Psychotherapy
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At the Salpêtrière they tell the story of a little boy who had the habit of saying the French word which the corporal in Victor Hugo's "Les Miserables" made use of when anyone told him that it was because Wellington was a greater general than Napoleon that the French Emperor was defeated at Waterloo. Nothing seemed to be able to break the boy of the habit of interjecting this word into conversations sometimes in which he had no part and sometimes toward which he was expected to take only a respectful and childlike attitude of silence. He was sent to the Salpêtrière. The ordinary remedies had failed entirely. One day he was allowed to go outside of the hospital, or rather stole out of the gate and played marbles with some street gamins in front of it. During the game he used the word in question and they proceeded to give him a good thrashing. It is Charcot who tells that this broke him effectually of the habit.
One of the childish customs that sometimes disturbs parents very much because it seems to be such an unaccountable lapse into barbarism, though it is really nothing more than a tic in the strict sense of the word, is the habit that some children acquire of removing portions of hardened material from their nose and then putting it into their month. Refined parents are apt to be so seriously disturbed by this that they fear for the child's mentality. Really the habit is not nearly so rare as is usually thought by some grown-ups who have forgotten about their own and others' childhood. In country places the habit is very common. It is not alone the dull children who do it but some very bright ones. Indeed, the tendency to the habit is so common that one wonders whether there is not something in nature that tempts to it. Parents who are fearful lest their children may be seriously hurt in health by the awfully insanitary habit may be reassured that after all a certain amount of the drainage of the nose is normally carried off through the posterior nares to the stomach and that no danger to health seems ever to have resulted from the practice. As a rule, the habit can be broken rather easily by a little judicious care and insistence, though I know of cases where relapses occurred and the habit continued surreptitiously.
Motor Tics .—Motor tics frequently develop as a consequence of some injury to a nerve or some intense overuse of it. Winking habits follow an herpetic involvement of the superior branch of the fifth nerve. Bell's palsy is sometimes followed in the face by a tendency to twitching on the unaffected side that makes the patient quite uncomfortable. Herpes zoster is sometimes followed by a catching of the breath, probably due to a little spasm in the muscles supplied by the nerve thus affected. Some of the yawning tics have this origin. Any neuritis may in the course of its betterment be followed by this curious tendency to explosion along the nerve that has been affected, as if the pathological process had more seriously interfered with inhibition than with the actual function of the nerve. Examples of over-exertion followed by twitchings are not rare. A scrubwoman who has seen better days and now has to carry a heavy bucket and use her right hand much with the brush may develop a twitching of the right arm. A janitor's wife who sweeps much may have a tendency to twitchings of the fingers as a consequence of the unusual exertion of holding the broom. Twitchings in the limbs of men who work at a foot lathe or other machine requiring foot power are not unusual though they are more often seen in the leg on which the workman habitually stands than in the other one and it seems to be oftener a strain on muscles than actual over-exercise that precedes the development of these tics.
Heredity.—Heredity plays as large a role in tics as it does in stuttering and other functional nervous disturbances. Occasionally the direct inheritance of some habit will be found, though there is nearly always more than a suspicion that a trick of speech or of act, which constitutes the tic, was learned by imitation rather than transferred directly. Besides, it is a case of a similarly constituted nervous system reacting in the same way to a similar environment, rather than any definite tendency existing by heredity in the nervous system. It is surprising what close observers children are and how easily they learn to imitate any habitual action of father or mother or, for that matter, of nurses or those who are close to them.
Mental Treatment.—The most important element in the psychotherapy of tics is their prophylaxis. They run in families, not by any inevitable hereditary influence, but as a consequence partly of imitation and of corresponding tendencies resulting from certain weaknesses in the family. Wherever they are known to be likely to occur, parents should be warned of the possibility and the first symptom of any motor habit should be considered the beginning of a tic. As we have said, they are likely to begin in muscles that have been overstrained for any reason, especially when patients are run down. They are often seen after herpes and certain facial neuralgias.
There is probably no tic, no matter how long or how serious, that can not be eradicated, or greatly modified, if the patient will take the trouble and if the treatment is conducted so as gradually to get rid of it. Peculiar movements cannot be done away with at once. They can be lessened in intensity and in frequency and then gradually the patient will be encouraged by their becoming less noticeable than before to make renewed efforts. The habit must be gradually undone and this will take as long as it did to form it originally. The exercise of contrary muscular movements carefully carried out, and of gentle repression with definite times of exercise during the day, gradually increasing the length of the intervals of repression, in the end proves successful. Only a determined struggle will effect a cure. It depends on the patient's will. Like a drug addiction, or a tendency to overeat, or a craving for alcohol, it must be gradually overcome and then care must be exercised to prevent relapses; for when the condition is somewhat better, to relax vigilance and give up effort will allow the old condition to reassert itself with startling rapidity. People suffering from severe tics will often give up. Without the patient's hearty co-operation cure is impossible. With good will its gradual diminution gives the patient a confidence in self and an uplift in character that is extremely valuable, not only for physical but for mental conditions.
CHAPTER IV
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 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 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.