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The evolution of speech therapy and stammering
218 It is possible that the legal position thus expounded may require review by the Minister's legal advisers, partly because of the forthcoming change in status of county councils and county borough councils as regards V.D., and because a new organisation--the Regional Hospital Board--will share with the local health authorities the task of contact tracing and partly because of the revocation of the Public Health (Venereal Diseases) Regulations 1916(b). I n general terms, the Minister's views on the duties of local health authorities are expressed in paragraph 49 of Ministry of Health Circular, 118/1947, which is here given in full. " T h e follow-up of persons under treatment for venereal disease, and of persons known or believed to be sources of venereal infection, should be carried out by staff closely associated with the venereal disease treatment centres, whether employed by Local Health Authorities or Regional Hospital Boards. The Minister relies on local health authorities t o co-operate in every way possible in this connection with the medical officers of the centres. He recognises that the medical officer of health of the local health authority will be concerned in the epidemiology and prevention of venereal disease." T h e Regional Consultant should endeavour to organise a full service of information about the prevalence of V.D. in the region and see that the medical officers of health in the region are kept fully informed. The Social ~urvey might be turned t o good use, not only for general information about morbidity but specially about the prevalence of the venereal diseases. Most large V.D. clinics are aware of areas in their spheres of activity from which patients, especially girls a n d young women, seem to come in greater numbers than from other districts. There is evidence in many cases of the existence of establishments sailing as close to the wind as they can without affording evidence such as would lead to conviction of their proprietors for keeping brothels and disorderly houses. When such areas are known to the Director of the V.D. clinic, he should send the fullest information to the local health authority, which otherwise might be ignorant of the situation. What action could usefully be taken by the local health authority is a matter for hard thinking, but surely the existence of such black spots in a community could be suitably brought to the notice of the public even if one did not contemplate the Chicago expedient of putting up a notice " Syphilis here. Keep out !" T h e interest of the medical officer of health in the epidemi•ology of V.D. must be communicated by him to his Public Health Committee if effective public concern is to be aroused. It is always necessary to bear in mind that, especially in peacetime, V.D. has little political kudos. A councillor of a local authority m a y in his election campaign bring tears to the eyes of his hearers when he talks about his interest in and what he has done or will do for the babies and the mothers, and OUt of the tears may come forth m a n y votes. Laymen who have come to terms with their inhibitiorls sufficiently to talk to the public about V.D., are in any case rare, and if any such become candidates for election to local councils they may be persuaded only too easily that the sentimental tear for M. & C.W. is mightier than the shamefaced blush for V.D. The medical officer of health, as all of you know only too well, has a hard job first to educate and then to induce energetic interest in the members of his Public Health Committee. For V.D. this may well be the hardest n u t for the medical officer of health to crack, but let him not easily give up on the plea that his committee is unteachable for it may be that the fault lies in the teacher. As Dr. J. A. Charles stated at a meeting in July, 1946, of the County Borough Medical Officers of Health Group, the medical officer of health is the epidemiologist par excellence for his area, and further, has responsibility under the Act for the health and social welfare of the whole population. These functions obviously give the medical officer of health a foremost position in grappling with the social and epidemiological problems of the venereal diseases. Paragraph 49 of Ministry of Health Circular 118/1947, which I quoted earlier, appears in that part of the Circular
PUBLIC HEALTH, August, 1948 headed " Prevention of Illness, Care and After-Care," and sets out the Minister's views on local authorities' duties and responsibilities under Section 28 of the National Health Service Act. Under this heading there are paragraphs numbered 37 to 50, of which paragraph 37 is introductory, and paragraph 50 is about recovery of charges from persons who have availed themselves of services provided by local authorities. I n Appendix E to the Circular an outline is given of the way in which local authorities should frame proposals for carrying out their duties under Section 28 of the Act. T h e venereologist will observe with cynical eye that paragraph 49 on venereal disease is the only one of paragraphs 38 to 49 which is not mentioned in Appendix E. Public Health is just celebrating its first hundred years; the Venereal Disease Service has just entered its fourth decade. Less than a hundred years ago public health was the Cinderella of medicine, but a long series of your distinguished predecessors headed by Simon, Farr and Chadwick, have played the part of the good fairy. T h e V.D. Service is still the Cinderella. T h e present transitional phase in the Health Service offers a unique opportunity to venereologists to think and act with vigour and foresight in order to give the V.D. Service a new look and nothing would be more fitting than that medical officers of health should extend a helping hand to those who have inserited from them the rags of Cinderella.
