Tics and Their Treatment
Cruchet concedes this to be a possible though by no means invariable mode of tic production, for the reason that the unconscious, or, more correctly, subconscious – polygonal, if you will – nature of imitation is undeniable, indeed self-evident.
Without entering into too great detail, it may not be amiss to examine this contention.
To imitate, in Littré's definition, is "to seek to reproduce what another is doing." How such an act is to be accomplished without the co-operation of the will we cannot conceive. Its duration being so brief, our recollection of the conscious stage may be very imperfect, but that is no ground for denying its reality. Involuntary execution of a gesture to-day does not exclude the possibility of its voluntary execution yesterday. If we find accurate reconstitution of the steps in our own habitual mental processes impracticable, a fortiori ought we to question the likelihood of our gaining full insight into the mechanism of the processes of others.
It is no doubt this perplexity which has induced Cruchet to regard the simple convulsive tic as the sole manifestation of the disease. On his own admission, nevertheless, this simple convulsive tic is of exceptional occurrence, apart from children, in whom mental trouble is conspicuous by its absence.
But the psychical disorders of infancy, however embryonic they be, are none the less real. Their insignificance may hinder their recognition, yet they are often the prelude to graver and more definite anomalies in later life. And if their detection demands painstaking study and repeated interrogation, fruitless results may very well mean that the investigation was not sufficiently thorough.
Moreover, the view that regards imitation as a prolific element in the genesis of tics has met with widespread acceptance.
The onset of the disease (says Guinon) is sometimes the consequence of the patient's partiality for mimicry. Contact with an affected person supplies the occasion. His first experience is a sort of constant preoccupation; the other's grimace is ever before his eyes, inviting imitation; at length he suddenly yields to the obsession, and his tic is in the making.
Reference has already been made to a case of Tissié's,36 where an eight-year-old child acquired from its mother an ocular tic, which a second child imitated in its turn. The cure of the latter was followed with the cure of the two others, by imitation.
The word "echokinesia" was imagined by Charcot to specify the inclination some people show to copy what they see others doing. It has also received the names of "mimicism" and "imitation neurosis." To quote Guinon again:
The movements most closely and most infallibly mimicked are facial. These the patient either is driven actually to reproduce, or feels impelled to reproduce, without allowing the impulse to pass into action. Simple and circumscribed gestures involving the limbs are similarly, if less frequently, the object of imitation. Such tricks as rubbing the nose or cheek or some other part, or stooping as if to pick up something on the ground, may be counterfeited in their entirety, though at other times the movement is only initiated.
Echokinesia may be considered a motor disturbance analogous and akin to tic, but distinguished by the fact that it occurs exclusively during the performance, and as the reproduction, of some movement executed by another. It is true, of course, a genuine tic may be a reminiscence of some gesticulation, but it is quite independent of time and place.
A similar difference exists between echolalia – the habit of repeating another's sounds or words at the moment of their ejaculation – and tics of phonation or of language; the latter are always ill-timed and inappropriate, though they may have had their origin in acts of imitation.
It has become classical to draw a comparison between these echokinesic phenomena and the observations of O'Brien apropos of latah among the Malays.
A sailor on board a boat will pick up a piece of wood and proceed to rock it as if it were a child, whereupon a latah standing alongside commences to rock the infant he holds in his arms. The sailor then throws the piece of wood on to the deck, and the latah promptly follows suit with the baby (Guinon).
This is echokinesia carried to an extreme, revealing a complete absence of inhibition from the higher psychical functions.
Prominent among influences calculated to facilitate the evolution of tics is the patient's environment, more particularly where children are concerned.
The parents are often disposed to be deplorably "fond." Their ignorance or their thoughtlessness permits the installation of obnoxious habits and fosters their growth into tics. Any endeavour after suppression usually serves to expose the inadequacy of the family authority to exercise control and compel obedience. For the watchful discipline that should curb all such childish tricks and caprices is unfortunately substituted a disastrous indulgence that only stimulates the development of these embryonic tics. It should not be forgotten, moreover, that the mental instability of the fathers is visited upon the children in the guise of a certain aptitude for psychical anomalies.
