Part 2

Since writing the report of this case the patient has been seen and examined. She seems to be in perfect health, and says she never felt better. There is not a vestige of the tumor remaining, except two or three small indurated spots that can be felt through the vagina.

STAMMERING, STUTTERING.

BY PROF. G. DELON, LATE OF PARIS, FRANCE.

Here is an universal and very strange infirmity, impeding speech, the origin of which must be anterior to the formation of languages. Hippocrates, the “Père de la Médecine,” Galen and Aristotle attributed it to an abnormal moisture of the brain and tongue and to a defective construction of the tongue, and their theories have been revived by modern writers. We find in Aristotle a double definition that stammering is an inability of articulating a certain letter, and stuttering an inability of joining one syllable to another. Notwithstanding the difference between the causes, the characteristics and the effects of both defects, several languages have but one word to express it; in French, for instance, “Bégaiement” means either stammering or stuttering. American dictionaries give the same definition for both; and in common talk no distinction is made, all stoppages in speech being called indiscriminately stammering or stuttering.

Speech being a combination of separate sounds produced by the expired air, it is certain that the first condition required for natural and correct speech is an undisturbed and normal action of the breathing apparatus.

The movements performed by the respiratory organs for the modification of the currents of air being produced by muscles owing their activity to nerves—motor and sensory—and the vocal organs being, like all parts of the organism, provided with nerves, it becomes evident that a general excitation of the nervous system, or any unusual excitement of the motor-nerves in action, will affect the muscles, cause irritation and create disturbances in inspiration, expiration and speech.

Normal inspiration is produced by a regular contraction of the diaphragm, and expiration is due to the elasticity of the tissue of the lungs. A spasmodic inspiration, during which a prolonged contracted spasm of the diaphragm takes place, produces stammering; such a convulsive contraction of the diaphragm can take place without attempting to speak, but any attempt to utter sounds during the spasm will result in stammering. At the end of the spasm, the air is then quickly expelled from the lungs. I have noticed stammering children that I have treated subject to frequent attacks of hiccough; in hiccough the expiration is quiet: an irritation of the nerves of the diaphragm brings about, with a violent inspiration, an attenuated convulsive contraction of the diaphragm, as in stammering.

In stuttering which is characterized by the presence of some spasm, in all articulations, labial, lingual, dental and guttural, although respiration is irregular and the respiratory organs do not work well, the inability to form and join the sounds comes from other sources than a spasmodic contraction of the diaphragm.

Stammering proper, when organic, might be called stammering of the diaphragm, and that distinction would be quite logical, as other organs wholly unconnected with speech show that peculiarity of being affected with stammering.

The influence exercised on the voice and speech by the respiratory mechanism is so considerable that a variety of theories on respiration have been advanced and discussed by physicians and specialists, not only with reference to speech impediments but specially for singing, elocution, acting and public speaking, and also in reference to general health. Writers and professors advocating exclusively so-called diaphragmatic, or costal, or abdominal respiration, are incorrect and perfectly deceived. The diaphragm, the ribs, and the muscles of the abdomen must all do more or less their special work, in order to carry on a normal and healthy respiratory act. An eminent physician, Dr. Ed. Fournié of Paris, says: “He who respires exclusively by one or the other of these alone (diaphragm, ribs or abdomen) must be indeed a sick man.” Costal or side-breathing is due to the elevation and depression of the ribs simultaneously with the contraction of the diaphragm. Abdominal breathing, the method taught to singers, is performed by the pressure of the abdominal muscles upon the anterior and lateral walls of the abdomen, forcing up the diaphragm, and thus expiring almost completely the air in the lungs.

Medical and scientific investigations concerning speech defects have been as considerable as it is contradictory. The observations of prominent doctors and specialists, some of them being afflicted themselves, have in the most argumentative thesis attributed stammering-stuttering to numerous and varied causes, the enumeration of which has a real historical and pathological interest:

Faulty action of the tongue, disorders of tongue-muscles, spasms of the glottis and epiglottis, troubles located in the larynx and in the hyoid-bone, abnormal depth of the palate, affections of the muscles of the lower jaw, spasm of the lips, abnormal dryness or moisture, or lesion of brain, nerves, muscles or tongue, nervous affection, intermittent necrosis, general debility or weakness, chorea, incomplete cerebral action, imperfect will-power, want of harmony between thought and speech, imitation and habit.—Such is the nomenclature of the principal ingenious theories exposed and upheld by those who have made a study or a business of the cure of speech defects. But some mistaken innovators, not satisfied with theories and investigations, gave to their ideas an experimental form. Forty and forty-five years ago a surgical craze, originating in Germany as a pretended cure of speech defects, was raging all over Europe. Stammerers and stutterers suffered a variety of operations, the horizontal section of the tongue, the division of the lingual muscles, the division of the genio-hyo-glossi muscles, the cutting of the tonsils and uvula, etc. Such suppression and mutilation of the vocal organs could not bring any cure, as it was proved, and some patients having died, the operating craze was put to an end forever. Since that it is by more gentle means that all attempts have been made to cure impediments of speech. The unfortunate stutterer has no longer to dread the misemployed zeal of surgical operators, and now it is even his own fault when he allows himself to fall into the hands of ignorant charlatans.

