Tics and Their Treatment Part 26

Whatever be the variety of tic, the remarks we have made, based as they are on clinical observation, are applicable to it. In particular, they have a direct bearing on Cruchet's psycho-mental tic. To quote that author again:

Hysteria and neurasthenia are two diseases which we meet at every turn in our study; and if we remember that, according to Raymond, fibrillary ch.o.r.ea of Morvan, paramyoclonus multiplex of Friedreich, electric ch.o.r.ea of Henoch-Bergeron, painless facial tic of Trousseau, and disease of Gilles de la Tourette-Charcot, are all mere varieties of myoclonus, which is itself a product of neurasthenia and hysteria, we are forced to admit that it is these conditions which dominate our conception of psycho-mental convulsive tic.

Thus it comes to pa.s.s that tic is lost in a crowd of widely differing convulsive phenomena, and is threatened with the permanent loss of its distinctive characters, while hysteria itself is like to become a perfect Proteus once more. Neurasthenia too is again to sink to the level of a receptacle for all manner of ill differentiated conditions.

We, on the contrary, feel it more than ever inc.u.mbent on us to resist the tendency to cla.s.s in the same section facts which clinical observation distinguishes, otherwise hysteria and neurasthenia will soon signify nothing at all. If tic is to be considered one of the polymorphic manifestations of these diseases, we shall be transported back fifty years, to the time of the famous "chaos of neuroses," out of which, in some ways at least, Charcot finally produced order.

TIC AND EPILEPSY

The co-existence of epilepsy and tic has been noted sufficiently often to open the question of their possible relationship. Of course the mental state of epileptics is such as to favour the development of tics.

Usually, however, the convulsive phenomena supposed to be of the nature of tic merit some other description.

In the first place, they may be Jacksonian in type, and under these circ.u.mstances confusion is scarcely possible. It is not without interest to compare the gestures and stratagems of defence which sufferers from tic devise, with the procedures adopted by some Jacksonian patients, such as compression of the arm or wrist by the fingers, or by string or more elaborate apparatus. There might conceivably be some hesitation in making a diagnosis if it depended on these arrangements, but the mere observation of one actual attack will dispel all difficulties.

We may mention the convulsive seizures of idiopathic epilepsy only to dismiss them. Loss of consciousness is an unfailing criterion.

It is more especially the a.s.sociation of epilepsy with the ill-defined group of myoclonus that we propose to discuss.

According to Maurice Dide,[160] myoclonus, which he calls motor pet.i.t mal, occurs in five per cent. of cases of epilepsy. Attention has also been directed to this question by Mannini[161]:

After an attack of epilepsy the convulsive twitches are at a minimum, but during the next few days the myoclonus, or rather the polyclonus, becomes increasingly intense and varied, until it reaches a maximum, which is crowned by a second epileptic fit. The spasmodic contractions begin in the face and invade the rest of the musculature; they recur in the form of seizures at diminishing intervals, leading to the epileptic attack, when the muscles pa.s.s into permanent contraction.

Sometimes the myoclonus takes the shape of fibrillary spasm, sometimes the whole of a muscle is involved; the twitches may be rhythmical and symmetrical, or arhythmical and asymmetrical, so much so that at a given moment the patient may present the clinical picture of convulsive facial tic, or paramyoclonus multiplex, of Gilles de la Tourette's disease, or electric ch.o.r.ea.

Mannini's view is that the varying convulsions known as myoclonus or polyclonus are akin to epilepsy, and are the outcome of the same cortical lesion, the nature of which has not as yet been fathomed--a lesion whose expression is hyperexcitability of the cells of the rolandic area. a.n.a.logous conclusions may be drawn from a case of epilepsy and myoclonus, with autopsy, reported by Rossi and Gonzales,[162] where a general ischaemic degeneration of the central nervous system was found, the greatest changes being discovered in the rolandic zones of each side, as well as in the extremities of the three frontal convolutions. Schupfer[163] has recorded cases of family myoclonus with epileptiform attacks.

We are content to note the facts. Any conclusion applicable to the tics is premature.

Various observers have drawn attention to the development of tics in persons formerly subject to epilepsy. Malm[164] has described a case of rotatory tic in a man who has been a known epileptic for ten years.

