Tics and Their Treatment Part 25

Following in the train of the tics may come a number of complications, insignificant enough as a general rule, the dread of which may in some cases actually be instrumental in stimulating the will's activity to rid the patient of his tic.

Dislocations have in violent cases been known to occur. Incessant repet.i.tion of a tic may lead alike to hypertrophy of certain muscles and atrophy of their antagonists, conditions which in aggravated instances may produce permanent malformation.

It is of course in cases of spasm and other convulsive phenomena dependent on structural disease of nerve centres or conductors that such trophic disturbances are most liable to occur. Gaupp[152] has described a case of partial congenital myotonia localised in the muscles of the forearm and hand, and a.s.sociated with atrophy, in a patient presenting certain stigmata of infantilism; but the condition can scarcely be cla.s.sed with the tics.

As for actual paralysis supervening on a tic, the case recorded by Gra.s.set[153] of a young girl in whom a tic of the right leg was succeeded by a trailing movement of the same limb in walking can hardly be considered conclusive, inasmuch as such incidents usually indicate hysteria or functional disturbances akin to tonic tics.

Biting tics are more apt to be accompanied by various sequelae, such as mutilations, excoriations, ulcerations of all sorts. By constant nibbling at his lip J. produced an erosion of the mucous membrane, which became infected and developed into an ulcerative stomat.i.tis. The accident, however, had a salutary effect on his tic.

We may quote another ill.u.s.tration from the history of the same patient to show how complications may sometimes be of curative value.

In January, 1901, in consequence of excessive cudgelling of one fist by the other, the back of the left wrist became inflamed and painful, but the bruise soon disappeared. In April of the same year, however, a large reddish ecchymosis made its appearance in the neighbourhood of the left elbow, with a painful swelling of the whole arm on the proximal side, and a few days later the discovery of a hard, cordlike ma.s.s along the border of the biceps made it clear that phlebitis had set in. With proper treatment the symptoms gradually diminished in intensity, but there can be no doubt of their origin in the reiterated violence of J.'s onslaught on his left arm.

The immediate outcome of the event was to put a brake on his exuberant gestures, and although the impulse was still sometimes urgent enough to tempt him to recommence, the thought of his phlebitis and fear of the dangers of a relapse were sufficient to recall him to his senses.

Apropos of complications the case of O. occurs to the mind, his biting tics ending in the premature loss of all his teeth, while his habit of rubbing his nose and his chin against the back of a chair led to the development of callosities. Tonic tics of the neck may in cases of long duration result in permanent deformities.

Apart from such complications, the vast majority of the accidents that accompany tics are attributable to various concurrent affections. A case reported by Fere[154] of rotatory movements of the head pa.s.sing some years later into the initial symptom of epileptiform convulsions ought not, in all probability, to be placed among the tics.

As for the grave mental affections that sometimes are superadded to long-standing tics, it is unjustifiable to cla.s.s them as complications; they are rather manifestations of psychical instability that have found a suitable medium for their evolution; in many instances they occur quite independently of the tics.

It may, however, be remarked that the persistence of a tic entails ceaseless preoccupation on the part of the subject, and may thus pave the way for obsessions or hypochondriacal ideas. The motor disturbance reacts adversely on the mental state of which it is the outcome. Hence an obsession may give rise to a motor display that has all the appearance of a tic, while the motor act in its turn may become an actual obsession.

CHAPTER XIV

THE RELATION OF TICS TO OTHER PATHOLOGICAL CONDITIONS

A vast number of disturbances of motility, distinguished as spasm, ch.o.r.ea, cramp, myoclonus, myotonia, etc., may be derived from the same pathological substratum as tic, and an equally vast number of psychical anomalies may spring from that psychopathic diathesis of which tic is merely the motor expression.

The frequency of these a.s.sociations is confirmed by innumerable clinical observations, many instances of which have been given already.

That the relations between tic and other diseases of the nervous system are very intimate is patent from every-day experience; such and such a tic may be succeeded, in the same individual, by a much graver condition in the shape of mental disease, general paralysis, tabes dorsalis, etc.

Inversely, some cases of ch.o.r.ea seem to terminate by leaving no trace of their occurrence beyond some little convulsive movement or tic. The position tic occupies is, then, a peculiarly interesting one, for it may be the starting-point of another affection, it may be an intercurrent phenomenon, or it may persist as the reminder of some previous disease.

For this reason it well merits attentive study.

In this chapter we shall examine the connections of tic with hysteria, neurasthenia, epilepsy, mental disease, and idiocy respectively.

TICS AND HYSTERIA

Our response to the question whether tics are hysterical in origin is a direct negative. Without attaching pathognomonic significance to stigmata, we may remark how seldom they are encountered among those who suffer from tic, and how rarely the latter exhibit any of the paroxysmal manifestations of hysteria.

Modifications of general sensibility such as anaesthesia or hyperaesthesia are unknown; the special senses are intact; in particular, contraction of the visual fields is never met with. Though these signs are negative, their importance from the point of view of diagnosis is none the less real.

The mental condition of patients with tic is no doubt a.n.a.logous to that of hysterical cases, but it is no less common in many others that present no sign of that neurosis. There is little or nothing in tic characteristic of hysteria, and one sometimes questions whether the _soi-disant_ hysteria of certain subjects of tic is the real disease.

In the same way as all who are predisposed, the sufferer from hysteria may develop a tic or tics, and although tic was held by Briquet, Axenfeld, Bouchut, and others, to be merely an accessory symptom of hysteria and _nervosism_, these doctrines were propounded prior to the a.n.a.lytic researches of Charcot.

