The difficulty of speech called stuttering has usually been considered rather as an unfortunate lack of control over the organs of articulation, somewhat corresponding to muscular awkwardness of any other kind, than as a pathological condition deserving the physician's attention. If anything was done for it formally, the first effort of the parents or the teacher was to correct the supposed bad habits and this failing the affection was relegated to someone who claimed to produce wonderful results by some special method. Perhaps, even oftener, stuttering was considered one of those affections, fortunately decreasing in number, that the child may be expected to outgrow. Often there was noted an hereditary element which was supposed to indicate incurability.

Stuttering deserves special treatment in a work on psychotherapy because it illustrates very strikingly one phase at least of mental influence over bodily function. While in the study of the etiology of the disease much has been made of anatomical features, nerves and muscles and anatomical anomalies of the speech organs and the respiratory tract, the sufferers from stuttering are certainly quite up to the average both in the physiology and anatomy of these regions. They are of all ranks and conditions of life, of all sizes and build, and it is evident that the trouble is not physical, but mental. They {571} pay too much attention to their speech and to the co-ordination of the many muscles engaged in speech production and the consequence is that they impair their power to use these organs. Practically all the cures recommended contain some element which distracts the attention from the speech to something else and so permits the function of the speech organs to proceed undisturbed.

A number of conditions develop in nervous individuals that resemble stuttering. There are disturbances of swallowing, disturbances of walking (astasia abasia), neurotic disturbances of writing, and of other uses of the hands and of the legs.

State of Mind.—It is perfectly clear to anyone who has closely observed the ways of stutterers that the state of mind is extremely important in these cases and indeed probably constitutes the underlying factor in the speech disturbance. Stuttering and all speech defects are much worse when the patient is laboring under excitement. This is so amusingly true that the impotence of a stutterer to say a word when he wants very much to say it is a commonplace in the cheap drama and never fails to raise a laugh. In ordinary conversation with friends the stutterer may have little difficulty. As soon, however, as he begins to talk with those with whom he is unfamiliar his speech defect becomes noticeable. When the others present are entire strangers and, above all, strangers whom he wishes to impress favorably, then his stuttering becomes pronounced. The mental element is the most important factor. Just as soon as consciousness of the task supervenes his power of co-ordination fails and stuttering begins.

Stuttering in Complex Activities.—There are many actions that become habitual and people are thus saved from the necessity of constantly performing them under the control of the will and the consciousness. Walking is a typical illustration of this and is seldom disturbed by consciousness, but there may be a stuttering in the gait of sensitive persons if they become overconscious when passing people who are watching them. Talking is even a more striking example of elaborate co-ordination without conscious effort. We have to bring into play more than a score of muscles whose movements are nicely and accurately co-ordinated, or else the effort at articulate speech is a failure. We have to change the positions of most of these muscles many times every minute, yet we do it without a thought of how it is done and most of us accomplish it with ease and perfection.

Stuttering Walk.—Stuttering, after all, comes most naturally under the head of dreads in the classification of the psychoses. Stuttering is not a physical difficulty so much as a nervous apprehension, and there may be a stuttering in any co-ordination as in speech. I have a patient under observation who, if people are looking at her, finds so much difficulty in walking because of a trembling that comes over her that she fears she may not be able to keep from falling. Boys at school whistle a certain air that requires a little halt in the gait to keep time with it, as their schoolgirl friends go by, and it is impossible for these not to drop into the peculiar gait indicated by the time of the tune.

Stuttering Writing.—There are many men who become so nervous about writing their signatures that they cannot sign while anyone is present. There are others whose penmanship becomes very irregular, or at least exhibits many signs of nervousness, whenever they think someone is watching them. Most of {572} the difficulties seen in speech may, indeed, be exhibited in writing. The same difficulty in beginning, the same elision of letters under stress of excitement, may occur.

