Tics and Their Treatment Part 22

Subsequently to his retirement from active business pursuits, the patient, a man fifty-nine years old, became depressed, morose, and irritable, till insomnia at length drove him in desperation to attempt suicide. By the merest chance he failed of his purpose. The development of involuntary sounds a few weeks later was followed at the end of a month by the equally involuntary e.j.a.c.u.l.a.t.i.o.n of his wife's and children's names--"Numa! Helen! Camille! Maria!" This habit persisted for as long as fourteen months, after which during three years he enjoyed excellent health. Owing to financial worries, however, a relapse occurred. Every few minutes he uttered various articulate cries in a loud, clear, and well-modulated voice, sometimes repeating the four names with great rapidity, at others calling out the same name with increasing violence. Severe convulsive twitches of arm and trunk musculature synchronised with his exclamations. The patient was incapable of either restraining or even modifying the cries; he was equally unable to replace one by another, to say Henry instead of Numa, or Jean instead of Helen.

For hours at a stretch he would repeat the names of friends who had come to visit him; on the day before a consultation on his case his one cry was the name of the new physician who was going to examine him.

A gradual improvement took place, and eighteen months after the onset of the condition the cure was complete.

In the same connection Pitres refers to a case reported by Calvert Holland.

A miner who had gone through the experience of incipient suffocation found himself two months later irresistibly impelled to exuberant speech. The rapidity and indistinctness of his enunciation of words were very much in evidence, as well as a tendency to stammering and to tautology. A further symptom consisted in rotatory spasms of the head; but after five months a satisfactory cure resulted.

We may cite a last instance from Ball:

A young girl was in the habit of kneeling down, making the sign of the cross, and repeating "Jesus, Mary, Joseph." The performance was limited to this order of events, but its practice in drawing-rooms and still more in thoroughfares led to her being certified as insane.

ECHOLALIA

In his description of the disease which bears his name, Gilles de la Tourette used the expression echolalia to denote a certain phenomenon of occasional occurrence among those who tic.

The patient (says Guinon) repeats echo-like the sounds he hears around him, and like the echo his reproduction of them is more or less lengthy. In its mildest form the symptom may consist in the repet.i.tion of a simple involuntary "ah!" which some one near by has e.j.a.c.u.l.a.t.ed, or the last word or two of some one's talk is mimicked, or in a more advanced stage the whole of a phrase is reproduced.

As a general rule the "echo" is rather obtrusive, but its commencement at least may be very different, the patient being astonished to find himself repeating in a subdued tone of voice what he hears others saying; and, struggling in fear to rid himself of the habit, he ends by sinking into a state of actual anguish. It is at this moment that he fails to inhibit his impulses and gives vent to the word he has been endeavouring to check, which he may repeat loudly and violently in a sort of fury. The fidelity and clearness with which the utterances of others are imitated are remarkable.

Sometimes by an effort of the will the patient is able to suppress, it may be imperfectly, the impulse to echo, so that while his tongue is under his control, his will gives rein to his other tics, and a regular muscular debauch takes place. In the mildest cases he can replace a word by a movement, by a little cough or an insignificant "ahem!" but not beyond a certain point, for he will thus restrain himself only when he is forewarned; a sudden and unexpected e.j.a.c.u.l.a.t.i.o.n in his neighbourhood will catch him off his guard.

In spite of their frequency among those who are addicted to tic, echolalia and echokinesis cannot be enumerated with the tics, seeing that their exhibition is dependent on the actions of others, whereas once a tic is established it requires no stimulus from without for its manifestation. Of course their affinity to the tics is very close: they spring from the same soil; they represent in the adult the persistence and amplification of the child's propensity for imitation, and therefore in their own way postulate a degree of mental infantilism.

Echolalia in the blind has been made the subject of an interesting study by Noir.

The echolalic repeats abruptly and rapidly what is said by others in his presence. That he does not stop to reflect is attested by his mimicry of bizarre words, technical terms, even of idioms in a foreign language.