THE EVOLUTION OF SPEECH T H E R A P Y AND STAMMERING * By E. J. BOOME, M.B., ~t.R.C.P., D.P.H., F.C.S.T. Formerly Principal Assistant Medical Officer, London County Council Disorders of speech have been noted by writers of all ages. Perhaps one of the first was Celsus, first century~ A.D., who says : - " When the tongue is paralysed, either from a vice of the organ or as a consequence of another disease, and when the patient cannot articulate, gargles should be administered of a decoction of thyme, hyssop, pennyroyal ; he should drink water, and the head, the neck, mouth, and the part below the chin be well rubbed. T h e tongue should be rubbed with lasserwort, and he should chew pungent substances, such as mustard, garIic, onion and make every effort to articulate. He must exercise himself to retain his breath, wash the head in cold water, eat horse radish, and then vomit." During the nineteenth century French surgeons thought that stammering could be cured by cutting off portions of the tongue. This proved disastrous. I n the British Museum there are painted masks used by the " devil dancers " of Ceylon for the cure of various diseases, including stammering and deafness. It was not until comparatively lately that the seriousness of these troubles was recognised by the medical and educational authorities of this country. I n 1912 the first Conference of Speech Training was held in London. Dr. Criehton Miller read a paper on stammering which first formulated the theory in England of the psychological causation of stammering. Also in this year, the late Miss Elsie Fogerty, in conjunction with authorities of one of the largest London hospitals, was responsible for the opening of one of the first clinics for speech disorders. Several other hospitals started speech work about this time. In 1918 the London County Council opened its first four centres for stammerers ; during the next few years the n u m b e r was gradually increased, until to-day there are 12 centres for primary and one for secondary pupils. I n 1931 the Central Association of Mental Welfare appointed a travelling speech therapist. I n addition to the speech work among mentally defectives, she advised upon children suffering from various forms of defective speech in schools under the local education authorities. As a result of this work, more and more authorities in the provinces appointed a whole or part-time speech therapist. *Abridgement of an address to the Refresher Course for School Medical Officers, London, April 7th, 1948.
PUBLIC HEALTH, August, 1948 In June, 1933, the Stockton Education Committee submitted the following resolution to the Association of Education Committees Conference at Brighton : " T h a t in view of the serious handicap to children with defective speech (stammering, etc.), and of the success that has attended the efforts made by certain education authorities to remove such disabilities, the Executive Committee of the Association of Education Committees be urged to press upon the Government the desirability of making provision for meeting the special needs of such children compulsory." This might be looked upon as the Charter of Speech Therapy. In 1942 the British Register of Medical Auxiliaries recognised speech therapists and admitted them to a National Register. " Only persons employed a s speech therapists approved by the Minister of Education are those who have been admitted to the Register of the Medical Auxiliaries." E l e v e n years after the Brighton Conference, in 1944, the Education Act, Section 34 (i) made it the duty of local authorities to ascertain and treat these cases. This was clarified by the Handicapped Pupils and School Service Regulations, Circular 41, 1945, and No. 1076, Statutory Rules and Orders. T h e attention of the meeting was drawn to the International Speech Conference to be held in London at the Royal Society of Medicine on September 20th, 21st, 23rd and 24th, 1948.
219 if the child does not hear speech he cannot learn to speak himself. Disorders Affecting the Development of Speech Deafness. Complete or severe deafness does not come within the province of this paper, but I should like to emphasise the importance of discovering as early as possible whether a child suffering from delayed speech has any difficulty in hearing. No sound can be imitated unless it is heard correctly. T h e r e are certain types of deafness which are not organic but probably of neurological origin. High-Frequency Deafness. T h e child can not hear the highpitched sounds, i.e., S . Z . F . T H . S H . C H . Low-Frequency Deafness. T h e child can not hear the lower sounds. It will not be necessary to point out the difficulties of learning to speak to a child suffering from one of these disorders. During the war, a child came to one of the centres suffering from very bad dyslalia. In addition to his speech trouble, he was highly nervous ; he cried very easily and had fits of temper and obstinacy. He was quite intelligent but was very backward in all scholastic subjects. His general condition improved slowly under treatment, and his speech also improved. He was terrified of doctors and dentists (his teeth were rather uneven), but the various doctors who had seen him in London and during evacuation all said his hearing was perfect. I had the temerity to disagree with these members of your learned profession, and after a good deal of persuasion I got him to go to County Hall, where he saw the E . N . T specialist, who diagnosed him as a case of high frequency deafness.
