THE RELATION OF TICS TO OTHER PATHOLOGICAL CONDITIONS
A vast number of disturbances of motility, distinguished as spasm,
chorea, 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 associations 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 chorea 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 anæsthesia or hyperæsthesia
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 analogous 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
analytic 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
association 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
passed 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 pronated 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 attitude 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 unobserved or forgets her professional
attitude, at once the arm resumes its normal position and activity.
An examination of sensation reveals a hyperæsthesia 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 analogy 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
constitute 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.
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 chorea of Morvan, paramyoclonus multiplex of Friedreich,
electric chorea of Hénoch-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 pass 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 incumbent on us to resist
the tendency to class 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
circumstances 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 association of epilepsy with the ill-defined
group of myoclonus that we propose to discuss.
According to Maurice Dide,[160] myoclonus, which he calls motor petit
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 pass
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 chorea.
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. Analogous conclusions may be drawn from a case of
epilepsy and myoclonus, with autopsy, reported by Rossi and
Gonzales,[162] where a general ischæmic 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 Féré,[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, passing 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 succumbed 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 Féré'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
épileptique_. 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 _arriérés_, 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 analyse his tics.
Considerable light has been thrown on the question by the important
information amassed 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 keratitis 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 pronounced. 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 class 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 constitute 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.
Their memory for recent occurrences is very poor, but in their
minds are stowed away vague souvenirs of events long past, which
they translate into action, and which they are incapable of
modifying, even as they are unable to add to their mental store or
to alter their mental routine.
A classic instance of this variety of tic is Ros., long known at Bicêtre
as "the waltzer."