About the authors:

Daniel Hudock, Ph.D., Certificate of Clinical Competence of Speech-Language Pathology (CCC-SLP), is an Assistant Professor at Idaho State University in Pocatello, Idaho, USA. As a person who stutters himself, he is very passionate about fluency disorders and helping those with fluency disorders. He currently serves on the International Cluttering Association and International Stuttering Association website committees, is the Northwestern Regional Chapter Coordinator for the National Stuttering Association in the United States, and is a Chapter Leader for the NSA’s Southeastern Idaho Chapters. He is a regular presenter at conferences and has several publications. His research interests are exploring: the communicative process during the observation of normal and disordered speech using eye-tracking, biobehavioral and neurophysiological measures; stuttering inhibition during the perception of second speech signals; EEG temporal and spectral components for sensory and motor integration and involvement during speech perception and production; and forming effective collaborations between Speech-Language Pathologists and Mental Health Counselors for the treatment of people who stutter.

Dr. Altieri, PhD, is an Assistant Professor at Idaho State University. His research investigates speech and language perception, including the extent to which listeners benefit from visual speech under different listening conditions. He has worked to develop and apply capacity measures to investigate efficient information processing, integration, and brain functioning in normal-hearing and hearing-impaired listeners.

Author Note

Daniel Hudock and Nicholas Altieri; Department of Communication Sciences and Disorders, Division of Health Sciences, Idaho State University

Correspondence concerning this presentation should be addressed to Daniel Hudock, Ph.D., Department of Communication Sciences and Disorders, Division of Health Sciences, Idaho State University, 921 South 8^th Ave, Mail Stop 8116, Pocatello, ID 83209-8116, USA. Phone: (011) 208-282-4403; Fax: (011) 208-282-4571; E-mail: Hudock@isu.edu

Part II: The Renaissance to the start of the 20^th century

Renaissance to the Modern Era

With Johannes Guttenberg’s invention of the printing press, the church began losing its control over scientific inquiry leading to the birth of the Renaissance. Physicians and philosophers once again were able to theorize about stuttering. Geronimo Mercuriali was a notable physician of the 16^th century who adhered to the humors theory; however, he went about treating stuttering in quite a different fashion than the Ancient Greeks. In hopes of rebalancing the humors, Mercuriali prescribed changes in diet, reduced sexual activity (for the men only) and purging (Appelt, 1911 as cited in Silverman, 1996). Believing that fear aggravated stuttering he recommended other treatments specifically to address the fear components. In his well known book The treatise on the diseases of children, he recommends that stuttering not be treated until age seven, since many children recover prior to that age (Silverman, 1996). Mercuriali is the first to reference the possibility of emotion influencing stuttering. This initial influence is currently maintained in dozens of theories relating to the persistence and therapy of stuttering. These theories suggest emotional, social, and psychological influences on stuttering.

In the 17^th century, advances were made on microscope designs, which enabled researchers to do more in-depth anatomical explorations of cadavers – which were previously forbidden by the church (Bartusiak, 2006; Chapman, 2008). Further anatomical exploration lead Giovanni Battista Morgagni, an anatomist known for his work with pathological cadavers, to suggest that stuttering was caused by an inflexible hyoid bone of the larynx (Bloodstein & Bernstein-Ratner, 2007). Other Italian anatomists blamed two abnormally sized holes in the hard pallet on the roof of the mouth along with other anatomical differences (Bloodstein & Bernstein-Ratner, 2007). The technological improvements on the microscope, along with separation of religion and science, diverted perspectives about stuttering from environment and observation to theories based on anatomical findings.

However, not everyone ascribed to anatomical theories. Robert Boyle, being a PWS himself and best known for Boyle’s Law of Gases, suggested that stuttering was a learned mechanism by imitation. As cited in Kahr (1999) “Lorenzo Magalotti, who met Boyle in 1668, recalled that it ‘seems as if he were constrained by an internal force to swallow his words again and with the words also his breath, so that he seems so near to bursting that it excites compassion in the hearer’¹¹” (p. 280). In more modern times, a similar learning based theory of stuttering re-emerged in the foreground from Wendell Johnson in the 1930’s (Johnson, 1955). Additionally, Pastor Cotton Mather – also a PWS but better known for implementing smallpox inoculations, plus his role in the Salem Witch Trials in Massachusetts, proposed that stuttering was caused by divine reprisal for the sins of anger and pride (Ward, 2006). Interestingly, this time period denotes the first fracturing and dispersal of mainstream notions related to stuttering. A divide between research and application was maintained until the creation of the field of Speech-Language Pathology in the mid 1910’s (Van Riper, 1992).