Writer's cramp is, after all, much more of the nature of a stuttering in writing than a real cramp. Over-action, added motions, and, finally, incomplete power to act as desired are seen in both cases. It might be expected that this would not affect so simple and familiar a set of motions as those required for a personal signature, but it does, as many cases illustrate. A typical example was the treasurer of a large trust company who had to sign a number of bonds, some thirty thousand. At the rate of 200 an hour, over three a minute, as he did the first day with others making it easy for him, it looked as though he could complete the task, huge as it was, in a month. At the end of a week, however, the rate had fallen to 120 an hour and, toward the end of the second week, one a minute on the average was all that could be accomplished. At the end of the month his signature, while retaining certain of its original characteristics, had become very different from what it was at the beginning and signing had become an extremely difficult matter. He had to take a rest from business for several weeks after accomplishing this apparently mechanical procedure.

Emotional Ataxia.—Dr. S. Weir Mitchell in his article on "Motor Ataxia from Emotion" in the May number (1910) of The Journal of Nervous and Mental Disease, discusses some cases in which inability to write even a signature came as a consequence of nervousness and emotional disturbance.

In one of Dr. Mitchell's patients, other manifestations of ataxia occurred as the result of the consciousness that people were watching the patient. At times he is compelled to leave a dinner table, since with strangers it is almost impossible for him to eat. If there are two or three at the table with him, however, and especially if he is worried about himself, he may become almost helpless, requiring both hands to get a cup of coffee or a glass of water to his mouth. A patient of mine with like symptoms has described to me equivalents of various kinds to his own difficulties in his sisters. One of them cannot play the piano before strangers, though an excellent musician. The other cannot crochet with any success if any but intimate friends are present. How much of this family trait is due to suggestion or psychic contagion would be hard to say. The state that comes over amateur actors and which makes them forget their lines, stammer in their speech, walk awkwardly, and trip easily, are really manifestations of this same incapacity to control even familiar sets of actions when there is great self-consciousness and over-attention.

Mental Influence.—The correction of these conditions comes through soothing the mind of the patient and getting him or her not to be so self-conscious as to disturb action by thought about it. It is easy to say this and extremely difficult to do it. In certain nervous organizations it is quite impossible to overcome the tendency to this ataxia or inco-ordination of voluntary movements. Much can be accomplished, however, by proper training and discipline in all cases, and, while the patient can never be completely cured, great improvement may be brought about by patient habituation under favorable circumstances. In Dr. Mitchell's cases the taking of a glass of whiskey or of wine sometimes stimulated the patient so that co-ordination became possible where it was impossible before. In nearly all cases of writer's cramp {573} and writing difficulties the power to write is restored for a time by such stimulation. Strong coffee will sometimes serve the purpose as well as alcohol. It is easy to understand, however, how dangerous is the resort to such stimulation.

Practice in Self-Control.—The excitement and nervousness incident to appearance before an audience which make thought and speech so difficult and action so awkward and so exaggerated gradually disappear as the individual becomes habituated to appearing in public. In most people there is never a complete loss of self-consciousness with entire freedom from nervousness, but the conditions are much improved so that there is no noticeable interference with ordinary actions and speech. Whenever there is some reason for additional excitement, however, as when a new play is being put on, or when some special audience is being entertained, there is a reappearance of many of the old symptoms due to a self-consciousness.

Stuttering in the Young.—The prognosis of stuttering when it develops at a certain period is much better than at others. The stuttering of the very young can usually be overcome by a little careful training, if it is taken early and treated patiently by a competent teacher. Not infrequently a certain amount of stuttering develops at puberty when the voice changes, partly due to the inability of muscles and nerves to co-ordinate so easily as before upon the rapidly-enlarging vocal chords and larynx, and partly to that greatly increased self-consciousness amounting almost to painful bashfulness which develops in boys about this time. Breathing exercises and especially slow expiration is an excellent thing in these cases and distracts their attention from themselves and their speech.

The chest has usually developed rather rapidly at this time and the muscles have to some extent lost control over it, and it will be found on careful observation that the breathing is particularly superficial, that the descent of the diaphragm is quite limited and that the use of this important muscle of respiration requires practice in order that it may be controlled properly.

