E. J. BOOME, M.B., Ch.B., M.R.C.P., D.P.H., Divisional Medical Officer, L.C.C.
Stammering is no longer regarded as a defect of the speech apparatus but is now definitely recognised as a nervous disorder. 1 could go further and add that in many cases it amounts to a disorder of the whole personality affecting behaviour, temperament and outlook. On investigation of cases it will be found in probably every instance that there is a neuropathic inheritance, by which I do not mean insanity or mental deficiency but nervous instability in some form or other. Frequently one or other parent is said to be nervy or highly-strung." In the Great War cases of shell-shock rarely occurred unless with a similar neuropathic history, and so may be considered on parallel lines with stam"
The determining cause of a stammer in many cases has been the repression of some concrete or imaginary fear or dread which can be dispelled by discussion. Puberty is seldom a determining cause since the stammer usually starts long before. However, it very often results in a definite relapse which may continue until the disturbing elements have resolved themselves. The acute self-consciousness induced by the change of voice alone is often enough to upset the stammerer's nervous equilibrium.
Self-consciousness is in any ease the lot of the stammerer, and it is not the only symptom adding to his difficulties. He is often emotional and easily upset, he goes about in continual fear of ridicule, he is "accused of being badtempered perhaps, or lazy. Worst of all is the sense of difference from his fellows and the general feeling of inadequacy induced by his inability to express himself. This sense of inferiority is not confined to his speech; it gradually colours his whole conception of himself. His appearance and manner are eloquent of his poor opinion of himself. He may hide himself as much as possible and never speak unless forced to do so, keeping in the background and avoiding responsibility, or he may be boastful and noisy, adopting an attitude of defiance that is just as much an indication of the inferiority sense. Constant fault-finding and discouragement will very rapidly undermine a child's self-confidence, and one whose manners, appearance or achievements arc the subject of continual criticism can hardly fail to develop an inferiority "
anxieties and fears, however small, take their toll of later react dcletcriously. Apart from this the present-day life is likely to increase any existing nervous tendency. One cannot help feeling that these conditions may be the factors underlying the increase in the incidence of stammering. There has certainly been a greater number of female stammerers recently than was observed ten to fifteen years ago. Some years back I was informed by a leading Japanese that authority stammering was practically unknown in his country. A recent returns 2% stammerers in the Japanese Army. report
mental energy and stress and strain of
Stammerers are never wholly free from fear, although many are so unconscious of the emotion as to deny its existence. Seth found at the University Psychological Clinic for children and juveniles in Edinburgh that it was possible on the basis of physiological symptoms alone, as revealed by the medical exambe to ination, reasonably certain of the presence of chronic anxiety in some Dreams and the like raised the proportion of cases of the cases. 30% showing of some degree anxiety, i.e., of irrational fear not specifically related to the act of speech, to about 50%. These figures arc borne out by investigations in London. Stammering in the past was frequently regarded as a sign of mental deficiency, and this view is still held by a small minority to-day. I would say that stammering is scarcely, if at all, more prevalent among amcnts and dements than it is among the normal population. In the ament, who is at best an unfinished product, the speech control is deficient in the same way as is his physical and mental make-up. When stammering exists in the mentally defective it will usually be found in one of the higher grade neurotic types. One of my duties is to examine these
mentally defectives, and in the of cerebral examining paralysis, often very high grade mentally, the general muscular spasm and athetosis aroused is often very noticeable. As with a stammer, the more difficult the test the more marked the spasm. course
Lefthandedness The connection between lefthandedness and stammering has been overstressed. In 1930, in the L.C.C. Annual Report, Miss M. A. Richardson found that the number of lefthanded children among normal speakers would appear to be double the number found among stammerers. Dr. Christopher Tibbits, School Medical Officer for the Nottinghamshire County Council Education Committee, in a very interesting report (1933) on Lefthanded Children," The proportion of stammerers is therefore greater in the whole school says: population than in the left handed fraction of the school population." This inquiry which is to be continued over a number of years will be followed with great interest. "
Prophylaxis In any discussion
concerning the treatment of stammering, prophylaxis place. Many a stammer has been confirmed by the attitude wrong adopted by parents or teachers, whereas, if rightly treated in the initial stages it might never have developed. How many children, for instance, develop a species of stammer during the process of learning to talk! One might call this type of stammering purely physiological. The explanation of it is simple. The child's mental processes are in advance of his powers of muscular co-ordination. He will try to speak as quickly as he can think, and the resulting confusion in the still developing speech mechanism is almost inevitably a species of stammer. If undue attention is drawn to the difficulty, or constant correction or ridicule applied, the child will become nervous. Very soon the act of speaking will be associated with anxiety and with the fear of making mistakes. By this time the stammer will have become firmly estabseems to me to
lished with its attendant symptoms of tension, over-effort and
All this might have been averted by rational treatment such as the prevention of undue excitement, plenty of rest and sleep and above all by not focusing the child's attention on his difficulties. Treatment number of writers on Stammering admit that it is a nervous disonly offer speech training as a cure. Stammering is not an organic speech defect. Elsie Fogerty says : When a child suffers from a lisp or tongue-tie, he will make the same mistake invarion the same sound. He should be educated or trained by careful repetition ably sticks on one to make these sounds sometimes properly. But the stammerer him letter, sometimes on another and sometimes not at all. Let go and play in a room by himself and he will probably talk without any difficulty to himself. So, too, in acting or reciting. What we have to do then is not to reeducate the child in speech, but to take away the difficulties which prevent him from using his power of speech."
