About the presenter: Steen Fibiger, Ph.D. Born 1945 in Copenhagen, Denmark. Educated at University of Copenhagen, Karolinska Institutet, Royal Institute of Technology in Stockholm, University of Stockholm, Western Michigan University, The Danish University of Education, Northwestern University, University of Helsinki. Active in Sweden, Denmark and USA since 1970 in the fields of speech science, stuttering, evaluation of speech therapy, speech therapy in Eastern Europe, epidemiology of communication disorders using twin data, and disability history. Chairperson for the Sponsored Membership Committee of the International Fluency Association, and member of the Fluency Committee of International Association of Logopedics and Phoniatrics.

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Stuttering in a Historic and Comparative Perspective

by Steen Fibiger
from Denmark

The Antiquity

Speech disorders have been described since the Egyptian Culture in the era 3,000-2,000 B.C. Also descriptions of speech disorders from the Babylonian, Chinesee and Palestinian culture are known which may include what we understand as stuttering today. From the era of Jewish culture we know the legends of Moses. Due to exegesis and lack of specific translations there is a mistaken myth about Moses as a stutterer (Fibiger, 1995). From the Greco-Roman culture we know descriptions of stuttering from the ancient writers, i.a. Herodotus, Hippocrates and Aristotle, and stuttering is attributed among others to Battus and Demosthenes, which especially concerning Demosthenes may be questionable (Fibiger, 1995). Through the era of Arabian culture the sources of Greco-Roman culture have been preserved. Like most other Indo-European languages also the Arabian word for stuttering is an onomatopoeia; in the Arabian language referring to the sound from the beak of a stork. Also in my part of the world, Scandinavia, we know from our ancient legendary history written by the poet and historian Snorri Sturluson (ca. 1230, translated in Monsen, 1990) about stuttering in the saga of the Norse King Olav Tryggvason (995-1000), verse 55.

The Middle Ages were characterized by the name reform of the Christian church which means that many people received identical Christian names in baptism. As a consequence people often had distinctive nicknames referring to a personal characteristic, which might be stuttering. Some examples are the musician, author, poet and Benedictine monk at the Abbey of Saint Gall in modern Switzerland, Notker Balbulus (Notker the Stammerer) who lived 840-912, the Byzantine emperor Michael Balbus (820-829) and the French king, Louis le Bègue (877-879).

From the Age of Enlightenment, beginning in the middle of the seventeenth century, to the establishing of the modern health services, beginning in the middle of the nineteenth century, we assume that quackery may be of some importance in relation to cure of stuttering. At the end of this quackery era stuttering therapy was developed with inspiration from some of the quackery methods. At the end of the eighteenth century also psychologists and phrenologists became interested in stuttering. (note: Phrenology is a defulnct field of study, once considered a science, by which the personality traits of a person were determined by "reading" bumps and fissures in the skull, developed by the German physician Franz Joseph Gall around 1800).

Modern Time

Before the middle of the nineteenth century scientists of modern surgery in France, Germany and England became interested in surgery of the tongue as a cure for stuttering. After two decades -- with no cure, many infections and some deaths -- those operations disappeared.

Combe (1826) elaborated his theory on stuttering from the phrenology science. It is a very complex theory relating to a conflict of the active faculties resulting in a plurality rather than a unity of functioning to the nervous impulse leading to a conflict in the transmission of energy to the peripheral speech mechanism, which in turn leads to a plurality of action in speaking and a lack of synchronization between language and thought. At the same time the medico-pedagogic emerged, partly as a further development of the methods used by the quacks, but also based on the Swiss Rudolf Schulthess (1830), who stuttered himself. Following that, didactic training therapy was elaborated and quackery reduced. The parts of the speech apparatus which were objects of training therapy were the tongue, the lips, the larynx, or the respiratory organs. Mistress Leight from Edinburgh was a very important person in the transition from quackery to didactic training therapy. She moved in 1825 from Edinburgh with the secret method of Mr. Broster to New York, and from New York the method was retransmitted back to the continental Europe (Arzneiliche, 1828; Magendie, 1828 & Zitterland, 1828). Her method was secret; but it was reported that the method was focused on rapid moving exercises with the tongue.

During the nineteenth century stuttering was explained

  1. on the background of a congenital malformation in the speech apparatus
  2. as a disorder in the peripheral or central nervous system, or
  3. as a malfunction in the respiratory organs.
At the turn of the nineteenth century, Adolf Kussmaul and Herman Gutzmann explained stuttering as a spastic coordination neurosis, and treatment was based on training vowels, regular and slow speech, and thinking before speaking (Kussmaul, 1877 & Gutzmann, 1898). Emil Frôschels, practicing in the middle of last century, was the last one from Central Europe advocating, that stuttering is caused by malformation in the speech apparatus. He was known for the use of chewing-excercises (Froeschels, 1948).