The accompanying case supplies conclusive evidence of the mischief wrought by weakminded parents, and of the calamitous results of hereditary predisposition and bad example combined.
S.'s mother is a lady of over fifty, who spends her leisure hours in writing novels, and who suffers from different varieties of phobia. In the first place, she has an absurd fear of cats and dogs. When she goes out, a maid follows at several yards' distance to prevent the approach of any dog from the rear; and if she is driving, the same precautions are observed.
Her dread of chest complaints is equally extravagant. A cold is her bugbear, a draught her bête noire. In the intervals of her literary labour she occupies herself with seeing that all doors and windows are properly shut. The room temperature is maintained at 68° F. at least.
Since her husband's death her devotion to her son's education has been fatal to his best interests. Her unfailing solicitude for his health, her constant terror of accident and illness, have reduced volitional effort in him to a minimum, and under this régime of tyrannical affection he has been as delicately nurtured as a young girl. Even at the age of thirty he must be indoors at night by ten o'clock, and a few minutes' delay will bring his mother to a state bordering on frenzy, and end in the dispatch of some one to seek him; whence all sorts of domestic discussions, and quarrels, and "scenes," with tears and mutual recrimination.
Little wonder then, with such an example, that, in spite of his own robust health, S. evinces the same senseless fear of chills and colds and currents of air, and tries the doors and windows so incessantly and so violently withal that they have to be repaired almost every month. In his own room they have been doubled and padded. His anxiety to avoid catching cold actually leads him to weigh the samples of cloth submitted to him, to ensure that his next suit of clothes will be of the same weight as his last.
With all this excess of tenderness, S.'s mother does not always err on the side of leniency. On the contrary, punishment is apportioned for the most trivial fault, although it is only necessary on S.'s part to simulate illness for his mother at once to yield to his most ridiculous caprice.
S. suffers from a rotatory tic of the head, which he attributes to a blow on the neck once administered by his mother by way of chastisement; but it may very well be questioned whether the torticollis was not rather a clever imposition intended to soften the mother's heart and bring about her repudiation of corporal punishment.
The case of J. is no less instructive, since he came of a family of veritable syphilophobes whose extraordinary frailties and sentimentalities contributed not a little to the progress of his disease.
A glimpse into the domestic life of L. is equally illuminating.
L. is an only child, who from infancy has usurped her parents' attention. Their uneasiness lest her "nervous movements" should prove detrimental to her general health is the explanation of her highly irregular attendance at school and of repeated holidaying. She may not go out alone, as her "incantations" are liable to arrest her in the middle of the street; at the same time lack of control over her legs may endanger her safety, and erratic arm gestures render the aid of a stick or umbrella useless.
To add to her misfortunes, her head has now begun to rotate to the right. She used four times a day to cross the narrow and little frequented road that separated her father's house from her place of employment; but since her last accident she has remained strictly within doors, trifling away the time in a chair, and finding in the petty life of a side-street all that she wants to attract her gaze or arouse her interest.
In this microcosm her father has been reduced to the position of a slave. He anticipates her slightest want and indulges her most fanciful whim; his commiseration for her woes is only equalled by his unselfishness in foregoing his own pleasure and his ingenuity in vindicating her weaknesses. In short, his ready acceptance of his daughter's instability argues a lack of mental balance on his own part.
Brain fatigue is another element in the formation of tics whose influence ought not to be underestimated. In the case of young D., nineteen years old, a clucking tic supervened during the period of preparation for an examination, to disappear at its close.
No less fruitful are anguish, anxiety, worry, disappointment, as will freely be conceded. Any prolonged concentration of the attention on a particular act or a particular idea presupposes a concomitant weakening of inhibitory power over other acts and ideas, which then become corrupt and inopportune, are incapable of further repression, and blossom into tics.
Indolence, too – the mother of all the vices, according to the adage – favours the outbreak of tics, and accelerates their growth. The idle patient's thoughts are all for his tic; its perfecting taxes his inventiveness.
