Tics and Their Treatment Part 2

No objective alteration in cutaneous sensibility in any of its forms is discoverable on examination of O., but he bewails a long array of subjective sensations, painful or disagreeable as the case may be.

Certain abdominal pains in particular occupy his thoughts: after being in bed about an hour he begins to suffer from pain in the abdomen and across the kidneys, so acute that he is forced to rise and walk about his room, or sit on one chair after another; at length it moderates enough to allow return to bed and permit of sleep. During these crises there is no sign of any local pathological condition, no distention or tenderness or evacuation of the bowel. They usually last for some days at a time and disappear suddenly, as when, after several nights' and days' uninterrupted suffering, his pains vanished as by an enchanter's wand once he set foot on the boat that was to take him to England.

We have had the opportunity of observing our patient in the throes of one of these attacks, and while we did not doubt the genuineness of his sufferings, we could not but be struck with the dramatic exuberance of his gestures. He wriggled on his chair, unb.u.t.toned his clothes, undid his necktie and his collar, pressed his abdomen with his hands, sobbed and sighed and pretended to swoon away. Such excessive reaction to pain is characteristic of a nervous and badly trained child, not of a man of his years. Notwithstanding his humiliation at these exhibitions of weakness, he can no more control them than he can his ordinary tics; in fact, the tics run riot during the crises of pain.

On several occasions the reflexes have been the object of examination.

The pupillary reactions are normal, as are the tendon reflexes of the upper extremity; but the knee jerks are much diminished, and one day we failed to elicit them at all, though we noted their return a week later.

A careful search for further signs of possible cerebro-spinal mischief proved negative, if we except a slight flexion of the knees when walking and a tendency to a shuffling gait.

Notwithstanding this absence, in O.'s case, of any definite indication of organic disease, we cannot afford, in our examination of patients, to overlook any symptom, however fleeting or trivial it may appear, since it is only by painstaking investigation both on the physical and the mental side that we can ever hope to determine the characters and fathom the nature of the affection, apart from the value of such an investigation as an aid to diagnosis, prognosis, and treatment.

With charming spontaneity and frankness, but critically withal, O. has furnished us with a picture of his mental state. Nothing could be truer or more instructive than this piece of self-observation, even though his obvious pleasure in hearing himself talk is a little weakness of which, to tell the truth, he is the first to accuse himself:

In childhood and at school my accomplishments were ever on the same dead level of mediocrity. I was neither brilliant nor backward; in the drawing-room or in the playground, I was good at everything without excelling in anything; the astonishing facility with which I learned to sing, play, draw, and paint, was linked with inability to distinguish myself at these pursuits.

Each new study, each new game, attract and captivate me at first, but I soon tire of them, and once a fresh enterprise has taken their place, indifference to them changes to disgust. If I am amused with a thing, I do it well; if bored, I throw it aside. I suppose it is characteristic of people who tic to be fickle and vacillating.

The versatility which is so fundamental an element in O.'s nature has not been prejudicial to his business career. He has managed and still manages important commercial undertakings, demanding initiative and decision, and, so far from sparing himself in any way, he has exhibited a combination of caution and audacity that has stood him in good stead.

It is more especially in the conduct of urgent operations that his alertness is displayed. His comprehensive grasp of the situation enables him to put his machinery at once into action, with eminently satisfactory results, if we judge by his prosperous and a.s.sured position.

His mobile and impulsive temperament is revealed in his every deed, but he shows at the same time a curious disposition to alternate between the pros and the cons of a question. It is the outcome of his extremely a.n.a.lytical and introspective mind.

I find myself seeking a knot in every bulrush. I experience a sensation of pleasure only to tax my ingenuity in discovering some danger or blame therein. If a person produces an agreeable impression on me, I cudgel my brains in the attempt to detect faults in him. I take it into my head to ascertain how anything from which I derive enjoyment might become an aversion instead. The absurdity of these inconsistencies is perfectly patent to me, and my reflections occasion me pain; but the attainment of my ends is accompanied with a feeling of pleasure.

In regard to my tics, what I find most insupportable is the thought that I am making myself ridiculous and that every one is laughing at me. I seem to notice in each person I pa.s.s in the street a curious look of scorn or of pity that is either humiliating or irritating. No doubt my statement is a little exaggerated, but my fellows and I have an overweening self-conceit. We wish to be ignored, and yet we wish to be considered; it is annoying to be the object of sympathy, but we cannot bear to become a laughing-stock.

Accordingly our goal is the dissimulation of our failing by any means feasible; yet nine times out of ten our efforts are abortive simply because we invent a tic to hide a tic, and so add both to the ridicule and the disease.

