Tics and Their Treatment
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, Noir26 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.]
CHAPTER V
THE ETIOLOGY OF TICS
THE circumstances favouring development of a tic in soil already prepared by psychical predisposition are manifold. Our studies in the pathogenesis of tic have illustrated the significance of exciting causes, so-called. We have seen how the motor part of the tic was originally directed to some definite object, and therefore provoked by some definite cause, and how the eventual disappearance of this cause does not justify the conclusion that it has never existed.
We shall be able to quote numerous instances in point when dealing with the different localisations assumed by the tics; what we wish to remark here is that the initial cause is by no means always easy to ascertain. The subjects of whom we are treating exhibit a vexatious tendency to invent a more or less fantastic etiology for themselves, and their statements cannot be accepted without rigorous investigation. Of any actual exciting cause they may be really ignorant, or more likely oblivious.
In this connection an important case is reported by Pierre Janet30:
A young man twenty-five years old was affected with a facial tic in the shape of constant grimaces, accompanied by violent expirations through one nostril. Six years of the condition had neither enabled him to determine its origin nor brought him any relief. He presented, in addition, the phenomena of automatic writing and was the subject of somnambulism, and when in the latter state explained that the tic arose from the effort to expel an irritating nasal obstruction due to an epistaxis six years ago.
Needless to say (adds Janet), there never had been any obstruction in the nose; the truth was that in the somnambulistic state he was reminded of a subconscious fixed idea of which he was ordinarily unaware.
Recognition of the causal factor, then, is not without value, as otherwise the tic's situation and form may rest inexplicable.
These exciting causes we shall discuss more closely at a subsequent stage, confining our attention for the present to one or two general considerations.
Age.– Tics may occur at any period, except in infancy. "Nervous movements" appearing previous to the age of three or four cannot be tics, as has been made plain in the chapter on pathogeny. It is only with the development of psychical function – about the age of seven or eight – that revelation of its imperfection, if such exist, becomes possible.
Initiation or exacerbation of a tic is very frequent about the time of puberty, when both physical and mental evolution is peculiarly apt to suffer interruption.
Sex.– Sex is without influence on the disease.
Race.– In spite of the absence of precise statistics on the subject, the opinion that the tendency to tic increases with the advance of civilisation is not, we think, premature.
We have had the curiosity to interrogate several travellers familiar with different savage tribes of Central Africa, who, although notified beforehand to be on the look-out, declare they have practically never met with tic in negroes. These observations require to be confirmed.
It may be questioned if the level of mental attainment of such primitive peoples is sufficiently high to allow of the establishment of tics. Their occurrence in the lower animals has been recorded, it is true; but with our ignorance of what constitutes an animal tic, and until further information is forthcoming, it is prudent not to speculate on these matters. We must be content with the remark that savages and animals are less exposed than the civilised to circumstances facilitating the development of mental instability.
Trauma and infectious disease may provide the occasion for either the appearance or the disappearance of a tic, but of themselves they are incapable of originating the affection.
One of Noir's patients had a brother similarly afflicted, and a sister in whom an attack of bronchitis at the age of five was accompanied by tics of arm and head, which recurred subsequently in an exaggerated form during smallpox. On each of two occasions on which J. suffered from influenza his tics increased in violence and extent; while in the case of G. aggravation heralded the approach of measles.
Young M., on the other hand, remained free of all his face and head movements during the immobilisation of a fractured leg, with the cure of which his tics returned.
To disturbance of the reproductive organs, in particular to uterine disorders and even pregnancy (Gowers, Bernhardt), has been ascribed the onset of tic.
Of the possible influence of climate, season, and atmospheric change in general, precise information is lacking. Stormy weather or a falling barometer frequently exercises a depressing effect on the subjects of tic, but this is habitual in all neuropathic individuals. Oppenheim declares he has seen severe cases of convulsive tic follow an earthquake.
