APHONIA, STAMMERING, AND CATALEPSY
S. R. Age 25. Russian Jewess; married; has four children. Patient
was brought to me in a state of helplessness. She could not walk,
and was unable to utter a word. When spoken to she replied in
gestures. When challenged to walk, she made unsuccessful attempts.
The step was awkward, the gait reeling, the body finally collapsing
in a heap on the floor. When I shut her eyelids, the eyeballs began
to roll upwards, the lids soon became cataleptic, and the patient
was unable to open them. When I insisted that she should open the
lids, she strained hard,--the muscles of the upper part of the
body became painfully tense,--wrinkled her forehead, and contorted
violently her face. After long insistence on her replying to my
questions, and after long vain efforts to comply with my request,
she at last succeeded in replying in a barely audible voice. When
whispering she kept on making incoordinate movements with jaws and
lips, began to shut her eyelids, rolled up the eye-balls, forced
the tongue against the teeth, stammered badly on consonants,
uttering them with great difficulty after long hesitation, the
sound finally coming out with explosive force.
I insisted that she must stand up, she raised herself slowly and
with effort, took a couple of steps, and sat down at once on the
chair. During the period of effort there was marked tremor in her
left arm. When she sat down, she threw her head backward, rolled
up her eyeballs, and began gradually to close her eyelids. She
remained in this position for a couple of minutes, and then began
spasmodically to open and shut the eyelids. When taken to her room,
the patient walked up, though with some difficulty, three flights
of stairs without the nurse’s support.
The patient was greatly emaciated,--she lived in extreme poverty.
She was married five years, and had given birth to four children.
Patient was suffering from severe headaches which set in soon
after the birth of the second child. At first the headaches came
at intervals of a few weeks, and lasted about a day, then with the
birth of the other children the headaches grew more severe and more
frequent, and finally became continuous. From time to time the
attacks were specially exacerbated in violence, she then complained
of violent pains in the head, excruciating agony toward the vertex.
The face was deadly pale, the hands and feet were ice-cold, the
pulse weak and sluggish. During the attack the head had to be
raised, since in any other position the pain was unbearable. The
pain was originally unilateral, starting on the left side of the
head. Of late the pain spread from left to right. The whole head
felt sore, like a boil, the scalp was highly sensitive. The intense
attacks, sweeping over the patient unawares, were accompanied by
twitchings of the eyelids, rolling of the eyeballs, dizziness,
sparks before the eyes, pains in the left side of the chest, and by
numbness and hypoaesthesia of the face, arms and legs. The patellar
reflex was markedly exaggerated, no clonus was present; the pupils
reacted well to light and accommodation.
The patient was admitted to a local hospital, and was allowed to
nurse her one year old baby. Three days after admission, while
nursing her baby, she was seized with a violent attack of headache
and pain in the left side. The arms felt numb and “gone.” The
patient was seized with a panic that the child might fall; hugging
the baby to her left breast she screamed for help in agony and
terror. Immediately following this seizure the patient lost her
voice, speech, and power of walking.
After staying in the hospital for two weeks, the patient was put
under my care.
The patient was an extremely timid creature. She lived in Russia
in a small town where the religious persecutions of the neighbors
were persistent and unremittent. To this were joined the petty
annoyances by the village police, the representatives of which
acted with all the cruel tyranny characteristic of the old Russian
regime. The patient’s family was in constant terror. In childhood
the patient has undergone all the horrors of the _pogromi_ with
all the terrors of inquisitorial tortures. A highly sensitized
impulse of self-preservation and intense easily stimulated fear
instinct were the essence of the patient’s life. She was afraid
of everything, of her very shadow, of anything strange, more so
in the dark, and at night. With this morbid self-preservation and
intensified fear instinct there were associated superstitions to
which her mind was exposed in early childhood, and in her later
life. The patient lived at home in the fear of the most savage
superstitions and prejudices, characteristic of the poor ignorant
classes of Eastern European countries, and outside the house she
was in fear of her life. The patient was brought up on fear and
nourished on fear. No wonder when she was run down, and met with a
fear shock, that the fear instinct seized on her and gave rise to
the symptoms of physical and mental paralysis.
To this life of terror we may add the extreme poverty in which the
patient lived in Russia and afterwards in this country. The hard
work in a sweat-shop and the ill nutrition ran down the patient
and further predisposed her to disability and disease. Patient
lived in constant dread of actual starvation, with fear of having
no shelter, with fear of no roof over her head. She was so timid
that she was scared by any sudden movement, or by a severe, harsh,
threatening voice. She was extreme suggestible, imitative, and
credulous. She was like a haunted animal, like a scared bird in the
claws of a cat. Fear often threw her into a state of rigidity.