A Few Notes on Stammering Stammering versus Stuttering. - - In English literature " stammering " has been used for 500 years,whereas stuttering is Low German and has only been in use for the past 100 years. T h e importance of Adler's work is emphasised, as according Congenital Auditory Impereeption to his theory neuroses and psychoses are the results of unsuccessful compensation. Wendell Johnson, in his book, In this disorder, a child can hear perfectly, he also makes " Because I Stutter," wrote : " Stuttering is a constant mental -attempts to imitate the words he hears, usually incorrectly, and physical pain, and although the stutterer learns in time to but he does not understand the meaning of the words. It is regard this pain nonchalantly, it remains important and can ascribed to developmental failure of the speech centres. never be wholly disregarded." It will be clear that a child suffering from any of these disTw o cases of stammering were quoted showing the influence orders will not develop speech at the normal time, but other of domineering elder brothers. causes for delayed speech are illness, mental deficiency and shock. As regards the latter, if a child on beginning to speak Treatment of Stammering has a shock it may stop the speech for a time. I saw several I am of the opinion that psychiatric treatment alone is inyoung children during the war who had suffered from blast sufficient for the alleviation and cure of stammering. Th er e or bomb shock, and the speech had been stopped. In many of must be muscular relaxation in addition. This is something these cases the speech developed normally after a period of rest, the patient does for himself and acts as an anchor. but in some cases it reappeared with a stammer or very bad Th e method of treatment to be followed should be relaxamultiple dyslalia. tion and personality adjustment. This means the treatment T h e r e is no fixed time for the beginning of speech, some of the stammerer and not of the stammer. T h e aim should children say words before they are a year old, others say hardly be to distract the stammerer's attention from speech rather anything coherent till they are nearly two. T h e normal child than to emphasise what is already an obsession. spends this period babbling in a language of his own and is T h e question of group treatment versus individual was preparing for comprehensive speech. also discussed. Baby talk is natural up to a certain time ; a child eliminates In conclusion, I would point out that other nervous condi- the sounds he cannot say, and then, as the muscles acquire tions, e.g., enuresis, headaches, raised blood pressure, etc., more power he learns to say them. Some sounds are later in respond to the benevolent and curative practice of relaxation. appearing than others, f o r example, " r," which requires particular co-ordination of the tongue muscles. When baby talk goes beyond the right time it becomes a SPEECH DISORDERS AND RELAXATION * defect, and should be treated as such. By HONOR BOOME, F.C.S.T. May I here put in another word for the crying necessity of Normal Development of Speech smaller classes in infant schools. A child of five should have Pre-linguistic Babbling. T h e baby exercises all the muscles a good working vocabulary and be able to pronounce most of the simple consonants, though probably not all the comrelating to speech. pound ones. There are, however, many cases of children Hearing and Understanding. T h e child must first hear the arriving at school whose speech is almost unintelligible--not sound, then understand and finally attempt to make it. It is impossible to over-estimate the importance of a good from any disorder but simply as the result of a bad pattern at pattern for the child to hear and copy. I am not referring to home. Quick staccato speech may be as bad for a child as slurred accent or dialect but to the fact that what is said to the child must be clearly and slowly articulated so that it is easy to slovenly speech. On going to school the child will probably hear a new pattern imitate. and may become confused. I f the class is very large and indiSome mothers, in their anxiety to keep a child quiet, think that it is better not to talk to him. This is a great mistake, as vidual attention can not be given to help the child in its initial difficulties, more serious trouble may arise. A good teacher with a sinai1 group to handle can help the Abridgement of an address, accompanied by a demonstration of relaxation methods, to the Refresher Course for Schbol Medical child over this difficult period and the speech will develop on Officers, London, April 7th, 1948. the right lines.