Heredity.– To this Charcot used to attach the greatest importance. In every case of tic, he maintained,31 however trivial, especially if attended with phenomena such as coprolalia, a hereditary element is discernible.
Similar heredity is of common occurrence. In Gintrac's cases, two brothers had the same facial tic. Blache's patients were three children in the same family. Delasiauve observed identical tics in brother and sister, and Piedagnel in mother and daughter. A father and two sons of whom Letulle has given an account all suffered from a tic of blinking. The same author has seen two brothers with a complex tic of face, scalp, arms, and diaphragm. More recently Tissié has recorded a series where a mother was affected with ocular tic, while the eldest son also had an ocular tic, which eventually spread to the face and was associated with a spasmodic cough; a younger son was likewise the subject of ocular tic.
A case has come under our notice of a young girl with a head-tossing tic which had been preceded by a variety of others now imitated by her youngest sister, such as sniffing, screwing of the face, shaking of the shoulders, abrupt pulling up of the garters, etc.
These and similar instances undoubtedly serve to show the effect of hereditary predisposition; but the element of imitation enters no less into the question, and the elimination of its influence, owing to family promiscuousness, is peculiarly arduous. To this point we shall revert immediately.
Dissimilar heredity, in any of its forms, neuropathic or psychopathic, is no less frequently met with, and emphasises the kinship of tic with almost all the psychoses and neuroses.
It is a matter of common observation for a tiqueur's father to be a neuropath, his mother a hysteric, his brother an epileptic, or his grandfather a general paralytic or a maniac, while neurasthenia, hypochondriasis, psychasthenia, etc., or organic disease of the nervous system, may occur among the collaterals. A case has been under our care of a boy M., who has two brothers and one sister, all in good health. The sister bites her nails. The mother is normal, but excessively weak where her children are concerned. The father is neurasthenic, and the grandfather has trigeminal neuralgia.
Occasionally a family history of syphilis or alcoholism is forthcoming. Sometimes tic and psychical troubles alternate. Flatau32 quotes a case of a mother with impulsions and a son with tics, and another of a mother and sister who tic, with a son possessed of fixed ideas.
In the subjects of tic and in their families, mental instability and intellectual superiority have repeatedly been conjoined. To refer again to the case of young J., no particular deviation from the normal was traceable on the part of any ancestor or relative on the paternal side, except that the father himself was unusually emotional and a prey to scruples; but the mother's whole family were either brilliantly clever or prematurely broken down, succumbing to "strokes" and paralyses of various kinds.
Many figures celebrated in history had their tic.
At the time of his early appearances Molière was held even in the provinces to be a comedian of a very inferior order, owing perhaps to a hiccough or throat tic of his leaving a disagreeable impression of his acting on those who were not aware of its existence.33
Brissaud recalls the curious picture of Peter the Great handed down to us by Saint-Simon34:
If he gave thought thereto, his mien became majestic and gracious, else was it forbidding, and almost savage, his eyes and his face occasionally distorted by a momentary tic that rendered his expression wild and terrible.
Similarly with the Emperor Napoleon35:
His moments, or rather his long hours, of work and meditation were characterised by the exhibition of a tic consisting in frequent and rapid elevation of the right shoulder, which those who did not know him sometimes interpreted as a sign of dissatisfaction and disapproval, seeking uneasily wherein they could have failed to please him.
Cases of tic in the descendants of great men are far from rare; we have met with several instances.
Among etiological factors of a general description, the rôle played by imitation is all-important, especially in the young. Mimicry is strong in the child's nature, and bad habits are quickly contracted. Should he be tainted with nervous weakness in addition, he is apt to tic on the slenderest pretext, in which case to encounter, or still more to be associated with, the subject of a tic would be the direst of misfortunes.
That such a contingency should arise is not essential. A novel gesture on the part of any one catches the child's attention, and he forthwith attempts its reproduction, finding therein a source of complacent satisfaction. On the morrow the movement is repeated, and again, till it oversteps the bounds of habit and enters the realm of tic.