The patient suffered from a fear of fatigue, from fear of
exhaustion, from fear of disability, from fear of paralysis,
pain, sickness, and death, fear of the negative aspect of the
most primitive, and most fundamental of all impulses, the impulse
of self-preservation. The fear psychosis, based on an abnormally
developed fear instinct which formed the main structure of her
symptom complex, had a real foundation in the psycho-physiological
condition of her organism. The patient actually suffered from
fatigue due to exhaustion, underfeeding, and overworking.
Married at the age of twenty, she bore four children in succession.
This was a drain on the poor woman, and further weakened her
feeble constitution. Her husband was a poor tailor working in
a sweat-shop, making but a few dollars a week. The family was
practically kept in a state of chronic starvation. The wolf was
hardly kept away from the door. The family was in constant dread of
“slack time” with its loss of employment and consequent privations
and suffering.
The husband was a hard worker, did not drink, but the long hours of
work, the low wages, the poor nutrition, the vicious air, and the
no less vicious environment, cheerless and monotonous, sometimes
gave rise to moods, discontent, anger, and quarrels, of which the
patient with her timidity stood in utter terror.
The patient’s dream life was strongly colored by a general
underlying mood of apprehension. The fear instinct of
self-preservation formed the soil of the whole emotional tone
of the psychosis, waking, sub-waking, dreaming, conscious, and
subconscious. Again and again did the nurses and attendants report
to me that, although the patient was aphonic and it was hard to
elicit from her a sound, in her sleep she quite often cried out,
sometimes using phrases and words which were hard to comprehend,
because they were indistinct, and because they were sometimes in
her native language. When awakened immediately, it was sometimes
possible to elicit from her shreds of dreams in regard to scares
and frights about herself, about her children, about her husband,
relatives, and friends. When she came under my care the patient
often used to wake up in the morning in a state of depression due
to some horrible hallucinatory dreams in which she lived over
again in a distorted form, due to incoordination of content and to
lack of active, guiding attention, dreams in which the dreadful
experience of her miserable life kept on recurring under various
forms of fragmentary association and vague synthesis, brought
about by accidental, external and internal stimulations.
The patient was taken to her room in the evening, and put to bed.
During the night she was somewhat restless, kept on waking up,
but on the whole, according to the nurse’s account, she slept
quite well. In the morning the patient had a hearty breakfast,
and felt better than the day before when she was brought to me.
The voice improved somewhat in strength and volume. During the
day she rested, felt well, and enjoyed her meals. Speech was
still in a whisper barely audible, but there was no stammering,
no muscular incoordination, no twitchings of the face. About four
in the afternoon patient sat up in bed, her voice became somewhat
stronger, though speech was still in a whisper. This improvement
lasted but a few minutes. When her arms were raised, the left hand
manifested considerable tremor and weakness as compared with the
right arm. After having made a few remarks which apparently cost
her considerable effort, she had a relapse, she again lost her
voice, and was unable to whisper. I insisted that she should reply
to my questions; she had to make a great effort, straining her
muscles and bringing them into a state of convulsive incoordination
before she could bring out a few sounds in reply. A little later,
about ten or fifteen minutes after I left the room, the nurse came
in and quietly asked her a question, the patient answered in a
whisper, with little strain and difficulty. An hour later the
patient regained her speech for a short period of a few minutes.
These changes went on during the patient’s waking period. Once
towards evening the patient regained her voice and speech to
such an extent that she could talk with no difficulty and little
impediment; the voice was so resonant and strong that it could be
heard in the hall adjoining the room. This however lasted but a few
moments.
After having had a good night’s sleep the patient woke up in good
condition; appetite was good. Voice was clear, though low. She was
in a state of lassitude and relaxation. I attempted to examine her
and kept testing her condition, physical and mental. I was anxious
to make a psychognosis of the patient’s case. The tests and the
questions strained her nervous system by requiring to hold her
attention, and by keeping her in a state of nervous and mental
agitation. She looked scared, anxious,--the scared, haunted look in
her face reappeared. The patient was no more than about twenty to
twenty-five minutes under experimentation when a severe headache of
the vertex and of the left side of the head set in. The eyeballs
began to roll up, eyelids were half closed; lids and eyeballs
were quivering and twitching. The hands were relaxed and looked
paralyzed. When raised they fell down by her side in an almost
lifeless condition. There was marked hypoaesthesia to pain and heat
sensations. The anaesthesia was more marked on the left than on the
right side. The left arm when raised and kept for a few seconds
showed marked tremor as compared with the right arm. This is to be
explained by the fact that the exacerbations of the headache, of
pain, and the general cataleptic seizures set in usually during or
after the nursing periods. The infant while nursing was kept by the
mother on the left arm, the left side thus bearing the pressure,
weight, and strain,--it was with the left side that fear became
mainly associated.