The opening of a school of eloquence by Mistress Leigh in 1825 in New York established an American tradition for almost 100 years. Until the end of the nineteenth century the American philosophy was a slight echo of the European philosophy. The well-known surgeon from Harvard University, Edward Warren (1804-1878) was the first American, who wrote about Stuttering (Riber & Wollock, 1977). Some of his theory was very close to modern theories proposed by Grandjean et al. (2008) stating that the developing embryo and foetus are extraordinarily susceptible to perturbation of the intrauterine environment, suspecting that unique environmental factors in the periods of embryonic, foetal and infant development might play a role for the development of a debility of the nervous system leading to stuttering (Fibiger et al., 2008 b). Relating to the literature at that time Warren did not mention Combe, but his ideas were close to the phrenology views of Combe (1826), and also involving psychological factors. The schools of eloquence, first established by Mistress Leight, continued with some kind of variance for almost 100 years. One of the schools was the Vocal and Polyglot Gymnasium in Philadelphia run by the physician, Andrew Comstock (Comstock, 1841; Jonas, 1976; Rieber & Wollock, 1977). Comstock regarded stuttering as a psychological problem in most cases and peripheral muscles inability to obey the commands of the volition. Therefore movement of all muscles in the body, beginning with respiration exercises, forced sounds, words, and sentences were parts of his eloquence treatment. He did not mention Warren, although their positions were compatible, but he praised James Rush (1827) for his system of elocution. One of the latest schools of eloquence operating in Pittsburgh at fin du siècle (note: French for 'end of the century; was a cultural movement between 1890 and the beginning of World War I. The term commonly encompasses both the closing and onset of an era, as it was felt to be a period of degeration, but at the same time a period of hope for a new beginning) was the school of "Dr. J". He also included vibration of the larynx, hot baths, hot drinks, eating yeast and prayers. Some of his treatments were regarded as medical treatments, but he was not a physician; he was however ordained. Therefore nobody could question his use of prayers (Jonas, 1976).

Beside the schools of eloquence in the nineteen century, this century was also characterized by a development of technology in the U.S. Several mechanical devices for cure of stuttering were invented, but no evaluation of any of the devices had been made. Some of the devices prevented certain physical actions, such as clamping of the teeth, improper movement of the tongue, and improper breathing; others strengthen or weaken certain muscles. Bates (1854) developed the first device, a silver tube which extends the length of the tongue and passes between the lips. The action is described as allowing free passage of air, even when the tongue is pressed against the roof of the mouth or teeth, and speech is prevented by an undue or spasmodic action of the muscles tending to stop the air (Katz, 1977).

The twentieth century

Speech therapy in the continental Western Europe developed as a paramedic discipline, primarily in Vienna by Frôschels (1913) under the German term Logopädie, and speech correction was established in some German cities.

As in Germany, speech correction was also established in the U.S. by some of the public school authorities in the big cities. Also environmental therapy was proposed where speech correction exercises were replaced by teaching topics of interest for the children. Later on the European studies concerning left-handedness inspired the neurologist S.T. Orton (1927) and the speech therapist Lee Edward Travis (1931) to propose that stuttering be explained as lack of cerebral dominance. This theory persisted only for a few years until university students who stuttered themselves went into the speech correction courses at the universities. One of those students was Wendell Johnson. During his education in speech corrections he went for therapy with focus on trying to re-educate himself to use left-handed tools. The background for this experimental therapy was Orton who had a theory stating that people who stutter had a lack of cerebral dominance; by changing from using right hand to using left hand, cerebral dominance could be established in the right hemisphere and stuttering would disappear according to the theory of Orton (1927). In reality stuttering did not disappear after using left-handed scissors and other tools for left-handed for half a year.

Dr. Bryng Bryngelson became a professor in speech corrections 1927 at the University of Minnesota, and he got inspiration from the educational movement focusing on helping students adjust to environmental requirements. Later, he was also inspired by the book of Knight Dunlap (1932) on Habit: Their Making and Unmaking, where Dunlap distinguishing between the learning and the learned process in the formation of habits. Bryngelson's treatment was based on research; it attacked the cause of stuttering; it demanded that the stutterer learned to control the symptoms, to make the stuttering voluntary. There would be no breathing exercises, no abnormal ways of talking, and no trick movements to time the moments of speech attempts. The concept was negative practice and the idea was to eliminate unwanted habits. Bryngelson made the proposal of stutter on purpose in order to fight for a voluntary control of the stuttering spasms. In this way a reduction of anxiety for the stuttering behaviour was put in focus. Bryngelson (1935) was the first to explore non-avoidance therapy for stuttering and the use of voluntary repetitions as a substitute for the real speech blocking.

Charles Van Riper started as a stuttering client with Bryngelson in August 1929. Bryngelson's procedures were already adopted by the University of Iowa Speech Clinic when Van Riper arrived there, 1930, as a student in speech corrections. Also Bryngelson stayed temporary at Iowa for his work on a Ph. D. in speech pathology. Van Riper elaborated the idea of desensitisation of your everyday communication situations and techniques for modifying your stuttering behaviour. We do not know if this story has happened in reality, but it illustrates very well the idea of Van Riper's approach, and he liked to tell good stories:

The basic idea that led to my living a very successful and happy life came to me while hitchhiking my way home from Rhinelander, Wisconsin. I had spent a month there as the hired man on a farm, pretending to be a deaf mute because my stuttering was so severe and grotesque. I could not get any other employment. I had hoped thereby to be able to live without talking, but after a month I couldn't bear it any longer and left to return to a home where I felt I would not be welcome.