Without lessening the value of former discoveries, I will say that the specialist of to-day must disagree with the most eminent authors and the most prominent works on that question, including Velpeau, Amussat, Becquerel, Lenbuscher, Bèclard, Bristowe, etc., and arrive at the conclusion that their testimony was one-sided, being confined to their own or few cases, and limited to mere theory and speculation. For the treatment of vices of speech, with the indispensable knowledge, long and practical experience alone will instruct what is the right method to pursue. The various theories on the nature and causes of that infirmity, and the enumeration of the different responsible organs may be, at the same time, partly false and partially true; but they have proved powerless to cure or relieve.

In all varieties and forms of stammering-stuttering all the vocal organs can be blamed, and have, in each case, to be reformed and improved. In the majority of cases we find some traces of the organic peculiarities aimed at by authors, even if their influence is doubtful. Respiratory trouble is at the bottom of every case. The internal organs, and the tongue, the lips and jaws are to some extent in an abnormal condition, and suffer a convulsive spasm; they have to be treated, strengthened and made flexible. The nerve-function of the organs of speech is also disturbed. We notice in the majority of cases, to a certain degree, organic weakness, nervousness, lack of will-power, and above all, disregard of all natural rules and ignorance of the use and natural functions of the organs of speech.

As to prognosis, I will say that all stoppages in speech, accompanied by spasms, sometimes hardly perceptible, and which are not the result of paralysis or lesion, may be classified as stammering-stuttering, and can always be cured, whatever may be their origin or cause, or their intensity, and that it is only a question of time and perseverance even for the most stubborn cases.

The treatment of stammering-stuttering, which does not comport any operation nor drugs, is purely educational. It consists in remedying the defect and teaching properly the science of speech. Still, I think, that in many cases a strict attention ought to be paid to hygienic measures; some medical care and prescription would help the patient and the instructor. In the actual condition of things no regular practicing physician can afford to devote his ability and time to the treatment of speech defects. But doctors have to study the infirmity, to know that it can be cured, that it is an interesting and complex disease, in the treatment of which the progress of medical science can bring a revolution. Physicians the world over having wholly neglected to consider that question, the result has been to leave it in the hands of incompetent persons. In principle the question of speech impediments cannot be separated from medicine. Physicians cannot ignore an infirmity in which the organism itself is undoubtedly involved, at times in a very intricate manner and to a considerable extent. Every true physician feels that he has a sacred mission—to alleviate suffering; the tortures of a large class of people partially deprived of the faculty of speech are well worth his care and attention. Medical students ought to be provided with the means of becoming versed in an affection offering such a large field for study and work, where so much light is needed, and where the prospects of discovery and improvement from a scientific and medical standpoint are so legitimate. The family physician, often consulted, will do good work in advising his clients to try and get rid of such a terrible affliction, to be cured without delay, and in preventing them from falling into the hands of quacks.

HOMELY FACTS.

BY F. STEWART, CLEVELAND, O.

Not long ago as a bottle was placed upon the counter of a pharmacist to be refilled, its inner walls were observed to be richly decorated with the active principles of the compound. A witch-hazel doctor standing by declared the decorated walls to be the secret of the patient's recovery, but upon inquiry it was found that the patient was no better. Still they had decided to try another bottle, and the apothecary was not the one to object. The investigation was carried no farther, but if it had been the same old story of _incompatibles_ would have been retold. To the aqueous solutions containing oleoresinous tinctures or extracts (such as cannabis indica, guaiac, benzoin, lupulin, ginger, myrrh, cubeb, eucalyptus, sumbul, and many others) a sufficient quantity of carbonate or calcined magnesia should be added. A few grains (say three to twenty) to the prescribed dose will suffice for a good suspension, and will be found in most cases unobjectionable of course in an acid mixture.

There are many conflicting reports of this class of medicines, owing to unscientific prescribing as well as unreliable preparations. The activity of this class of medicines demands nothing short of strong alcohol for their extraction. Yet many weak and worthless preparations may be found in the market. If the unscientific observers would look more to the quality of their goods, these conflicting reports would begin to subside.