According to Fere,[165] epilepsy may supervene in patients who at one time suffered from tic. As an example, he quotes a case of tic localised in the left ear and dating from infancy; the patient had reached his thirty-fifth year when the recrudescence of the tic ushered in the first attack of epilepsy, which consisted of elevatory movements of the left ear and convulsions of the left half of the face, pa.s.sing thence to the right arm and the left leg, and becoming generalised. The fact that the twitches of the left ear could not be imitated voluntarily suggested that the original "tic" may have been the result of some minute cortical irritation, the increase of which became eventually the determining cause of a Jacksonian attack.

Another case due to the same author concerns a woman of fifty-four years, subject from her youth to fixed ideas.

For the last four years she has had seizures which may be attributed to her idea that she must see the whole of the objects on her left. Under the impulse of this idea, she turns her eyes upwards and to the left, rotates her head in the same direction, and her body too, if she happens to be on her feet. The performance is gone through fifteen or twenty times a day.

In addition, she suffers from epileptiform attacks, which commence by this deviation of head and eyes to the left, and spread to the arms and to the left leg, leading to loss of consciousness as they become generalised. The patient finally succ.u.mbed to an apoplectic stroke followed by left hemiplegia.

In this instance the connection between the fixed idea and the patient's gesture favours the diagnosis of tic, but the subsequent history of the case makes one consider it with reserve. All such cases ought to be followed up carefully, and we may modify Fere's conclusions somewhat to declare that the appearance of a convulsive movement in an adult, or the aggravation of a similar movement of ancient date, should lead one to suspect epilepsy and to look for signs of it: "The patient runs more chance than risk in being treated as an epileptic."

We have had the opportunity of observing, in one of our mental torticollis cases, a condition not unlike what is known as _absence epileptique_. The term "incantation" was applied by the parent to his daughter's habit.

On two occasions we noticed the patient's eyes turn upward and remain fixed for a moment or two, while her expression changed to one of tranquillity and unconcern--a sign of distraction, not of ecstasy. She merely appeared to be thinking of something other than the immediate topic of conversation, and after two or three seconds resumed her ordinary ways.

These brief "absences" are trifling enough, of course, but their painstaking study is of inestimable aid in the matter of diagnosis.

They began at the age of seven or eight, and at first occurred as often as sixty times in a day. What the patient did was to raise her head, and turn up the whites of her eyes; in a second or two her countenance had resumed its ordinary expression. From their onset, the "incantations"--to use her father's term--gradually increased in frequency and length, and attained a sort of maximum when she was eleven years old, slowly diminishing thereafter till at present they have become rather exceptional. They proved to be a source of great tribulation to L., seeing that she was exposed to the practical jokes of her companions, who used to seize the occasion to relieve her of any books or toys she had in her hand.

During the "absence" there is no change of colour, nor has there ever been any vertigo or sense of rotation. She has never actually fallen, though she has allowed things to drop out of her hands.

Once it is over, she is aware of it, but her memory of what has just taken place is very vague, though she usually can tell what preceded it. She can be aroused from the "incantation," to sink back into it an instant later, as though she had not dreamed enough. Sometimes a series of "incantations" occurs, one following on the heels of another. Occasionally she utters such words as "yes, yes!" or "no, no!" in an impatient tone of voice, and plucks at her hair or clothes, or toys with the handkerchief which is never out of her hands.

Call these phenomena "epileptic absences" if you like, but after the reverie is over, L. knows quite well that she has had it; besides, prolonged bromide treatment has been totally inefficacious.

One of us has come across a somewhat similar condition in a ten-year-old girl:

Fifty times a day she interrupts her work or her play to retract her head and roll her eyes upward. The duration of the attack is not longer than ten seconds, and there is no cyanosis or distress of any kind. The application of tactile or painful stimuli at these times makes her shut her eyes and withdraw her head or her limbs, and she can tell afterwards what was done. She knows that she has had a "sensation," and remembers any noise that occurred while she was in that state.

Otherwise, there is little to note. For one month she presented very mild convulsive movements in the left arm and leg, but no trace remains of them to-day. Treatment with bromides has failed to effect any modification.

Examples of the same nature, but said to be of hysterical origin, have been recently published by Luzenberger:[166]

A young girl, twelve years of age, has brief attacks in which she loses consciousness, and turns her head to the right, while the angle of the mouth is drawn to the left. This sort of attack recurs forty or fifty times a day, and has been going on for three or four years.

The reporter thinks the case a difficult one to diagnose, though the trifling nature of the symptoms, and their evolution, do not suggest epilepsy. One may question, however, whether they indicate hysteria.

