Tics and Their Treatment Part 24

Notwithstanding its slow evolution (says Brissaud), the neurosis, in so far as it was a disorder of motility, seems to have completely disappeared. The importance of this for prognosis is fundamental, but from the point of view of diagnosis it is no less significant, seeing that the nature and form of the movements suggested chronic or Huntington's ch.o.r.ea.

A case described by Gilles de la Tourette[139] as disease of the tics seems really to have been one of variable ch.o.r.ea.

A woman of twenty-two, who had never been very strong, had an attack, at eight years, of involuntary movements of face and arms which prevented her feeding herself, and at the hospital a diagnosis of ch.o.r.ea was made. Two months later cessation of the movements allowed of her return to school, but a second attack followed after two years, and a third a year later. At the time of observation she was in the throes of her sixth relapse. Every one who had seen her considered the condition as ch.o.r.ea.

Tourette, however, was dissatisfied with the diagnosis. There was no suggestion of its being Sydenham's ch.o.r.ea, or hysterical ch.o.r.ea, still less of its belonging to Huntington's variety. According to the author, the muscular twitches were amorphous and indefinite, and characterised by extreme variability in form, expression, and intensity.

In our opinion the clinical picture is that of variable ch.o.r.ea, and we are confirmed in our opinion by a consideration of the patient's mental condition.

She comes of a p.r.o.nounced neuropathic stock. One of her two sisters is nervous and impressionable, and probably a neurasthenic, while the other is subject to hysterical attacks. She herself is of a profoundly nervous temperament; she cannot go to bed without a.s.suring herself several times that no one is concealed beneath it; she suffers from fears and dreads and obsessions of all sorts; she is, in fact, an "unstable," a degenerate.

In one of our patients the symptoms were unilateral, const.i.tuting a variable hemich.o.r.ea.

It is a matter of some difficulty to furnish an adequate description of the movements of the right arm. We note, first of all, that their activity depends on whether the arm is free or held in a fixed position. Voluntary movements are carried out stiffly, but are interrupted by sudden deviations, sometimes of rather a wide range, and highly irregular in distribution. Notwithstanding these breaks, the end to which the movement is directed is always attained with precision.

While L. was an apprentice dressmaker, she occasionally used to make various contortions with her arm, though if her attention was diverted they did not occur, and as a matter of fact she did her work well enough. Once she became familiar with the mechanical act of sewing, the involuntary performances ceased. Before her disease a.s.serted itself, she had commenced to learn the piano, and she continued to make unimpeded progress, as her teacher discovered a method of holding her elbow which checked all convulsive twitches.

The involuntary movements of the right leg were so insignificant as to be almost negligible; they united to produce a sort of irregular tremor which became appreciable only when the patient was very tired or very annoyed. Sometimes a long walk was followed by a certain hesitation in putting the right foot to the ground, and by defective inhibition of the antagonists of the desired movement.

Sometimes one foot was knocked against the other, and sometimes the right appeared to a.s.sume an equinovarus position. On the other hand, we have seen L. walking in the street with her father, when no anomaly could be detected in her gait. The distraction of any occupation such as dancing or playing a game has the effect, for the time being, of banishing the greater part, if not all, of the spasmodic phenomena.

This is undoubtedly a case of Brissaud's variable ch.o.r.ea of a unilateral type, and a consideration of the symptoms confirms the intimate relationship between it and tic.

Various intermediate forms have been noted. In one of Brissaud's cases, variable ch.o.r.ea and multiple tics co-existed. Fere[140] reports a case of variable ch.o.r.ea preceded by tic, and Bernard another in which starting, trembling, facial tic, variable ch.o.r.ea, etc., were a.s.sociated.

Tics of phonation are often superadded to the gesticulations of variable ch.o.r.ea. Brissaud refers to the case of a girl of sixteen in whom involuntary movements resembling those of this type of ch.o.r.ea were coincident with a sort of hiccough, and a more or less inarticulate cry; at a later stage the movements became very infrequent, the hiccough was more constant, and the cry developed into a coprolalic e.j.a.c.u.l.a.t.i.o.n.

Variable ch.o.r.ea and variable tic are obviously very closely allied. The movements of the latter, however, are distinguished by their greater abruptness and smaller variety. They are tics by reason of their systematisation and co-ordination; they are variable because they pa.s.s from one region of the body to another. There is no necessary relation between them; each has an individuality of its own and is independent of the rest. In variable ch.o.r.ea, on the other hand, one movement pa.s.ses insensibly into another, and the variants of any particular one are legion.