In Women.—Perhaps the most interesting thing about stuttering is that it is ever so much rarer in women than it is in men. Something less than one-fourth as many women suffer from it as men and this is true for all periods of life. Women are usually more bashful and self-conscious than men, but this rarely goes to the extent of disturbing their speech faculties. Ungallant observers have suggested that the sex quality of ready speech is too profoundly seated in nature to be disturbed by mere bashfulness, but there seems to be no doubt that the breathing of women has much to do with the difference between them and men in the matter of speech defects.

When stuttering occurs in women the defect is much less tractable and is usually dependent on a more serious disturbance of the psyche or of the central nervous system. The prognosis of cases of stuttering in women is not so good as in men, but remarkable cures are sometimes effected by mental treatment of the self-consciousness which causes the speech defect.

Correction of Respiratory Defects.—This last point, the correction of all pathological conditions in the respiratory tract, is especially important. Many stutterers are for one reason or another mouth breathers. If they are mouth breathers because they have adenoids, these must be removed. This must {574} be done early in life, certainly not later than the third or fourth year, or else there will come a serious deformation of the chest and that chicken-breastedness, which is not undesirable in itself, but which hampers to some extent the action of the diaphragm because that muscle cannot act as well in the deformed as in the natural chest. Not all who are chicken-breasted have any defect of speech, nor any tendency to stutter, but when there is a natural tendency to a lack of inco-ordination because of sub-normal nervous ability the presence of such a deformity makes the prospect of cure much less favorable than would otherwise be the case. If the mouth-breathing is due to stoppage of the nostrils, this must be relieved.

Realization of Allied Conditions.—A helpful suggestion for stutterers is found in the recognition of the fact that there are so many conditions allied to stuttering and so many people afflicted with them. Under the heading Neurotic Esophageal Stricture stuttering in swallowing is treated of. In the chapters on urinary symptoms stuttering in urination is discussed. Any set of muscles requiring careful co-ordination may thus be disturbed. The stutterer is apt to look upon his affliction as a very special individual annoyance. When he learns that in practically every set of muscles requiring nice adjustment for function like difficulties may occur, that in every action requiring careful co-ordination of muscles there may be a similar disturbance, and yet that in most of them careful mental discipline, especially training in self-control, proves a source of relief, he takes new courage to face the struggle necessary to overcome the self-consciousness which is the root of most of these troubles.

A striking form of inability to co-ordinate muscles so as to enable them to perform their ordinary function is aphonia, or mutism, sometimes spoken of as hysterical mutism. After some sudden emotion or fright or accident a neurotic person proves to be quite unable to talk. He cannot utter a sound. In Prof. Raymond's clinic at the SalpÊtriÈre I once saw the classical case described by Charcot and presented at his clinics several times. It was a man whose wife had run away from him and been taken back three times. Each time on her disappearance he had an attack of aphonia, inability to utter a sound of any kind. It lasted for from several weeks to a few days. The cases are much commoner in women. After a disappointment in love or a scare the patients become unable to speak. Sometimes they can whisper but cannot phonate. The affection is entirely functional or neurotic, and if the patient's mind is properly predisposed speech returns without difficulty or delay. A little massage of the muscles of the throat or of the tongue by means of a tongue depressor or the use of Politzer's bag in the nose with the assurance that after proper swallowing movements the ability to speak will return, have proved successful. Occasionally hypnotism is recommended for these cases, but many of them are too highly neurotic to be readily susceptible to hypnotism and, besides, suggestion in the waking state proves just as effective.

After several days of speechlessness it seems little short of marvelous to make a patient talk readily after a little massage of the throat. It is all dependent, however, upon confident assurance and the suggestion to talk. The physician himself must possess absolute confidence in his power to bring this about, for the slightest sign of doubt or hesitation will make it impossible {575} to influence the patient and will completely destroy his psychotherapeutic efficiency.

