of fluent speaking, owing to the presence of some word or letter which at one time offered great difficulties. Temperamental idiosyncracies, such as extreme sensitiveness and solicitude, serve to increase the patient's speech fear. Harshness and threats on the part of stern parents or teachers, and, especially, any evidences of levity or derision on the part of school- or play-mates, will serve to augment the victim's embarrassment.

ers.

TREATMENT.

Many and varied are the methods employed in the treatment of stutterThere seems to be a wide diversity of opinion as to the efficacy of these methods, but I feel safe in saying that they are usually in inverse ratio to the claim of the promulgators. Every quack institution claims the open sesame to this realm of mysteries, and is prolific of voluminous liter-ature, couched in the most prolix phraseology, the object of which is, in every case, self-exploitation and aggrandizement, and the hoodwinking of a credulous and gullible public.

There are, nevertheless, certain basic principles to which most recognized authorities subscribe. These are:

I. Instruction in articulation and vocalization.

Instruction in articulation and vocalization consists of exercises intended to show the patient the correct lip and mouth position necessary to produce the sounds, letters and words which offer the greatest difficulty.

Next comes instruction in rhythm of speech. Stutterers, as a rule, have no appreciation of the time element of expression. To restore order out of chaos is one of the first duties of the instructor. Rhythmic expression depends upon rhythmic thought and rhythmic breathing. Hence the patient is taught to recognize the time value necessary to correct speech, i. e., the time required for expressing and obliterating a thought conceived before attempting to express the next. The regulation of the patient's breathing is of great value in this connection. Deep breathing has its value as a form of hygienic exercise, but is of no avail in the treatment of stutterers. What the patient requires is instruction in normal, natural breathing during vocalization, with a view to overcoming the habit common among stutterers of beginning speech with either too large or too small a supply of air in their lungs. They must also learn to suit the length of clauses or sentences to the amount of air at their disposal, and to guard against a continuance of speech beyond the limits of a normal expiration.

Finally, attention must be given to the voice. Most stutterers have no appreciation of what constitutes normal voice, and many, in fact, habitually

assume a forced, unnatural voice, with the hope of diverting their attention from their defect. They must, therefore, be trained to recognize the normal voice, and to compare the same with their own faulty tones. They must be drilled in the production of chest tones, and to substitute these for the head tones, which, being a deviation from the normal, tend to check the freedom of speech.

It is hardly necessary to add that these exercises must be carried out persistently, constantly and insistently. For this reason, and the fact that all deterring influences must be avoided, and the patient be brought into close communion with his teacher, it is of the utmost importance that the treatment be carried out in an institution equipped for this purpose, and under the guidance of the best possible instructors. This is especially true of patients in the third stage, in which speech-fear is the dominant factor. Even patients in the second stage should have the benefit of such instruction, their required detention being obviously of shorter duration, and the chances for permanent cure comparatively better.

Treatment in the school and home, through the agency of teachers and parents, is also an important factor, and is frequently quite sufficient to abort a case in its incipiency. To make this a practical regimé, the parents of every child giving evidence of faulty speech, and every teacher having in her charge such a pupil, should be provided with the following simple instructions:

I.

1. Everything which deranges or weakens the patient, and everything which unduly excites him, either mentally or physically, should be avoided. This includes, especially, the playing of baseball and football.

2. The patient should never be permitted to talk too rapidly or when · out of breath.

3. When the patient finds it difficult to pronounce a word, he should never be permitted to repeat that word, but always the entire sentence.

4.

No association with other stutterers should be permitted.

5. The patient should never be punished for his defect, or mimicked, or questioned for the purpose of compelling him to use a difficult word for the amusement of others.

6. A confirmed stutterer should be taken from school at once, and placed in a suitable institution, to receive instruction in correct speech, even at the cost of a few weeks of schooling.

CONCLUSION.

Stuttering must, sooner or later, be looked upon as a factor in modern economics. This fact has long been recognized abroad, with the result that the treatment of stutterers comprises a part of the public educational system. In Germany and Austria, capable instructors are appointed, whose

duty it is to conduct special classes in the different schools at stated intervals, for the instruction of pupils afflicted with speech defects. The results obtained point inevitably to these conclusions:

I. The positive efficiency of this method in controlling stuttering in its first stage, and

2. The absolute inefficiency of the same to effect any permanent results in the second and third stages, and the consequent imperative necessity of placing such cases in proper institutions for prolonged treatment. School treatment must, therefore, be looked upon as being essentially inhibitive, seventy-five per cent of incipient cases being reported cured. Granting that this per cent is comparatively small, when we consider the total number of cases encountered, it is, nevertheless, of far-reaching importance in the control of this malady, and its continuance bespeaks its value as an economic factor to the State. We must plead guilty to the grossest inconsistency when we establish special classes in our schools for so-called backward children, and absolutely neglect to make any provision for those whose affliction is of minor degree, and yet of such momentous importance. "That a cure in almost every case can be attained by the application of the physiological rules of normal speech, is beyond question, and although the effort necessary for its eradication, in certain cases, may vary according to the age and tractability of the sufferers, modern science. can boast of victory, even in the severest cases."

822-4 Rose Bldg.

A GOOD APERIENT.