Mention may be made in passing of the effect of "professional movements" in predisposing to the subsequent apparition of a tic in the muscles concerned. We have already alluded to the relation between tics and certain cramps or occupation neuroses, and we shall refer to the topic again at a later stage.
It would appear that even the memory of a familiar gesture sometimes suffices to initiate the condition: witness Grasset's case of post-professional colporteur tic, where the subject reproduced the movement of swinging a bag over his shoulder, a souvenir of his former avocation.37
A final example, none the less instructive though it occur in lay literature, may be cited from Alfred de Vigny38:
With a child's delight the worthy battalion commander gravely made ready to speak. He readjusted his polished shako on his head, and gave that twitch of the shoulder appreciated only by such as have served in the infantry – that twitch which is meant to raise the knapsack and momentarily to lighten its load; it is a trick of the soldier's which with his elevation to officer's rank becomes a tic. Another sip of wine followed this convulsive gesture, a kick of encouragement in the little donkey's stomach, and he began…
The description could not have been more accurate. The passage from the voluntary to the involuntary – the kick too may have been a tic – and the obvious infantile traits in the old gentleman's character, make the picture remarkably complete.
Apart, however, from the causes we have just enumerated, and others to be noticed below, we must emphasise the fact once again that mental predisposition is a sine qua non for the development of tic.
CHAPTER VI
PATHOLOGICAL ANATOMY
OUR ignorance of the pathological anatomy of tic is profound. Hitherto all the cases labelled tic in which a post-mortem examination has been made have in reality been spasmodic affections differing essentially from the tics as we understand them, according to the ideas of Trousseau, Charcot, and Brissaud. As far as we are aware, not a single sectio of a genuine case of tic is on record where a lesion, of whatever nature or whatever site it be, has been discovered to which the tic might be attributed. Either an autopsy is not obtained, or if it is, no special abnormality is remarked, or else the diagnosis has been erroneous and the changes described have not been those of tic.
It would be premature, of course, to conclude that tic is a disease sine materia. The affirmation is quite unwarranted. As is the case with numbers of neuroses and psychoses, we must for the present rest satisfied to observe symptoms; the mystery of their morbid anatomy will remain unsolved until our methods of investigation attain perfection. Magnan39 says of "superior degenerates" that clinical observation reveals functional disorders so distinct and so invariable that it is impossible they should not be the outcome of some pathological modification of the organism. It is true he declares in another place40 that the mentally unstable have all a family likeness, consisting not in identity of well-defined anatomical lesions, but in similarity of functional derangements. As it is, from the motor point of view tic is a functional act, and the governing centre is a functional centre that has become hypertrophied, so to speak, by being educated to excess. This physiological centre must not be confused with the "centre" of current anatomical terminology; it does not exercise an exclusive control over a particular territory – several such may co-exist in a single anatomical area.
Our lack of knowledge concerning the precise localisation of these functional centres is paralleled by our ignorance as to the manner of their involvement.
Noir has prudently observed that the manifestation of co-ordinated tics in cases of widespread cerebral disease, and the frequent occurrence of the most extensive and complex varieties in patients who have suffered from meningeal affections, suggest their cerebral origin. On these points, however, anatomo-pathological information is to seek, and for that matter the direct dependence of such an habitual movement as a co-ordinated tic upon one lesion is scarcely within the bounds of probability. Tic pertains to a psychical rather than to a motor sphere, and is to be regarded as a disease of the will.
With this statement, and with the expression of our hope that subsequent work will aid in the elucidation of the question, we shall close the chapter of the tic's pathological anatomy. It may not prove superfluous, however, to indicate why and how the facts gleaned from pathology and supposed to be in harmony with the clinical picture of tic should be allocated to other morbid entities.
