The following is the chapter on stuttering from an early text in speech therapy, written by West. It is a mimeographed and bound book in a soft, dark red cover, embossed with the title Disorders of Speech and Voice. The page which had the date of publication is missing, but it is probably the 1933 edition of West, R. (1933). Disorders of speech and voice. (2nd edition) Madison, WI: College Typing Co.
This book provides an interesting piece of early history in the professional discussion of stuttering. The section on stuttering is found in "Part III" which is entitled "Psychogenic Disorders." This section has two chapters - XI General Considerations (p. 78-89) and XII "Stuttering (Dysphemia) p. 90-98
The commonest of all disturbances of speech in the twilight zone of psychogenic disorder, discussed in the previous chapter is stuttering, or, as it is more technically named, dysphemia.*
Stuttering is characterized by sudden and frequent spasms, tonic and clonic, (usually limited to the neuro-muscular mechanism of speech, but sometimes spreading to other somatic nervous and muscular systems) during which the flow of speech is interrupted, and in the intervals between which the speech, though fluent, may exhibit vocal tenseness and even, in some cases, articulatory clumsiness. There are many carrying pictures of stuttering spasms: blocking in the explosive phase of the sounds [b], [p], [d], [t], [g], and [k]; repetition of these sounds; the holding of the fricative sounds such as "th", "sh", and [f]; the laryngeal blocking on voiced continents; the inspiratory gasps that interrupt the expiratory movements of speech. Sometimes the chief locus of the spasms disturbing speech seems to be the musculature of the face and the lips, sometimes that of the tongue, again that of the larynx, or yet again that of the respiratory machinery. Acoustically the stuttering may appear to be even a mete hesitation in the onward flow of speech.
So much for the phenomena of stuttering. Now what can be said of the inner condition of dysphemia, which is correlated with these phenomena?
If one may judge from the appearance of the stuttering as a symptom, dysphemia is aggravated by situations that arouse the emotion of fear in its various forms, -- anxiety, embarrassment, "self-consciousness", etc. When the patient is free of fear, he may be able to talk without stuttering, whether he is freed of his fear by (a) removing him from situations that arouse this emotion, or by (b) getting him intoxication so that he does not realize the potentialities of the situation, or by (c) arousing some other emotion such as anger, hate, or amusement. Stutterers find it to easier to talk to children that to adults. They can usually manage fairly well to read to themselves, or to babies too young to understand them, or to animals. They can usually whisper more readily than they can talk aloud. Many stutterers can read concert better than they can read alone. An analysis of these phenomena suggests that any situation that calls the patient's attention, and the attention of his auditor, to his speech causes the dysphemia to become worse. Situations in which it is necessary for him to make a favorable social impression are difficult for him, since such impressions are made so largely by means of speech. Situations, on the other hand, in which he uses articulate speech not as the direct means of social adjustment, but as an indirect aid to an adjustment made through a medium other than speech, render speech comparatively easy for him. Such situations are those of singing, reading in unison, counting objects, etc. A stutterer can often say a word merely as a name of a black and white symbol, when he can not utter that word in meaningful sense.
There are certain demonstrable differences between the stutterer and the non-stutterer aside from the spasms that occur during the speech of the former. The chief of these are: (1) the slowness of diadochocinesis of the articulatory muscles of the stutterer and (2) his lack of inflection of the vocal tine. It may be that the two are related; -- that the lack of vocal inflection is but an indication of a spasticity of musculature which also renders it sluggish in repetitive movements.
In slowness of diadochocinesis the stutterers are much like the spastics, (For a discussion of this phenomenon the render should refer to the numbered paragraphs on page 17.) In the attempt to analyze any case, balancing the psychogenic factors over against the psychogenic, the degree of sluggishness of the diadochocinesis can be taken as a measure of the degree to which the stuttering may be regarded as a physiological problem. As a practical measure of diadochocinesis the number per second of movements of the brow may be added to the number per second of jaw movements. If the patient can move the brow at the rate of 2.5 per second and that jaw at the rate of 4.6 per second, then his rating is listed as 7.1. The normal rating for the adult male is 9.25; that of the female is 8.15. A rating for the male of 7.00 or below should be regarded as significantly subnormal; while the rating for the female may fall as low as 5.50 before it be regarded as significantly low. The movements of the brow may easily be counted and timed with a stop watch; the jaw movements may be recorded on a kymograph, using a rubber tube between the teeth, one end of which is connected to a recording tambor, and the other end of which is closed.