Alike in speaking and in writing O. betrays an advanced degree of mental instability. His conversation is a tissue of disconnected thoughts and uncompleted sentences; he interrupts himself to diverge at a tangent on a new train of ideas--a method of procedure not without its charm, as it frequently results in picturesque and amusing a.s.sociations. No sooner has he expressed one idea in words than another rises in his mind, a third, a fourth, each of which must be suitably clothed; but as time fails for this purpose, the consequence is a series of obscure ellipses which are often captivating by their very unexpectedness.

His writing presents an a.n.a.logous characteristic.

It has often happened that I have commenced a business letter in the usual formal way, gradually to lose sight of its object in a crowd of superfluous details. Worse still, if the matter in hand be delicate or wearisome, my impatience is not slow to a.s.sert itself by remarks and reproaches so pointed and violent that my only course on reperusal of the letter is to tear it up.

By way of precaution, therefore, O. has adopted the plan of having all his correspondence re-read by his colleague. Strangely enough, to his actual caligraphy no exception can be taken. The firmness of the characters, the accuracy of the punctuation and accentuation, the straightness of the lines, are as good as in any commercial handwriting.

With the aggravation of his head tics writing has become a serious affair. Every conceivable att.i.tude has been essayed in turn, and at present the device he favours is to sit across a chair and rest his chin or his nose on the back; in this fashion he can write all that is required.

O.'s every act is characterised by extreme impatience. In his hurry he comes into collision with surrounding objects or breaks what he is carrying in his hand, not because of defective vision or inco-ordination of movement, but because of his eagerness to be done.

In spite of the fact that I know my recklessness to be absurd, that I see well enough the obstacles around and the danger of an encounter, I am conscious of a paradoxical impulse to do exactly what I should not do. In the same instant of time I want what I do not want. As I pa.s.s through a door I knock against the door-post without fail, for the sole reason that I would avoid it.

There is impatience in his speech. His volubility makes him out short his own phrases or break in upon the conversation of others. If an idea suggests itself, he must give it expression. Perhaps the word wedded to the idea is not at once forthcoming, yet he does not hesitate to invent a neologism, which is often amusing in spite of or because of its oddness, and if it please him he will enter it in his vocabulary and use it in preference to the other.

To wait is foreign to his nature. The least delay at table exasperates him; any order he gives must be executed instanter; no sooner has he set out than he would be at his journey's end. An obstruction or difficulty in the way is the signal for a fresh outburst; his irritation soon exceeds all bounds; his language degenerates into brutality, his gestures become increasingly violent and menacing.

It is not with any surprise, then, that we learn in O.'s case of incipient homicidal and suicidal ideas.

At times when my tics were in full force evil thoughts have often surged over me, and on two or three occasions I have picked up a revolver, but reason fortunately has come to the rescue.

As a matter of fact, the suicidal tendencies of some sufferers from tic are seldom full-blown. The will is too unstable to effect their realisation. Hence the patient's hints at doing away with himself are nothing more than empty verbiage. Similarly with the inclination to commit homicide, it vanishes as soon as it arises.

The term "vertigos" is used by O. to designate a long series of little "manias" or obsessional fears from which he suffers, among which may be enumerated dread of pa.s.sing along certain streets and a consequent impulse to walk through others; dread of breaking any fragile object he holds in his hands, coupled with the temptation to let it fall; fear of heights, and at the same time a desire to throw himself into s.p.a.ce.

I have often stood on the edge of the pavement waiting for a vehicle to pa.s.s, and at the moment of its approach darted across just under the horse's nose. On each occasion I have been conscious equally of the absurdity and yet of the irresistibility of the idea; each time the attempt to withstand it has been labour lost.

O. is a great nosophobe. At one time he was immoderately apprehensive of contracting hydrophobia, and used to flee from the first dog he saw. To his sincere regret he had several of his pet dogs killed, because of his conviction that they would become infected, although he felt such harsh measures to be quite unjustifiable. At a subsequent stage he turned syphilophobe for no adequate reason. He was alarmed lest a minute pimple on his chin should develop into a chancre. Recently his chief misgiving has been that he may become ataxic or demented.

Among his various afflictions mention must be made of an umbilical hernia, supposed to have originated in the chafing of his umbilicus by a belt he was wearing during a long spell in a canoe. As a matter of fact, the hernia is purely imaginary--at any rate, there is no trace of it to-day. Yet at the first it bulked very largely in his mind, and he is still fully persuaded of its reality, though no longer of its gravity.

O. further complains of all sorts of noises in his ears, but these are simply the ordinary sounds that one can produce in the middle ear by clenching the jaws together. He will not accept so obvious an explanation, however, preferring to regard them as indubitable evidence of the "lesion" with which he is preoccupied. The tinnitus, therefore, is rather of the nature of an illusion than of a hallucination.

