic. 17.i. Loud ness of voice, 98. Lowering tones at cud, 206. 'lone, 204. Melody, 74, 194. Melody cure, 77. Melody plot. :. Mental cramp. '.i7. Mental daze, .*,, Intellectual dis- turbance. Mental flurry. 11. Metronome. JIMI. Monotony, 11, 33. Motor aphasia, 50. Mouth recorder. Multiple gel Muscular action, defects of, 88. Muscular control Muscular dystrophy. 163. Muti.sin, hysterical, Iv Nasals, 118. Nature of .stuttering. :U. Negligent lisping, -i:i, 112. Neurotic lisping. M">, 17.'*. New method of speaking, 57. Occlusives, 117. octave twist, 78, 192. Office treatment, 67. Operation as a cause of stutter- ing, 6. Organic lisping, 43, 162. Organs of enunciation and phona- tion. 113. Overshot jaw, 165. Overtenaion in stuttering, 12. Palatal arch, L'_'7. Palate defects. 167. 168. 170. Palatography, 114. IVnmanship .stuttering, 38. Periods, 206. Phobia, 38. Phonetic alphabet, 11-'. Phonetics. 22. Pncumograph, 22. Principles for treating stuttering, 57. Progressive bulbar paralysis, 52. Prophylaxis of stuttering, s. Pseudobulbar paralysis, 53. Psy. hanalysis, 67, 69. 101. Ps\choneurosis, stuttering 94 a form of, 7. Public speaking, 214. INDEX 251 Quality of voice, 81. Reading, 94, 192. Reading together, 210. Reading with decided voice, 211. Readjusting the subconscious, 100. Readjustment of environment, 98. Rear palatal arch, 227. Recording drum, 23. Recording tambour, 22. References, 245. Relation, 220. Relaxation, 61, 224. Relaxed palate, 170. Relaxing the jaw, 226. Running associations, 104, 109, 219. School, the stutterer at, 3. School work, 215. Sentences for indistinctness, 159. Septum, 170. Shock as a cause of stuttering, 6, 16. Singing, 90, 91, 192, 197. Slowness, 85, 198. Smoothness, 201. Social timidity, 39. Sonants, 118. Spasms in stuttering, 10. Spastic speech, 49. Speaking, 92, 193, 198, 224. Speaking together, 211. Speaking with confidence, 211. Speech clinic, 72. Spelling, 208. Spontaneous speech, 94, 216. Stages of stuttering, 15. Stammering, 44. Starting, 201, 205. Statement and question exercise, 193. Statistics of stuttering, 9. Strengthening first word, 205. Stuttering, description, 1 ; det- riment to welfare, 2 ; at school, 3 ; at home, 4 : a disease, 4 ; regarded as a habit, 5 ; causes, 5; connected with nervousness, 6 ; contagiousness, 7 ; after exhaustive diseases, 8; pro- phylaxis, 8 ; statistics, 9 ; symp- toms, 10 ; forms or stages of, 15 ; habit stage, 15 ; fright stage, 18; indifferent stage, 20; con- nection with character, 20 ; ex- perimental study of, 22 ; na- ture of, 34 ; Kussmaul's theory, 34 ; relation to other neuroses, 37; author's theory, 38; dif- ferential diagnosis, 42 ; therapy, 56. Subconscious, 70. Subconscious readjustment, 67. Talking with people, 222. Tambour, 22. Tambour indicator, 121. Technical terms, 246. Telephoning, 96, 221. Theory of stuttering, 36. Therapy of stuttering, 56. Thinking, 86, 217. Tic, 37. Tic speech, 47. Tissue paper indicator, 153. Tone of voice, see Laryngeal tone. Tone placing, 202. Tongue defects, 163. Tongue gymnastics, 160, 225. Tongue movements recorded, 25. Tongue-tie, 18, 43, 164. Tooth defects, 165. Transacting business, 223. Trumpet, 204. Turbinates, 170. Undershot jaw, 165. Velar hook, 153. Velum defects, 150, 168. Vocal quality, 81, 202. Voice tone, see Laryngeal tone. Vowels, 116. Word lists, 228. Writer's cramp, 38. UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This txx>k is DUE on the last date stamped below. SEP 7 i960 /ttJGS f JUN 4 1965 Y20 AUG19 Form L-30m-7.'60(C8244)444 . VLIFORMA _LES RY