Under no circumstances can she make any air pass through the larynx. SPEECH WITHOUT USING THE LARYNX. By E. W. SCRIPTURE.

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SPEECH WITHOUT USING THE LARYNX. By E. W. SCRIPTURE. SINCE the publication of an account of speech without a larynx by Czermak in 1859, cases of this kind have been observed repeatedly.

1 SPEECH WITHOUT USING THE LARYNX. By E. W. SCRIPTURE. SINCE the publication of an account of speech without a larynx by Czermak in 1859, cases of this kind have been observed repeatedly. It has been reported of several of them that they could speak with a fair degree of audibility and could produce sounds that seemed to have something of a laryngeal tone in them. Happening to meet such a case I thought it would be worth while to make a record of the speech with a view of investigating the source of this apparent laryngeal tone. Fig. 1. Recording speech by the Phonautograph. The girl, F. H., seventeen years old, had undergone tracheotomy at the age of three. Ever since that time she has breathed through a tracheotomy tube and has been unable to breathe when the tube is stopped or removed. Observation with the laryngoscope shows that the top of the pharynx is closed over the larynx and no air passes through. On retching the larynx is brought up and becomes visible. Under no circumstances can she make any air pass through the larynx.

398 E. W. SCRIPTURE. She can speak quite distinctly and correctly in a faint, almost toneless voice. Such a condition seems quite astonishing, because all speech sounds require breath.

2 398 E. W. SCRIPTURE. She can speak quite distinctly and correctly in a faint, almost toneless voice. Such a condition seems quite astonishing, because all speech sounds require breath. Without breath the person may go through all the movements of enunciation but he will produce no sound; his speech is visible but not audible. The patient's method of producing audible speech was studied with the aid of the phonautograph. In this method the person speaks into the mouthpiece of a wide tube leading to a flexible membrane. The movements of the membrane are amplified by a light lever and Fig. 2. Record of 'ah-ah-ah-ah' snung on the notes c, e, g, c' by a normal female voice. Each wave records one vibration of the larynx. registered on a blackened revolving surface. The arrangement is shown in Fig. 1. A record of 'ah-ah-ah-ah' sung on the notes c, e, g, c' by a normal female voice are reproduced in Fig. 2. The small waves record the voice tone, or the vibrations from the glottis. They become shorter in each successive record as the tone is raised; in the last note they are just half as long as in the first one: The waves run along evenly and smoothly as is usual in normal voices. A record of 'ah-ah-ah-ah' sung on the notes c, e, g, c' by F. H. is reproduced in Fig. 3. It begins with a jerky line that records the

SPEECH WITHOUT LARYNX. 399 efforts at intake of air. This is followed by quite regular waves. The succeeding records of 'aah' show faint and fairly regular waves.

3 SPEECH WITHOUT LARYNX. 399 efforts at intake of air. This is followed by quite regular waves. The succeeding records of 'aah' show faint and fairly regular waves. These waves become successively shorter as the pitch is raised. Careful observation of F. H. reveals the mechanism by which she produces these tones. A movement of the muscles at the side and front of her neck, just under and behind the jaw, can be seen from the outside; the movement is of a kind that might contract the pharynx. Fig. 3. Record of 'ah-ah-ah-ah' sung on the notes c, e, g, c' by F. H. without the use of her larynx. The fall in the line at the start shows that air is being taken into the mouth. The following rises and fall's show that air is sometimes emitted and sometimes taken in. Finally there is a rather explosive puff followed by fine waves. These waves are quite regular; they were heard as a tone. They record the tone of the voice. In any other record they would be attributed to the vibrations of the vocal cords; here they are due to vibrations of a kind of artificial glottis formed by the tongue against the velum. The shortening of these waves in the succeeding records -shows that this tongue-velum glottis can be adjusted to produce notes of different pitch. The irregularities in the last line show that the vibration is not so smooth and regular as in the real glottis. With the mouth open the tongue can be seen to be raised tightly against the rear edge of the palate and the front part of the velum (Fig. 4). There is some slight movement on attempting to change the pitch. The mechanism is evident. The air in the pharynx is compressed; it is allowed to escape between the tongue and the velum in such a way as to produce a tone. The tone is produced by causing the surfaces of the tongue and the palate to vibrate somewhat as the vocal cords do. The change in pitch is produced by changes in the tension. In