In the 18^th century, Moses Mendelssohn hypothesized that stuttering was caused by too many ideas flowing from the brain simultaneously (Bothe, 2004). His psychological view of increased demands over inherent capacities did catch on for a time, although not for about a decade, and re-emerged again in the late 1980’s (Starkweather, 1987). Additionally, Erasmus Darwin, a PWS himself and grandfather of Charles Darwin, suggested in the late 18^th century that stuttering was a motoric difficulty that had become habituated due to emotional conditioning; this was perhaps the first multifactorial view of stuttering (Bloodstein & Bernstein-Ratner, 2007). Doing self-therapy, he practiced using soft articulatory contacts with repeated practice of difficult sounds, both of which are currently still employed in some therapeutic protocols. Furthermore, over practice, the adaptation effect was widely studied throughout the late 20^th century. Another major point about Darwin’s theory was that he believed stuttering was a learned response contingent on fear. Joseph Sheehan (1970) expanded on this idea that the fear to fail while speaking conflicted with the desire to speak fluently and when these conflicts were at equilibrium stuttering occurred (i.e., approach-avoidance conflict).

In the 19^th century, neurophysiology appeared as science and alternative hypotheses began to emerge. In 1817, the French physician Itard published a book stating that stuttering was caused by debility of the nerves that control the timing of the articulators and larynx. Itard’s mention of the larynx as also being deficient was the first time this notion had been proposed as a location for stuttering behaviors (Eldridge, 1968). Additionally, researchers continued to examine neural pathways to articulators and laryngeal components hoping to find invariant cues for causal agents to stuttering (Bloodstein & Bernstein-Ratner, 2007). Similar to previously discussed interventions, Itard’s treatment location differed from the proposed etiological site. His therapy targeted the tongue by placing a gold or ivory fork under the tongue to support the “weak and large tongue” (Bloodstein & Bernstein-Ratner, 2007; Hunt, 1861; Silverman, 1996). In the 1960’s through the 1990’s, the idea of the deficient larynx reemerged as a possible bearing for the occurrence of the symptoms of stuttering, although most theories also included functional brain influences (Bloodstein & Bernstein-Ratner, 2007; Wingate, 1976; Zimmerman, 1980 a,b,c).

In 1825, Madame Leigh proposed the idea that stuttering occurred due to abnormal tongue thrusts; she had clients place the tip of their tongue on the roof of the mouth behind the teeth (alveolar ridge) while speaking (Silverman, 1996). As the separation between researchers and clinicians persisted, elocutionists typically administered therapy by focusing on vocal exercises and strategies to improve tongue strength. Research turned to more physiological-based theories.

In the early 1800’s, Joseph Frank suggested that stuttering was a depraved habit caused by speaking when the lungs are out of air and that blocks occurred when the vocal folds were paralyzed during extreme contraction (Van Riper, 1992). McCormac supported this claim, when in 1828 he noted that PWS habitually spoke without adequate air in their lung (Van Riper, 1992). During McCormac’s treatment he had PWS take deep inhalations and focus on continual forced exhalation while speaking. In the same year, Arnott suggested that stuttering is caused by a spasm of the glottis (Van Riper, 1992). His therapy involved initiating each word with the “e” sound instead. (Interestingly, controlled, diaphragmatic breathing and using an “e” sound during voluntary stuttering strategies are still primary components of some behavioral therapies). Other methods of the time consisted of de L’Lsere use of a miniature metronome called a “muthonome” to pace clients’ speech while they spoke (Wingate, 1976). Metronome effects on stuttering had been extensively examined throughout the late 20^th century. On a homeopathic note, remedies for this time consisted of bleeding the lips with leaches, ingesting Finish (insect repellent used on cows) and eating goat feces (Hunt, 1861).