Neurotic Esophageal Stricture.—A rare but interesting form of neurosis, which should be studied in connection with stuttering because of the light shed on both by their relations to each other, is that seen in the sufferers from so-called neurotic esophageal stricture. These patients are unable to swallow solids except after determined deliberate effort and occasionally the discomfort caused by this effort leads them to eat much less than is sufficient for their nutrition. The physician is sometimes tempted to overcome the spasmodic closure or partial closure of the esophagus by bougies and dilators, and these the patients learn to pass by themselves. I have never known any of these cases to be benefited more than temporarily by this treatment and I have seen two that were made distinctly worse. Forcible dilatation by concentrating attention on the affected parts hampers the proper flow of nervous impulses and the ordinary reaction to these which should occur.

To appreciate how closely related to stuttering this spasmodic closure of the esophagus is, it is necessary to see these patients swallow when they do not know that they are under observation. For when they are on exhibition for the physician, when their condition is intensified by the excitement of the occasion and by the definite purpose to make the doctor appreciate how serious is their case, they swallow with more difficulty. Nearly always they have more difficulty in eating in public than with friends, and it is only with those with whom the patient is on a footing of perfect familiarity that the best swallowing power is obtained.

In sufferers from esophageal stricture of the neurotic type the muscles by an unfortunate perversion of nerve force contract in front of the bolus instead of behind it. This contraction may be so complete as to prevent even the swallowing of liquids. Usually, however, liquids can be swallowed without much difficulty. Such patients, then, if they become much run down in weight, must be fed on milk and eggs and ice cream and the gruels and soups until they gain in weight. While they are much under weight their condition is distinctly worse and their power of co-ordination much less. It is, however, not hard to make them gain in weight. This gain in weight acts as a strong suggestion which persuades them that they are getting better and this of itself soon helps them to control their muscles. Local treatment does harm rather than good. Ice in small pieces swallowed shortly before a meal seems in some patients to have the effect of making the muscles less prone to follow the inco-ordinate nervous action and thus renders swallowing much easier. In some, and especially in nervous people, warm liquids have the same effect, while ice produces further irritation. Acids nearly always increase the spasmodic condition. Sucking a piece of hard candy for some time before a meal, especially if it is not too sweet nor flavored with acid, helps some people.

Nearly all of them when carefully questioned prove to have special foods that are more difficult of deglutition than others. Not infrequently these idiosyncrasies for food are found to follow ideas with regard to their digestibility. If the patient is hurrying for any reason and suddenly becomes conscious that he is not masticating sufficiently, swallowing at once becomes much more difficult.{576}

The main element in the treatment, however, must be as far as possible to get the patient's mind off his condition. The more attention he gives to it the worse it will be. No treatment that we have will cure it any more than stuttering can be cured, though a deliberate effort to form a habit for the control of the swallowing muscles will often do much to lessen the discomfort and the inability to swallow.

It is important in all these cases to be sure that there has been no incident in childhood which might have caused the production of scar tissue in the esophagus with a consequent stricture. Sometimes it is many years before this manifests itself and, as in the case of the urethra, even ten to twenty years may pass before serious trouble comes. When the first symptoms are noticed, the actual stricture may be so slight as scarcely to be possible of diagnosis by the bougie. Occasionally the first symptom of a cancer of the esophagus is an inability to swallow, and cancers of the esophagus have been known to occur in quite young people, especially young men. I remember seeing a case at autopsy in Vienna where the first symptom had been the difficulty of swallowing and the man, at the recommendation of friends, swallowed a glass of beer with some black peppers in it and these stuck in his esophagus and produced death. Such cases are exceptional but must not be forgotten. Neurotic esophageal stricture is entirely benignant and its prognosis altogether favorable.

Treatment.—The treatment of stuttering presents the best example that we have of the influence of the mind over neurotic difficulties of any and every kind. Many forms of treatment have been announced as successful, most frequently in the hands of men who have themselves been stutterers and who have helped themselves by them. This would seem to make it clear beyond all doubt that discoveries in direct therapeutics had been found. As a matter of fact, however, when a review of all the methods is made, they are seen to be so different from one another and founded on such essentially diverse principles that the only common connecting link to be found is in the occupation of mind with something else besides speech which all these methods recommend. We have had successful cures announced by surgery, by discipline, by making speech more difficult by obstacles of various kinds, by special positions of the tongue—up against the palate or down against the floor of the mouth—by associated movements, by rhythmic speech, by special control of the muscles of respiration, and of many other structures much less related to speech. The interesting phase of all this is the uniform success claimed by different specialists using many different methods.