During the height of the attack the patient was quietened, her
fears allayed, and a five-grain tablet of phenacetine was given her
with the authoritative remark that the drug was sure to help her.
As soon as she swallowed the tablet the patient opened her eyes,
and said she felt better. About an hour later, when another attempt
at an examination was made, patient had an attack of headache,
cried, said she was afraid, but she answered in a whisper when
spoken to. She talked slowly, in a sort of staccato way. I insisted
that she should talk a little faster and pronounce the words
distinctly. She made violent attempts to carry out my command, but
got scared, began to hesitate, and stammer, her voice and speech
rapidly deteriorating with her efforts, ending in complete mutism.
During the day I tried from time to time to keep up the experiment
of insisting that the patient should speak, and every time with
the same result of bringing about an attack.[12] The patient began
to stammer and stutter, becoming more and more frightened the
more the nurse and myself insisted that she should make an effort
and reply to our questions. Still, when the patient’s attention
became distracted, when she was handled gently, when her fears were
allayed, the speech and sound improved in quality and in loudness,
and at times her sentences were quite fluent, her enunciation quite
distinct.
This state of instability lasted for several days until the patient
became somewhat familiar with the surroundings. In one of her
better moments the patient told me that she thought her stammering
began with a definite event. One evening when she was fatigued with
the labors of the day for her family, a stammerer came in to see
her. The stammering made a strong impression on her. She felt the
strain of the stammerer; she could not control the sympathy and the
strain, and involuntarily began to imitate stammering. She began to
fear that she might continue to stammer and be unable to enunciate
sounds and words. The more she feared the harder it was for her to
speak or even to use her voice.
A few days later the patient began to improve, she began to adapt
herself to her surroundings, and did not get so easily scared.
About eight days after the first examination the patient woke up
one morning in a state of depression; she cried a good deal. She
did not sleep well the night before, dreamt and worried on account
of her children. She was afraid that something might have happened
to them in her absence, perhaps they were sick, perhaps the
husband could not take good care of them. She talked in a whisper,
her eyes were shut. When I insisted on opening the eyelids, she
opened them, but did it with difficulty. I put her into a hypnotic
state. In about a minute her eyes rolled up, and the eyelids shut
spasmodically. There was present a slight degree of catalepsy.
Mutism was strongly marked. Upon sudden and unexpected application
of an electric current, the patient opened her eyes, cried out,
but soon relapsed into a state of lethargy. Gradually patient was
brought out of the lethargic state.
A couple of hours later, after she had a good rest a few more
experiments as to her sensori-motor life were attempted. I
asked her to raise objects, tested her sensitivity to various
stimulations, her concentration of attention, asked her questions
about her life, about her family, took again her field of vision.
All that was a great effort to her. While I was taking her field of
vision the patient’s eyes began to close, and it took about twenty
seconds before she could open them. She opened them with effort,
but shut them again. This time it took her about 45 seconds before
she could open the lids. Fatigue, or rather fear fatigue, set in
sooner with each repetition of experiment and test, and lasted a
longer time.
For several days the patient kept on improving slowly. She then had
another relapse. She slept well the night before, but woke up early
about six in the morning; she began to worry about her family, and
complained of headache. About half past eight the headache became
severe, there was again pain in the left side, the left hand began
to tremble, and felt anaesthetic, the eyelids closed, and could not
open, aphonia returned, in fact she fell into a state of mutism.
About ten o’clock patient opened her eyes, but she was unable to
talk. After long insistence on her reply to my question as to how
she was, she finally replied in a whisper: “Well,” then added “I
have a bad headache.” She had great difficulty in replying to my
questions, moved her jaws impotently before she was able to emit
a sound, her muscles were strained, the face was set, tense, and
drawn, the brow was corrugated, the eyeballs rolled up, and the
eyelids shut tightly. The patient was unable to raise her hands,
they lay powerless at her side. When raised the arms were found
to be lethargic, fell to her side, only the left hand manifested
light, fibrillary twitchings and a gross tremor. When insisted upon
that she must raise her arms, she became agitated, scared, began
to moan and cry. Claimed severe pain in head, in chest, in heart.