The lack of inflection of the stutterers can be noted by the trained ear. After considerable experience with the stutterer, the clinician will become aware of the tenseness and inflexibility of the stutterer's vowel sounds. There is another type of monotony that should be differentiated from the inflexibility of the stutterer's voice. This other type is characterized by an even pitch throughout the whole sentence. It suggests a lack of muscular energy, -- an asthenia, -- an inability to make inflection, because inflection requires muscle contractions, and the energy is not at hand to support the contractions. The stutterer's voice, on the other hand, shows charges from word to word, or even from syllable to syllable, but reduced inflection during the utterance of a unit sound. His lack of inflection seems due not to an asthenia but rather to an inability to change one muscle set to another, to an inability to make shifts of inhibition. The normal speaker practically never holds a vowel level in pitch. His attack on the vowel is a sliding one, and he glides through it and on to the next sound with a constant change of pitch. This the stutterer finds it difficult to do. In fact, the stutterer soon learns that if he tries to make the natural inflection on sound units, he is more apt to be blocked then if he adopts a level tone. If he essays inflection, his muscles go into spasms in the movement involved in these inflections; hence he avoids them. If he avoids them completely, as many teachers of the stutterer would advocate, his speech sounds almost like that of the spastically paralyzed; hence his condition in this regard may be thought of as being half way between normal speech and paretic speech, or as wavering between these two states.
Dysphemia should not be regarded as necessarily pathological, i.e., as being rooted in the failure of some part to perform its basic biologic functions. The muscles, nerves, glands, and viscera of the stutterer may be functioning quite normally not only as separate parts of the organism but also as co-functioning parts that in their concerted action subserve the natural and innate processes of human life, -- all these conditions may obtain and yet the patient stutters. Let the stutterer be of the type who blocks on the plosive continents. Examine his tongue, jaw, velum, and pharynx. They are normal; and if not normal, their abnormality is of a sort that is not etiologically connected with the stuttering. Neurologically the patient gives no evidence of abnormality of the V, VII, XI, and XII nerves, which serve the articulatory structures. These organs perform their basic functions of chewing, sucking, swallowing, gagging, smiling, sobbing, sneezing, etc. without the slightest suggestion of impairment. Test the strength of any muscle group involved in the articulation of these sounds and it will be found normal. Examine the efficiency of organs and the body that support these muscles in their activity, such as the heart, lungs, liver, etc., and they will be found normal. Study the functioning of the cerebral cortex with any other test but speech and no abnormality explaining lingual spasms can be proved. One can go even a step farther: break up the plosive sounds into their basic muscle movements, and test the structures as to whether or not these movements can be made, and it will be found again that there is no indication of pathology. The movements of the sound [k] can be made, but when [k] is a part of a series of events in the attempt at a social adjustment of the patient, the blocking takes place.
Stuttering seems primarily social and emotional, and yet there are very definite biological backgrounds for dysphemia.
Of the prime significance in the analysis of the nature of dysphemia is the difference in its incidence in the two sexes. The ratio of stuttering boys to girls above 36 months of age varies all the way from 3 to 1 to 8 to 1. It is obvious that, whatever theory as to the nature of dysphemia one adopts, he must hypothecate some etiological factor that is related to the difference between the sexes. It is equally obvious that this difference between sexes does not directly point to any pathological factor. A second item concerning is that in the public school groups, from the age of six to the age of 10, the number of cases increases markedly, particularly among the boys; and the distribution curve shows a rapid decrease in the number of stuttering as the children approach puberty. Dysphemia appears, then, to be a phenomenon of childhood. The fact that it disappears, or tends to, when a major endocrine metamorphosis takes place, leads one to suspect that the cause of stuttering may in part involve the ductless glands.
