author that it is well to state a physiological principle that appears to figure largely in the production and perpetuation of the malady. It is the principle of physiological antagonism. Within the brain antagonisms of functions may be aroused. If a person attempts to hold the breath in a prolonged manner, he will soon perceive that there is a disagreeable antagonism going on within himself. His effort becomes painful, and the antagonism becomes very intense. Presently there is a surrender somewhere, and the experimenter resumes his respiration. In this experiment, the following explanation would seem to express the modus operandi. It is perhaps some portion of the cerebrum that issues an inhibitory command to the medulla oblongata to arrest respiration. The respiratory center obeys for a time, but remonstrates-in fact, gently resists at first, but finally overcomes the antagonistic force of the cerebrum, and sets the mandate of the latter at naught by putting, again, the machinery of respiration in motion. We say that perhaps the so-called "sense of suffocation" is simply the expression of an antagonism between the medulla oblongata and the cerebrum.

Now, the pathological phenomena of stammering would seem to strongly sustain the principle of intra-cranial, or encephalic, antagonism. From what is known by means of analogical evidence, it may well be supposed that ordinary language effort is carried on by an inferior part of the brain, independently of any particular direction by the higher brain; that is, there is an automatic machinery for common utterance, in which the superior brain is not much concerned-in fact, concerned no more than to give a general order for the execution of the details of speech. In such instance, the higher brain-mass acts as it does when it sends a general impulse to the spinal cord for the purpose of precipitating the act of walking, which act is carried out in detail by its servitor, the cord; the cord itself resembling, in the principle of its conduct, the above mentioned automatic language machinery. Now, when this language machinery is mal-educated, and as a consequence has formed a mal-habit, we can readily perceive what difficulty may ensue. It is perhaps exactly the same as that which occurs in stammering. In fact, stammering is perhaps a proof of the division of labor between the encephalic masses; and at the same time a proof of the antagonism that may be aroused between, and among, them. Indeed, it is upon this principle of antagonism that we would rivet the attention of the investigator. We have already seen how that clonic and tonic spasms ensue during the efforts of the stammerer, how that vertigo, perspiration, and exhaustion take place, and how that the abdominal muscles, the diaphragm and the thoracic muscles seem to participate in what appears to be a fierce struggle. Pathological antagonism between the cerebrum (in which is located the primary and supreme language centre), and the inferior ganglia of language, is the only hypothesis that will explain the matter. That a struggle is going on during a paroxysm of stammering is as plain as day.

So, by reflection, it will be seen that nearly all the primary phenomena of stammering conform to this principle of antagonism between ganglia.

We now proceed to further note the appearances of stammering, and then to consider its treatment. Among the things that enhance the difficulties of the stammerer are whatever temporarily decreases the power of the heart, as common embarassment, fear and loss of assurance; and decrease of the rapidity of nervous conduction, as from cold, or from the placidity incidental to quietude.

During the hot weather of summer stammerers are often greatly improved, only to get worse again upon the supervention of the cold of winter. Buoyancy of spirit affords relief, despondency increases the trouble. Consciousness of the presence of superior and arrogant persons plunges the common stammerer into difficulty. The presence of a benign superior aids him. There is a popular impression that the trouble of the stammerer is greatly increased by active emotional excitement. We are of the opinion that this is incorrect and that the reverse holds good. Vigorous mental excitement usually aids and relieves the stammerer, while sluggish mental movement renders his impediment worse. Of course a blind rage or a state of joyous ecstasy embarasses and clogs or totally destroys the utterance of almost any one-of the man of glib tongue as well as of him of impediment of speech-but an indignant sense of wrong felt in the bones of the stammerer, or a sense of healthful joy, often does away, temporarily, with all difficulty of utterance. We remember an instance in which a most inveterate stammerer was forced out by clamor to speak before a popular audience upon a subject in which he was deeply interested. He arose enveloped in his own confusion, and commenced to stammer in the most extraordinary and seemingly abject manner. He was about to sit down in despair, when his eye accidentally rested upon the gloating and glaring face of an enemy in the crowd, whose moment of supreme joy seemed to have been reached in beholding the discomfiture of the stammerer. Suddenly the stammering man arose above his life-time misfortune and delivered a most eloquent oration without the least further manifestation of lingual impediment. In his case we suppose the heart was stimulated to the manifestation of great force by the irritation; great quantities of blood were sent rapidly to that most distant yet super-eminent portion of the brain, the cerebrum, which effectually controlled the inferior ganglionic masses concerned in articulation.

