TICS OF SPEECH
In movements of inspiration or of expiration the passage of air through
a more or less contracted glottis gives rise to all sorts of sounds,
some of which, under certain conditions, must be included in the
category of tics.
The most elementary of these, and at the same time the most common
(says Guinon), is the involuntary exclamation. In the midst of his
tics and grimaces, a cry--ah!--escapes the patient's lips at
intervals, a shrill, sudden, and momentary cry which interrupts his
talk, or breaks in on a period of silence, and which he repeats
only once or perhaps several times in succession. The thread of his
conversation, nevertheless, is seldom if ever discontinuous, and
his audience is witness of its rationality and accuracy of
expression. Rather more complicated is the ejaculation "ouah!"
Sometimes one meets with noises that are faithful reproductions of
the sounds emitted by various animals.
Guinon is disposed to exclude such simple involuntary explosions as
"ahem! ahem!" from the tics, though he admits the analogy to them. He
says the sound exactly resembles the trifling little clearance of the
throat which is repeated a thousand times a day by people suffering from
chronic angina. We, however, are inclined to look upon it as an ordinary
spasmodic reaction evoked by some laryngeal or pharyngeal irritation,
which in spite of the removal of the latter continues to take place, and
because of its meaningless repetition is fairly to be classed as a tic.
All that we have said of blinking, for instance, is applicable in this
connection.
Of course the embellishment of one's discourse with more or less
audible expirations is of frequent occurrence: the hesitating eh ... eh
... to which children give vent in the recitation of their lessons is
not confined to them alone. It can scarcely be maintained that these
laryngeal noises are tics, since their production is coincident with the
exercise of the faculty of speech; hence they are not unlike "functional
cramps." On the other hand, the unexpected bark or gurgle that breaks
the silence is a pure tic of phonation.[117] Those who suffer in this
way reveal characteristic stigmata in the immediateness of the
compelling idea and the exaggerated nature of the subsequent
satisfaction. To unravel the intricacies of the origin of these tics is
a matter of considerable difficulty, though probably imitation is not
without influence in their genesis. Reference will be made later to a
tic of this kind attributed by Charcot to imitation.
Among the insane similar cries are often the outcome of delusions. At
the Congress of Limoges a case was reported by Briand of an old man who
imagined himself transformed into a clock and swung his arms with
pendulum-like regularity, indicating the hours by uttering raucous
sounds at the proper intervals. However curious these sounds were, the
fact of their being appropriate is decisive against their classification
as tics.
Unmistakable tics of speech, however, do occur.
Speech is a complex of different muscular acts, and, being so, is liable
to be disarranged in various ways, by defect in respiration, phonation,
articulation, even in ideation. Organic affections aside, it is
inadmissible to describe as tics each and all of the functional
disturbances of speech that are not based on any discoverable material
lesion of nerve centres. One must in fact distinguish between troubles
of speech confined to occasions when the faculty is in operation and
those that consist in not merely useless but inopportune utterance.
However arduous it may occasionally be to draw this distinction, however
common the occurrence of transitional forms, it has the advantage of
limiting the scope of the term "tic of language." To the latter category
only can the description be applied.
For this reason we think it preferable to exclude stammering,
stuttering, and all defects of phonation or articulation whose existence
is revealed only in the act of speaking. At the same time reference must
be made to facts linking these functional anomalies to the tics, and to
instances of the latter existing with or succeeding the former.
Such is the case with stammering.
According to Letulle,[118] stammering is a tic of speech whose beginning
is a functional disturbance of nervous centres, as is that of tics in
general. Holding as we do, however, that one of the features of tic is
its appearance in season and out of season, we cannot class stammering
as a tic, since its exhibition is restricted to the exercise of a
certain function, viz. speech. It is therefore comparable to a
"professional cramp," and we may briefly note the analogies it offers to
the tics.
Stammering,[119] which in more than fifty per cent. of cases is
hereditary, and associated with a neuropathic diathesis, usually betrays
itself in childhood and becomes aggravated at puberty. The old idea
which credited stammerers with exceptional intellectual powers, in whom,
however, rapidity of thought surpassed rapidity of action on the part of
the muscles of articulation, is exploded, and to-day those thus
afflicted are assigned their true place among the volitionally infirm.
In a few rare cases stammering has been due to organic disease of the
centres for articulate speech, or of bulbo-pontine nuclei; it has been
supposed also to result from genuine spasm on a reflex arc, and this is
a possible explanation; as a general rule, however, the pathogeny of
stammering is identical with that of tic. Its dependence on such
affections of nose, larynx, and pharynx as hypertrophic rhinitis and
adenoids has been emphasised by Biaggi[120]; and Derevoge,[121] in
directing attention to the association of volitional enfeeblement with
respiratory troubles, remarks that stammerers sometimes have a phobia
for certain words. Many observers have been convinced of the psychical
nature of the affection from the fact of its disappearance during
singing, as well as from the effect anger, elation, and other stimuli
have in momentarily inhibiting it. The same is of course true of the
tics.