We can say that we have at least some approach to the cure, because we know that it is a nervous condition and not an organic defect of the speech apparatus. This is a great stride after the speech training methods of the past which usually did not alleviate and frequently aggravated the trouble. The present therapy tends to ignore the spoken word instead of emphasising the stammerer's obsession with it by speech gymnastics. Articulatory exercises may induce a temporary improvement, sometimes amounting to an apparent cure, but they do not, as a rule, result in a permanent cessation of the trouble. The reason for this is that such exercises can in no way reach the cause of the condition, nor can they release the tension caused by the nervous or unstable state of the patient. The only thing that can help the sufferer to recover mental and nervous poise without any danger of increasing his difficulties is muscular relaxation. There is nothing new in the principles of relaxation. It is an art that has been known and practised for centuries but it has gradually been lost in these days of rush, hurry, anxiety and stress. It is an art that needs re-learning and is essential for the alleviation of the symptoms of highly-strung individuals, whether they suffer from stammering or some other nervous complaint. Such patients have to be taught how to let go," often almost muscle by muscle, until that state of relaxation is reached when the real work begins. It is at this stage that the true curative powers of relaxation manifest themselves by a general, all-round improvement in the patient. This curative value of relaxation is unfortunately not sufficiently recognised to-day. It looks so easy when a class of children is seen practising it, that it is hardly to be wondered at if many visitors to a Centre for stammerers depart fully convinced that they know all about so apparently simple a method. The technique of true relaxation can, however, be very elusive and can only be successfully taught by those who have personally been through the whole process. It is not only the stammer itself that derives benefit from relaxation, in fact it is often the last symptom to yield to treatment. In the earlier stages of practice the patient usually shows improvement in general health; he finds himself able to face life more confidently; he worries less over trifles. Children very often show a marked improvement in school work or in games with the gradual increase of confidence, concentration and co-ordination. It is remarkable, too, how they will lose the habit of enuresis (bed-wetting) which has perhaps been chronic for years. Some have been known to cease the habit after the first week of attending at a Centre for stammerers. However frequent the enuresis may have been in the past it always clears up long before the patient has cured himself of stammering. Similarly, headaches, constipation, nervous debility, etc., will disappear under the influence of curative relaxation. The stammer itself, unfortunately, takes much longer to disperse, and disappointment is often felt at the slow progress of many children. Cases have been known to make little or no advance over a period of three years or more, after which time they may make a sudden and complete cure. A whole class stick in the most disheartening way for months at a time will sometimes now
only to make startling progress eventually. One has therefore learnt never to give up a case. Even when the parents do not co-operate it is still possible for many children to carry the cure through to a finish. Most parents, however little educated, wish to help, but their manner of helping often leaves so much to be desired that it remains as much of a lone struggle for the child as if there were no parental help. Where it is difficult to get into touch with the home
obtain reports from the social worker who is often instrumental persuading the parent to visit the Centre and discuss the case with the therapist. Even when the parents arc able and willing to co-operate cases can be very slow, but these are not subject to the constant stream of discouragement as are their less fortunate brothers. The question of whole time as opposed to part time treatment for stam1 am inclined to think merers in the schools is one that is sometimes raised. that the latter is ccrtainly the better. It has been found that excellent results The child's normal accrue where the children attend a Centre twice weekly. routine is hardly interfered with and he is not made to feel that he is different from his fellows. Moreover, where reorganisation of the nervous system is in progress, it is found that greater advance is made in the intervals than during the actual time of instruction, and stimulation is far more effective if intermittent than if constant. Travelling to and from the Centre by tram 01* omnibus is often a decided help in restoring confidence to a hitherto timid child. Whole time treatment, on the other hand, tends to separate the individual It provides him with the ideal environment too much from his fellows. instead of helping him to adjust to, and to deal with, the existing home conI was perfectly ditions. The result of this type of treatment is too often: all right while 1 was away but as soon as I came home I found myself stammer-