It is an interesting circumstance that stammering is worse in the forenoon than in the afternoon. In connection with this circumstance it is notable that human temperature is lower in the forenoon than in the afternoon; and also that the general encephalic functions are more thoroughly aroused and vivid in the afternoon, and that the temperature of the day and of apartments is commonly warmer. Under the conditions named as incidental to the afternoon there must be a considerable increase of the velocity of nervous conduction.

Coincidental with the utterance of the stammerer there is often a sort of consentaneous muscular by-play carried on, more or less apparent; as a patting of the foot, playing with the fingers, or with a button, twisting or pulling at a handkerchief, making facial contortions, etc. Such movements disembarrass the stammerer somewhat. In some instances these irrelevant movements occur when the stammerer is not speaking or reading, and then they resemble chorea very much. They are often incidental to eating or smoking; and also often occur when the patient is at comparative rest.

The

CAUSES OF STAMMERING.-Antecedent disease, interfering with the articulation temporarily, may be such a cause. Pertussis may be such a cause. violent and protracted laryngeal spasm, the spasmodic phonation, conjoined to other extensive movements, which take place independently of, and in spite of, the will, in this disease, are well calculated to mal-educate that portion of the brain which presides automatically over common language function. As before

said, it may well be supposed that ordinary language effort is carried on by an inferior portion of the brain, independently of any particular direction by the higher brain; that is, there is an automatic machinery for common utterance, in which the higher brain is not ordinarily much concerned. Well, in the violent paroxysms of whooping-cough, all the muscles concerned in speaking and more too, are thrown into violent and unco-ordinated action, beyond any manner of control by the will. The disease exists for weeks, and often for months, an abundant time for the automatic brain to become disastrously in the habit of sending an irregular and improper impulse to the muscles concerned in utterFor reasons that are readily obvious, during, and at the conclusion of whooping-cough, stammering may supervene. Several of the most extravagant cases of stammering we ever saw were sequels of whooping-cough, the person stammering upon every word and between words.

We are of the impression that children recovering from extreme adynamia in acute diseases are somewhat liable to stammer afterward, especially if the adynamia have caused temporary speechlessness, from which the patient has recovered by degrees.

A very large proportion of stammerers are made by imitating other stammerers, either consciously or unconsciously so doing. A person may consciously and, for a time, willfully imitate (mimic) a sufferer from the malady, and in the meantime so mal-educate his language machinery that finally when he attempts to speak aright he finds himself not only quite unable to do so, but a frightful victim of that which he has ridiculed in an innocent and unoffending person. In all such instances as the latter it would be good justice to permit the patient to suffer on for ten or fifteen years before being cured. In those instances, wherein a ridiculing imitator has not acquired the habit, it would be well enough to give him an expiatory term in the penitentiary of about ten years. At least we have ascertained that that is what all innocent sufferers think about it. A large number of stammerers take on their trouble by unconscious and unavoidable imitation; as a child may imitate its parent, its brother, or sister, an intimate schoolmate, and so on. Cases that supervene in this manner are not so inveterate as are those that arise through ridicule or a malicious purpose, for the reason that the direction of the attention is not so intense in acquiring the difficulty.

It is worthy of remark that one member of a family of children may be an inveterate stammerer, all the other children unavoidably and passively imitating him; but it is almost invariably true that the ones who are the imitators will, after keeping up the imitation for a while, cease to be stammerers to any considerable degree. Especially is this the case if the latter be permitted to act as they will, without any fierce interdiction. To fiercely interdict a child from stammering is exceedingly dangerous, as it only infixes what would otherwise prove a passing impediment. We have witnessed the baneful effects of attempting to "break" children from stammering. A child has not much inhibitory and antagonistic brain by which to control its perverse and semi-automatic language ganglia, therefore, make no appeal, but allow the child to outgrow his malady by his increase of cerebral development.

Illustrative examples can be adduced to prove that there is often well-marked hereditary tendency to stammer. Children born of stammering parents usually

stammer with great facility. One case has fallen under our observation, in which no imitation or any other assignable cause could be ascertained excepting heredity. The father was an inveterate stammerer, but the child had no opportunity to imitate him. The malady was not assailed; as it had appeared spontaneously, so it passed away spontaneously, after a comparatively transient duration.