The year 1841 brought about a new type of treatment; Johann Friedrich Dieffenbach believed that stuttering was caused by a spasm in the glottis that migrates up the tongue, thus causing it to cramp (Bloodstein & Bernstein-Ratner, 2007; Scripture, 1913). He hypothesized that if he severed that pathway then the tongue would no longer cramp and stuttering would be cured. His first procedure was performed on January 7^th 1841 on a 13-year-old boy who severely stuttered (Hunt, 1861).

“…his operation to cure this spasm consisted of making a horizontal incision at the root of the tongue and excising a triangular wedge across it. More than 250 PWS in France and Germany were reported to have undergone the procedure in 1841 (without anesthesia). Though he claimed good results some PWS died and other surgeons did not substantiate results. By the end of the year (1841) it was abandoned (Hunt, 1861). pg. 47”

According to Eldridge (1968), other surgical procedures for stuttering at the time consisted of severing the hypoglossal nerve, piercing the tongue with hot needles, blistering the tongue with ointment, encouraging smoke as a sedative for the vocal folds, and administering peppermint oil and chloroform to alleviate diaphragmatic spasms, though the most common were tonsillectomies, removal of the adenoids, and clipping of the frenulum (Blanton & Blanton, 1936). Additionally, there were even cases of trepanning / trephination (cutting a hole or holes in the skull) (Silverman, 1996). None of these procedures are currently practiced for stuttering reduction; however recent discussions have originated regarding the potential use of deep brain stimulation implants to alleviate overt stuttering (McGuire, 2013).

As the Victorian age approached, society’s interest in functional mechanics increased. Treatments for stuttering begin to resemble this paradigm shift. American scientists were still searching for the organic causes of stuttering, while treatments shifted to assistive devices to aide with fluent speech productions. For example, Bates sold a flattened tube of silver that was seven-eighths of an inch in length and three-eighths of an inch in diameter which was fastened to the roof of the mouth to keep the soft pallet open and reduce the spasms by having continuous airflow (Silverman, 1996; Van Riper, 1973). Another invention was a collar secured around the neck that was fitted with a metal plate over the thyroid cartilage with a screw and spring giving pressure on the cartilage (Van Riper, 1973). These are only two examples of the hundreds of inventions from this time (see Van Riper’s The Treatment of Stuttering (1973) for a more comprehensive review). Currently, there are still devices to aide in the reduction of stuttering, some of which even employ similar collars as explained above; however, the collars are currently used as actuators to switch on or off sensory feedback devices (Bloodstein & Bernstein-Ratner, 2007). Other non-collar devices provide forms of sensory feedback to the PWS, while maintaining the hope of stuttering reduction.

The Victorian Age also spawned interest in the field of Psychology. Alexander Melville Bell, grandfather of Alexander Graham Bell, believed that stuttering was not of organic origin and was a learned and imitated process. As he was an actor and elocutionist, he treated the symptoms with controlling techniques and over practice. Some of these behavioral strategies are still employed in current therapeutic protocols. In Germany however, professionals became more interested in a psychological perspective as proposed by Moses Mendelssohn nearly 100 years earlier. “They [PWS] do not think of what they are going to say before they say it or they think fasters than they talk.” (Eldridge, 1968 p. 36). Mendelssohn’s issue of processing rate continues from the 19^th century though today. A cohort of researchers continues to investigate language-processing differences by rate and function using functional neuroimaging measure (for a summary see A Handbook on Stuttering, Bloodstein & Bernstein-Ratner, 2007). Another psychological theory of the time includes Markel in 1842, who suggested that stuttering was caused by a failure in confidence in the ability to communicate (Appelt, 1911). Real interest in psychological aspects of stuttering grew after Klencke published an influential book in 1860 suggesting that PWS (i.e., “stammerers”) needed psychological help (Silverman, 1996). Treatments became focused on the person as a whole and were mainly directed at social-psychological anxiety aspects. He recommended decreasing the environmental stress imposed on the individual (Appelt, 1911). Environmental stressors continue to be taken into account when progressing up clients’ hierarchy of difficult situations. Crucially, environmental factors comprise portions of most multifactorial models of stuttering.

