TICS—INSANITY—IDIOCY
Insanity in any of its forms may be accompanied by clonic or tonic convulsive movements—movements that may be of the nature of tics or spasms or stereotyped acts, or that may belong to conditions which we distinguish by the names of myoclonus, polyclonus, myotonia, catatonia, etc. It is highly probable that many instances have been described as spasms which, according to our nomenclature, must be considered tics. Brodie, to take an example, quotes a case where a "spasm" of the spinal accessory was replaced by a mental affection. Alternation of hallucinatory mental confusion with "spasm" of the neck muscles has been observed by Oppenheim, as well as a case where the "spasm" originated in the course of an attack of alcoholic mania. In another, due to Gowers, "spasm" of the muscles of the neck was preceded, at a ten years' interval, by an attack of melancholia.
Most of the cases of this nature would be held to-day to be instances of mental torticollis.
That tics and mental disease accompany each other is notorious, but a discussion of the question would carry us beyond our limits. We must say a word, however, on the tics of idiots.
The study of tic as it occurs in idiots, imbeciles, and arriérés, has engrossed the attention of alienists since the days of Pinel and Esquirol. Cruchet says the mental state of the idiot and the imbecile is so characteristic that the diagnosis of convulsive tic in such cases is never attended with any difficulty. Yet the task is sometimes sufficiently delicate, for we maintain that upon our insight into the subject's mental condition depends our ability to analyse his tics.
Considerable light has been thrown on the question by the important information amassed by Bourneville, as well as by the fine psychological studies of Sollier and the meritorious thesis of Noir, from which we shall borrow largely in this place.
In the first instance, we meet with tics in every way comparable to those we have already described, and we may give one or two examples.
R. accidentally wounded his left eye at the age of eleven, and contracted a tic which consists in spasmodic blinking of the eyelids, though no sign of ocular lesion is left. A diminution in its intensity has been taking place, which has culminated recently in its spontaneous disappearance.
N. had an attack of ciliary blepharitis and keratitis which left an opaque patch on the upper and inner part of his left cornea, and he has blinked ever since. Yet there is no local irritation to justify the continuance of the movements.
The tics are occasionally as numerous and violent as in Gilles de la Tourette's disease, and are accompanied with cries and with coprolalia.
L. is afflicted with abrupt blinking of the eyelids, retraction of the head, and elevation of the lip. Once the tic is established, it persists on an average for from eight days to a month, and during this time no effort on his part will check it. Sometimes he makes peculiar growling noises; sometimes he cannot prevent himself from stooping down as if to pick up stones; sometimes he is unable to restrain himself from touching everything within reach.
From the age of five, C. exhibited frequent blinking movements, and gestures which seemed to indicate that his clothes were uncomfortable. No attempt at modification was attended with success. The tics steadily increased, till he found himself uttering cries and letting obscene words escape his lips. For a long time they remained in abeyance, then reappeared in his face and trunk, in the form of salutation movements. His propensity for clastomania, pyromania, and kleptomania necessitates his being kept under strict supervision, and though he is intelligent and has a good memory, he is also lazy and inattentive.
Other tics of still greater complexity and peculiarity are met with among those whose psychical imperfections are very pronounced. Some "co-ordinated tics" are remarkable for their intricacy; they consist of a series of movements which mimic some act of everyday life. In this group may be specified various rhythmical movements, such as those of balancing, head rotation, and striking or beating oneself—the krouomania of Roubinowitch; they may be compared to the mother's rocking of her infant, inasmuch as they have a soothing effect on their subject, however brutal the movement itself sometimes may be.
In most cases the patient is seated and rocks himself to and fro in an antero-posterior direction. Or it may be the head only that is rhythmically moved from side to side, and the performance may go on indefinitely. A mere touch or a word, on the other hand, is commonly sufficient to interrupt its sequence.
There remains a final class of co-ordinated tics, which Noir distinguishes by the epithet "large," tics which are confined to idiots of good physical development. They consist of a movement or series of movements of considerable amplitude, and constitute the predominant clinical feature of the patient's idiocy. Here we find subjects who jump, or climb, or turn round and round; in other cases they are reduced to the level of mere automata, and go through a long series of actions in a mechanical way.
Their memory for recent occurrences is very poor, but in their minds are stowed away vague souvenirs of events long past, which they translate into action, and which they are incapable of modifying, even as they are unable to add to their mental store or to alter their mental routine.
