THE MENTAL CONDITION OF TIC SUBJECTS
The existence of psychical abnormalities in the subjects of tics is no
new observation. Charcot[18] used to say that tic was a psychical
disease in a physical guise, the direct offspring of mental
imperfection--an aspect of the question which has been emphasised by
Brissaud and by ourselves on more than one occasion.[19]
How is the involuntary and irrational repetition of a voluntary and
rational act to be explained? Why is inhibition of a confirmed tic so
laborious? It is precisely because its victim cannot obviate the results
of his own mental insufficiency. Exercise of the will can check the
convulsive movement, but it is unfortunately in will power that the
patient is lacking. He shows a peculiar turn of mind and a certain
eccentricity of behaviour, indicative of a greater or less degree of
instability (Brissaud). Noir writes in much the same strain, that
careful examination will readily demonstrate the secondary nature of the
motor trouble; behind it a mental defect lurks, which may pass for
singularity of character merely, or childish caprice, but which none the
less may be the earliest manifestation of fixed ideas and of mania.
It is a matter of some difficulty to describe adequately the features of
this mental condition; their extreme variability has its counterpart in
the diversity of the motor phenomena. In this polymorphism of psychical
defect is justification for the numbering of the tic patient with the
vast crowd of degenerates, and indeed Magnan[20] is content to consider
tic one of the multitudinous signs of mental degeneration. As a matter
of fact, one does find numerous physical and mental stigmata in those
who tic, just as one finds them in those who do not.
It therefore becomes desirable to specify in greater detail the mental
peculiarities of patients who, by reason of their motor anomalies, form
a distinct clinical group both from the neuropathological and from the
psychiatrical point of view. The pathogeny of these motor troubles will
thus be elucidated and valuable indications for treatment obtained.
Whatever be our theory of tic, whatever be the shape the individual tic
assumes, it is in essence always a perturbation of motility,
corresponding to a psychical defect. No doubt appearances are deceptive,
and the brilliance of the subject's natural gifts may mask his failings.
His intelligence may be high, his imagination fertile, his mind apt,
alert, and original, and it may require painstaking investigation to
reveal shortcomings none the less real. This practice we have
scrupulously observed in all the cases that have come under our notice,
and we believe that the information gleaned in this way, coupled with
the results of previous workers, warrants the attempt at a systematic
description of the mental state common to all who tic.
Charcot[21] had already remarked the presence of certain signs or
psychical stigmata indicative of degeneration, or of instability, as he
preferred to say, inasmuch as the mental anomalies of these so-called
degenerates were not only frequently unobtrusive, but in a great many
cases associated with intellectual faculties of the first order. His
contention has been amplified by Ballet:[22]
The striking feature of these "superior degenerates" or "unstables"
it not the insufficiency, but the inequality, of their mental
development. Their aptitude for art, literature, poetry, less often
for science, is sometimes remarkable; they may fill a prominent
place in society; many are men of talent, some even of genius; yet
what surprises is the embryonic condition of one or other of their
faculties. Brilliance of memory or of conversational gifts may be
counteracted by absolute lack of judgment; solidity of intellect
may be neutralised by more or less complete absence of moral sense.
In the category of "superior degenerates"--to use Ballet's
terminology--will be found the vast majority of sufferers from tic, of
whom O. may serve for the model. A no less instructive example is that
of J.:
Of superior intelligence, lively disposition, and ingenious turn of
mind, J. is dowered with unusual capabilities for assimilation.
Everything comes easy to him. At school he was one of the foremost
pupils, and his work elicited only expressions of praise. He is
both musical and poetical; his quickness and neatness of hand find
outlet in his passion for electricity and photography; for
mathematics alone he has little inclination.
In a word, as with physical imperfection, so with mental--it may consist
either in absence, arrest, or delay, or in overgrowth, increase,
exaggeration, and these contrary processes may co-exist in the same
individual. Sufficient stress, however, has not been laid on a
practically constant feature in the character of the _tiqueur_--viz. his
_mental infantilism_, evidenced, as was noted by Itard in 1825, by
inconsequence of ideas and fickleness of mind, reminiscent of early
youth and unaltered with the attainment of years of discretion. We must
remember that imperfection of mental equilibrium is normal in the child,
and that perfection comes with adolescence. In the infant
cortico-spinal anastomoses are awanting, and volitional power is
dependent on their establishment and development. At first, cortical
intervention is inharmonious and unequal: the child is vacillating and
volatile; he is a creature of sudden desire and transient caprice; he
turns lightly from one interest to another, and is incapable of
sustained effort; at once timid and rash, artless and obstinate, he
laughs or cries on the least provocation; his loves and his hates are
alike unbounded.
