peared at the age of seven. At that time his stuttering was four. It did not vary until he graduated from high school at the age of seventeen. At this time he showed marked improvement and his stuttering was only one. For a year, while he was working in a hardware store as a clerk, his speech continued unchanged. Then the work grew irksome and the speech defect began to get worse, going from one to six. He received treatment for his speech at this

time from a careful and sympathetic teacher, and the defect went

down to one. He became a station agent and as this work caused a great deal of strain his speech defect went up to four.

For two years while he worked as a drayman his stuttering remained the same. When the war came he was denied enlistment because of his speech defect; but in three months his speech became entirely normal. He joined the army at the age of twenty-five, and was sent to France where he was a runner carrying messages from one company to another. For six months he served much of the time under fire without any speech trouble at all. Then his divi

sion moved into Germany and the patient's speech defect began to get worse. He was bored and homesick. His speech defect got so bad that he could not carry on his army duties and it reached its maximum amount of continuousness at ten.

The patient was admitted to the hospital, sent back to the United States, and placed in a veterans' hospital. He was treated for a year by psychotherapy and his speech defect dropped back to one. He was discharged as very much improved. Six months after leaving the hospital his speech defect had gone up again to five, but at the end of a year he wrote and said that his speech was perfectly normal. He is now successfully employed.

TREATMENT OF STUTTERING

In general, the treatment of stuttering may be divided into the following heads: (1) physical hygiene; (2) mental hygiene; and (3) speech training.

To begin with the third of these, it may be said that the work in speech training is quite simple. Articulatory exercises should never be used, as they are not only useless but also harmful. Some teachers find vocal and breathing exercises helpful, but we have stopped using them altogether. Exercises for relaxation are given whereby the control of the cortex of the brain is established over the lower nerve centers. While the individual is in this relaxed state he is asked to talk naturally; and through physiological training and through suggestion is built up a new set of speech habits and a new attitude of confidence toward his speech. Later on, as the individual improves he is placed in classes where the members talk informally, carry on discussions, and act in plays. Drawling, queer tones, waving the hands, and such devices are never used.

As to physical hygiene, the child's sleeping conditions are so arranged that he sleeps alone, that he gets fresh air, and that he gets sufficient hours of sleep. In the case of the nervous child we also have him relax after luncheon and after dinner. In very nervous cases we have other periods of the day set aside for rest and relaxation. The diet of the child is important. The majority of children who stutter require special attention as to their food. Out of three hundred cases of stuttering one hundred and ninety-three

were found to be finicky about their food, and two cases were neurotic vomiters. Finickiness about food in most cases means finickiness about other things. Moreover, a child who is finicky about his food is likely to be poorly nourished. Children who do not eat enough green vegetables may have a vitamine deficiency, which may make for irritability of the nervous system. For these reasons, then, great stress is laid on developing normal appetites in these children. Care is taken to see that they get the proper amount and kind of exercise. If there are any physical conditions which make for irritation, such as diseased tonsils or infected sinuses, they are corrected. Tonsils should not be removed unless they are diseased. Sometimes operations are performed only because the physician believes that removal of the tonsils will cure stuttering.

The work in mental hygiene falls under two heads: (1) reeducation of the individual's emotional life, and (2) reorganization of the individual's home and school life.

In the case of the stutterer we find feelings of timidity, fear, anxiety, and sometimes specific mental conflicts that give rise to the hysterical type of stuttering. These difficulties are discussed with the child in such a way that he can understand them; and ways are pointed out to him whereby he can win success and find a healthy outlet for his normal desire to make friends. We especially try to see that the child gains some success at home, in the school, and on the playground.

The home life is studied to see if the parents treat the child with too much tenderness or too much harshness. The parents are urged to maintain consistent discipline, to teach obedience, but to avoid unnecessarily suppressing the child's natural instinctive urges. The child must be taught to play; to get along with other boys and girls. He must be allowed to rough it and must not be "babied" too much. In the school, the teacher should be asked to stimulate, and to praise the child when he deserves it, but not to permit him to get out of things because of his stuttering.

The problem of stuttering can best be met in public schools by properly trained teachers of speech correction. These teachers should be social workers with training in psychiatry, and having a special knowledge of the mechanism of speech and the ability to reëducate children with emotional difficulties. The teachers should be supervised by a psychiatrist.

The best type of organization maintains a child guidance clinic in the school system, from which the work of the teachers of speech may be coördinated. The children who stutter should be taken in small groups and given treatment daily. Part of the time each day should be devoted to individual work and part to group work. In the group work the children should be asked to tell stories, and to have games requiring speech, such as playing store and selling tickets. The object of this work is not to train in public speaking nor in speech, but is to teach the children to adjust themselves to the group. The teachers of speech should not confine their work to the schools, but should visit the homes and arrange the child's life in such a way that he will develop the emotional poise and confidence necessary for correct, smooth speech.

A great deal of the efficiency in the speech training depends upon the personality of the worker. Sometimes people with good personalities cure stutterers of their symptoms solely through the suggestible influence of their personalities. This explains why people with such various methods or no methods at all get results in certain cases. The results in such cases are always unsatisfactory, because the emotional attitudes are likely to remain, and under strain the symptoms of stuttering return.

Sure results can be obtained only through complete reeducation of the stutterer's emotional life so that he understands himself and is able to meet life without fear and without anxiety. When this emotional reeducation has been accomplished, the speech defect will take care of itself.

SPEECH DEFECTS OTHER THAN STUTTERING

T

MARGARET GRAY BLANTON 1

HE speech surveys of a number of years ago not only contained a large number of names for the various disorders of speech, names which seemed to be overlapping, but these names were so lacking in descriptive quality that it was impossible to tell from the terms used what defects of speech were meant. "Poor speech," for instance, might mean any defect, including dialectal speech, or bad grammar. In connection with our own survey, therefore, we undertook to formulate a descriptive terminology, stating that our proposed terminology was tentative and on trial. We have, in fact, found it very serviceable, with the exception of the term "letter substitution" which has been changed to "lettersound substitution." 2

This classification is: (1) delayed speech; (2) stuttering, which includes stammering; (3) letter-sound substitution; (4) oral inactivities; and (5) vocal difficulties.

For the purpose of classification, it is necessary to divide the disorders into clear-cut and distinct groups, though a speech defect in which some other speech defect does not play at least a secondary part is very uncommon. Oral inactivity often accompanies stuttering, and letter-sound substitution often accompanies oral inactivity. But, for purposes of study and with this reservation, the defects may well be classified as above.

As Dr. Blanton's article is a study of stuttering, I will not discuss that disorder except in so far as it is sometimes a complication of the other disorders. Nor will this article attempt to deal with the speech disorders resulting from paralysis and aphasia.

'This work was done in collaboration with Dr. Smiley Blanton at the Speech Clinic of the University of Wisconsin.

'For this modification we are indebted to Miss Sophie A. Pray of New York City.