Based on Erasmus Darwin’s psychologically based approach-avoidance style conflict, Reinhold published Principles of Psychology (1890), a seminal book that supported Darwin’s notion that conflict arises from the desire to speak fluently and the fear of failure. As with other psychologists of the times he recommended treating stuttering with psychological intervention. As previously mentioned Joseph Sheehan’s (1970) theories and therapies shared many similarities of both Darwin and Reinhold. Many of these procedures are still used, in some form, during most current therapies.

Towards the end of the 19^th century, the field of Psychology was undergoing a paradigm shift. Psychoanalysis became a dominant area in theory and application. Interestingly, as reported in Silverman (1996), Freud did not believe psychoanalysis could help stuttering as reported by personal correspondence with Esti Freud “Psychoanalysis did not understand the mechanism of stuttering and that psychoanalytic techniques had been valueless in treating it.” (p. 174). Several students of the psychoanalytic method, some of Freud’s own students, however, ascribed that stuttering was caused by repressed emotions and could only be permanently cured using the psychoanalytical method (Appelt, 1911; Silverman, 1996). Appelt’s (1911) book Stuttering and its permanent cure, strongly supported psychoanalytic intervention for the PWS.

Summary

Part 2 of this review provided insights into the development of theories of stuttering beginning with the Renaissance and progressing to the 19^th century. A picture of how these physiologically-based theories and therapies influenced more contemporary stuttering interventions was also introduced to the reader. Part III, yet to be compiled, will review current theories and practices, which focus on the neuro-cognitive influences of stuttering, rather than anatomical or peripheral aspects. Of course, the historical emphasis on the emotional, behavioral, and environmental components of stuttering and other fluency disorders has proven to be invaluable in many respects.

References

Appelt, A. (1911). Stammering and its permanent cure. London: Methuen.

Bartusiak, M. (2006). Archives of the Universe: 100 Discoveries That Transformed Our Understanding of the Cosmos. Vintage.

Bloodstein, O. & Ratner, N. B. (2007). A Handbook on Stuttering (6 ed.). Delmar Cengage Learning.

Bothe, A. K. (2004). Evidence-Based Treatment of Stuttering: Empirical Bases and Clinical Applications. Mahwah, NJ: Psychology Press.

Chapman, J. (2008). Bishop Gore and the Catholic Claims (Large Print Edition). BiblioLife.

Eldridge, M. (1968). A history of the treatment of speech disorders. Melbourne, Canberra: Cheshire.

Hunt, J. (1861). Stammering and Stuttering; Their Nature and Treatment. General Books LLC.

Johnson, W. (1955). Stuttering in Children and Adults: Thirty Years of Research at the University of Iowa. University of Minnesota Press.

Kahr, B. (1999). Robert Boyle: a Freudian perspective on an eminent scientist. The British Journal for the History of Science, 32, 277-284.

Maguire GA, Yeh CY, Ito BS. Overview of the Diagnosis and Treatment of Stuttering.  Journal of Experimental and Clinical Medicine. April 2012. Vol 4 (2). 92-97.

Scripture, E. W. (1913). Surgery in the treatment of stuttering. American Journal of Surgery, XXVII(1), 201.

Sheehan, J. G. (1970). Stuttering: Research and Therapy. New York: Harper & Row.

Silverman, F. (1996). Stuttering & Other Fluency Disorders 2nd EDITION. Alyn & Bacon.

Starkweather, C. W. (1987). Fluency and stuttering. Englewood Cliffs, N.J.: Prentice-Hall.

Van Riper, C. (1992). The Nature of Stuttering. USA: Waveland Press.

Van Riper, C. G. (1973). The Treatment of Stuttering. Englewood Cliffs, NJ: Prentice Hall.

Ward, D. (2006). Stuttering and Cluttering. New York: Psychology Press.

Wingate, M. E. (1976). Stuttering: Theory and Treatment (The Irvington speech & hearing series). John Wiley & Sons Inc.

Zimmermann, G. (1980). Articulatory behaviors associated with stuttering: A cinefluorographic analysis. Journal of Speech and Hearing Research, 23(1), 108-121.

Zimmermann, G. (1980). Articulatory dynamics of fluent utterances of stutterers and nonstutterers. Journal of Speech & Hearing Research, 23(1), 95-107.

Zimmermann, G. (1980). Stuttering: A disorder of movement. Journal of Speech and Hearing Research, 23(1), 122-136.