4 40() 0. IV. SUCRIPI'URE. short, the lackinig glottis is replaced by an imitationi glottis formied by the tongue and the velum. It might be asserted that the tone is produced by arousing the vibrationis of the resonance cavity of the mouth just as by blowing across the opening of a bottle, and that the change of tone is produced by altering the size of the cavity. This cannot be true, because alteration of the size of the mouth cavity changes the character of the vowel. A normilal person can raise the tongue against the palate and produce a rough tone by forcing the breath through; he can also raise the tone, but as he does so the vowel changes from 'ah' to 'ee.' He can also produce and raise the tone with an ordinary whisper and with q Pseudoglottis Figr. 4. Method of producing a pseudo-glottis when the larynix is niot utsed. Air is collected by cenlarging tlle lower pharynx. The back of the tonguc is raised against tlhe velum. The contraction of the lower pharynx presses the air out between the tongue and tlle velum, producing >a tone. The pitch of this tone is regulated by muscular contractioni of the tongue and velumii. the same result. This patient keeps the 'ah' quality throughout; therefore the tone she produces is not a cavity tone. There is additional proof that the tone she uses is not a cavity tone. Such tones are of much higher pitch; they never register with the phonautograph. The record in Fig. 3 shows definite waves; these must have been produced by some body equivalent to the larynx. The different vowels are produced by F. H. by varying the mouth cavity. For 'ah' the iiouth is open. The vowel 'oh' starts with a rather open imouth but the lips are soon rounded. A similar movement produces 'oo.' For 'awe' the lips are rounded and then opened. For 'eh' and 'ee' the appropriate lip positions are taken; the vowel 'cc' is specially distiniet. To produce the occlusives 'p, b, t, d' etc.,

5 SPEECH WITHOUT LARYNX. 401 the breath is cut off for a moment at some point in the air passage. A normal record of 'papa' with both syllables equally accented is shown in Fig. 5. During 'p' the lips are closed and the glottis open; during Fig. 5 (upper tracinig). Record of 'papa' by a normiial female voice. The straight line at the start registers the time during which the lips are closed and no bieath is emitted. The sharp upward jerk is due to the sudden puff of air that escapes as the lips are opened. This is followed by the fine waves that register the vibrations of the larynx while the mouth is open for the vowel. The sudden fall registers the closure of the lips for the second 'p,' and so on. Fig. 6 (lower tracing). Record of 'papa' by F. H. The waving of the line at the start shows the variation in taking in air in order to supply air for the word. The straight line for the time during which the lips are closed (the occlusion) in the 'p' is followed by a sharp and rather forcible jerk upward that registers the explosion as the lips open. The fairly regular small waves thereafter register the vi-brations of the vowel that were produced by the tongue-velum glottis and not the real one. As much of the air contained in the pharynx has been spent, the second 'p' does not have so forcible an explosion. the vowel the mouth is open and the glottis is vibrating. A record of 'papa' by F. H. is given in Fig. 6. The air 'swallowed' into the pharynx is used to produce the explosions for 'p' and to vibrate the tongue-palate glottis that imitates the laryngeal vibrations of the vowels. A record of 'tata' by F. H. is shown in Fig. 7. It reveals a marvel Fig. 7. Record of 'tata' bv F. H. The downward movement of the line registers the intake of air into the pharynx. This is followed by a straight line for the time during which the point of the tongue is closed against the palate (the occlusion). The sharp jerk upward is produced as the tongue releases a puff of air (the explosion). Not long afterward the faint vowel waves appear. These are produced not by the larynx but by the vibration of the back of the tongue against the velum. To get the tongue in this position its tip must be released at the end of 't' and the back must be raised; this is what is happening during the time of the rather irregular line after the explosion of 't' and before the vowel waves.