He is distinctly emotional, and lives at the mercy of his emotions, but from their very bitterness he contrives to derive some pleasure. His pa.s.sion for horse-racing is not due to the fascination of the sport, but to a bitter-sweet sensation which the excitement of the scene calls into being. He is indifferent to arrest or aggravation of his tics; all that he seeks is the a.s.sociation of a certain sense of anguish with certain "tremolos in the limbs," wherewith he is greatly delighted.

In the domain of his affections there does not appear to be any abnormality. O. is an excellent paterfamilias, adoring his children, but spoiling them badly at the same time. In this part of our examination we did not press for details, but as far as we have gathered he is capable of sympathies keenly felt though rarely sustained.

Thus, whatever be the circ.u.mstances, changeableness, versatility, want of balance, are manifested clearly in all his mental operations; and when he remarks himself on the youthfulness of his disposition, he is simply stating a truism as far as those who tic are concerned, for, in spite of the advance of years, their mental condition is one of infantilism.

Under our direction O. has devoted several months to the eradication of his tics, and he has not been slow to appreciate the aim of the method or to acquire its technique. One of the first results was the repudiation of various procedures more harmful than otherwise, and the successful endeavour to maintain absolute immobility for an increasing s.p.a.ce of time. The outcome of it all has been a gradual diminution of the tics in number, frequency, and violence, and a corresponding physical and mental amelioration.

We do not intend in this place to enlarge on the details of our treatment: suffice it to say that it consisted in a combination of Brissaud's "movements of immobilisation" and "immobilisation of movements" with Pitres's respiratory exercises and the mirror drill advocated by one of us. To-day the utility of these measures is an accepted fact; but at the same time we rely on an inseparable adjunct in the shape of mental therapeusis, seeking to make the patient understand the rationale of the discipline imposed.

Our task has been lightened to an unusual degree through O.'s intimate acquaintance with the beginnings of his tics and his striking faculty of a.s.similation. On many occasions he has antic.i.p.ated our intentions and of his own accord outlined a programme in harmony with the indications we were about to give him. Thanks to this happy combination of circ.u.mstances, the improvement effected by our treatment has been quickly manifested.

I am conscious of very material gain. I do not tic so often or with such force. I know how to keep still. Above all, I have learned the secret of inhibition. Absurd gestures that I once thought irrepressible have succ.u.mbed to the power of application; I have dispensed with my para-tic cane; the callosities on my chin and nose have vanished; and I can walk without carrying my head in the air. This advance has not been made without a struggle, without moments of discouragement; but I have emerged victorious, strong in my knowledge of the resources of my will.... To tell the truth, at my age I can scarcely hope for an absolute cure. Were I only fifteen, such would be my ambition; but as I am, so shall I remain.

I very much doubt whether I shall ever have the necessary perseverance to master all my tics, and I am too p.r.o.ne to imagine fresh ones; yet the thought no longer alarms me. Experience has shown the possibilities of control, and my tics have lost their terror. Thus have disappeared half my troubles.

The same sagacity that O. displayed in a.n.a.lysis of his tics has enabled him to grasp the principles of their subjugation. Notwithstanding that his guarded prognosis is evidence for his appreciation of the hindrance his peculiar mental const.i.tution is to a complete cure, he has impartially put on record his definite progress towards health of body and mind.

Such, then, is the faithfully reported story of our model, such are his confessions.

During ten years' intercourse with sufferers from tic it has been our interest to a.n.a.lyse and reconstruct the pathogenic mechanism of their symptoms, and in the vast majority of cases it has been possible to determine the origin of the tics and to confirm the a.s.sociation with them of a peculiar mental state. We have thus been able to supplement earlier and weighty contributions to the subject by numerous suggestive instances, prominent among which is the case of O., whose spontaneous and impartial self-examination forms an invaluable clinical doc.u.ment.

Its importance is enhanced by the fact that its observations are corroborated by a survey of other examples of the disease.

With commendable good-humour, keenness, and sincerity, O. has of his own accord plunged into the minutiae of his malady, and exhibited a rare appreciation and precision in the scrutiny of his symptoms. The mere enumeration of them stamps the record as one of outstanding clinical importance, but it is the study of their pathogeny that is so fascinating. For a moment the doubt crossed our mind that O.'s explanations might be merely a reflex of information culled from scientific journals or of conversations with medical friends, but this is not so. He has been prevented by his profession both from cultivating a taste for and from devoting any leisure to psychological and physiological questions, while he evinces an actual antipathy to medical literature, fearful as he is of contracting disease. The point we are desirous of emphasising, therefore, is simply this: that the results of O.'s voluntary and unprejudiced self-examination are in perfect harmony with the declarations of our older patients and with the statements of the majority of those that have made a special study of the tics. For these reasons we have taken O. as the prototype of the _tiqueur_.

CHAPTER II

HISTORICAL

We have just become acquainted with an individual who may, we believe, be considered the type of a species, and have described all his tics.

What is a tic, then?