Tics and Their Treatment Part 10

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 cla.s.sed with tic. It is only when the obsession or the fixed idea entails the automatic repet.i.tion of some motor phenomenon that a syndrome can be const.i.tuted 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 ident.i.ty 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. .h.i.therto 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 a.n.a.logies 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 circ.u.mstances favouring development of a tic in soil already prepared by psychical predisposition are manifold. Our studies in the pathogenesis of tic have ill.u.s.trated 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 a.s.sumed 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 p.u.b.erty, when both physical and mental evolution is peculiarly apt to suffer interruption.

_s.e.x._--s.e.x 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 const.i.tutes 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 circ.u.mstances 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 Tissie 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 a.s.sociated 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, s.c.r.e.w.i.n.g 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 kins.h.i.+p 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, succ.u.mbing to "strokes" and paralyses of various kinds.

Many figures celebrated in history had their tic.

At the time of his early appearances Moliere 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 role 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 a.s.sociated 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 Littre'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 reconst.i.tution 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.