Kitabı oku: «Tics and Their Treatment», sayfa 16
TICS OF RESPIRATION – SNORING, SNIFFING, BLOWING, WHISTLING, COUGHING, SOBBING, AND HICCOUGHING TICS
Respiratory tics are exceedingly numerous. They concern the diaphragm and the muscles of inspiration or expiration, and are accompanied by synergic movements of the muscles of the nose, lips, tongue, palate, pharynx, as well as by laryngeal noises or by tics of the face and limbs. They embody disturbances of various functional acts, and may be subdivided into inspiratory and expiratory tics.
It is only as regards their frequency that such reflex mechanisms as yawning and sneezing are liable to be modified by the intervention of the will. Saenger115 records the case of a woman twenty-nine years old, not affected with hysteria, who used to suffer from attacks of yawning and of stiffness in the arms, followed by rapid contractions of the tongue lasting for about a minute. He describes the condition as one of "idiopathic spasm" – probably a species of tic. It is in hysteria, however, that functional variations in sneezing and yawning are most commonly found, and the latter, moreover, may constitute the aura of an epileptic fit. Yawning occurs in a most intractable form in meningeal affections, and in cerebral and cerebellar tumours.
"Rhincho-spasm," a snoring tic, has been observed by Oppenheim in a case of neurofibromatosis. In certain tics of this nature, and in sniffing tics, the onset is sometimes attributable to the presence of adenoids.
Among various expiratory tics may be enumerated the habit of blowing through one's nose or mouth. Schapiro has reported a case of expiratory "spasm" due to contraction of the buccinators. Whistling ought to be considered a stereotyped act, rather than a tic, as Letulle maintains.
Spasmodic troubles of respiration, defined indifferently as "spasmodic dyspnœa," "spasmodic asthma," "spasmodic cough," "asphyxial spasm," "nervous cough," etc., ought not to be classified as tics; in many cases they are genuine spasms, arising from some irritation in sensory paths. At the instant of any contact, or under the influence of a sudden noise or a bright light, a patient of Edel's used to become distressingly dyspnœic. Evidently the condition was one of spasm.
Coughing tics also are of remarkably common occurrence. Many individuals ceaselessly interrupt the thread of their conversation to make more or less audible explosive expirations, for which there is neither reason nor necessity, since the respiratory paths are free from all irritation or obstruction. These useless little coughs do not always deserve the appellation of tics; in many instances they are mannerisms comparable to the gestures of conversation or reflection, although in some people their insistence, abruptness, and irresistibility might justify their incorporation in the other category. Their co-existence with tics of face and limbs has been noted, as in a case published by Tissié116 of an eight-year-old child, with ocular and facial tic and spasmodic cough.
Clonic contraction of the diaphragm gives rise to conditions imitated or caricatured by the tics, in particular sobbing and hiccoughing. It must not, of course, be forgotten that these are apt to occur in hysteria, as well as in organic disease of the nervous system, and in grave infectious states. Careful and searching inquiry must therefore precede any expression of diagnosis.
Tonic diaphragmatic contraction is of very much greater rarity. In such cases abdominal respiration comes to a momentary standstill, whereas thoracic respiration is accelerated. The patient is in imminent danger of being asphyxiated, and the insertions of the diaphragm sometimes become painful. What is known as acute pulmonary eructation is occasionally the sequel to this convulsive affection. Tonic contraction of the diaphragm is nearly always of an hysterical nature, and is doubtless akin to the aerophagic type.
CHAPTER X
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 Biaggi120; 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. Pick124 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 Aimé125 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.
Uchermann126 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.