The theory that there is some physiological factor of significance in causation of dysphemia is supported not only by these facts of distribution of cases of stuttering by age and by sex, but also by the serological findings. Certain chemical entities are found in the blood in proportions different from the established ratios. These are: (1) inorganic phosphates, (2) sugar, (3) potassium, (4) protein, and (5) calcium. Of these are first two are found in greater quantities in the stutterer's blood, while the third and fourth are found in lesser quantities. As to the fifth, calcium, though the total amount is higher than normal, that part of the calcium that is capable of diffusion through the membranes of the body is present in normal quantities. High sugar rating of the stutterer's blood may not be in any sense etiological; it may be, merely the result of the emotional turmoil in which his frequent blockings of speech involve him. On the other hand, one would expect for so constant an embarrassment as stuttering the body would make compensatory adjustments of the blood sugar production, were the sugar merely the result of social anxiety. Aside from the sugar, however, the amounts of the other four blood components mentioned above all fall within the range of health and safety, though they differ from the accepted averages. Apparently the specific amount of any one of these components is not a matter of any meaning in explaining the stuttering; it is rather the ratio of one component to another that is involved in dysphemia. In the normal blood picture, when the total calcium is increased, the amount of inorganic phosphates is decreases; but with the stutterer the amount of inorganic phosphates increases as the total calcium is increased. On the other hand, in the normal blood picture, when the calcium is increased, the protein is increased; but with the stutterers, when the calcium is increased, the protein tends to decrease. Potassium and inorganic phosphates normally rise and fall together, but they are negatively correlated in stutterers, and again potassium is negatively correlated with the protein in the blood of normal speakers, and yet in the blood of stutterers the amounts of their components rise and fall together. These findings seem to show that there are significantly different linkings between and among certain elements of the blood in dysphemia as over against those of the non-stutterer. These patients, (if they can be labeled so) seem to exhibit a different metabolic mechanism from that of the normal speaker. The difference, though unimportant in conditioning of vital processes, is of a fundamental nature and disastrously effects speech. The difference varies in degree from case to case. It seems cleat that there lies a borderline in this difference between these two biochemical types in which the appearance of the symptom of stuttering depends upon psychic factors. Persons in this borderland will exhibit no stuttering, if their mental hygiene has been fortunate; others like them will stutter at times, and at other times will speak quite normally. On one side of this borderland are a group of persons of normal biochemical type who never stutter; and one the other side are a group whose dysphemia is so marked that they stutter even when reading or speaking to themselves in complete private. It is the behavior of the group in the borderland, whose stuttering appears and disappears with changes in their social medium, that gives ride to the notion that dysphemia is purely a phenomenon of poor mental hygiene. Emotional changes probably serve merely to project the patient for a time into a condition of profound dysphemia by a temporary alteration of his serologic and hence of his metabolic and neurological picture. That this temporary alteration is a profound one is attested by the findings: (1) that during stuttering vasomotor changes take place with a decided constriction of peripheral vessels; and (2) that, apparently, during the symmetrical action of analogous muscles on the two sides of the face is somewhat disturbed, thus indicating a rather fundamental disorganization of the integrating center of the central motor system.
In summary then we should describe dysphemia as a physiologic condition of the human organism, which, though in no way disturbing the basic muscular functions, yet seriously interferes with the production of speech. It may be said with some point that the stuttering is not an unnatural phenomenon; but that speech is an unnatural function, at least, for a considerable group of humans, mostly males, whose condition may be described not as pathological, but as dysphemic.
One of the factors complicating the production of speech and doubtless facilitating the appearance of the symptom of stuttering is the bodily mechanism for reacting to situations that arouse the emotion of fear. In a very large sense, the human represents an animal type imperfectly and incompletely evolved to meet its changed environment. Human intelligence has proceeded farther in the modification of our environment, than nature has gone in the evolution of our physical and biochemical machinery. There is no reason to suppose that modern man is basically different from his barbarian ancestor. The savage has inherited from a lower form - some primate - an automatic device that cared for his safety in threatening emergencies. The peripheral vessels constrict to prevent the shedding of blood; the cardiovascular machinery is toned up, to provide a more rapid metabolism; the blood sugar increases, to provide a store of emergency fuel; the larger somatic muscles are toned up and their rate of metabolism increased to provide for exertion; the rate of breathing is increased; and the musculature of the face, jaw, tongue, and throat becomes practically spastic, in a set emotional pattern. These results are achieved through the mediation of the nervous and glandular system. Every one of these results seems to presuppose that the emergency to be provided for is one that calls for violent muscular activity, -- fight or flight.