In several cases considered to be tics of the face, cortical lesions have been discovered at the posterior end of the second frontal convolution, in the centre for voluntary and co-ordinated movements of the contra-lateral facial muscles. It has become classical to cite an example described as long ago as 1864 by Debrou41 under the title "painless facial tic," but a glance at the observation suffices at once to negative its classification as a tic, and to justify the diagnosis of a spasm of a quite peculiar sort.
On February 26, 1862, a porter, aged forty-nine, was suddenly seized with an "attack of the nerves," and at its close lost his speech. When examined at the hospital two days later, he was found to have full use of his limbs, understood perfectly all that was said to him, and evinced great impatience at being unable to respond except in writing or by gesture. He made signs to indicate that his head was paining him, and that he had difficulty in swallowing. In addition, abrupt, forcible, and rapid movements of the facial muscles on the right side were taking place; the angle of the mouth and the outer angle of the palpebral aperture were being dragged on; the external ear was elevated, or moving to and fro; the platysma was twitching visibly and the hyoid bone so acted on as to pull up the larynx spasmodically. The exhibition was an exact replica of the effect produced in animals by intracranial galvanisation of the facial nerve. Moments of absolute repose alternated with periods of spasm of a few seconds' duration, which addressing or handling the patient seemed to aggravate. There was synchronous spasm in the masseter muscles, resulting in elevation of the inferior maxilla. No other region of the body was affected.
On the night of March 2 the attacks of spasm and of pain increased in intensity and frequency, without any other change in their nature. The patient's mind remained unclouded, and as he was still deprived of the faculty of speech, he again indicated in writing the severity of his sufferings. About eleven o'clock at night the situation became more distressing; he began to be profoundly agitated, then passed into a more or less maniacal state, in which his limbs were involved in powerful muscular spasms, his eyes rolled in their sockets, and his respiration commenced to be stertorous, while the violence of his struggles necessitated the intervention of two assistants to control him. An hour or two later, during one of these attacks the end came.
At the autopsy, under the arachnoid and spreading over the left hemisphere at the junction of its anterior and middle thirds, was a large blood-clot, dark, coagulated, and free in the cerebral substance, which it had penetrated for a depth of about one centimetre. It appeared to be of about four or six days' formation, and probably dated from the incipient "attack of the nerves." Painstaking scrutiny of the cerebellum and cranial nerves failed to reveal any further pathological condition.
To tell the truth, we are not averse to wagering that to-day the opinion of the surgeon would be invited on a similar case, where the motor reactions of the so-called tic are manifestly based on a Jacksonian type.
In a case recorded by Chipault and A. Chipault,42 and characterised by brief epileptiform attacks involving the left side of the face, cerebral exploration proved ineffectual, but at the post-mortem a subcortical glioma of the size of a cherry was discovered underneath the posterior end of the second frontal convolution. Is a case of cerebral tumour to be labelled tic?
It is quite exceptional, in fact, for lesions of the cortical facial centres to give rise to muscular movements suggesting facial tic. Take another instance:
An interesting case (says Brissaud), and one that is everywhere quoted, is reported by Schultz, in which an aneurism of the vertebral artery, at the point where the basilar arises, compressed the trunk of the left facial nerve, and occasioned a "tic" of ten years' duration. As a matter of fact, one could not have a better example of spasm pure and simple.
Féré43 cites the following incident in support of the contention that encephalic trauma may engender a tic:
A man in falling on his head sustained an injury to the cranial vault over the posterior section of the left parietal bone, at a spot exactly corresponding to the posterior part of the angular gyrus, and immediately became afflicted with a convulsive tic of the zygomatics and orbicularis palpebrarum on the right. Conformably to Ferrier's experimental localisation of the motor centre for the eye muscles and lids in the angular gyrus, irritation of this centre by the cranial injury was the diagnosis made.
The proffered interpretation of the motor phenomena by cortical excitation is entirely justifiable, but no convulsion consecutive to traumatism can ever pass muster as a tic.
