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CHAPTER XIII
THE COMPLICATIONS OF TIC
FOLLOWING in the train of the tics may come a number of complications, insignificant enough as a general rule, the dread of which may in some cases actually be instrumental in stimulating the will's activity to rid the patient of his tic.
Dislocations have in violent cases been known to occur. Incessant repetition of a tic may lead alike to hypertrophy of certain muscles and atrophy of their antagonists, conditions which in aggravated instances may produce permanent malformation.
It is of course in cases of spasm and other convulsive phenomena dependent on structural disease of nerve centres or conductors that such trophic disturbances are most liable to occur. Gaupp152 has described a case of partial congenital myotonia localised in the muscles of the forearm and hand, and associated with atrophy, in a patient presenting certain stigmata of infantilism; but the condition can scarcely be classed with the tics.
As for actual paralysis supervening on a tic, the case recorded by Grasset153 of a young girl in whom a tic of the right leg was succeeded by a trailing movement of the same limb in walking can hardly be considered conclusive, inasmuch as such incidents usually indicate hysteria or functional disturbances akin to tonic tics.
Biting tics are more apt to be accompanied by various sequelæ, such as mutilations, excoriations, ulcerations of all sorts. By constant nibbling at his lip J. produced an erosion of the mucous membrane, which became infected and developed into an ulcerative stomatitis. The accident, however, had a salutary effect on his tic.
We may quote another illustration from the history of the same patient to show how complications may sometimes be of curative value.
In January, 1901, in consequence of excessive cudgelling of one fist by the other, the back of the left wrist became inflamed and painful, but the bruise soon disappeared. In April of the same year, however, a large reddish ecchymosis made its appearance in the neighbourhood of the left elbow, with a painful swelling of the whole arm on the proximal side, and a few days later the discovery of a hard, cordlike mass along the border of the biceps made it clear that phlebitis had set in. With proper treatment the symptoms gradually diminished in intensity, but there can be no doubt of their origin in the reiterated violence of J.'s onslaught on his left arm.
The immediate outcome of the event was to put a brake on his exuberant gestures, and although the impulse was still sometimes urgent enough to tempt him to recommence, the thought of his phlebitis and fear of the dangers of a relapse were sufficient to recall him to his senses.
Apropos of complications the case of O. occurs to the mind, his biting tics ending in the premature loss of all his teeth, while his habit of rubbing his nose and his chin against the back of a chair led to the development of callosities. Tonic tics of the neck may in cases of long duration result in permanent deformities.
Apart from such complications, the vast majority of the accidents that accompany tics are attributable to various concurrent affections. A case reported by Féré154 of rotatory movements of the head passing some years later into the initial symptom of epileptiform convulsions ought not, in all probability, to be placed among the tics.
As for the grave mental affections that sometimes are superadded to long-standing tics, it is unjustifiable to class them as complications; they are rather manifestations of psychical instability that have found a suitable medium for their evolution; in many instances they occur quite independently of the tics.
It may, however, be remarked that the persistence of a tic entails ceaseless preoccupation on the part of the subject, and may thus pave the way for obsessions or hypochondriacal ideas. The motor disturbance reacts adversely on the mental state of which it is the outcome. Hence an obsession may give rise to a motor display that has all the appearance of a tic, while the motor act in its turn may become an actual obsession.
CHAPTER XIV
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 Janet157 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 Scherb158 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 Mannini161:
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. Schupfer163 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. Malm164 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.
