Further, little attempt is made either by the tiqueur or the stammerer to correct his failing, so that prognosis improves with the adoption of systematic treatment. Stammering is a functional anomaly; it is a derangement of respiration, phonation, and articulation. However normal be the movements of lips and throat in the execution of certain acts, they are far from being normal in the exercise of speech. As a preliminary to speaking the stammerer clenches his teeth and approximates his lips, thus effectually preventing the inrush of air except by the nares; simultaneously he contracts his tongue and obstructs the isthmus of the pharynx, while the glottis also may close spasmodically. Then he abruptly expands his thorax and inhales a considerable quantity of air, yet is he ever on the verge of breathlessness, for he cannot voluntarily arrest himself, or make a break between two respirations. He seeks to continue speaking though his lungs are empty of air; he cannot control expiration by antagonistic contraction of inspiratory muscles; often he finds himself unable to commence speaking at all.
The glottis is either open, allowing the silent escape of air, or it is completely occluded. In the midst of syllables or words the voice is frequently "cut" by a sudden halt indicative of spasmodic closure of the glottis. A contrast to the ease with which vowels are pronounced is provided by the difficulty experienced in the enunciation of various consonants. Convulsive movements of the lips frustrate the endeavour to form the series of successive positions which the consonants demand.
An association of stammering with convulsive phenomena of a different nature has often been remarked. Instances of this have been given by Janke.[122] One patient takes a few paces backward, limping with his left leg till he finds something to give him support, and knocking his shoulder several times against wall or furniture, as soon as he encounters it; if he is seated he rises slowly from the chair, holding it with his hands the while, and forthwith falls back into his seat in order to begin. Another taps his fingers on his thigh whenever the word he is about to utter commences with "g" or "k."
In Brissaud's clinique we have met with a couple of instructive cases:
The first concerned a showman who used to exhibit a series of dissolving objects by means of mirrors, and who found one day that he could not speak without scanning his syllables and explosively ejaculating his words; at the same time his conversation was punctuated by sudden and exaggerated shutting of the eyes and by facial contortions. After a pause the inauguration of a phrase was ushered by still more energetic and widespread spasms of the head and even of all the body.
The other was an eighteen-year-old Jewish boy, who before beginning to speak gave vent to a hard sound like "kh" four or five times in succession, each being accompanied by a violent rotation of the head to the right, wrinkling of the face, and a little jump. The patient then addressed himself to speak with the utmost assurance, there being no sign of tic or stammer unless he stopped for a moment and endeavoured to recommence. On the other hand, he could sing to perfection.
There may also be troubles of speech of a tonic kind, whereby a more or less complete and sustained mutism is produced, an excellent example of which has recently come under our notice:
A young girl, various members of whose family are stammerers, occasionally suffers from an extraordinary sensation of anguish in the course of conversation; she flushes and then becomes suddenly immobile, finding it impossible to articulate or even to utter a sound. Her glottis contracts forcibly; her efforts at expiration are ineffectual, or else the air escapes in little explosive puffs, and at the same time her lips twitch and her eyelids flicker. The whole seizure is over in a few seconds, whereupon the patient launches into conversation with volubility, until pulled up by a fresh attack. She shows remarkable acumen, moreover, in an analysis of her symptoms. "What happens is that I am suddenly overwhelmed with the fear of being unable to pronounce a given word, and at the thought my lips are sealed, I cannot make a sound, my throat is compressed, my tongue refuses to obey me, and my condition becomes one of abject misery." Curiously enough her phobia is not related to a particular word, and moreover her articulation is accurate and not embarrassed in presence of certain of the consonants. Phonation and respiration are implicated as well as articulation. The origin of this "cramp of speech" in psychical abnormalities is manifest.
To a similar affection characterised by total inability to speak in a high or a low voice, whispering only being practicable, the term "spastic aphonia" has been applied. It is at the moment when the patient wishes to speak that the spasm occurs, as in a case reported by Hasslauer,[123] which resisted all treatment and was considered by him to have features in common with hysteria and occupation neuroses.
There can be little doubt that the arrest of movement in these cases is comparable to what obtains in writers' cramp, and therefore, rigorously speaking, a tonic tic.