PUBLIC HEALTH, August, 1948 headed " Prevention of Illness, Care and After-Care," and sets out the Minister's views on local authorities' duties and responsibilities under Section 28 of the National Health Service Act. Under this heading there are paragraphs numbered 37 to 50, of which paragraph 37 is introductory, and paragraph 50 is about recovery of charges from persons who have availed themselves of services provided by local authorities. I n Appendix E to the Circular an outline is given of the way in which local authorities should frame proposals for carrying out their duties under Section 28 of the Act. T h e venereologist will observe with cynical eye that paragraph 49 on venereal disease is the only one of paragraphs 38 to 49 which is not mentioned in Appendix E. Public Health is just celebrating its first hundred years; the Venereal Disease Service has just entered its fourth decade. Less than a hundred years ago public health was the Cinderella of medicine, but a long series of your distinguished predecessors headed by Simon, Farr and Chadwick, have played the part of the good fairy. T h e V.D. Service is still the Cinderella. T h e present transitional phase in the Health Service offers a unique opportunity to venereologists to think and act with vigour and foresight in order to give the V.D. Service a new look and nothing would be more fitting than that medical officers of health should extend a helping hand to those who have inserited from them the rags of Cinderella.
THE EVOLUTION OF SPEECH T H E R A P Y AND STAMMERING * By E. J. BOOME, M.B., ~t.R.C.P., D.P.H., F.C.S.T. Formerly Principal Assistant Medical Officer, London County Council Disorders of speech have been noted by writers of all ages. Perhaps one of the first was Celsus, first century~ A.D., who says : - " When the tongue is paralysed, either from a vice of the organ or as a consequence of another disease, and when the patient cannot articulate, gargles should be administered of a decoction of thyme, hyssop, pennyroyal ; he should drink water, and the head, the neck, mouth, and the part below the chin be well rubbed. T h e tongue should be rubbed with lasserwort, and he should chew pungent substances, such as mustard, garIic, onion and make every effort to articulate. He must exercise himself to retain his breath, wash the head in cold water, eat horse radish, and then vomit." During the nineteenth century French surgeons thought that stammering could be cured by cutting off portions of the tongue. This proved disastrous. I n the British Museum there are painted masks used by the " devil dancers " of Ceylon for the cure of various diseases, including stammering and deafness. It was not until comparatively lately that the seriousness of these troubles was recognised by the medical and educational authorities of this country. I n 1912 the first Conference of Speech Training was held in London. Dr. Criehton Miller read a paper on stammering which first formulated the theory in England of the psychological causation of stammering. Also in this year, the late Miss Elsie Fogerty, in conjunction with authorities of one of the largest London hospitals, was responsible for the opening of one of the first clinics for speech disorders. Several other hospitals started speech work about this time. In 1918 the London County Council opened its first four centres for stammerers ; during the next few years the n u m b e r was gradually increased, until to-day there are 12 centres for primary and one for secondary pupils. I n 1931 the Central Association of Mental Welfare appointed a travelling speech therapist. I n addition to the speech work among mentally defectives, she advised upon children suffering from various forms of defective speech in schools under the local education authorities. As a result of this work, more and more authorities in the provinces appointed a whole or part-time speech therapist. *Abridgement of an address to the Refresher Course for School Medical Officers, London, April 7th, 1948.
PUBLIC HEALTH, August, 1948 In June, 1933, the Stockton Education Committee submitted the following resolution to the Association of Education Committees Conference at Brighton : " T h a t in view of the serious handicap to children with defective speech (stammering, etc.), and of the success that has attended the efforts made by certain education authorities to remove such disabilities, the Executive Committee of the Association of Education Committees be urged to press upon the Government the desirability of making provision for meeting the special needs of such children compulsory." This might be looked upon as the Charter of Speech Therapy. In 1942 the British Register of Medical Auxiliaries recognised speech therapists and admitted them to a National Register. " Only persons employed a s speech therapists approved by the Minister of Education are those who have been admitted to the Register of the Medical Auxiliaries." E l e v e n years after the Brighton Conference, in 1944, the Education Act, Section 34 (i) made it the duty of local authorities to ascertain and treat these cases. This was clarified by the Handicapped Pupils and School Service Regulations, Circular 41, 1945, and No. 1076, Statutory Rules and Orders. T h e attention of the meeting was drawn to the International Speech Conference to be held in London at the Royal Society of Medicine on September 20th, 21st, 23rd and 24th, 1948.