These traits in the child's character pertain equally to the patient
with tic, in whom retarded or arrested development of volition, physical
and mental evolution otherwise being normal, is the principal cause of
faulty mental balance. That this view is correct may be inferred from a
comparison of the individual patient with healthy subjects of his own
age. The chief element in mental infantilism is maldevelopment of the
will. While in the child deficiency of what one might call mental
ballast is usually atoned for by well-conceived discipline and
education, it is accentuated by misdirected teaching. Now, it not
infrequently happens that the upbringing of the predisposed to tic is
not all that might be desired, seeing that mental defect on the part of
the parents renders them unsuitable as instructors of youth. Parental
indulgence or injustice is the fertile source of ill-bred or spoiled
children, in whom, spite of years, persist the mental peculiarities
proper to childhood. From the ranks of these spoiled children is
recruited the company of those who tic, for tics, generally speaking,
are nothing more than bad habits, which, in the absence of all
restraining influence, negligence and weakness on the side of the
parents have allowed to degenerate into veritable infirmities. These the
patients themselves are incapable of inhibiting, for whatever be their
age, they remain "big children," badly bred and capricious, and ignorant
of any self-control. Hence one of the first indications in their
treatment is to submit them to a firm psychical discipline, calculated
specially to strengthen their hold over their voluntary acts. Take the
following case:
J. is nineteen years old, intelligent, educated, ready to graduate
were it not for the interruptions his studies have undergone, and
to all appearance arrived at manhood's estate. None the less he
presents to-day the mental condition of nine years ago: he is
fickle, pusillanimous, naïve, emotional; he laughs at trifles and
is provoked to tears at the first harsh word; his nature is
restless, his mind inconsequential; he is by turns elated or
depressed for the most trivial of reasons. Notwithstanding his
seventy-one inches, he must still be fed, dressed, and put to bed
by his mother!
An identical mental state obtains in infantilism, properly so called,
where to arrest of mental development physical imperfection is
superadded. In cases of infantilism the psychical level corresponds more
or less intimately to the somatic level, an observation borne out in the
case of J.:
From the morphological point of view he shows one or two stigmata
of infantilism: his great height need not be held to disprove this,
for gigantism and retardation of sexual development are often in
association. In spite of his nineteen years, J. has still a
eunuch's voice and a minimum of axillary and pubic hair--in fact,
one might say that physically he is thirteen years old, and
mentally ten.
Or take Mademoiselle R., aged twenty-six:
Her intellectual attainments are those of a child of twelve, her
age when her first tics made their appearance. Her artlessness and
timidity are simply childish, and at the same time she lacks
womanly charm and feminine ways.
Or again:
Young thirteen-year-old M. has been afflicted with tics of face,
head, and shoulders for the last three years. Though small, he is
well enough built, and has no obvious physical anomaly except an
odd admixture of blonde and brown in his hair and eyebrows. His
teeth are bad and misplaced, and several of the first dentition
persist. There is no sign of pubic or axillary growth. As a general
rule he is mild-mannered and docile; sometimes, however, he is
irritable, impatient, emotional beyond his years. His degree of
intelligence is very fair, but idleness and inconstancy are
prominent traits in his character. The ease with which he
apprehends is counterbalanced by the readiness with which he
forgets, while his reason and judgment are those of a child of
seven. The discordance between his actual age and his mental
standard is therefore striking enough.
Another of our patients is L.:
Her intellect is quite up to the average, but the exaggerated
importance attached by her parents to her "nervous movements" has
only served to intensify her whims. Her eighteen years do not
prevent her from revealing signs of mental infantilism in every
action of her daily life, but, thanks to suitable treatment, she
has been astonishing her father by unheard-of audacities--has she
not recently ventured to cross the street alone, and alone to go an
errand to a neighbouring shop?
X. has a tic of the eyes and has reached the age of forty-eight, yet he
told us he was not so much his children's father as their playmate. At
the age of fifty-four O. could still remark on his youthfulness of
character. The same is true of S., who has attained his thirty-eighth
year.