After walking several miles I sat under a tree to rest near a field where a man was ploughing. Soon an old man in a Model-T Ford pulled up beside me and he got out to talk with the farmer. I noticed that he had an odd way of speaking with many little hesitations but didn't think it was stuttering. When they finished their conversation, I accosted the old man with the thumb gesture for hitchhiking and he told me to get in the car. Then of course came the inevitable question: "What's your name, son, and where are you going?" Oh, how I stuttered when I tried to tell him with gasping, facial contortions and body jerks! And then the old bugger started laughing outrageously. I could have killed him! Seeing my anger, he said, "Take it easy, son. Take it easy. I'm not laughing at your stuttering. I've been a stutterer all my life and I used to jump around and make faces like you do but I'm too old and tired to fight myself now so I just let the words leak out. And they do!"

Well, that hit me hard. All my life I'd been trying to talk without stuttering and avoiding it and hiding it whenever I could and all that had happened was that I got worse. That old man was telling me that what I should have been seeking was a way of stuttering that would be tolerable both to others and myself, that it was possible to stutter so easily and effortlessly that it wouldn't matter, that I could stutter and be fluent anyway. The insight that I should learn how to stutter hit me like a bolt of lightning. I wouldn't just wait until I was too old and too tired to stutter hard.

It wasn't easy unlearning all my struggling and avoiding but every time I stuttered I had an opportunity to change it to a more fluent form and so I persisted. At first the gains were small and the failures many but successes, even partial successes, encouraged me. Moreover, my fears and embarrassments melted away. Most of my listeners do not even recognise that I've stuttered when I do and I probably stutter as much now as I ever have but it's no big deal anymore.

Well, that's the message I'd like to pass on to my friends of the tangled tongue. Merely accepting one's stuttering is not enough; speaking out is not enough. Learn how to stutter!"(Van Riper 1996).

Bryng Bryngelson, Wendell Johnson, and Charles Van Riper developed the so-called non-avoidance therapy approach which, as time went on, predominated stuttering therapy.

Dr. Wendell Johnson continued at University of Iowa and developed the so-called "diagnosogenic theory" of stuttering, according to which stuttering arise as a problem that involves the interaction of listener and speaker -- that is, of the speaking child and parents/supervising adults. Such excessive parental concern about imperfect speech, together with a competitive and perfectionistic parental style, and a family drive for upward mobility have been implicated in stuttering etiology for several decades (cf. Guitar, 2006 p.116-7 and Johnson, 1959 (note: Johnson presents extensive data on parents' perceptions of the onset of their child's stuttering compared with other parents' perceptions of their child's normal dysfluencies. Data from a master thesis by one of his student (Tudor, 1939) threatened to undercut his belief, which was unswerving, that stuttering is purely behavioral (Dyer, 2001; Enard, 2001; Reynolds, 2003 and Yairi, 2006)). Today we have found of particular interest a heritability factor of 0.8 for stuttering and a total of nonshared environmental factors of 0.2 (Fibiger et al. 2008 b). Nonshared factors are etiologically relevant nongenetic events that affect individuals uniquely and, to some extent, idiosyncratically (e.g., birth events, traumas or illnesses, peers influences, etc.).

After World War II anti-authoritative and anti-academic life-adjustment education programs in high schools replaced the traditional subjects of study built around what were generally called areas of living (Kliebard, 1987). As a consequence the non-avoidance stuttering approach was further developed. But after the Soviet Sputnik was launched by October 4, 1957, the academicians won again the education programs, and the National Defence Education Act was passed by the Congress on September 2, 1958. This paradigm shift also changed stuttering therapy from the non-avoidance approach to more behavioral fluency shaping programs. A reaction to this positivistic movement, the humanistic psychology, was established around 1961 (Maslow, 1962). The humanistic psychology did not get much influence on stuttering therapy except for self-help groups and psychological counselling and guidance (Graham, 1986).

In the former Soviet Union, speech pathology was a part of what was called defectology, developed by Vygotsky (1993) in 1929. Defectology has often been translated or explained as abnormal psychology and learning disability. Within this framework stuttering therapy in the former Soviet Union and other socialist East European states was developed as the so-called complex method. It might include physiotherapy, behavioral therapy, speech correction, music therapy, remedial gymnastics, logorhytmics, phonopedic breathing exercises, and medical treatment by internists, neurologists and psychiatrists (Beliakova & D'yakova, 2001; Brajovi_, Brajovi_, & Ivanau_, 1974; Nekrasova, 1975; Seliverstov, 1979; Vlasova, 1983; Volkova & Shahovkaya, 1999). Now many East-European countries have entered a process of transitional integration, and stuttering therapy and education of professionals in Eastern Europe are currently undergoing a positive and multifaceted development where internationally stated positions have been adopted (Fibiger et al. 2008 a).

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Thanks to Ms. Bodil Frolund, Richmond, Virginia for her valuable proofreading.

You can post Questions/comments about the above paper to the author before October 22, 2008.

July 30, 2008
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