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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