From the beginning of history cures have been suggested. That idea, still held among the non-medical, that the sufferer from a difficulty of speech is tongue-tied and needs to have the frenum cut, is as old as the history of medicine. Galen suggested cauterization of the tongue. Aetius, the first prominent Christian physician of whom we have any record, divided the frenum of the tongue. So did Paul of AEgina. Of course, in the Renaissance, when the old medical classics were revived, this became a favorite method of treatment. Hildanus is sure that it accomplishes great things. This idea has never been entirely given up, and recurs from time to time in the practice of those who do not reason much, but who look for some ready explanation and, above all, some direct method of treatment. Much more {577} serious surgical intervention has been suggested from time to time, however. Velpeau advised division of the extensor muscles of the tongue. Of course a number of surgeons have quite properly insisted on the removal of the tonsils, uvula, polyps in the nose and other obstructions of respiration.

Singing in Treatment.—A number of the stuttering cures employ singing as a method of training in forthright utterance. Few people stutter when they sing. Most people can be given confidence in themselves and their power to talk right on by being shown that as soon as they try to follow a set of notes there is little or no difficulty in utterance. The teaching of singing, then, is of distinct value in many cases. Taking advantage of this a number of those who correct stuttering endeavor to introduce a certain rhythm into speech. So long as the rhythm can be maintained stuttering does not occur. As Kussmaul has pointed out the rhythmus acts as an efficient will-regulator, so that nerve impulses go down regularly and are not interrupted by consciousness and by the sudden starts and stoppages due to fear and tremor and mental uneasiness. Undoubtedly the lesson of this method of teaching is extremely important as an index of how stuttering may be relieved.

Regulation of Respiration.—A number of systems to correct stuttering depend on the regulation of breathing. It has been shown over and over again, and notably by Prof. Gutzman of Berlin, [Footnote 42] that one of the most important differences between stutterers and those who talk naturally is that the normal individual talks during expiration as may be seen in Fig. 23, while the stutterer begins at the end of inspiration or at least where normally on the respiratory curve expiration is just about to begin, but instead of permitting his diaphragm to go up as in ordinary expiration, the stutterer makes it sink lower and lower in a forced inspiration.

[Footnote 42: See my translation of one of his clinical lectures In The International Clinic for July, 1899.]

Fig. 23.—Normal Diaphragm Curve in Normal Breathing. Expiration as we Talk Normally.

Fig. 24.—Curve in Diaphragm Before and During Talking by a Stutterer.

Attention to Something Besides Speech.—The attention must be centered on something besides speech itself. This is the important element in any method of treating stuttering. If it is allowed to occupy itself with that {578} nothing will save the individual from getting tangled in the efforts that he makes to co-ordinate the complex movements necessary, though if he would only allow them to proceed automatically, as do the rest of mankind, there would be no difficulty at all. Washington Irving, so ready with the pen, could not utter two successive sentences at a banquet without having to sit down, with expression absolutely inhibited from excitement. Expression, thought, utterance—all may be inhibited by overconscious attention, which may also disturb all other complex activities.

The most interesting methods of treatment for stuttering are those which involve the use of various hindrances to speech and which would seem to be least likely to make it possible for a person already laboring under speech difficulties to talk with more ease. The secret is, of course, that the added impediments so distract the attention of the patient that he is unconscious of the co-ordination necessary for speech and so accomplishes it without difficulty. It is because of over-attention to himself that the disturbance occurs. These methods developed very early in history. We all know the tradition of Demosthenes overcoming his impediment by placing pebbles in his mouth. One of the most earnest advocates of a similar method, who had himself suffered very seriously from stuttering was the Rev. Charles Kingsley, one of the most distinguished of English literary men. He cured himself, or at least greatly relieved his symptoms, by keeping a cork fast between his back teeth.