It is as arduous a task to define the term "stability of the will," as
it is to explain what is meant by physical or mental health. But as it
is not essential to preface descriptions of disease with a disquisition
on the signs of good health, so anomalies of voluntary activity may
surely be noted without a preliminary excursus on normal volition.
Will power may deviate from the normal in either of two directions--in
the direction of excess or of insufficiency. To both of these two forms
of volitional disturbance the subjects of tic have become slaves.
Weakness of will is seen in irresoluteness of mind, flight of ideas,
want of perseverance; exuberance of will in sudden vagary or imperious
caprice. The man who tics has both the debility and the impulsiveness of
the child; to his impatience his incapacity for sustained effort acts as
a set-off; he is impressionable, wavering, thoughtless, even as he is
mettlesome and irascible. He does not know how to will; he wills too
much or too little, too quickly, too restrictedly.
As a single example of volitional activity, let us take the attention.
Diminution of attention on the part of tic patients has been judiciously
commented on by Guinon:
It is impossible for them to address themselves to any subject:
they skip unceasingly from one idea to another, and apply
themselves with zest to some occupation only to forget it
immediately. No further proof of this need be sought than the
inability of the patient, if he be at all severely affected, to
read, a proceeding at once intellectual and mechanical, and
absolutely familiar to most. Read the patient cannot, and though
the attempt to concentrate the attention diminishes or inhibits the
tic at once, there is no sequence in his effort; his eye jumps
erratically from one line to another, and his many unavailing
trials end in his throwing the book away.
Excess of voluntary activity is disclosed in the whole series of
impulsions.
The germ of homicidal or suicidal tendencies, which we have indicated in
the case of O., is discoverable also in one of Charcot's patients.[23]
_M. Charcot_ (to the patient)--Tell us what you said the other day
about razors.
_The Patient_--Whenever I see a razor or a knife, I begin to thrill
and feel afraid. I imagine I am going to kill some one, or that
some one is going to kill me. I have the same sensation when I see
a gun, or even if the notion of a gun comes to my mind. The mere
thought of it agonises me. The fancy of murdering some one strikes
me, and up to a certain point I am envious of fulfilling the
desire. Often I am conscious of an irresistible longing to fight
somebody, and I am frequently impelled to it by the sight of a
cabman. Why a cabman more than any one else, I have not the
remotest idea.
We have already touched on the close affinity between an act and the
idea of the act, and we have emphasised the absence of any appreciable
interval between the idea and its execution, unless the brake of
volitional interference be put on at the proper moment. It is in these
circumstances that the feeble of will betray their debility; the
inadequateness or inopportuneness of their will's activity allows the
performance of the act they would fain repress.
A no less characteristic feature of the subject of tic is his
impatience.
J. bolts his food without waiting to masticate it, and the instant
his plate is empty jumps up from the table to walk about the house.
He returns for the next course, which he swallows as precipitately;
delay makes him impatient, and all are forced to rush as he does.
Meal time for the whole family has become a perfect punishment.
Alarmed enough already at his tics, the parents are terror-stricken
by the tyrannical caprices of this big baby, who outvies the worst
of spoilt children in his behaviour.
Mental instability is not uncommonly associated with a general
restlessness and fidgetiness during intervals of respite from the actual
tics. The patient experiences a singular difficulty in maintaining
repose. Every minute he is moving his finger, his foot, his arm, his
head. He passes his hand over his forehead, runs his fingers through his
hair, rubs his eyes or his lips, ruffles his clothes, plays with his
handkerchief or with anything within reach, crosses and uncrosses his
legs, etc. None of these gestures can properly be considered a tic, for,
however frequent be its repetition, it is neither inevitable nor
invariable. If they are superfluous and out of place, the absence of
exaggeration or absurdity negatives their classification as choreic.
They are a sign not so much of motor hyperactivity as of volitional
inactivity. They are tics in embryo.
The patient's emotions are similarly ill balanced. Any rearrangement in
his habits he finds disconcerting; he is upset by an unexpected word, a
deed, a look; his timidity and sensitiveness are extreme--fertile soil
for the development of tics.
So, too, with his affections, his likes and dislikes, his friendships
and enmities--there is commonly a disproportion about them that betokens
mental deficiency. At one time it is fear or repulsion that actuates
him; at another it is an unnatural tenderness, a sort of _philia_, if
the term may be allowed.
Anomalies such as these, however, are met with in all the mentally
unstable, and do not present any special feature when they occur in
those who tic.
