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, Noir[26] 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 Janet[30]:
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. Flatau[32] 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-Simon[34]:
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 Napoleon[35]:
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.
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 Vigny[38]:
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. Magnan[39] 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 place[40] 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 Debrou[41] 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.
Féré[43] 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.