There have been many other curious suggestions for the cure of stuttering. What was known as the American method had great vogue in the early part of the nineteenth century. It was probably invented by Yeats of New York, though it came to be known as the Leigh method. Yeats, himself a physician, seemed to fear that he might fall into professional disrepute if he advertised the method in any way, so he had his daughter's governess, a Mrs. Leigh, open an institute for the cure of stuttering in which this method was practiced and it proved to be very successful. The entire secret of it was to have the patient raise the tip of the tongue to the palate and hold it there while speaking.

Another mode of treatment that attracted considerable attention consisted mainly of just exactly the opposite maneuver, that is, keeping the tongue as far as possible firmly placed on the floor of the mouth during speech. It is evident that neither of these suggestions does anything more than occupy the patient's attention with an additional activity, so that his speech function may be allowed to proceed automatically of itself, as it will if not disturbed by attention to it and by conscious attempts to regulate the various activities of it. Instruments were invented to help the patients to secure various positions of the tongue. Itard, for instance, during the second decade of the nineteenth century invented a golden or ivory fork to be placed beneath the tongue, so as to support it.

After the various methods of managing the tongue, the most popular curative maneuver has been that of regulating the breathing. During the nineteenth century there were at least a dozen different methods, all of which had a number of reported successes, of treating stuttering by means of breathing exercises.

Very simple methods of diverting the attention from speech are quite {579} sufficient in many cases to bring improvement. For instance, the insertion of extra letters that are themselves easy to say between words or preceding consonants that are hard to utter has been a favorite method among the specialists in stuttering. Johann MÜller, as I said, suggested an e. Others have suggested an n. Occasionally stutterers themselves form the habit of using an m or a to and find that it aids their facility in uttering difficult sounds over which they would otherwise halt and stutter. A combination of these methods, as, for instance, an e between all words and the placing of an easy n before the most difficult sounds, has been repeatedly revived as an infallible method of treatment.

All this serves to show that in patients whose functions are being interfered with by over-attention diversion of mind must be the main remedy. If this can be secured, the function they are disturbing will be allowed to proceed unhampered. What will prove effective for one patient will fail with another, however. After the patient gets used to a particular form of diversion another must be tried. Simple methods are sometimes sufficient to secure good results. The one thing is not to be discouraged and to proceed from one effort to another, satisfied even if relief is obtained for a while, for after relapse another method of treatment may always be tried.

Suggestion for Stuttering.—There are many systems to train people out of the spasmodic inco-ordination that constitutes stuttering. All of these systems have their successes, but, as is well known, all of them have their failures. When the patient has confidence in the teacher and his method there is practically always quite a remarkable improvement, at the beginning. This improvement is more noticeable during the first month than at any other time. Not infrequently after this there is a tendency for patients to drop back into old habits, apparently discouraged, as a consequence of loss of confidence. It is the mental element that means more than anything else. It is the old, old story that we have to repeat with regard to every chronic ailment.

Distraction of Mind.—Each inventor is sure that his method is the best and his "cured cases" support his claim. Others who try his method, however, never succeed as well as he does and those who are interested invent methods of their own. I have on my desk, as I write, six different, infallible—to their authors—methods of treating stuttering. I am sure that none of them succeed absolutely, that is, none of them will cure every case and most of them will not succeed beyond a moderate degree, except where the enthusiasm and the confidence of the inventor or an immediate disciple of his is behind them to make them efficient. There are all sorts of elements in these cures, but most of them depend on their power to distract the patient from his over-attention to himself and what he is doing when he talks, so as to permit without hindrance the automatic movements which are so necessary for the complex function we call speech. Those who have spent most time in treating stutterers confess that the effect produced upon the patient's mind is an extremely important part of the treatment and that, if this cannot be secured, failure is almost certain. If the patient has no confidence that he can be cured and by this particular method, failure is inevitable from the very beginning and just as soon as a patient loses confidence improvement ceases.{580}