An acquaintance with the mental state of our patients enables us to
understand the mode their tic adopts. As one thinks, so does one tic. To
the transiency and mutability of the child's ideas correspond what are
known as variable tics, which rarely have a definite localisation, and
become fixed only when certain ideas become preponderant. The existence
of a solitary tic, however, is not at variance with that disposition we
have qualified as infantile, for mental infantilism is the original
stock; on it, as a matter of fact, may be grafted further mental
disorders in the shape of fixed ideas, phobias, or obsessions.
Should a fixed idea entail a motor reaction, it may give rise to a tic
as ineradicable as the idea itself, and a series of fixed ideas may be
accompanied by a succession of corresponding tics.
The frequency with which obsessions, or at least a proclivity for them,
and tics are associated, cannot be a simple coincidence. Without
defining the word obsession, let us be content to recall the excellent
classification given by Régis, according to whom they mark a flaw in
voluntary power, either of inhibition or of action. On the one hand we
have _impulsive obsessions_, subdivided into obsessions of indecision,
such as ordinary _folie du doute_; of fear, such as agoraphobia; of
propensity, such as those of suicide or homicide. On the other we find
the _aboulic obsessions_, such as inability to stand up (ananastasia),
or to climb up (ananabasia), or the astasia-abasia of Séglas, or the
akathisia of Haskowec. Perhaps we ought also to place here sensory
obsessions in the shape of topoalgia, and even hallucinatory affections.
In all these varieties of obsession increase or diminution of volitional
activity is undeniable. But this alteration in the function of the will
is no less distinctive of tic, and if we compare the psychical stigmata
of obsessional patients--the asymmetry of their mental development,
their intellectual inequalities and lack of harmony, their alternating
excitability and depression, their unconventionalities, eccentricities,
and imaginativeness, their timidity, whimsicalness, sensitiveness, and
all the other indications of a psychopathic constitution--if these are
compared with the mental equipment of the sufferer from tic, we cannot
but notice intimate analogies between the two, analogies corroborated by
a glance at their symptomatology.
An obsession may be of idiopathic origin, or it may be causally
connected with some particular incident, sensation, or emotion. A
conflagration may determine fear of fire, or a carriage accident
amaxophobia. Further, the obsession is irresistible, as is the tic:
opposition endures but for a moment, and is therefore vain. Nor is the
inhibitory value of attention or distraction any less ephemeral. This
feature of tic was noted as long ago as 1850 by Roth, who held its motor
manifestations to be phenomena of "irresistible musculation."
Consciousness is maintained in its integrity both before and after, but
not during, an obsessional attack, and this is equally true of tic, as
are the preliminary discomfort and subsequent satisfaction that attend
the obsession. Noir makes the appropriate remark that idiots affected
with krouomania, in whom sensory disturbance is awanting, so far from
suffering pain through sundry self-inflicted blows and mutilations,
seem, on the contrary, to be thus afforded a certain feeling of relief,
if not of actual relish.
Whenever Lam., who exhibits incessant balancing and rotatory
movements of the head, is seated in proximity to a wall, he knocks
his head sideways against it until a bruise results, and appears to
find therein a source of genuine satisfaction.[24]
If, then, an obsession provokes a motor reaction at all, it may
originate a tic, and, in the case of tonic tics, this is a very common
mode of derivation, as one may well understand how an obsession may
occasion an attitude.
Grasset cites the example of a young girl who would never lean backwards
in a railway carriage or on any chair or bench, preferring to sit bolt
upright on the edge. In this instance the adoption of a stereotyped
attitude was directly attributable to an obsession.
Another example of an attitude tic is furnished by the case of young J.:
Standing or seated, he always has his half-flexed left arm firmly
pressed against the body in the position assumed by hemiplegics.
Its pose and inertia and the awkwardness of its movements unite to
suggest some real affection, the existence of which the constant
use of the right arm and the elaboration by the patient of
intricate devices to obviate disturbing the other tend to
substantiate. Nevertheless, the impotence is entirely imaginary. To
order he can execute any movement of the left arm with energy and
accuracy; his left hand will button or unbutton his clothes, lace
his boot, handle a knife, and even hold a pen and write.
It seems that the position of the arm was chosen deliberately to
alleviate a supposed pain in the shoulder, and unceasing resort to
this subterfuge of his own inventing, which he considered a
sovereign remedy, ended in its voluntary adoption being succeeded
by its automatic reproduction.