It is an interesting fact that of twelve cases of echolalia that have come under our observation, fifty per cent. occurred among the blind. The coincidence is a rational one; blindness and echolalia are united as cause and effect. In the case of the person born blind the auditory memory is in such an advanced state of development that, if he be not very intelligent, he will seek to fix the sound of an auditory impression in his defectively organised mind as soon as he hears it, and being unable to whisper it mentally, he stimulates his auditory centres by a less delicate process, and forthwith repeats aloud the word he has just heard.

This is why we meet with instances of the echolalic blind repeating a sentence before replying to it. It is instructive to note in this connection that the choicest example of echokinesis we have seen was in a deaf mute, in whom no doubt the visual phenomena were a.n.a.logous to the auditory phenomena of the echolalic.

Noir is inclined to apply this mechanism to the case of echolalics who are not actually blind. He quotes instances which go to show that their visual memory is awanting, that as far as it is concerned they are "blind."

The hypothesis is attractive. It may be further remarked that the echolalia is a "motor," in the same way as the patient afflicted with hallucinations of sight or hearing is an "auditory" or a "visual."

Echolalia is amenable to treatment, and is even capable of cure. Noir gives an interesting example of the evolution of the process.

If I say to an echolalic, "Are you hungry?" he will instantly answer, "Are you hungry?" Under the influence of re-education the reply will eventually change to "Are you hungry? are you ...? Yes, sir, I'm hungry," then to "Yes, sir, I'm hungry," and finally to "Yes, sir."

Echolalia, however, is not an exclusive appurtenance of those who tic.

We can remember a case of general paralysis in the clinique of Brissaud at the Hotel Dieu, who had the regular habit of repeating the question that was addressed to him; if it were a little long, only the last ten or fifteen words were echoed. A case is quoted by Cantilena of a woman with right hemiplegia and partial epilepsy who invariably reiterated the closing phrase of anything said to her. Several cerebral tumours were discovered at the autopsy.

It is conceivable of course that an actual lesion, as well as a congenital developmental defect, may interfere with the will's inhibitory powers, in which case auditory or visual stimuli are transmitted to motor centres unmodified, the result being the production of sounds or of other movements.

COPROLALIA

Coprolalia, the _manie blasphematoire_ of Verga, is, according to Gilles de la Tourette, one of the most frequent affections of speech in the disease of convulsive tics.

There is no necessary connection, as a matter of fact, between tic and coprolalia, though of course they may co-exist, sometimes in a.s.sociation with other syndromes; they are in reality only episodic syndromes of hereditary insanity.

A distinction ought to be drawn between coprolalia and the use of trivial or inconvenient terms, words with which even some well-educated persons are wont to garnish their conversation. Guinon had a case of a man who in the presence of his mother resorted to language of a kind absolutely disallowed in polite society. In the etymological sense of the word, no doubt, he was a coprolalic, but it cannot be said that he was suffering from tic.

On the other hand, the abrupt and impetuous utterance of oaths or obscene expressions, to the e.j.a.c.u.l.a.t.i.o.n of which an irresistible impulse seems to drive the patient independently of time and place, amounts to a coprolalic tic of speech, and reveals a deplorable volitional debility on his part; for he is incapable of checking an act to the impropriety of which he is fully alive.

The victims of this disease (says Guinon) have an extraordinary propensity for choosing the foulest and most indecent words, however elevated their position and correct their breeding.

Reference may be made to the cla.s.sic instance of the Marquise de Dampierre, who all her long life was in the habit of repeating certain immodest sayings even on the most solemn occasions.

According to Guinon the reason of this bizarre preference for obscene remarks is absolutely unknown, although Charcot's view[129] that coprolalia is frequently nothing more than echolalia is one of some plausibility. He refers to one of his patients who alternated her coprolalic utterances with a sort of barking noise that was an exact imitation of her favourite dog.

We ourselves have had for a long time under observation a youth in the service of Professor Brissaud whom some instinct seemed to prompt to repeat any lewd expression he happened to hear, or indeed any which might be so interpreted. It might then be said of him that his coprolalia varied with his surroundings and with his own ideas; it was accompanied by inconstant and irregular convulsive movements of the limbs.