6 402 E. W. SCRIPTURE. of skill in vocal mechanics. After making 't' by putting the tip against the palate to produce an occlusion and an explosion, the tongue rapidly readjusts itself to a new position in order to form the imitation glottis required for the following vowel. The patient always made a distinction between 'p' and 'b,' ' and 'd,' etc. In normal speech the greatest difference lies in the absence of laryngeal vibrations in 'p,' 't,' etc., and the presence of them in 'b,' 'd,' etc.; the patient could not make this difference. Another difference lies in the fact that in normal speech the explosions are stronger for 'p,' 't,' etc., than for 'b,' 'd,' etc. This latter difference was marked in the speech of F. H. as may be seen in comparing the record of 'baba' in Fig. 8 with that of 'papa' in Fig. 6. A normal '1' is made by passing air along one or both edges of the tongue while the larynx vibrates. F. H. produces the rubbing sound of the air along the passage but cannot use her pseudo-glottis at the Fig. 8. Record of 'baba' by F. H. There is less violent intake of breath than in Fig. 6 because there is less needed for 'baba' than for 'papa.' The explosions ale weaker. same time. Her '1' is therefore toneless or surd. It sounds exactly like the surd '11' in Welsh. The nasals are produced like the corresponding occlusives but there are no explosions. 'Mama,' 'nana' and 'sing' sound like 'papa,' 'tata' and 'sick.' The patient has such skill in using the pharyngeal air supply that she can speak quite long sentences. Fig. 9 shows a record of 'Peter Piper's peppers.' The 'p's' are all very sharply and forcibly made but they gradually become weaker as the air is exhausted. Except in this respect and in the faintness of the vowel waves the record does not differ from a normal one. Three years ago I reported a case of laryngectomy of a man of sixty-five. His speech was quite inaudible after the operation. To produce the explosive 'p' he was taught to close his lips and compress the air in his mouth and pharynx by tension on the cheeks and in the back of the throat. On opening the lips there was a puff of air that produced a quite audible 'p.' For 't' he placed the point of the tongue against the palate and compressed the air in his throat. By releasing

7 SPEECH WITHOUT LARYNX. 403 the closure of the tongue he produced a distinct 't.' For 'k' the back of the tongue was raised and released with pressure in the same way İn normal speech 'b,' 'd,' 'g' are distinguished from 'p,' 't,' ' k' mainly by the presence of a tone from the larynx. This patient could not produce a tone and the sounds could not be distinguished. He was taught to give the puffs of air through the cannula for 'b,' 'd,' ' g' and thereby to make a distinction between the two groups of sounds by adding a rushing noise to one group. ENSM 11 1 Fig. 9. Record of 'Peter Piper's peppers' by F. H. The lower part of the figure follows on the upper part. Each 'p' has a sharply marked occlusion and a well-defined explosion. The explosion becomes steadily weaker; for the last 'p' it is hardly visible. There is practically no 's' for 'Piper's' but there is an exaggerated one at the end, when there was no need of economising air in the pharynx and all the rest might be safely used. For the vowels there was no closure of the mouth that would enable this patient to compress any air; consequently the vowels were blanks and his speech consisted wholly of consonants. He was taught to give puffs from his cannula during the vowels, whereby they became distinguishable from pauses. The patient died in a few months by extension of the carcinomatous growth. He did not have time to learn-and at his age would probably nevei have been able to learn-the really remarkable mechanism that F. H. has developed of her own accord. REFERENCES. For a summary of cases of speech without a larynx: Kussmaul, Stbrungen der Sprache, 2. ed. (by Gutzmann), 267, 360, Leipzig, 1910; Gutzmann, Sprachheilkunde, 2. ed. 524, Berlin, For the case of laryngectomy referred to: Scripture, Speech without a Larynx, Jour. Amer. Med. Assoc. 1913, May 22, LX. p For detailed accounts of the methods of recording speech: Scripture, Elements of Experimental Phonetics, Yale University Press, 1902; Stuttering and Lisping, Macmillan, New York and London, 1913.

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