The assumption of this position for his arm was at first attended
with satisfactory results, but, as might have been foreseen, its
inhibitory value decreased gradually, so he had recourse to other
means. It was then that the right hand was made to grip the left
and press it more energetically than ever against the epigastrium.
In this complex attitude both arms simultaneously participated, but
again its efficacy was purely transitory. Evidently dissatisfied
with his methods of immobilisation, and convinced that
experimentation would end in the discovery of the desired
arrangement, J. proceeded to employ the right hand in impressing
every variety of passive movement on the left hand, wrist, forearm,
and upper arm, and soon there was no checking these gymnastic
exercises. He would suddenly grasp the wrist and pull and screw it,
while the left shoulder and elbow resisted nobly; or he would bend,
or unbend, or twist his fingers, or seize the arm below the axilla
and knead it or rub it, forcing it against or away from the thorax;
he would pound the muscles and pinch the tendons, sometimes in a
brutal fashion; in short, the situation degenerated into nothing
more nor less than a pitched battle between the left arm and the
right hand, in which the latter endeavoured by a thousand tricks to
bring the former into subjection. Victory rested always with the
affected arm.
Each time that this absurd combat recommenced, the patient
experienced a sensation of relief; resignation to the imperious
motor obsession was even followed by a sense of well-being. On the
other hand, resistance was accompanied by actual anguish--he would
fidget desperately in his chair, cross and uncross his legs, sigh,
grimace, rub his eyes, bite his lips and nails, twist his mouth
about, pull at his hair or his moustache, he would look anxious or
alarmed, would become by turns red or pale, and beads of
perspiration would gather on his face. At length he would be
compelled to yield, and the bloodless battle of his upper limbs
would close more furiously than ever.
In this case the typical features of obsession are excellently
illustrated--its irresistibility, as well as the concomitant distress
and succeeding content.
Conversely, however, a tic may be said to develop into an obsession if
the exciting cause of the latter be the motor reaction.
In various psychopathic conditions (says Dupré[25]), especially
where the genito-urinary apparatus is concerned, this pathogenic
mechanism is encountered. Some source of peripheral irritation in
bladder, urethra, prostate, etc., provokes cortical reaction, and a
reflex arc is established with centrifugal manifestations in the
guise of motor phenomena, which in their turn originate all sorts
of fixed ideas, impulsions, and obsessions, forming an integral
part of the syndrome.
There is frequently no direct or obvious connection between a patient's
obsession or obsessions and his tics. The former may consist, both in
children and in adults, in extraordinary scrupulousness, perpetual fear
of doing wrong, absolute lack of self-confidence, sometimes simply in
excessive timidity, exaggerated daintiness, or interminable hesitation.
We have often seen youthful subjects betray in their disposition weak
elements such as the above, which at a later stage have proved the
starting-point for more definite obsessions. Their intelligence and
capacity for work earn the approbation of their teacher, yet they are
for ever dissatisfied, haunted by the dread of having overlooked some
iota in their task; they dare not affirm that they know their lessons,
they stammer over their answers, mistrust their memory, make no promises
and take no pledges, and thus bear witness to an absence of confidence
in themselves which affects them profoundly, for they are well enough
aware of its consequences.
An admirable instance of this is furnished by the case of young F., or
by little G., ten years old, who suffers from a facial tic, and
constantly hesitates when asked to give a measurement, an hour, a date,
a figure, solely by reason of a conscientious fear of not being
absolutely accurate in his reply.
In children the emotional excitement of their first Communion often
favours the development of religious scruples. By a sort of metastasis,
diminution of the convulsive movements goes _pari passu_ with
aggravation of the mental phenomena, until such a time as the devotional
exercises are done with, when there is a return to the previous state.
Arithmomania betokens an analogous turn of mind. Certain patients are
compelled to count up to some number before performing any act. One
cannot rise from his seat without counting one, two, three, four, five,
seven, leaving out six since it is disagreeable to him. Another must
repeat the same movement two, three, ten times, must turn the
door-handle ten times ere opening it, must take five steps in a circle
before beginning to walk (Guinon). A patient of Charcot's used insanely
to count one, two, three, four, used to look under his bed three or four
times, and could not lie down until assured that his door was bolted. A
further example is reported by Dubois:
A young woman twenty years of age first began to suffer from
convulsive tics five years ago. Without any warning she used to
bend down as if with the intention of picking up something, but she
had to touch the ground with the back of her hand, else the
performance was repeated. Twenty or thirty times a day this act was
gone through; in the intervals she kept turning her head to the
right, looking up at the curtains in a corner of the window, and at
the same time making a low clucking sound that attracted the
attention of those in the room. For nine or ten years these two
tics have prevailed, and have been accompanied with certain
obsessions, such as the impulse to count up to three, to regard any
person or object three times, etc. With the generalisation of the
convulsive movements various phobias have made their
appearance--viz. fear of horned animals, of earthworms, of cats, of
blight, etc.