As has before been stated, stammering sometimes has its origin in a traumatic injury that has long since passed away, leaving the individual sincerely convinced of being unable to articulate a certain sound or sounds. One such case has fallen under our notice. Before we had an opportunity to try to effect a cure, the individual passed from under our observation.

Putting aside the subject of causes, there is a phenomenon which at first view seems difficult to explain, but which is really quite intelligible. It is that when the attention of the stammerer is strongly riveted upon his impediment to utterance, his difficulty in articulation is greatly enhanced. We say we believe this is the rule. His intelligent mental attention may be fixed upon a difficult word, and yet he finds himself all the more unable to utter it properly. The cause of this embarrassment is that the commanding super-phonetic impulse is general and not special. The superior ganglionic mass issues a general order again and again to the inferior and simply executive language ganglion (or ganglia), with no other effect than to still further confuse the special impulses of the latter. If, with steady deliberation, the supreme, cerebral centre set about issuing a certain mandate involving the details of how the word is to be articulated, the difficulty vanishes, and the proper enunciation ensues. And, be it remembered, the more powerful the supreme centre the more efficiently will it assume control of the inadequate, but resisting forces below it. From the principle here shown, it may be clearly seen that persons of very high mental organization are infinitely more apt to make a good recovery from stammering than those of inferior capacity. This is also the principle reason that stammering affects children more than it does adults. We think that the affection is persistent in negroes, a class whose general cerebral capacity is weak.

Stammering is not analogous to aphasia, due to cerebral lesion. As evidence of this, the force of the affection fluctuates from mildness to severity, and from severity to mildness; and may be even wholly suspended for a while, reappearing again in full violence. Also, the style of a stammerer's difficulty changes; within a series of years it may be quite protean. This mutability in force and form could not exist were the physical basis, that portion of the brain concerned in language, mutilated.

TREATMENT OF STAMMERING.-The treatment of stammering, carried out intelligently, should usually be successful. A large number of the cases, if wholly uninterfered with, have a tendency to spontaneous recovery. This is especially true of young children who have acquired the impediment of speech by unconscious imitation. Indeed, the plan of total non-interference should be adopted in treating all young children who stammer. Ridiculing or forbidding the difficulty, or even attempting to benignly educate them out of it, only unfortunately infixes it. The child should be placed in circumstances of absolute freedom of general growth, physically and mentally, and, by such a course, in the vast majority of cases the trouble will gradually disappear. It seems

exceedingly probable that temperature and climate have their influence. A warm climate enhances recovery by increasing the velocity of nervous conduction. The self-confidence of the child should be cultivated. It should be taught to the fullest extent consentaneous motion, as practiced in dancing and calisthenic exercises. It should be taught music, another highly consentaneous exercise. It should be removed from all opportunity to imitate another stammerer. The whole mental nature of the child should be incited to equable activity.

The intelligent adult stammerer should be thoroughly apprised of the nature of his difficulty, both as to general principle and as to detail. He should be thoroughly drilled in elementary articulation, and in all modes of motion requiring consentaneous action. His general culture should be carried on to an extreme extent. Finally the highest nerve centers will get the mastery of those lower ones that are immediately concerned in utterance, and will teach them a right automatic function. To do all this requires a high form of will on the part of the patient.

Those who belong to the more lowly class, intellectually, are difficult to treat. They make very imperfect spontaneous recoveries, for the obvious reason that the higher brain is weak. When special and conscious treatment is applied, the moderate intellect and will of the sufferer only feebly and inefficiently co-operate in the effort at restoration attempted by the intelligent physician. They are benefited by much society among equals.

Intelligent sufferers from stammering should be cured, if possible, as the disastrous modification which the constant embarrassment that the impediment of speech induces, is mortifying and sad, veiling and rendering a naturally exalted intellect quite abject. Especially is the evil effect of stammering seen in the greatest degree in the cases of those who are of high mental endowments, and have, still, not wealth or high station to act for them as powerful collateral adjuvants.

ONE YEAR'S WORK IN LAPAROTOMY.*

BY J. H. CARSTENS, M. D., DETROIT, MICHIGAN.

PROFESSOR OF OBSTETRICS AND CLINICAL GYNECOLOGY IN THE DETROIT COLLEGE OF MEDICINE, ETC. TABULATED STATEMENT OF RESULTS.

*Abstract of a paper read at the meeting of the MICHIGAN STATE MEDICAL SOCIETY, May

5, 1892.

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