219 if the child does not hear speech he cannot learn to speak himself. Disorders Affecting the Development of Speech Deafness. Complete or severe deafness does not come within the province of this paper, but I should like to emphasise the importance of discovering as early as possible whether a child suffering from delayed speech has any difficulty in hearing. No sound can be imitated unless it is heard correctly. T h e r e are certain types of deafness which are not organic but probably of neurological origin. High-Frequency Deafness. T h e child can not hear the highpitched sounds, i.e., S . Z . F . T H . S H . C H . Low-Frequency Deafness. T h e child can not hear the lower sounds. It will not be necessary to point out the difficulties of learning to speak to a child suffering from one of these disorders. During the war, a child came to one of the centres suffering from very bad dyslalia. In addition to his speech trouble, he was highly nervous ; he cried very easily and had fits of temper and obstinacy. He was quite intelligent but was very backward in all scholastic subjects. His general condition improved slowly under treatment, and his speech also improved. He was terrified of doctors and dentists (his teeth were rather uneven), but the various doctors who had seen him in London and during evacuation all said his hearing was perfect. I had the temerity to disagree with these members of your learned profession, and after a good deal of persuasion I got him to go to County Hall, where he saw the E . N . T specialist, who diagnosed him as a case of high frequency deafness.
A Few Notes on Stammering Stammering versus Stuttering. - - In English literature " stammering " has been used for 500 years,whereas stuttering is Low German and has only been in use for the past 100 years. T h e importance of Adler's work is emphasised, as according Congenital Auditory Impereeption to his theory neuroses and psychoses are the results of unsuccessful compensation. Wendell Johnson, in his book, In this disorder, a child can hear perfectly, he also makes " Because I Stutter," wrote : " Stuttering is a constant mental -attempts to imitate the words he hears, usually incorrectly, and physical pain, and although the stutterer learns in time to but he does not understand the meaning of the words. It is regard this pain nonchalantly, it remains important and can ascribed to developmental failure of the speech centres. never be wholly disregarded." It will be clear that a child suffering from any of these disTw o cases of stammering were quoted showing the influence orders will not develop speech at the normal time, but other of domineering elder brothers. causes for delayed speech are illness, mental deficiency and shock. As regards the latter, if a child on beginning to speak Treatment of Stammering has a shock it may stop the speech for a time. I saw several I am of the opinion that psychiatric treatment alone is inyoung children during the war who had suffered from blast sufficient for the alleviation and cure of stammering. Th er e or bomb shock, and the speech had been stopped. In many of must be muscular relaxation in addition. This is something these cases the speech developed normally after a period of rest, the patient does for himself and acts as an anchor. but in some cases it reappeared with a stammer or very bad Th e method of treatment to be followed should be relaxamultiple dyslalia. tion and personality adjustment. This means the treatment T h e r e is no fixed time for the beginning of speech, some of the stammerer and not of the stammer. T h e aim should children say words before they are a year old, others say hardly be to distract the stammerer's attention from speech rather anything coherent till they are nearly two. T h e normal child than to emphasise what is already an obsession. spends this period babbling in a language of his own and is T h e question of group treatment versus individual was preparing for comprehensive speech. also discussed. Baby talk is natural up to a certain time ; a child eliminates In conclusion, I would point out that other nervous condi- the sounds he cannot say, and then, as the muscles acquire tions, e.g., enuresis, headaches, raised blood pressure, etc., more power he learns to say them. Some sounds are later in respond to the benevolent and curative practice of relaxation. appearing than others, f o r example, " r," which requires particular co-ordination of the tongue muscles. When baby talk goes beyond the right time it becomes a SPEECH DISORDERS AND RELAXATION * defect, and should be treated as such. By HONOR BOOME, F.C.S.T. May I here put in another word for the crying necessity of Normal Development of Speech smaller classes in infant schools. A child of five should have Pre-linguistic Babbling. T h e baby exercises all the muscles a good working vocabulary and be able to pronounce most of the simple consonants, though probably not all the comrelating to speech. pound ones. There are, however, many cases of children Hearing and Understanding. T h e child must first hear the arriving at school whose speech is almost unintelligible--not sound, then understand and finally attempt to make it. It is impossible to over-estimate the importance of a good from any disorder but simply as the result of a bad pattern at pattern for the child to hear and copy. I am not referring to home. Quick staccato speech may be as bad for a child as slurred accent or dialect but to the fact that what is said to the child must be clearly and slowly articulated so that it is easy to slovenly speech. On going to school the child will probably hear a new pattern imitate. and may become confused. I f the class is very large and indiSome mothers, in their anxiety to keep a child quiet, think that it is better not to talk to him. This is a great mistake, as vidual attention can not be given to help the child in its initial difficulties, more serious trouble may arise. A good teacher with a sinai1 group to handle can help the Abridgement of an address, accompanied by a demonstration of relaxation methods, to the Refresher Course for Schbol Medical child over this difficult period and the speech will develop on Officers, London, April 7th, 1948. the right lines.