“Pain in heart, in head, I am afraid,” she moaned in a whisper.
There was loss of kinaesthetic sensibility, patient complained that
she did not feel her arms, “they are not mine.” She had to look
at the arm in order to find it. There was also present anaesthsia
to other sensations such as pain, touch, heat, and cold. After a
couple of hours’ rest the sensibility returned. The sensibility was
affected more on the left side than on the right, and also returned
earlier on the right side.
When the fatigue and the scare subsided the patient was tested
again. This time the reactions to sensory stimulations were normal.
The patient was touched, pinched, and pricked, she reacted to
each stimulus separately, and was able to synthesize them and
give a full account of their number. Kinaesthetic sensibility was
good,--she was fully able to appreciate the various movements and
positions in which her limbs and fingers were put.
The patient was left to rest, quietened, treated carefully,
avoiding sudden stimulations, allaying her fears and suspiciousness
of danger, lurking in the background of her mind. After a few
hours she sat up, made an attempt to raise herself from bed, got
up with some effort, and sat down in an easy rocking chair next to
her. Her eyes were wide open. Asked how she was, she replied in a
whisper that she felt quite well. The effort however fatigued her,
her head began to drop, eyelids began to close, and the eyeballs
began to roll up. Twitchings were observed in the eyelids, and
tremors in the left arm. She was again put to bed and given a rest
of a few hours. She opened her eyes, and told me that she was weak.
This statement she herself volunteered. I found that she could move
her hands easily, and that the numbness was completely gone.
For a whole week the patient kept on growing in health and in
strength, her sensori-motor reactions improved, she walked round
the room for a few minutes, talked in a low voice for a quarter
of an hour at a time without manifesting her symptoms of fatigue;
her appetite and sleep improved accordingly. At the end of the
week there was again a relapse,--she did not sleep well the night
before, dreamt of being hunted and tortured, woke up depressed, had
no appetite for breakfast, complained of headache, pains, worries,
and fears. The headaches have abated in their virulence during last
week, but now they seemed to have reappeared in their former vigor.
When I began to examine her she looked frightened, her eyeballs
rolled up, her eyelids closed. The aphonia was severe, patient lost
speech and voice. When spoken to she could not answer. Asked if
she heard me, she nodded her head affirmatively. There were slight
twitchings of her left hand and also of the muscles of her face.
When attention was attracted to the arm the twitchings increased in
violence and rapidity. With the distraction of the attention the
twitchings disappeared. When the left hand was put in the patient’s
field of vision, thus making her attention concentrate on that
limb, the tremors increased again, becoming finally convulsive in
character.
I insisted she should try to open her mouth, and say
something,--she made fruitless efforts, moving incoordinately the
muscles of the face and of the forehead, but she could not utter a
sound. She could not move her arms on command, could hardly wriggle
the fingers of her hand. She appeared like a little bird paralyzed
by fear. When the arm was raised passively it fell down slowly
being in a cataleptic state.
I allayed the patient’s fear. I strongly impressed her with the
groundlessness of her fears, and also with the fact that everything
was well with the children, and that her husband will be good and
gentle with her. The patient was permitted to see her family.
The husband was made to realize that he must treat her with more
consideration. He came often to visit her, and learned to treat
her well. He soon found a better position, was advised to remove to
a healthy locality and to more cheerful surroundings. The children
were well cared for. The patient found deep satisfaction in the
midst of this family happiness. The fear state abated,--the patient
became more confident, more hopeful for the future, and began
to improve. The infant was weaned so that the strain of nursing
was removed. The patient’s appetite began to improve; she gained
several pounds in a few days. Long periods of examination and
investigation of her nervous and mental state no longer exhausted
or terrified her. Her concentration of attention could be kept up
from a quarter to half an hour at a stretch without giving rise to
fatigue, headache, or to a seizure with its consequent psychomotor
effects. The haunted look of fear disappeared, and along with
it were also gone the fatigue and dread of physical and mental
exercise or work. She could work and walk with ease the whole
length of the room and of the hall. She began to take more and more
interest in her appearance and in dress. For many minutes at a time
she looked out on the street taking an interest in all that was
done and what was going on.
The case was discharged, and was sent home. She continued to stay
well.
FOOTNOTE:
[12] In fact from my long experience with cases of stammering,
stuttering and mutism I may say that where no organic lesion may be
suspected, the disturbance is one of self and fear.