A classic instance of this variety of tic is Ros., long known at Bicêtre as "the waltzer."
CHAPTER XV
THE DISTINCTIVE FEATURES OF TIC
WE are scarcely inclined to believe in the possibility of condensing into an adequately concise and adequately precise formula our conception of tic, or at least all the notions which contribute to it. Because most authors feel it incumbent on them to fall in with this nosographical custom, definitions have been proposed whose brevity only serves to confuse the issue. Opinion on the interpretation of certain words which concern our subject is far from being unanimous, and, as we remarked at the outset, accuracy in our terminology is urgently called for. This has been our reason for preceding our definitions by the results of clinical observation and pathogenic analysis.
Our idea of tic, however, may be couched in the following terms:
A tic is a co-ordinated purposive act, provoked in the first instance by some external cause or by an idea; repetition leads to its becoming habitual, and finally to its involuntary reproduction without cause and for no purpose, at the same time as its form, intensity, and frequency are exaggerated; it thus assumes the characters of a convulsive movement, inopportune and excessive; its execution is often preceded by an irresistible impulse, its suppression associated with malaise. The effect of distraction or of volitional effort is to diminish its activity; in sleep it disappears. It occurs in predisposed individuals, who usually show other indications of mental instability.[167]
We are in a position, now, to elaborate the details of this definition. Tic is a psychomotor affection, and there are two inseparable elements in its constitution, a mental defect and a motor defect.
The prevailing mental defect is impairment of volition, which takes the form either of debility or of versatility of the will. This being characteristic of the mind of the child, its continuance in spite of years argues a partial arrest of psychical development. Hence the epithet infantile may be employed to qualify the patient's mental state.
Other psychical troubles, which similarly are anomalies of volition, may be superadded, in particular impulsions and obsessions.
Speaking generally, a certain degree of mental instability is a distinguishing feature of the patient with tic.
The defect of motility consists at first in the provocation of a motor reaction by some external cause, or by an idea.
In the former case, the reaction is the cortical response to a peripheral stimulus, and its logical execution becomes by dint of repetition habitual and automatic. With the disappearance of the stimulus it continues to manifest itself, without cause and for no purpose, in which circumstances the feebleness of the inhibitory power of the will is revealed.
In the latter case, the motor reaction is called into being under the influence of an idea, normal or pathological, which eventually ceases to operate, and by virtue of the same pathogenic mechanism the act remains, inopportune and exaggerated.
The objective manifestation of tic is a clonic or tonic convulsive movement, an anomaly by excess of muscular contraction.
In the clonic variety there are undue rapidity and increased frequency of the movements.
In the tonic variety, the duration of the contraction is prolonged.
The intensity of the movements, likewise, is abnormal in degree.
In spite of these disfigurations, so to speak, of the original movement, it is practically always possible to detect in them co-ordination and purpose, the cause and the significance of which ought to become the object of our search.
The motor disorder can never be reduced to mere fibrillation, nor indeed to fascicular contraction unless in some one muscle different bundles have different physiological attributes. It is usual for several muscles to be concerned, and their anatomical nerve supply may be from separate sources.
Like ordinary functional motor acts, tics are distinguished by co-ordination of muscular contraction and repetition; they are preceded by a desire for their execution, and succeeded by a feeling of satisfaction.
These features, however, are carried to excess.
In addition, the functional act is inapposite, sometimes even harmful; it may be described as a parasite function.
The muscular contractions follow each other at irregular intervals; they come in attacks, which, it is true, are highly variable in frequency, duration, and degree.
Volition and attention exercise a restraining influence on the motor phenomena, but repression is accompanied by malaise, sometimes by actual anguish.
Distraction suspends the activity of tic; physical fatigue and emotion are calculated to arouse it.
Tics always disappear in sleep.
They are unaccompanied by any alteration in sensation, in the reflexes, or in the trophic functions.
They are not associated with pain.
In this general way we have indicated the distinctive features of tic, and we may take the opportunity to remind ourselves of their extreme variability.
In discussing the question of diagnosis, we shall have occasion to emphasise the importance of fruste, atypical, and transitional cases, not because we think they can be systematised as yet, but because they may be capable of new pathogenic interpretations which we cannot afford a priori to set aside.
We venture to believe that tic has a clinical individuality of its own which we have tried to portray, and we go so far as to say that an appreciation of the points we have touched on will prove of service in matters of diagnosis.