A physician once told an apothecary that he prescribed fluid extracts because he found them more reliable than the tinctures. This was not true, and could not be proven. Upon investigation it was found that his prescribed dose of fluid extract of digitalis was equivalent to fifty-five drops of the tincture, a dose larger than he intended to prescribe. With such science the witch-hazel doctor will ride a high horse, and come in on the home stretch with flying colors. No singer can sing well who sings too many songs, and no beginner will prescribe well who prescribes too many medicines. This song has been sung much but not half enough, for it is not borne in mind. Many fail with a remedy simply because they have failed to master it.

Mastering the few is said to be the key to success, and the writer believes it, for he has seen it proven. An eminent physician from New York was once called in consultation to a western city. His prescription was mercury iodide, potassium iodide, and infus. gentian. He stated (and the other physician said, “I see”) that the only object of the potassium was to dissolve the mercury iodide. But potassium's great affinity for iodide accepted it, at once dropped the free mercury to the bottom, likely to be taken all at the last dose, equal to fifteen or twenty grains of blue pill. He had failed to master this remedy.

The witch-hazel doctor could not declare this time that the untaken medicine saved the patient's life, for he died before taking it. But he could smile at the prescription appropriately, were none of his own to be found on file.

Another phase of fashion reminds one of the old saying “distance lends enchantment;” for there is just as good sense in going to New Brunswick to have a boil lanced as there is in bringing syrup hypophosphates from that place.

The present pharmacopœia contains a splendid formula for this syrup—one, too, with which phosphoric acid, quinine and strychnine are perfectly compatible. A pharmacist that will not exert himself to furnish the very best article for a physician's prescription is not entitled to the physician's respect. But for a physician to expect a pharmacist to send all over town for some foreign preparation that might, in almost all cases, be better made at home, affords a weapon to retard medical science and advance the nostrum manufacturer. The more scientific physicians well know and admit that a good pharmacist can better judge of a compound than a physician, who seldom stops to test it, but prescribes it a few times and, in many cases, never thinks of it again, or, perhaps, not until he presents his bill and finds the patient's money all gone for semi-proprietary medicines that cost from fifty to one hundred per cent. more than would have paid for better compounds. Physicians will only have to examine these medicines after they have stood a year or two, and in many cases a much less time, to see the force of this argument.

Among these nostrums are found numerous preparations we could mention, including many emulsions, elixirs, etc. It is comforting to see the better class of physicians giving these nostrums a “wide berth.” Others will follow their example if they investigate and master their remedies.

Having no time to continue this rehearsal, I close with a _plea for more science, more investigation_, that we may not have to send to Buffalo for syrups of Dover powder or farther east, west or south for nostrums, but master the remedies we have, saving to the physician and patient from fifty to one hundred per cent., thus mitigating the popular cry of the high price of medicine. There should be a table of incompatibles in every medical college as prominent as the multiplication table in the schools, or pharmacists should be allowed more freedom to prepare medicines properly, instead of being held to the letter.

The writer should not complain, for he has been liberally treated by the profession in this respect; but he does not feel at liberty to add magnesia to a mixture unless so ordered. A pharmacist did this at one time in a tar-and-water mixture, gaining great praise from the physician. (Making the tar quite thin with a little alcohol, then absorbing the whole with magnesia, and emulsifying by adding the water gradually.)

BREUS' OBSTETRIC FORCEPS.

BY C. B. PARKER, M. D.,

Professor of Physiology and Lecturer on Gynæcology in the Medical Department of Western Reserve University, Cleveland, O.

The accompanying wood-cuts represent the forceps recently introduced to the profession by Dr. Breus, formerly first assistant in the clinic of Prof. Carl Braun, Von Fernwald, in Vienna.[1]

Footnote 1:

Archiv für Gynäcologie XX Band 2 Heft.

It is the simplest in construction of the so-called axis traction forceps, and is specially designed for the extraction of the head presenting high above the pelvic brim. In size, shape, curves, handles, lock, etc., it is an exact model of the J. Y. Simpson forceps—the favorite instrument of the Vienna school.

Unlike the ordinary forceps, however, it is constructed with a hinge-joint (_a_ Fig. 2) at the angle of the fenestrum with the shaft, which permits of a movement of the blades through an arc of about 40°. An elbow on the lower margin of the blade arrests the further movement in the downward direction, and a prolongation of the upper fenestrum of the blade, in the form of an arm (_b_), is continued backward parallel to the shafts. This arm turns at an angle of 100° in front of the lock and terminates in an eye, through which the split pin seen at the side of the instrument passes. The pin fits loosely in the eyes and restricts, while still permitting considerable latitude of movement to the blades. At the suggestion of several gentlemen to whom the instrument was shown, the shaft has been lengthened nearly one inch. In other respects the forceps is an exact counterpart of those now used in the lying-in department of the General Hospital in Vienna.