A no less frequently quoted experiment of Gilbert, Cadiot, and Roger,44 supposed to confirm certain results obtained by Nothnagel, is now a standard case in the history of tic hypotheses. The animal in question was a dog affected with spasmodic twitches of the ear, which the successive removal of cortical facial centre, internal capsule, corpora striata, and cerebellum, signally failed to alleviate, and which disappeared only with the destruction of the corresponding nucleus in the pons. Their inability to find any anatomical change determined the experimenters in favour of the view that the trouble was functional, and they described it as a tic.
It would be foolhardy to deny the existence of a lesion on the ground that it was not discovered. Negative findings of this sort are valueless. The sole conclusion to draw from the incident is the all-important rôle played by the bulbar centres in the production of convulsive movements, which are in such circumstances, of course, nought else than spasms.
Compression of cranial nerves by tumours or aneurisms of the base has been the cause of symptoms imagined to be identical with those of tic. The case of intracranial neoplasm mentioned by Oppenheim, in which irritation of the upper branch of the trigeminal was accompanied by homolateral facial contraction, is wholly comparable to the so-called "tic douloureux."
No less positive is our refusal to accept as tics spasmodic contractions in association with or subsequent to facial palsy or contracture of peripheral or central origin. They are spasms, not tics. Cruchet, for instance, describes indifferently as labial tic or intermittent labial hemispasm clonic elevation or depression of the oral aperture developing in central facial paralysis, especially in children. As example he refers to the case of a child in whom an ictus at the age of three years was followed by a typical spastic hemiplegia on the left side, with athetoido-choreic movements chiefly in the arm.
At first the left side of the face was flaccid and deviated in the other direction, but at the time of examination it presented no unusual feature beyond a continual twitching, a real convulsive tic, of the upper lip.
Now, whatever a facial convulsion of apoplectic origin, secondary to facial palsy and accompanied with spastic hemiplegia and athetosis, may be, it is at all events no tic.
Take one more case, given by Buss45 as "convulsive tic of the left side of the face."
The patient was an atheromatous subject, with cardiac hypertrophy, bronchitis, and emphysema. When he first came under observation at the hospital, his eyelids, cheek, and buccal commissure were the seat of painless clonic contractions, which a month later were complicated by giddiness, vomiting, inability to stand or walk, lancinating pain over the right side of the face, weakness of the right limbs, and left facial paresis, and had become fugitive and insignificant. Loss of consciousness was followed by flaccidity of all four extremities, hyperpyrexia, and death. The section showed a hæmorrhage of the dimensions of a pigeon's egg which had destroyed the left half of the pons, and an atheromatous dilatation of the left posterior cerebellar artery, impinging at one spot on the seventh and eighth nerves of the same side. Microscopical examination of their trunks and of the facial area in the pons disclosed no abnormality.
The pathological anatomy of this case indicates its nature unmistakably, and its symptomatology and evolution, moreover, do not bear the remotest resemblance to those of tic.
In the opinion of Debrou,46 convulsive tic is a functional derangement of a motor nerve, analogous to the neuralgia of a sensory one. To strengthen his argument he relied on such cases as those of Romberg, Schultz, Rosenthal, Oppolzer, where disease of neighbouring structures (enlarged glands, otitis media, caries of the temporal bone, etc.) was the agent in the production of muscular twitches in the domain of the facial. In our view, however, they are simply spasms provoked by irritation on the centrifugal path of a reflex bulbar arc.
The slight contractions occasionally seen both on the paralysed and on the non-paralysed side in the secondary contracture stage of facial palsy – a condition noted by Duchenne of Boulogne, Hitzig, and others, and distinct from fibrillary twitching – are nothing more than spasms, and the same obtains where the palsy is consecutive to affections of the ear.
Chipault and le Fur recently47 communicated to the Academy of Medicine a case of intermittent attacks of acute pain in the right hypochondriac region, associated with violent contractions of the muscles of the right abdominal wall, which they described as a tic comparable to tic douloureux of the face. It was seen at the subsequent operation that the eighth, ninth, and tenth posterior spinal roots on the right side were surrounded in their passage through the meninges by a patch of matted and cicatricial arachnoiditis, dissection of which was instrumental in effecting immediate relief.