The work carried out at the Centre can be materially helped or hindered the attitude of the schoolmaster. A school where the routine and discipline by are maintained without fuss or strain will be able to report an improvement in any stammerer attending the Centre than will a school where slackness and over strictness prevail. The schoolmaster who can keep a restful atmosphere in his classroom will be doing a great deal to help any stammerer working under him. He will incidentally find this to be good for the whole class. I heard recently of several teachers who have tried the experiment of giving up the first few moments in the classroom to acquiring a sense of ease and restfulness. The results I understand are excellent. The children are attaining a higher standard of work and the teachers report a distinct decrease of strain in themselves. In cases of severe stammering it is generally found advisable to ask that the child may be excused from all oral work until he has regained some measure of confidence. This helps to obviate that state of strained anticipation in which so many stammerers live. They can sit back and divert the nervous energy hitherto used up by the ever constant dread into more creative channels. Schoolmasters arc as a rule most anxious to help. I have come across many
instances of a head teacher giving up his room to the child for practice when lie has known the home conditions to be poor and unlikely to provide any facilities for curative relaxation. Educational One is often asked to advise parents whose child proposes entering for a scholarship. The parents want guidance as to whether it is worth while, for instance, or as to whether the strain of working for and taking the examination is justified. The points to remember are: 1.
the whole does well at most examinations as the majority practical character and his speech is therefore no
than the normal
Parents and teachers should be warned that, owing to the increased strain and tension, the stammer itself may tend to become temporarily worse. The stammerer who is not allowed to enter for scholarship examinations is likely to feci thwarted and to lose confidence and interest. He feels " that he is a dud and refuses to take any further part in helping himself.
stammerer as a
the stammerer wins many scholarships, the nervous strain is great and lie should be allowed increased periods for relaxation before, during, and after the examination.
I consider that the child should be allowed to take the examinaion. His will not interfere with the written work, and if there is an oral test
examiners should be warned to deal gently with the candidate and to let him take his time. I remember the case of a medical student who had a bullying examiner and was unable to utter a sound until another examiner took him in hand with sympathy and understanding. He was then handed back to the first man having recovered sufficient poise to satisfy him. An interesting sidelight 011 the stammerer's temperament is furnished by comparing his preferences in school subjects with those of normal speakers. The comparison is made between the evidence set out by Dr. Cyril Burt and that collected from Centres for Stammerers in London. Broadly speaking, both normal speaking children and stammerers prefer the same subjects at the age of seven, but dancing comes first with both boy and
At the age of ten the stammerer is
becoming more conscious of his disability places singing higher than do those on Burt's list. It is that is also too, significant higher place given to history, literature and scripture. The attraction of these subjects lies in the opportunities offered for silent rather than for oral reading. The difficulty is deeply felt at the age of thirteen when the children are very self-conscious and when the onset of puberty frequently complicates matters. Boy stammerers place reading last on the list at this age and girls do not place it at all. There would seem to be a very definite desire on the part and
MENTAL WELFARE of both ant
Looking over the stammerer's preferences?apart from the natural objection to making to indicate that he is a fool of himself "?there is nothing O O other than normal in his outlook on the curriculum; neither do his selections indicate any tendency to mental deficiency. "
I am not disposed to believe much in the hereditary transMcMinn says: mission of stammering, as I have known several instances where the children of inveterate stammerers have never had the slightest trace of it." Some years ago I interviewed a woman with a severe stammer. She had brought her with chorea to see me. Neither this Ogirl nor her two daughter suffering O brothers, aged nine and twelve, had the least trace of a stammer and had always been normal speakers. Among 522 eases in the London Centres 179 were found with stammering in the family," but 1 am inclined to the view that the child inherits peculiar neuropathic tendencies which predispose him to stammering, rather than to the view that the actual stammer is inherited. Enquiries were made during the year 1932-33 into the familial distribution of stammering incidence. The results are given in the following table. Of 455 cases investigated, 273 were found to have another member of the family who stammered, this member being an immediate relation in 174 cases. O