The principal advantages secured by these forceps are:

1. That they are best adapted to draw in the pelvic axis.

This was the special claim set up by Aveling for his Sigmoid forceps. Tarnier also, in introducing his axis traction forceps to the profession in 1877 (for an account of which see _British Medical Journal_, May 26, 1878), proves by means of diagrams and figures that, “in pulling on the classical forceps, it is impossible to make the traction exactly in the line of the pelvic curve,” and that two forces are actually exerted—one in the direction of the inferior straight, and the other at right angles to this in the direction of the pubes, while the head tends downward in the pelvic curve—the resultant of these two forces. This “vicious pressure” upon the pubes represents not only so much force lost, but also tends to injure the maternal soft parts, and can only be overcome by using the axis traction forceps. As the head descends, the pelvic curves of the blades become less and less, until, as the head arrives on the floor of the pelvis, the forceps are nearly straight. At the moment the head sweeps over the perineum the blades are still further deflected, until they form an angle with the shafts, as shown in the dotted lines of Fig. 1, thus forming the perineal curve of Herman's, Aveling's and Tarnier's forceps.

2. These forceps give the greatest permissible freedom of movement to the head during traction.

By the loose connection of the blades each possess a degree of independent movement, but always in a plane parallel to the other, so that the head may rotate during traction. The carrying out of this important principle is the chief advantage of this instrument over all other axis traction forceps.

3. An index is supplied by the arms and pin, which serves to indicate the advance and position of the head.

The application of Breus' forceps is in no wise more difficult than that of the ordinary instrument. Having disinfected, warmed and lubricated the blades, and the patient being prepared by an irrigation of a solution of bichloride, one part in 2,000, and placed in the lithotomy position, the handle of the left blade is taken up by the thumb and three fingers of the left hand (as one would hold a fiddle bow), the index finger pressing the projecting arm firmly against the shaft, as the thumb of the right hand guides the blade forward in the groove between the index and middle fingers introduced into the vagina. The right blade is then introduced in a similar manner and locked, and the pin inserted in the eyes of the projecting arms. The traction is made upon the handles in the axis of the brim, without changing its direction until the head presses on the perineum. Prof. Braun prefers, at this point, to remove the forceps and complete the delivery in the ordinary way.

The same precautions are necessary in using the axis traction as the ordinary forceps. Especially must it be remembered that, as the force is exerted directly in the axis of the pelvic curve, and none being lost, much less is required, and generally the force of one hand is quite sufficient. To avoid too great compression of the head, the compressing force should be removed by opening the lock in the interval of each traction.

Breus' forceps, after being tested successfully in all possible difficult cases—in many where the operator had failed with the ordinary forceps, as I myself have seen—is now recognized as the instrument best adapted to those cases where the head presents high above the pelvic brim.

CORRESPONDENCE.

BALTIMORE NOTES.

BY SPENCER M. FREE, A. M., M. D.,

Professor of Diseases of Children in the Baltimore Polyclinic, Baltimore, Md.

It is said of Baltimore that socially it is different from other large cities in the _freedom_ as well as the cordiality with which it extends its hospitality. The business men and their clerks are polite and attentive. They do not display the trait, so common in the metropolis, of incognizance—even to rudeness—if one chances to be on a tour of inspection instead of purchase. The impression is at once made, and very forcibly, that a Baltimorean has plenty of time, that he is not hurried. He will stop on the street and direct a discomfited stranger, and has been frequently known to turn aside from his duties and accompany the lost one to where he could take care of himself. This is a natural element in the entire populace, and is very prominent in the medical profession. A stranger is welcomed so heartily that he feels at home immediately, and can settle down among friends.

It occurs to me that this easy-going feeling has had much to do in keeping our city from occupying the prominent position in education and authorship that her opportunities, and conditions in general, would lead us to expect. I am glad to say that she is arousing from her lethargy, and recently her pen has been busy. Several works have emanated from the profession here which have attracted much attention, and have been quite extensively read. Notably among them is a 'Text-book of Hygiene,' by Dr. Rohe, and 'The Physician Himself,' by Dr. Cathell, which has reached a fifth edition and a sale of over fifteen thousand copies. I should like to say, concerning these two works, that no physician, especially if he be under thirty-five years of age, should be without them. Two other works, 'A Manual on Nervous Diseases,' by Dr. A. B. Arnold, an old, experienced and able teacher, and one on 'Practical Chemistry,' by Dr. Simon, have been much studied and commented upon. They are limited to special subjects and will not naturally obtain a large class of readers. These, like the long-delayed blade of corn, which pushes its emerald tip heavenward and bears upon its face the sparkling matin dew, give promise of a fertile soil and of abundant fruitage.