Further, little attempt is made either by the _tiqueur_ or the stammerer
to correct his failing, so that prognosis improves with the adoption of
systematic treatment. Stammering is a functional anomaly; it is a
derangement of respiration, phonation, and articulation. However normal
be the movements of lips and throat in the execution of certain acts,
they are far from being normal in the exercise of speech. As a
preliminary to speaking the stammerer clenches his teeth and
approximates his lips, thus effectually preventing the inrush of air
except by the nares; simultaneously he contracts his tongue and
obstructs the isthmus of the pharynx, while the glottis also may close
spasmodically. Then he abruptly expands his thorax and inhales a
considerable quantity of air, yet is he ever on the verge of
breathlessness, for he cannot voluntarily arrest himself, or make a
break between two respirations. He seeks to continue speaking though his
lungs are empty of air; he cannot control expiration by antagonistic
contraction of inspiratory muscles; often he finds himself unable to
commence speaking at all.
The glottis is either open, allowing the silent escape of air, or it is
completely occluded. In the midst of syllables or words the voice is
frequently "cut" by a sudden halt indicative of spasmodic closure of the
glottis. A contrast to the ease with which vowels are pronounced is
provided by the difficulty experienced in the enunciation of various
consonants. Convulsive movements of the lips frustrate the endeavour to
form the series of successive positions which the consonants demand.
An association of stammering with convulsive phenomena of a different
nature has often been remarked. Instances of this have been given by
Janke.[122] One patient takes a few paces backward, limping with his
left leg till he finds something to give him support, and knocking his
shoulder several times against wall or furniture, as soon as he
encounters it; if he is seated he rises slowly from the chair, holding
it with his hands the while, and forthwith falls back into his seat in
order to begin. Another taps his fingers on his thigh whenever the word
he is about to utter commences with "g" or "k."
In Brissaud's clinique we have met with a couple of instructive cases:
The first concerned a showman who used to exhibit a series of
dissolving objects by means of mirrors, and who found one day that
he could not speak without scanning his syllables and explosively
ejaculating his words; at the same time his conversation was
punctuated by sudden and exaggerated shutting of the eyes and by
facial contortions. After a pause the inauguration of a phrase was
ushered by still more energetic and widespread spasms of the head
and even of all the body.
The other was an eighteen-year-old Jewish boy, who before beginning
to speak gave vent to a hard sound like "kh" four or five times in
succession, each being accompanied by a violent rotation of the
head to the right, wrinkling of the face, and a little jump. The
patient then addressed himself to speak with the utmost assurance,
there being no sign of tic or stammer unless he stopped for a
moment and endeavoured to recommence. On the other hand, he could
sing to perfection.
There may also be troubles of speech of a tonic kind, whereby a more or
less complete and sustained mutism is produced, an excellent example of
which has recently come under our notice:
A young girl, various members of whose family are stammerers,
occasionally suffers from an extraordinary sensation of anguish in
the course of conversation; she flushes and then becomes suddenly
immobile, finding it impossible to articulate or even to utter a
sound. Her glottis contracts forcibly; her efforts at expiration
are ineffectual, or else the air escapes in little explosive puffs,
and at the same time her lips twitch and her eyelids flicker. The
whole seizure is over in a few seconds, whereupon the patient
launches into conversation with volubility, until pulled up by a
fresh attack. She shows remarkable acumen, moreover, in an analysis
of her symptoms. "What happens is that I am suddenly overwhelmed
with the fear of being unable to pronounce a given word, and at the
thought my lips are sealed, I cannot make a sound, my throat is
compressed, my tongue refuses to obey me, and my condition becomes
one of abject misery." Curiously enough her phobia is not related
to a particular word, and moreover her articulation is accurate and
not embarrassed in presence of certain of the consonants. Phonation
and respiration are implicated as well as articulation. The origin
of this "cramp of speech" in psychical abnormalities is manifest.
To a similar affection characterised by total inability to speak in a
high or a low voice, whispering only being practicable, the term
"spastic aphonia" has been applied. It is at the moment when the patient
wishes to speak that the spasm occurs, as in a case reported by
Hasslauer,[123] which resisted all treatment and was considered by him
to have features in common with hysteria and occupation neuroses.
There can be little doubt that the arrest of movement in these cases is
comparable to what obtains in writers' cramp, and therefore, rigorously
speaking, a tonic tic.
A case has been recorded by F. Pick[124] of a man of thirty-eight years
of age afflicted with convulsive movements of the face and troubles of
speech.
Whenever the patient tried to speak oral contortions and deviation
of the tongue ensued, and hands and feet began to beat the air
without his being able to utter a single word. The agitation was
increased by emotion and diminished with volitional movement.
Another instance is referred to by Aimé[125] under the name of tic of
elocution, where the combination of convulsive movements of neck,
shoulder, and arm with spasm of articulation of eight years' standing
disappeared under the influence of methodical re-education.