However easy it is, then, to separate the two clinically, it is none the less true that they spring from the same soil of mental defect. Variable ch.o.r.ea differs in nature from other ch.o.r.eas, though its form is the same; it may be distinguished from tic by the type of movement, but in essence it is identical.

CHAPTER XII

ANTAGONISTIC GESTURES AND STRATAGEMS

However harmless and insignificant a tic may be, it is a source of annoyance to its subject of which he constantly seeks to disembarra.s.s himself. But the feebleness of his will militates against any sustained effort, and if for a brief s.p.a.ce he can conserve his immobility, victory eludes his grasp, for his tics resume the offensive and increase in violence. More than ever convinced of his helplessness, he resorts to measures that serve but to accentuate the mischief. Thus it comes to pa.s.s that he desists from his attempts at repression and admits himself vanquished.

Some there are, nevertheless, whose inventive faculty leads them to adopt singular att.i.tudes, to execute curious gestures, to utilise elaborate apparatus--proceedings always more or less childish, whose employment is usually followed by success, but only for a time. The history of O. acquaints us with a whole series of these subterfuges, for which the expressive name of para-tics was invented by him, tricks intended to mask or to modify existing tics, but they soon themselves became as involuntary and as inevitable.

Not all who tic are imaginative enough to conceive such plans, and many have no thought of showing fight at all, but it is worth while dwelling on this point for a little, especially in view of the frequency with which certain tics are accompanied by methods of correction evolved by the patient.

To begin with, we may quote the case of mental torticollis. The sufferer's head is irresistibly driven to the right, say, yet he replaces it immediately by the mere application of his right forefinger to his chin, and the correct att.i.tude is maintained so long as the finger is applied. Of the variants of this efficacious antagonistic gesture the most common is the grasping of the head in the hands, or its support in the palm, or the simple contact of the fingers with chin, or cheek, or temple. In some cases the mere threat of this gesture suffices for the purpose. S. approximates his hand to his left ear, but before he has actually touched it his head turns spontaneously to the right. It would be difficult to find more conclusive evidence of the purely psychical value of such corrective acts.

Sometimes the resources at the patient's disposal are confined to one measure, though more frequently he avails himself of several, as in a case recorded by s...o...b...[141] The antagonistic gesture may fail of its object if some one other than the patient put it to the test. Even with the expenditure of considerable force he may make no impression on the tonic contraction; this rule, however, is by no means general.

One of our patients, whose head used to be strongly tilted on to his elevated right shoulder, while his right arm was flexed, his left shoulder depressed, and his whole trunk deviated to the former side, was able instantaneously to resume his normal att.i.tude by merely placing his thumbs one on either side of his head. If any one else sought to correct his vicious position he could do so by applying his fingers to two well-defined spots on the occiput, towards the base of the mastoid processes.[142]

Occasionally the antagonistic gesture is of the nature of a paradox. We may cite an example from Raymond and Janet.[143]

If we ask the patient whether she cannot sometimes prevent her head from rotating, she declares she can, and demonstrates how it is done by lightly touching her forehead with her finger tips. Now, in view of the fact that her head is deviated to the left and backwards, it will be seen that no pressure exerted in front could obviate this. What really happens is that at the moment of contact not only does she inhibit the movement by the aid of her will, but she also makes a slight forward inclination of her head to rest it on the point of support. No performance of this description could have any efficacy in the case of a genuine spasm due to irritation on a reflex arc.

At length the day arrives when the hand is unequal to the task, and the patient endeavours to utilise more resistant bodies, such as the back of a chair or the wall of the room, as in a case of retrocollis reported by Brissaud. These devices in their turn prove insufficient, and relief is obtained only in the rec.u.mbent position. Fournier[144] has seen a case of convulsive twitching of the right sternomastoid and trapezius arrested when the head was reclining on a pillow.

Even in bed, however, there is usually something to complain of: the pillow is too high, or too low, or too soft; the rustle of the packing is disagreeable, the sheets are too rough, etc., etc. It is then that all sorts of unlikely arrangements are adopted, and the patient puts his head under the bolster, or lets it hang over the edge of the bed, or piles up additional cushions and mattresses calculated to retain it in the desired situation.

Frequently the stratagems are highly ingenious and complicated.

Madame K.,[145] forty-three years of age, suffers from clonic movements of the head which disappear with the adoption of a torticollic att.i.tude, the face looking to the left. Nothing is easier than voluntarily to correct this att.i.tude, but the clonic movements at once rea.s.sert themselves, although they may momentarily be kept in abeyance by placing the hand on the chin.