That is the picture of the savage's machinery for meeting a situation; and that also is the machinery of modern man. The only difference lies in the sort of response that the two men find appropriate. The situation in which the savage finds himself is one in which violent activity of the grosser musculature is appropriate; but the situation in which the modern man is often caught in his social adventures is one in which relaxation of the grosser musculature of the body id desirable and skillful manipulation of certain of the finer muscles of the body is absolutely required. The savage has machinery fitted to his needs, the modern man has machinery fitted to his needs, only when the emergency is one in which he can act like a savage. When the emergency is one in which he must say calmly and quietly, "Ah, Mrs. Jones, I am delighted to meet you; may I present my sister, Miss Smith", the machinery that he inherited from the savages not only does not help him, but actually stands in his way.
Many persons, when they are flustered in embarrassment, are unable to write smoothly, play a musical instrument, or hold a cup of coffee. It is even more difficult to control the articulatory musculature in such a situation than it is to control the muscles of the arm and hand; for the reason that the musculature of the face, mouth, and throat are, more directly than that of the arm and hand, under the control of the centers of the nervous system that subtend emotional responses of the motor system, probably the thalamus and striate bodies. Thus, wherever the speech situation has an emotional coloration there arises a conflict for the control of the lower motor neuron to the articulatory musculature. Those muscles often therefore come under the dominance first of the emotional centers and then of the cerebral motor cortex. If this shift is rapid enough a decided tremor of the articulatory muscles results. Such a tremor, symptomatic of an emotional state, appears frequently in dysphemia just before the spasms of stuttering occur. Thus, since speech is so largely emotional, the dysphemic person frequently is blocked. It so happens, therefore, that the very part of his musculature that is most difficult for him to control under emotional conditions is the part that social conventions require him to use for his communication. Dysphemia would be less disastrous if man talked with his hands.
A second factor complicating the problem of stuttering is the reaction of the patient himself toward his own stuttering. Thus far in our discussion we have mentioned the factors that produce the phenomena of stuttering as symptoms of a primary cause; but there is a definitely reflexive and secondary effect of the stuttering that serves to aggravate and accentuate the symptoms. The occurrence of the spasm of stuttering caused the patient greater social anxiety than he would otherwise experience; this, in turn, makes the speech less efficient; and as soon as he becomes oppressed by the potency of this viscous cycle, a definite psycho-neurosis develops. This is spoken of as the secondary phase of stuttering. With many adults it is doubtless the larger aspect of this problem; but with children, the secondary phases may be almost wholly lacking.
In as much as the stutterer resembles the spastic in certain of his symptoms, certain of the therapeutic techniques that are used with the spastics may be used with the stutterer. Relaxation and gymnastic exercises are particularly indicated. A detailed exposition of the principles upon which these exercises should be built may be found on pages 20 and 22 of this manual. In the administration of these exercises, however, nothing should be said or done that gives the patient the notion that there is anything seriously wrong with him or that those who are working with him are sorry for him or anxious about him. The attitude of the clinician should be wholly that of the trainer who is preparing an athlete for a difficult contest. Just as a baseball coach would take great pains to correct the faults of technique of the very ordinary batting of his star pitcher, so the clinician must prepare the stutterer to meet his speech situations.
Everything possible should be done to prevent the child from becoming morbid about his failure of speech. With young children no attention should be called to the stuttering; with older persons, no nagging should be employed. Every therapeutic measure that is undertaken should be so administered that the secondary phase of the stuttering will be avoided and psychoneurosis forestalled. With stuttering improper treatment can easily aggravate the condition that it is intended to alleviate. These remarks are particularly pertinent to the use of psycho-analysis. There is no one quite so morbid and introspective as he who believes that his normal reactions are evidence of psychic traumata.
For the handling of the psychogenic aspects of the problem of dysphemia the reader is referred to the next previous chapter, (pages 78-89).
The adult patient, having developed the psychoneurotic aspect of his dysphemia, has two chances out of three against him that he will ever be rid of his stuttering. The boy of three years, on the other hand, who is properly handled so as to prevent his becoming anxious about his condition, has equal chances in his favor. It is the degree of the involvement of the secondary or psychoneurotic element in the case that determines the prognosis. No child can come up through his development, stuttering every day of every year, without becoming more or less psychoneurotic about his condition. Hence the prognosis becomes more unfavorable as the child natures. The prognosis is a great deal better with girls than with boys.