Onomatomania is another form of obsession which may be mentioned,
exemplified by the dread of uttering some forbidden word, or by the
impulse to intercalate some other. The term _folie du pourquoi_ has been
applied to the irresistible habit of some to unearth an explanation for
the most commonplace of facts: "Why has this coat six buttons?" "Why is
so-and-so blonde?" "Why is Paris on the Seine?" etc. This mode of
obsession is frequent among those who tic, and is curiously reminiscent
of a familiar trait in the character of children, thereby supporting our
contention of the mental infantilism of all affected with tics.
Prominent among the mental anomalies of the subjects of tic are found
different sorts of phobia: fear of death or of sickness, of water,
knives, firearms--topophobia, agoraphobia, claustrophobia, etc.
The following most instructive case has been observed by one of us over
a period of several months:
S.'s earliest attack of torticollis, of two or three days' duration
merely, occurred when he was fifteen years old, and was attributed
by his mother--whose mental peculiarities, in especial her fear of
draughts, are no less salient than those of her son--to a chill
occasioned by a flake of snow falling on his neck. S. is so blindly
submissive that he accepts this pathogeny without reserve. Five
years ago a second torticollis supervened, which still persists
to-day, and of which his explanation is that he was obliged, when
standing at a desk, to turn his head constantly to the left for two
hours at a time in order to see the figures that he had to copy,
and was forced, after the elapse of some months, to relinquish his
work owing to pain in the occipital region and neck. From that
moment dates the rotation of his head to the left.
At the present time his head is turned to the left to the maximum
extent, the homolateral shoulder is elevated somewhat, and the
trunk itself inclines a little in the same direction. The permanent
nature of this attitude necessitates his rotating through a quarter
of a circle on his own axis if he wishes to look to the right. On
the latter side the sternomastoid stands out very prominently, and
effectually prevents his bringing the head round; nevertheless he
is greatly apprehensive of this happening, and as he walks along a
pavement with houses on his right he keeps edging away from them,
since he is afraid of knocking himself against them. By a curious
inversion, common enough in this class of phobia, he feels himself
impelled to approach, with the result that he cannons against the
wall on his right as he proceeds.
Contrary to the habit some patients with mental torticollis have of
endeavouring to ameliorate the vicious position by the aid of high
starched collars, S. has progressively reduced the height of his
until he has finished by discarding them altogether. As a matter of
fact, it is the "swelling" in the neck caused by the right
sternomastoid that is at the root of his nervousness, for he is
convinced that it preceded the onset of the torticollis, and he has
a mortal dread of aggravating it by compression.
Hence one may perhaps understand what line of erroneous reasoning
has led to the establishment of the wryneck. The fear of draughts,
instilled in his youthful mind by his mother, had the effect of
driving him to half-strangle himself with a tightly drawn
neckerchief, to hinder the inlet of air and minimise the risk of
catching cold, and when he commenced to turn his head to the left
at his work, the pressure of the band round his neck was felt most
of all on the contracted right sternomastoid. A glance at a mirror
convinced him that the unusual sensation was due to an abnormal
muscular "swelling," whereat he was vastly alarmed; he hastened to
change his collar, but all to no purpose. By dint of feverish
examination and palpation of the muscle, he soon acquired the habit
of contracting it in season and out of season, till at length an
unmistakable mental torticollis supervened.
It sufficed to explain to S. the role played by the sternomastoid
in head rotation, and to demonstrate the absurdity of his
interpretation of the so-called "swelling": the gradual relaxation
of the muscle and consequent diminution in the "tumour's" size not
only satisfied him of its benign nature, but afforded such a sense
of relief as was quickly made obvious by a notable improvement in
his condition.