After all, there is not so very much to choose between the coprolalic and the individual whom impatience or anger forces to blaspheme or at any rate to utter words that do not form part of his ordinary vocabulary. And though the e.j.a.c.u.l.a.t.i.o.n be not audible, the first degree of coprolalia consists in the mental presentation of the objectionable phrase. Among those who suffer from obsessions mental coprolalia is far from uncommon. A patient with _folie du doute_, mentioned by Seglas,[130] was afraid to p.r.o.nounce indelicate words because he felt himself articulating them mentally, and sometimes he used to ask whether they had not really escaped him. One step more, and these verbal hallucinations a.s.sume the characters of a genuine tic.

CHAPTER XI

THE EVOLUTION OF TIC

Tic is, from its nature, highly variable in its evolution; each tic has a development peculiar to itself. Mental differences among individuals have their counterpart in physical differences, in health as well as in disease, and a comprehensive sketch of the evolution of tic is therefore impracticable. We shall restrict ourselves accordingly to a few general remarks.

In the great proportion of cases of tic the onset is an insidious one.

We have already made a sufficiently detailed examination into the pathogenic mechanism to obviate any repet.i.tion in this place, but we may note how unsettled the earliest manifestations are, how a tic may pa.s.s from one muscle or group of muscles to another, and even when its exciting cause is patent an apprentice stage always precedes its final establishment. Of the truth of this the history of J. provides an excellent instance. Another one is from Pitres:

A nine-year-old boy received a severe shock one day through being pounced on by some companions who were in hiding behind a wood pile, and though the emotion was of short duration, he commenced a few days later to exhibit involuntary muscular twitches of the upper part of his body, and to utter suppressed cries. The phenomena increased in violence and in frequency, and, in spite of treatment, a year later he was not freed of them entirely. For an unknown reason the tics renewed their activity when he was seventeen and continued so for the next three years, until a spell of Pitres' respiratory exercises effected a complete cure.

An evolution such as the above may be considered more or less typical of the great majority of tics.

We have seen that the tic may be localised indefinitely in one and the same muscle or muscular group, but its site may also vary from day to day. Two tics may co-exist and coincide, or a third may appear with the disappearance of the others. Unexpected resurrections may succeed periods of complete repose.

Tic always shows a tendency to invade; regarded as a functional act, it moves in the direction of greater complexity.

After involving the orbicularis, for instance, a tic will spread to neighbouring groups, in particular to those muscles whose synergic contractions form a special expression of countenance. That is why tics of the eyelids are a.s.sociated with movements of the pyramidales, frontales, and corrugators. Tics of the lips or of the alae nasi very commonly extend to the corresponding elevators. It is not surprising that muscular groups accustomed to act in physiological unison should also be affected together (Noir).

Moreover, the fecund imagination of the victim to tic is calculated to facilitate the invention of all sorts of modifications, complications, parodies, and caricatures of the functional acts on which his tics are grafted.

Tics are constantly varying in amplitude, degree, and frequency; as O.

remarked spontaneously, "We have our good days, and we have our _mauvais quarts d'heure_." The sedative effect of rest, solitude, silence, and obscurity may be contrasted with the detrimental results of fatigue, noise, fear of ridicule, etc.

However incapable S. is of rotating his head to the right when requested to do so, the movement is executed with the utmost readiness should his attention be drawn in that direction. But if he hesitates, even momentarily, before looking round, he cannot then do so without the preliminary performance of all sorts of contortions, ending in a twist of his body through a half circle to the right. Sometimes he actually turns round two or three times, after the fashion of a dog chasing its tail. Let him have a pleasant visit, on the other hand, let him engage in a discussion, or be engrossed in a play, let him administer a rebuke to some one, and immediately his trouble is forgotten, his speech is accompanied with animated gestures, the vicious position of his head vanishes--in short, he becomes normal.

An intercurrent affection may act either as a deterrent or as a stimulus; with convalescence, however, there is usually a re-establishment of the mischief. The most potent influence over the phenomena of tic is wielded by a sense of well-being, to employ Janet's discriminating expression. Well-being is a panacea for the _tiqueur_ no less than for the hysteric. The tic of the worried financier disappears, as we have had occasion to note, under the magic of a rise in stocks or a knowledge of solvency. The child's happiness is bound up in his freedom, which explains the cessation, in Tissie's little patient, of all convulsive movements during the holidays.