Tics and Their Treatment Part 19

The object in view in the act of scratching is relief from some such source of cutaneous irritation as a pimple, an abrasion, a burn, the bite of an insect, etc., and so long as the cause persists, the function is being rationally exercised; but to persevere mechanically, involuntarily, immoderately, in the absence of pruritus or of other paraesthesiae, is a sign that the functional act is growing into a tic.

Innumerable tics are thus developed, and they are intimately a.s.sociated with biting tics.

S. pa.s.ses his hand every instant over his forehead, O. over his eyes, T.

over her lips, P. over his moustache, young J. over his budding whiskers, etc., etc. These elementary tics are scarcely more than stereotyped acts, and may maintain the semblance indefinitely, though there is also the likelihood of their becoming immeasurably more p.r.o.nounced.

M. scratches his lips with his nails till they are bleeding; E. suffers from a facial tic, and sc.r.a.pes at his forehead and temples to such an extent that his complexion is perpetually blooming with a crop of little bleeding excoriations; in some places, as a result of ceaseless rubbing and tapping, the skin is thickened and discoloured--a condition that might be known as "scratchers' corns." Madame W. used to tear at her toe nails with her fingers whenever she had retired for the night; and at the present time, as a result of incessantly pa.s.sing a fine gold chain between the pulp of her fingers and the nails, she has succeeded in half detaching the latter from their bed.

A case reported by Raymond and Janet[100] is one of unusual severity.

A little girl ten years old was covered from head to foot with scabs and sores, some of which on the body were several centimetres in diameter and looked very ugly. These she had contrived to inflict on herself, in spite of every precaution and admonition. It appeared that successive attacks of measles and of whooping-cough at the age of five had entailed long rest in bed, and had been followed by a tardy convalescence, in the course of which the development of a few pimples on the forehead was the signal for her to commence scratching them and any other part of her body where there was the least discomfort, or where the skin was at all roughened. This merciless self-mutilation ended in the production of large and painful excoriated areas; nevertheless a tic had sprung from the habit, and it remained inveterate.

Another a.n.a.logous case is quoted by the same observers[101]:

In this instance, apart from the obvious existence of a confirmed tic, the patient had a curious look about the eyes which a nearer glance showed was caused by complete absence of the eyelashes. He had a trick when speaking or talking of lifting his right hand and running his finger carefully along the margin of the lids, and if it encountered an eyelash projecting beyond the skin, he promptly plucked it out. The endless repet.i.tion of this toilette rendered the eyelids barren of lashes.

TICS AND WRITING

Are writing tics to be recognised?

Tricks and turns of writing, however ridiculous, involuntary, and ingrained they be, scarcely deserve to be called tics. Those flourishes and ornaments that some people take delight in adding to their letters can no more be considered the expression of a pathological state than the superabundant gestures, the redundant words, the exuberant mimicry, of which others are so prodigal. They are simply modes of exteriorisation peculiar to the individual, and if in their superfluity and excess they go beyond the strict requirements of the case, still, they are only mannerisms of writing or of speech. Their manifestation is rigorously dependent on the performance of some function, and is not preceded by an imperious need of execution.

More akin to the tics is stereotypy of written language, so common an appanage of mental disease. The term is intended to include such habits as repet.i.tion of a particular formula, underlining of words, constant use of hyphens in the same way, writing of certain pages in a hand differing from the rest of the ma.n.u.script. Seglas[102] has done excellent work in the a.n.a.lysis and interpretation of these troubles. One of his patients used every week to write letters bearing the same complicated address, and signed invariably with the following rigmarole:

De Senez de Mesange, great Prince Napoleon, great Prince of the Blood Royal and Imperial of the Universe, great Admiral, great Marshal of my armies, ... great Procurator of the Republic, Royal and Imperial, great President of the Republic, Royal and Imperial, great Pope, great Duke, great King, great Emperor--Jupiter, Louis XIV. and Louis XV.

Another would write after almost every sentence:

_Dieu et son droit_, let him be cursed in all that is most cursed _qui mal y pense_.

This was a sort of exorcism, a cabalistic formula enabling the persecuted unfortunate to defend herself against the wiles of the evil spirit.

A tic of writing, however, is of a totally different nature. He who, without pen or pencil, is constrained by irrepressible impulse to go through the movements of writing with his fingers, convulsively, impetuously; and he who, without rhyme or reason, feverishly traces characters utterly at variance with the ideas he would express, are alike subjects of a writing tic. Of the former, we know no characteristic example, while in the latter case the study of the phenomenon would lead us too far into the realm of automatic writing and graphic impulsions. We must content ourselves with recalling its occurrence in an undeveloped form in the case of O.