A singular tic of genuflexion occurred in a case reported by Oddo, of
Marseilles:
The dominant note in the young girl's character is her cowardice;
she is afraid of everything. Every evening before the return of her
father she repeatedly looks into the corridor to see that no one is
there; as soon as her parent arrives, she locks the door behind him
hurriedly to prevent any one else appearing; every now and then in
her fear of a footstep she listens at the door, and it is this
gesture, this attitude of listening, that has degenerated into a
tic which no amount of remonstrance or derision seems to affect.
Phobias such as these are associated with an evident tendency to
melancholia and hypochondriasis. The majority of our patients are
ridiculously preoccupied with the state of their health; the
extraordinarily introspective nature of their minds is manifest in their
meticulous observation, their laborious analysis of their most trifling
sensations, the zeal with which they devise the most complex
explanation for their simplest symptom, usually for the sake of making
the prognosis seem more grave.
At the other pole from these silly fears and dislikes we meet with
various absurd predilections and meaningless attractions: one can sit
only on a certain seat, sleep only in a certain bed; another cannot
enter a room except by a particular door; a third will make a long
detour to pass along a certain street; in this street he will always
walk on the same side, and lengthen or shorten his stride to step always
on the same flagstones. We are acquainted with the history of a wretched
commissionaire who could not go an errand in Paris without starting from
the Place Clichy, and the interminable twists and turns on his route can
be imagined when his duty took him from Montrouge to the Bastille.
Akin to the conditions we have been enumerating is an exaggerated love
of order, somewhat unexpected in those whose mental disarray is often
extreme. Some cannot sleep without previously arranging their clothes in
an unvarying plan. One of Guinon's patients contrived to have one half
of the objects in front of him to his right, and the other half to his
left. In the case of a little nine-year-old hydrocephalic child with
tics and echolalia, Noir[26] makes the following remarks:
The fundamental element in the child's character is an overweening
vanity coupled with an excessive orderliness. Her desire of
personal ornament is such that at one time she is lost in
admiration of a new dress, at another, she is decking herself out
with old pieces of tarletan. When going to bed she folds her
clothes in the same exact order each evening. Her self-conceit
makes her furiously jealous of the attention paid to any other
patient in her presence.
A similar mental state has been observed by Noir in other
hydrocephalics.
The same tendency is revealed in an inane search after precision in the
most petty details, the natural result in the case of conversation, for
instance, being that its thread is quickly lost in endless digressions
and parentheses within parentheses.
A score of other mental peculiarities, commonly described as "manias" by
the lay mind, are nothing else than fixed or obsessional ideas in
miniature, as Grasset says, and he narrates how for a time he himself
used to be irresistibly forced, on entering a railway carriage, to
divide the figure representing the number of the carriage by the number
of the compartment. He further cites the case of an otherwise normal
individual, who whenever one foot strikes on a stone raised a little
above the level of the ground, is obliged to seek an analogous sensation
for the other, and who cannot let one hand touch anything cold without
giving its fellow the opportunity of receiving an identical impression.
A common impulse is to count the windows in the house one is passing, or
the bars of the railings. Sometimes it is a "mania" for setting things
straight, or for rubbing out marks in a book; but while these and
similar psychical accidents are singularly prone to develop in the
subjects of tic, they are not to be considered in any way special to
them.
Hallucinations, too, and sometimes actual delusions, may form a basis
from which springs a motor reaction that passes into a tic.
If even the most sane among us (says Letulle) are conscious of a
wellnigh invincible propensity to repeat a particular movement or
expression or sequence of thought, we can understand how the
temptation falls with overwhelming force on such as suffer from
persistent hallucinations or fixed ideas. Take, for instance, this
woman who utters a shrill cry and waves her hand before her face;
the regularity of her action is a sequel to the delusion that
possesses her, for in her imagination she is chasing away the birds
that would pluck out her eyes. And when at a later stage these
visual hallucinations are lost in a progressive dementia, the
gesture becomes an incurable tic.
Here is another patient: his habits of continually washing his
hands, of expectorating as he passes any one, have their
explanation in his dread of being poisoned by imaginary foes, and,
though subsequent mental disintegration precludes the possibility
of the delusion continuing, the trick remains to the end of life.
A case has been put on record by Wille,[27] under the name of "disease
of impulsive tics," concerning a young man twenty-two years of age, who,
in addition to the grave taint of a psychopathic heredity, exhibited
early indications of irritability and a tendency to obsessions.
Systematised movements of face, shoulders, and arms, accompanied with
coprolalia, were not long in appearing. It was noticed that the
psychical symptoms were periodic, and that their nocturnal exacerbation
coincided with the advent of hallucinations. Two attacks of mania came
on, but a cure followed after four years' time.