Our sole object in referring to these cases has been to note the co-existence of these "absences" with motor phenomena closely allied to the tics, if not with tics themselves. We cannot be satisfied with finding a common bond for all such conditions in mental degeneration, but it is perhaps premature to seek to interpret the facts.

TICS--INSANITY--IDIOCY

Insanity in any of its forms may be accompanied by clonic or tonic convulsive movements--movements that may be of the nature of tics or spasms or stereotyped acts, or that may belong to conditions which we distinguish by the names of myoclonus, polyclonus, myotonia, catatonia, etc. It is highly probable that many instances have been described as spasms which, according to our nomenclature, must be considered tics.

Brodie, to take an example, quotes a case where a "spasm" of the spinal accessory was replaced by a mental affection. Alternation of hallucinatory mental confusion with "spasm" of the neck muscles has been observed by Oppenheim, as well as a case where the "spasm" originated in the course of an attack of alcoholic mania. In another, due to Gowers, "spasm" of the muscles of the neck was preceded, at a ten years'

interval, by an attack of melancholia.

Most of the cases of this nature would be held to-day to be instances of mental torticollis.

That tics and mental disease accompany each other is notorious, but a discussion of the question would carry us beyond our limits. We must say a word, however, on the tics of idiots.

The study of tic as it occurs in idiots, imbeciles, and _arrieres_, has engrossed the attention of alienists since the days of Pinel and Esquirol. Cruchet says the mental state of the idiot and the imbecile is so characteristic that the diagnosis of convulsive tic in such cases is never attended with any difficulty. Yet the task is sometimes sufficiently delicate, for we maintain that upon our insight into the subject's mental condition depends our ability to a.n.a.lyse his tics.

Considerable light has been thrown on the question by the important information ama.s.sed by Bourneville, as well as by the fine psychological studies of Sollier and the meritorious thesis of Noir, from which we shall borrow largely in this place.

In the first instance, we meet with tics in every way comparable to those we have already described, and we may give one or two examples.

R. accidentally wounded his left eye at the age of eleven, and contracted a tic which consists in spasmodic blinking of the eyelids, though no sign of ocular lesion is left. A diminution in its intensity has been taking place, which has culminated recently in its spontaneous disappearance.

N. had an attack of ciliary blepharitis and kerat.i.tis which left an opaque patch on the upper and inner part of his left cornea, and he has blinked ever since. Yet there is no local irritation to justify the continuance of the movements.

The tics are occasionally as numerous and violent as in Gilles de la Tourette's disease, and are accompanied with cries and with coprolalia.

L. is afflicted with abrupt blinking of the eyelids, retraction of the head, and elevation of the lip. Once the tic is established, it persists on an average for from eight days to a month, and during this time no effort on his part will check it. Sometimes he makes peculiar growling noises; sometimes he cannot prevent himself from stooping down as if to pick up stones; sometimes he is unable to restrain himself from touching everything within reach.

From the age of five, C. exhibited frequent blinking movements, and gestures which seemed to indicate that his clothes were uncomfortable. No attempt at modification was attended with success. The tics steadily increased, till he found himself uttering cries and letting obscene words escape his lips. For a long time they remained in abeyance, then reappeared in his face and trunk, in the form of salutation movements. His propensity for clastomania, pyromania, and kleptomania necessitates his being kept under strict supervision, and though he is intelligent and has a good memory, he is also lazy and inattentive.

Other tics of still greater complexity and peculiarity are met with among those whose psychical imperfections are very p.r.o.nounced. Some "co-ordinated tics" are remarkable for their intricacy; they consist of a series of movements which mimic some act of everyday life. In this group may be specified various rhythmical movements, such as those of balancing, head rotation, and striking or beating oneself--the krouomania of Roubinowitch; they may be compared to the mother's rocking of her infant, inasmuch as they have a soothing effect on their subject, however brutal the movement itself sometimes may be.

In most cases the patient is seated and rocks himself to and fro in an antero-posterior direction. Or it may be the head only that is rhythmically moved from side to side, and the performance may go on indefinitely. A mere touch or a word, on the other hand, is commonly sufficient to interrupt its sequence.

There remains a final cla.s.s of co-ordinated tics, which Noir distinguishes by the epithet "large," tics which are confined to idiots of good physical development. They consist of a movement or series of movements of considerable amplitude, and const.i.tute the predominant clinical feature of the patient's idiocy. Here we find subjects who jump, or climb, or turn round and round; in other cases they are reduced to the level of mere automata, and go through a long series of actions in a mechanical way.