Numerous and ingenious have been the devices framed by this lady, but in no instance has their success been other than transient. Her latest invention is a stiff high collar fashioned of several thicknesses of a heavy material. At the risk of strangling herself she has so compressed her neck that no movement is possible, but the right arm has now become the seat of action.

A patient of Gra.s.set[146] used to promenade in the grounds of the hospital holding a cane in his teeth and maintaining his head in position by keeping one finger on the end of the stick.

Another patient, under the care of Nogues and Sirol,[147] whose head was fixed in irresistible anteroflexion and rotation to the left, had invented a most elaborate piece of apparatus, the adoption of which was followed by perfectly satisfactory results.

On the frame of a pair of pince-nez deprived of the gla.s.ses he fixed a piece of iron wire ten centimetres long in such a way that it stood out from the spring at right angles to the plane of the pince-nez. It was sufficient to wear this thing on his nose to inhibit the spasm, and to be able to talk, walk, do anything unhampered by his torticollis; it was not even necessary to concentrate his gaze on the extremity of the rod.

In the case of one of our patients, N., whose head we had on several occasions succeeded in keeping straight while he was writing by directing a pin towards his left cheek, the idea was entertained of utilising this procedure out of doors, and accordingly a long pin was fixed in the collar of his overcoat. There never was the slightest p.r.i.c.k on his cheek, but we strongly dissuaded him from the continuation of this objectionable practice.

Antagonistic stratagems of this kind are met with in other tics.

A curious case of mental trismus is reported by Raymond and Janet,[148]

where the patient always spoke through his clenched teeth, but opened his mouth widely enough when showing his tongue or when eating. To overcome the tonic contraction of his ma.s.seters he used to insert a minute piece of cork between his jaws, though he could also open them to articulate properly by holding his chin with his hand.

Chatin's patient[149] nullified the permanent contraction of his masticatory muscles by insinuating his little finger between the dental arches.

In this connection reference may again be made to the fixation att.i.tude adopted by young J.[150] for his left arm, a subterfuge of his own invention which he considered a sovereign remedy. In essence it was nothing else than an efficacious antagonistic gesture, inspired by a tic and become its indispensable complement. Of other ingenious ideas of his brief mention may be made.

Convinced of the necessity and possibility of checking the movements of his shoulder, he sought the aid of his "immobilising mattress," an ordinary mattress spread in a corner of the dining-room, on which he flung himself and reclined from morning to night, making the wretched thing his companion, solace, and confidant, who alone understood and could alleviate his tics. In his anxiety to find some point of resistance for his left arm to work against, he had a second and much narrower mattress put under the first, so that prodigious efforts were required on his part to maintain equilibrium on the cylindrical surface. This was exactly what he desired, and for a time he ceased to tic.

An equally curious case is that of one of Raymond and Janet's patients afflicted with multiple tics.[151]

He was a man thirty years old, who denied having had tics for more than four years; he had always been eccentric, however, and came of a family some of whose members were dullards and others hysterics.

His career at school and college was brilliant, but his vain and erratic disposition had prevented him from realising his boundless ambitions, and carrying into effect many ingenious schemes. For that matter, a prominent trait in his character was a curious scrupulousness that led him to seek an impossible perfection for all his actions. Anything he put his hands to he thought might be better accomplished if he had a system for the purpose; he had, for instance, all sorts of plans for improving his caligraphy, for holding the pen, interminable "tips" for correct punctuation, for learning, for reciting. To such an extent was he embarra.s.sed by these procedures that he could not write two letters consecutively.

Purposeless voyages to Africa ended in his contracting conjunctivitis, malaria, and dysentery, and he returned to France worn out and more eccentric than ever. Thereafter the state of his health, and above all his functions of respiration and digestion, became matters of absorbing attention. A system had to be thought out for breathing better and for avoiding possible suffocation. He next devoted himself to the question of alimentation, and conceived the idea of moistening each mouthful of food with water, soon finding it desirable to wet his lips, apart from meal time, in order to breathe better. One day during a journey by train he suffered agonies from want of his drop of water.

Examples such as these serve to ill.u.s.trate how the misplaced ingenuity of the sufferer from tic complicates his misfortunes instead of banishing them, and indicate to what extremes his eagerness to obtain respite may lead him.

All these gestures and stratagems may be considered as manifestations of ideas of defence, comparable to what obtains among those afflicted with obsessions and delusions of persecution.

CHAPTER XIII

THE COMPLICATIONS OF TIC