It may be questioned whether we are not dealing here with a case of
dementia præcox, rather than with the true Gilles de la Tourette's
disease; at any rate, tic may be a concomitant of grievous mental
affections.
Another case of still more advanced mental deterioration may be quoted
from Bresler:[28]
In this patient contractions of facial and limb musculature at the
age of nine were succeeded by some years of epileptic outbreaks;
and outrageous conduct towards his mother and sister, coupled with
acts of wanton brutality and destruction, at length necessitated
his removal to an asylum. He suffers from convulsive tic of face
and shoulders, while his speech is drawling and syllabic, and
interrupted by guttural ejaculations corresponding to the
manifestations of his tic.
It is superfluous to dilate further on this part of our subject, and we
shall take another opportunity of dealing with the question of tics in
idiots and the mentally backward. For the present, the statements of
the chapter may be summarised in a few words:
In the mental condition of the subject of tic there may be
differentiated two elements: the one is fundamental, and is sufficiently
described in the phrase mental infantilism; the other is superadded, and
consists of a multiplicity of psychical imperfections which reveal, at
the same time as they exaggerate, the inherent defects constituting the
former, in particular volitional infirmity. By this means a useful
clinical distinction may be drawn between various tics, according as
they take their rise in one or other form of mental affection, and at
the same time the practical gain is considerable, for treatment must be
directed both to the physical and the psychical aspect of the malady,
and its success in the former sphere is greatly dependent on intelligent
recognition of and acquaintance with the nature of the latter.
Manias, obsessions, phobias, and other accompaniments of the
disease known as tic (says Grasset)--those abnormal phenomena that
testify to the affection as the stigmata of hysteria confirm that
neurosis--are nothing more than psychical tics; that is to say,
special types of the disease. If their occurrence is frequent and
indeed habitual, their absence in no way invalidates the diagnosis.
They resemble coprolalia, salutations, etc., in being accidental
and not essential symptoms.
We are entirely at one with Grasset on this last point; but if they do
occur, are they to be denominated tics? We must beg to be excused for
dwelling with such insistence on a question of words, but we are assured
that the rigorous limitation of the word tic to conditions in which it
is possible to recognise two inseparable and indispensable elements, one
motor and the other mental, cannot fail to simplify matters. Otherwise,
of course, we are merely adding to the meaning of a term already
interpreted in far too liberal a fashion.
Abuse of language such as this leads to inevitable confusion. Noir, for
an instance, in whose excellent thesis there is abundant evidence of
painstaking observation and judicious discernment, is constrained to
write:
_Tics of idea_ are exemplified by fixed and obsessional ideas, such
as _folie du doute_, misophobia, arithmomania, etc., and are allied
to motor tics in that they consist of isolated or complex
psychomotor reactions, which may, however, assume a purely
psychical form. They are mental affections clothed, in the case of
convulsive tic, in a motor garb.
In our opinion, all such formulas as "tic of idea," "psychical tic,"
"mental tic," "motor tic," etc., ought to be abolished. An obsession
ought to be called an obsession, and there ought to be a similar
understanding in the case of phobias and fixed ideas, for each and all
may exist independently of any motor reaction whatever, and therefore
can never be classed with tic. It is only when the obsession or the
fixed idea entails the automatic repetition of some motor phenomenon
that a syndrome can be constituted to which the name of tic may be
applied. As a matter of fact, a tic can no more be exclusively mental
than exclusively muscular. A mental condition that does not find
expression in a motor reaction is not a tic, and to speak of purely
mental or purely motor tics is a contradiction in terms. Cruchet's
proposed category of _psycho-mental_ tics serves only to aggravate the
misunderstanding, so long as everyday usage emphasises the identity of
the two words "psychical" and "mental."
[Tics are not the private property of the human species. The word
appears to have been first employed in reference to horses, and while
little attention has hitherto been paid to the subject in veterinary
annals, its methodical study has recently been undertaken by Rudler and
Chomel.[29] It is remarkable how intimate are the analogies established
by these observers not merely between the tics of animals and of
mankind, but also between their respective mental conditions. Physical
and psychical stigmata of degeneration are as obvious in the horse that
tics as in the man who tics, and it is not without interest to note that
the tics of such animals as have the most rudimentary psychical
development present a close resemblance to those that occur among the
least advanced of the human race, among idiots and imbeciles.]