PROGNOSIS
The prognosis in a case of tic depends solely on the mental state of the
patient. After what has been said of the rôle played by psychical
disorders in the genesis of tic, we can readily comprehend the reason
for this. The intensity and tenacity of any tic are determined by the
degree of volitional imperfection to which its subject has sunk. He who
can will can effect a cure; be it a simple tic, or be it a case of
Gilles de la Tourette's disease, if he can struggle long and
energetically, the tic's doom is sealed. Permanent cures have
undoubtedly been obtained, but they are the exception. Left to himself,
the victim to tic can seldom escape from it.
As far as life is concerned, tics are harmless, yet, according to Gilles
de la Tourette, the prognosis is by no means always unchanging.
The establishment of a tic is never followed by its ultimate
disappearance; it may be modified in all sorts of ways, yet the
expert observer will not fail to mark its presence. A complete cure
is not to be expected, for however much paroxysms may be alleviated
and their frequency reduced, the morbid condition has become a sort
of function, a product of the patient's mental constitution.
The statement may be taken to imply that no tic abandoned to itself ever
vanishes completely, but the generalisation is inaccurate. Systematic
treatment may lead not only to amelioration, but also to cure. Certain
tics of children are by nature ephemeral, and disappear spontaneously,
never to return. It is easy to understand how that may be. Psychical
evolution and physical evolution alike are liable to singular
variations. Hence the development of a tic in early life is no reason
for despair, seeing that we are not justified in the assumption that the
volitional debility which it proclaims is to persist. We must believe
that volition may be reinforced, and we must further the attainment of
this end by every means at our disposal. Negligence on our part is
highly culpable.
Tics of childhood are curable: we draw attention to the fact afresh.
Their spontaneous dissolution is not unknown, but parents must not
consider the question merely one of time. They must impress on their
children the sobering effect of good behaviour and decorum. Discipline
of this kind may be a long and delicate task, but to condone indulgence
in untimely movements, on the pretext that they are merely quaint, is a
mistake fraught with the gravest consequences.
When a child holds its knife or fork incorrectly, or puts its elbows on
the table, or its finger in its nose, we feel that the habit is
displeasing; but how much more serious the outlook if the trick consists
in biting the lips, or tossing the head, or blinking the eyes! The
former is an offence against good taste; the latter is a tic in embryo.
It may be said, as a general rule, that the chances of spontaneous cure
are in inverse proportion to the age of the patient and the duration of
his tic.
Tics of adult life may also be cured, less often, it is true, than in
the case of children. Oppenheim gives the history of a woman with a
rebellious facial tic of twelve years' duration, which ceased on the
occasion of a certain happy event in the family life. Of course one
wants to know whether it ever returned, for many so-called cures are
simply remissions.
T. had suffered from torticollis for a whole year, but on the eve of her
son's marriage it stopped entirely for three days, and she deemed the
cure permanent; it was not long, unfortunately, ere she underwent a
relapse.
Brissaud[192] quotes an instructive case of temporary cessation of tic.
A patient afflicted with mental torticollis of three years' standing
learned that his son had been injured and had been removed to hospital
to undergo an operation. In an instant his torticollis disappeared, but
a reassuring report from the surgeon a few days later was followed by a
recrudescence of the condition.
It is true a hardened _tiqueur_ may be relieved of his tic, but the
potentiality remains. He is still at the mercy of the impulse to tic,
should it arise. Cruchet gives the history of a young man who suffered
in succession from convulsive movements of negation, facial tic,
blinking of the eyes, abrupt yawning, and twitches of the shoulder--all
in the space of two years. Each disappeared in its turn, independently
of treatment, without leaving any trace behind. In cases of this
description a new tic is ever imminent. The facility with which one tic
replaces another is a matter of common observation. We have often had
occasion to observe relapses, or partial relapses, in which an
altogether new tic suddenly makes its appearance on the top of one which
has either been improving or has actually been checked.
Apart, however, from obdurate forms of long standing, especially such as
are accompanied by signs of grave mental defect, we maintain that the
subjection of patients to appropriate treatment for an adequate period
has a favourable influence on prognosis. The curability of tic was
denied by Oddo, but he has recently seen fit to change his opinion, and
to confine his pessimistic views to Gilles de la Tourette's disease.
The prognosis of the mental state of victims to tic is outwith our
province: it is a topic long since handled by psychiatrists. We may ask,
however, whether any particular prognostic import is to be attached to
the tics themselves.
In cases of Gilles de la Tourette's disease the progressive unfolding of
motor disorders suggests a corresponding evolution of psychical
derangements which may end in dementia. Brissaud warns us that in cases
of mental torticollis we must be on our guard against the apparition of
some much more redoubtable affection than the torticollis, for that,
sometimes, is an incident in the prodromal stage of general paralysis of
the insane. Séglas has had a case of ærophagic tic which eventually
became one of general paralysis, and a similar instance occurred in the
practice of one of us.
Not long ago Dufour[193] advanced the opinion that the occurrence of a
motor syndrome consisting of the automatic movements of tic, in a case
of delusional insanity, heightens the gravity of the prognosis as
regards chronicity. It had been already remarked by Morel that such of
the insane as contract tics usually degenerate into dements. Most of the
contributors to the study of idiocy have noted the relation between the
degree of intellectual debility and the extent of the automatic and
rhythmical movements.
In this connection Joffroy has made some interesting statements.
Sometimes there is not merely co-existence, but an actual
parallelism between the motor and the psychical disturbance. I have
under observation at present a young woman suffering from attacks
of agitation, with delusions and hallucinations, who has developed
a facial tic in the course of her psychosis, and increase in the
violence of the tic is associated with abrupt utterance of
imperfectly formed syllables. During the last two months she has
been having attacks in the evening, when the psychical troubles
have become more intense, and simultaneously there has been
aggravation of the tic and incessant emission of laryngeal sounds
and syllables. Here then is a parallelism between the two groups of
symptoms.
I am disposed, however, to believe that the usual prognosis given
where motor and mental defects co-exist is too guarded. I have seen
the catatonia of dementia præcox disappear spontaneously, in spite
of its intensity and the unfavourable outlook prophesied by all who
had seen the case.
In distinction, then, from the value of a knowledge of the patient's
mental condition, we consider the motor reactions of tic of little
prognostic significance.