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Stuttering Ataxia In Talking Walking Writing Etc





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
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 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 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 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
Salpetriere 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 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.



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
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.]


Expiration as we Talk Normally.]



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 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
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 Mueller, 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.





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