Pitres,[155] whose opinion is so weighty in matters neurological, considered a predisposition to tic as a sign of hysteria, for which neurosis the subjects of tic were candidates, and supported his contention by various clinical examples:

A resin-gatherer of Landes carried all day from tree to tree a notched stake of wood by which to climb up the pine-trunks. The weight of it on his left shoulder began to cause a slight but persistent aching, which was followed by involuntary deviation of the chin to that side. The movements took place at the rate of ten to thirty a minute, but diminished materially in frequency and degree whenever the patient lay on his left side, or when he inclined his head voluntarily on either shoulder, and disappeared entirely if he was asleep, or if he sang, or whistled, or recited in a loud voice.

Examination of his visual fields revealed a marked restriction, and every effort to cure the condition proved ineffectual.

Pitres' conclusion is that the condition is one of tic, probably caused by the habit of carrying the stake, and probably also of hysterical origin. It is true the hysteria is reduced to its most simple elementary symptomatic expression, but it is difficult not to recognise its activity in the concentric contraction of the fields of vision.

Nothing is more likely, we think, than that we are dealing in this instance with a tic occasioned by a professional act, but we doubt whether alterations in the visual field are sufficient to justify a diagnosis of hysteria.

In another case of the same author, where a facial tic made its appearance in a hystero-neurasthenic after a series of worries, the a.s.sociation of the two is of course undeniable, but it does not follow that tic is in essence hysterical.

Take another example from Chabbert:

A little girl of twelve years, with a bad family history, began to exhibit involuntary movements as the result of a succession of frights, which led at the same time to the production of certain hysterical phenomena. The stigmata were unmistakable, and in addition the girl was an echolalic.

Here there seems to have been a combination of hysteria with the disease of convulsive tics. Charcot,[156] however, drew a sharp line of distinction between them, although they may co-exist in the same individual.

Apropos of this subject Raymond and Janet[157] call attention to the fact that in the somnambulistic state the memory may be much more extensive than in the waking state, and may recall events that have not pa.s.sed the threshold of consciousness, which nevertheless have been the determining cause of various phenomena of the conscious life. In this way may be explained the genesis of certain tics, although it is not a necessary sequel that they themselves are stigmata of hysteria.

Sometimes, however, that disease does appear to play an indispensable part in originating convulsive movements. An interesting case in point has been published by Scherb[158] as "beggar's tic."

The patient is a young girl eighteen years old, born of an alcoholic father and an hysterical mother, and brought up amid deplorable surroundings, socially and morally. At the age of seven she contracted diphtheria, and a doctor was called to visit her.

The mere sight of him so frightened her that the whole of the right side of her body went into a state of contracture, with mouth and eye deviated to the right, the arm p.r.o.nated and adducted, the leg stiff and the heel raised off the ground. Some gradual improvement took place after a month, but her mother saw in the incident a means of attracting public sympathy, and encouraged the child to maintain the vicious att.i.tude by sending her into the streets to beg. And so she appears to-day, her right foot trailing, her toes flexed, her forearm bent, her hand extended and fingers curled up.

Whenever the patient is un.o.bserved or forgets her professional att.i.tude, at once the arm resumes its normal position and activity.

An examination of sensation reveals a hyperaesthesia of the right half of the body, with _points douleureux_ over the left ovary and the left mamma, as well as over the larynx. There is no contraction of the visual fields; reflectivity is normal; Babinski's sign is absent.

The author considers the case one of "professional mental tic" in a predisposed patient--in other words, the tic is a "mental bad habit" in an individual psychically abnormal.

There is a certain a.n.a.logy between this condition and mental torticollis in the insignificance of the effort by which the patient corrects the deformity, compared with the great force exerted by any one else to obtain the same result. Yet the symptoms strongly suggest hysteria; their unilaterality, and the combination of motor and sensory alterations, are altogether too special to have been caused by any other morbid process.

Of course everything depends on the exact interpretation to be put on the word hysteria. As far as we are concerned, to consider a symptom of hysterical origin because it seems to be purely functional is sadly to misunderstand the question. The absence of what we call organic signs is a negative feature common to all neuroses, each of which, hysteria included, ought to have definitely fixed limits.

According to Babinski,[159] hysteria is a mental state which renders its subject capable of auto-suggestion. The distinguishing mark of the condition is that its symptoms may be reproduced with mathematical accuracy by suggestion, and may by similar means be made to disappear.

Now, while auto-suggestion may undoubtedly be a factor in the evolution of tic, it is rather too much to maintain that an "evil suggestion" may const.i.tute a tic by itself, and we question whether the influence of persuasion alone will suffice to bring about a cure. Nothing short of re-education, faithfully practised for months and years, will produce any effect, and even this method seldom results in more than a progressive amelioration. Sudden cures are familiar in hysteria, but unknown in tic. Treatment by hypnotism is rarely successful unless the patient is also a full-fledged hysteric, and this is quite the exception.

TICS AND NEURASTHENIA

The relations between tic and neurasthenia need not detain us.

Neurasthenic and _tiqueur_ alike may suffer from aboulia, obsessions, and nosophobia, and the same depressive causes may favour the establishment of the two diseases; but this is true of any form of psycho-neurosis. To identify the one with the other is to misinterpret the physical signs of the condition as described by Beard. The term neurasthenia has been so badly abused that its fundamental symptoms have been lost sight of. Yet the polymorphic nature of these symptoms is no reason for failing to recognise the genuineness of the neurasthenic syndrome, characterised as it is by headache, rachialgia, topoalgia, gastro-intestinal atony, neuro-muscular asthenia, insomnia, and mental depression. The occurrence of any one of them in a case of tic is of no special significance; for the diagnosis of neurasthenia rests on their combination, and it is precisely this combination that is so exceptional in tic.

From time to time the co-existence or alternation of tics and headache has been remarked, but the headache bears a much closer resemblance to migraine than to the headache _en casque_ of neurasthenia.