Kopczynski cites the case of a man with facial and other tics who used
often to utter a long string of words or even a whole sentence in an
extremely monotonous voice, resuming his natural tone thereafter;
occasionally, too, he used to pause in the middle of a remark for as
long as forty seconds.
Mention must be made here of true spasms of phonation or laryngospasms,
the result of local irritation, which disappear with its removal.
Central lesions, of course, might conceivably produce the same effect.
Uchermann[126] has reported a case of recurrent attacks of mutism
at intervals of five or ten minutes in a man of sixty-eight,
examination of whose larynx during the seizure showed the glottis
to be in spasm. Synchronously with these rhythmical clonic
alternations of adduction and abduction occurred tonic
contractions of the masseters and clonic contractions of the
palate, tongue, and forearm. The phenomena had lasted for about a
month when a right hemiplegia was superadded, and was followed by a
fatal issue three weeks later. Unfortunately no autopsy was
obtained to verify the observer's opinion of a lesion in the
neighbourhood of the left precentral sulcus, involving the centres
for mastication and phonation, for the tongue and for opening of
the glottis.
If now we direct our attention to the content of speech, we shall see
how it too may reveal anomalies not unlike tics.
Letulle quotes the case of a man who could not utter four consecutive
words without sandwiching a "sir" between them. Similarly, the "don't
you know," "do you see," "you know," of so many people are repeated _ad
infinitum_. One of us has an acquaintance who interlards his talk with
"you understand," and this formula is reiterated without modification
though he may be addressing his friend in the second person singular.
There used to be a poor creature driven by destitution to sell papers in
the streets, or to figure as a negro in the corridors of the Hippodrome,
who was wont to garnish his speech with a "Well, my boy! all right, by
Jove!" repeated at intervals, whoever it was he happened to be speaking
to, and even though it was their first time of meeting.
In Ibsen's play of _Hedda Gabler_ is a character George Tesman, a weak
being who begins every sentence with "I say, Hedda," and ends with a no
less invariable "eh!"[127]
These habitual words and phrases--and many more instances may be
cited--are analogous to the mannerisms exhibited during concentration of
the attention on the performance of certain acts. They cannot be
considered tics unless reproduced at other times as well. Moreover,
while the use of such terms may be overdone, it can hardly be said to be
unreasonable. However irritating their effect, they indicate simply an
exuberance of style and a degree of inattention, not a grave mental
shortcoming.
Of a less trivial nature is a curious anomaly that consists in the
complication of speech by the introduction of meaningless expressions
uncontrolled by the will. This is a functional defect very much akin to
the tics.
A distinguished medical colleague was in the habit of muttering the word
_cousisi_ as he talked.[128] Séglas described similar occurrences as
"stereotyped acts of speech." One of the Salpêtrière patients used to
close every sentence with the phrase "in all and for all." Another's
opening remark was always "Araken-Doken-Zoken." It is permissible to
regard many of the neologisms imagined by the insane as examples of
stereotyped speech. A patient, for instance, who suffered from delusions
of persecution, said he was being pursued by the Evil Eye
("_reluquets_"--_reluquer_, to leer at). With the eventual disappearance
of the association linking the original idea to the neologism, the
patient may no longer be capable of explaining the meaning of the
phraseology he has invented, but in the case of those whose mental level
is more nearly normal the coining of new words need not be more than a
sort of eccentricity, which is generally accompanied, however, by other
indications of instability. We may remind ourselves of O., with his
"vertigos" and "para-tics."
But if, finally, words or phrases escape the subject's lips at moments
of silence, with whose imperious and unexpected emission he is powerless
to cope, then we are dealing with true tics of speech. Their
investigation has been conducted by Guinon with great analytical skill.
At the upper end of the ladder among exclamations we meet words
involuntarily and senselessly repeated, in a loud tone of voice, to
the accompaniment of tics and grimaces. These expressions fall
naturally into two groups that require to be rigorously
differentiated.
In the first of these the words uttered may be simply anything;
each patient may have his own, and so their number is absolutely
limitless. Occasionally one is in a position to discover in the
antecedents of the case the reason for the choice of a particular
word in preference to another, as in the instance of the man whose
involuntary ejaculation, "Maria!" was the echo of a passion he had
conceived years before for a young girl of that name.
Such troubles are unmistakable tics. The mechanism of their production
is identical, be the actual localisation brachial, facial, or laryngeal,
and this applies in particular to the motor verbal hallucinations so
excellently studied by Séglas. As a matter of fact, tics of speech are
often nothing more than the mode of exteriorisation of these
hallucinations. The same is the case with verbal impulsions.
In this rubric of tics of speech we may class various cases recorded
under differing titles, among which an interesting one due to Pitres may
be quoted:
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 ejaculation 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
repetition of a simple involuntary "ah!" which some one near by has
ejaculated, 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 ejaculation 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
analogous 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 Hôtel 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 blasphématoire_ 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 association
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 ejaculation 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 classic 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 ejaculation 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
Séglas,[130] was afraid to pronounce 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 assume the characters of a genuine tic.