According to the Revista di Chimica et Farmacia, a good aperient should combine three virtues: The normal physiological stimulants, that is, some stimulating food; the artificial physiological stimulants, the alkaline salts, and the medicinal stimulants, the bitters. The following two formulas take all these qualities into account, and consequently yield a well-balanced, active but gentle aperient :

Twenty minutes before meal time, one of the powders is dissolved in

a cup of warm water, and taken. This is followed by a teaspoonful of

the potion.

NORMAL FIXATION OF THE UTERUS.

BY BYRON ROBINSON, B. S., M. D., Chicago.

[Written for the MEDICAL BRIEF.]

(Continued from March issue.)

(E) LIGAMENTA SACRO-UTERINA.

The sacro-uterine ligaments possess the eponym, "plicæ Douglasi," or folds of Douglass, the Scotch anatomist and obstetrician (James Dougiass, anatomist and obstetrician, Professor in London, 1675-1741). They extend from the cervix uteri to the sacrum (and rectum). They are vari· able structures, and difficult to define in dissection. They are composed of limited quantity of muscle and considerable quantity of connective tissue. Besides the name of Douglass, there is associated the name of Professor Luschka (Hubert Luschka, German anatomist, 1820-1875, professor in Tuebingen). As attached, the "muscles of Luschka" are contained in the utero-sacral ligaments. The names of Duges, Madam and Boivrn are also associated with these ligaments. The sacro-uterine ligaments may be valuable in dimension (diameter, length, position), in origin and insertion, in quantity of contained muscular fiber, and a symmetry may exist. The origin is fan-formed from the sacrum (and rectum), and the fibers converge, becoming inserted in the cervix. In palpating the sacro-uterine ligaments, which I have performed for many years, especially during vaginal hysterectomy, I find extreme variation in dimension (length, diameter), position, symmetry and distensibility. Some writers attribute a remarkable signification to the sacro-uterine ligaments as powerful supports of the uterus. I think these authors are led into the error of thinking that on drawing the uterus distalward the resistance is demonstrable by the tensionized sacro-uterine ligaments, while, in fact, the "supporting beam of the cervix," or base of the ligamentum latum, accounts for considerable of this resistance. For fifty years celebrated names have designated the sacro-uterine ligaments as "principal uterine supports," "veritable suspensory organs of the uterus," as "ligamenta suspensoria uteri portiæ." One can say that the sacro-uterine ligaments are tethers which fix the limits of uterine mobility. The sacro-uterine ligaments do not exercise marked suspensory influence over the uterus. It is purely a matter of experiment that in dislocating the uterus proximalward and distalward the sacro-uterine ligaments are placed on tension-but experiments in this matter are exactly similar to pathology. The sacro-uterine ligaments can not serve as a strict suspensory or fixation agent, where they are only put on tension by the most extensive uterine excursion. It seems to me that the sacro-uterine ligaments are neither important suspensory nor fixation agents of the uterus, but are among the numerous threads that suspend and fix the uterus to adjacent organs and walls.

(F) VESSELS AND NERVES.

It is not the natural function of the vessels to act as suspending or fixing agents for organs. Also the vasa uterina are tortuous, and could be a suspension or fixation apparatus only on tension, which would elongate the vessels. It traumatizes a nerve to suspend or fix an organ. Hence vessels and nerves possess no agency of a suspensory or fixation nature for the uterus.

(G) THE CONNECTIVE TISSUE.

Under connective tissue we comprehend the loose tissue that intervenes between organs and courses along vessels and nerves. There can be no doubt that the connective tissue surrounding organs, nerves and vessels possess some suspensory power. However, connective tissue possesses neither elasticity nor fixation to withstand resistance. Loose connective tissue, under normal relations, produces practically no fixation apparatus. Pathologically connective tissue may furnish a source of strong resisting power, e. g., in the atrophic state. Loose connective tissue is vastly different than the multiple cleavable planes of powerful fascia which, in my opinion, is a maximum supporting apparatus for many viscera.

(H) THE CONNECTION OF THE UTERUS WITH NEIGHBORING ORGANS. The uterus is connected with the vagina, bladder, rectum, as neighboring organs. The vagina is the most intimately connected neighboring organ. The relation of the vagina to the cervix is first a support; second, it limits the dorsal excursions of the uterus; third, the vagina, with the sacro-uterine ligaments, serves as a dorso-ventral resting beam for the cervix. I have called the base of the ligamenta lata a transverse resting beam for the cervix. Hence, the cervix rests on the center of a cross, of which the transverse beam is the base of the ligamenta lata, and the dorsoventral beam is the vagina and the sacro-uterine ligaments. The state of the vagina-resting nullipara, or multipara, menstrual, gestating or puerperal-indicates the strength of its support. The vagina acts as a muscular column extending from the cervix to the triangular ligament, aiding to steady the cervix. However, I can not view the vagina as the special supporter of the uterus, though doubtless the fixation of the vagina to the cervix-subpubic arch and triangular ligament aids to fix the cervix more or less. The vagina can act as a column of uterine support, because it is thoroughly fixed to adjacent tissue and organs. It is intimately supported adjacently by the urethra, bladder, rectum, pubic bones and perineum, as well as with the powerful triangular ligament. Besides, the forces which retain the vagina in position also aid in retaining the uterus. Though the connection between the vagina and urethra be extremely intimate, that between the cervix and bladder is loose, unsuitable tissue,