Among those who are affected with tics, disorders of writing are very infrequent, even where the tic's exhibition is displayed in the upper extremities. One of the distinctive features of tics, in fact, is the brevity of the interruption they cause in the performance of any voluntary act on the part of the patient. Tics of arm or hand effect but little modification of his writing. He is rarely taken aback by his tic's convulsive demonstration. He can permit the co-existence, on a perfect understanding, of two automatic acts, normal and abnormal, writing and tic.

One of Guinon's patients was wont to proceed in the following way: if asked to write, he would lean on the table, pick up his pen, and just ai it was about to touch the paper, make several little movements of circ.u.mduction with his right hand, as a child does.

Thereafter, he would sometimes pa.s.s on at once to trace the letters; at other times he would have to grind his teeth, contort the right half of his face, put out his tongue, pucker his nose, or dip his pen spasmodically into the ink ten consecutive times--e.j.a.c.u.l.a.t.i.n.g. ahem! ahem! the while--before being able to commence. He would often cease altogether, to make one or two grimaces, or to wave his hand about. As far as the actual writing was concerned, its distinctness and evenness were no less praiseworthy than its style and content, and though a glance at his gesticulations led one to expect blots and irregularities in his ma.n.u.script, he conducted his task with a.s.surance and correctness.

Of course, if the tic, whatever it be, exceed a certain limit of frequency and violence, accurate writing may amount almost to a physical impossibility, in which case the patient usually discontinues, although if called on to exercise his will he can always pen a few words and even a few lines. However this may be, the spots and scrawls and zigzags and shaky cramped characters we a.s.sociate with such organic affections as tabes, Friedreich's disease, paralysis agitans, etc., are wholly exceptional in the case of tic.

While, then, disturbances of the function of writing are seldom ascertainable in those who tic, we have convinced ourselves on more than one occasion of the truth of the converse, that the exercise of the faculty is sometimes intimately combined with the evolution of tics of neck and shoulder.

S. dated his mental torticollis from the time when he used to copy figures for several hours a day. As a matter of fact, he wrote an excellent hand, and experienced no difficulty in performing the necessary movements, but continued writing increased the rotation. N.'s torticollis was the sequel to long spells of office work, during which he never laid down his pen. In the case of L., the wryneck and the convulsions of the right arm were preceded by a sort of writers' cramp of the right hand, and subsequently of the left.

In the accompanying instance, the development of which one of us has had the opportunity of observing, the appearance of the torticollis was at first confined to occasions of writing, but gradually it came into evidence with other arm actions, and eventually established itself in a permanent fas.h.i.+on.

P., fifty years old, occupies a responsible position in a big railway company, is director in a large office, and performs his duties with peculiar conscientiousness and zeal. Naturally an emotional man, he was much distressed by an unusually sad family bereavement about the middle of 1900, which coincided with a period of great overwork. As he was obliged every day to arrange innumerable papers and affix his signature to them, he began to notice that each time he wrote his name his head turned to the right involuntarily, and he felt a sensation of discomfort in the neck and right shoulder. He tried to remedy the faulty position by holding his chin with his left hand; nevertheless, in the course of the next few months the movement began to a.s.sert itself not merely as he wrote his signature, but also when he cut his food at table, or sharpened a pencil, or trimmed his finger nails.

_October 14, 1901._--Whenever P. proceeds to write, his head is immediately rotated to the right and maintained in that att.i.tude by successive contractions. Simultaneously, the right side of the face is distorted by a grimace, the right eye blinks, and the right corner of the mouth is drawn down by a strong effort of the platysma. The state of affairs is unaltered so long as he is handling a pen, though, curiously enough, his caligraphy itself is flawless. The more firmly he grasps his pen, the more violent the spasms; the subst.i.tution of a pencil abates them somewhat, as does writing on the floor with a cane, while if he traces letters in the air in front of him with his finger, they do not occur at all. When both hands are occupied in writing, the head still turns to the right.

He was advised to incline his head on his right shoulder as he wrote, and to force his right sternomastoid to contract, in carrying out which instructions he managed to form several hooks and rods correctly without any torticollic movement, and was both elated at the success of the experiment and dejected by the thought of his infirmity. Accordingly all writing was prohibited, all signature making reduced to a minimum, and he was recommended a simple pencil exercise, to be performed with slowness and deliberation while the head was kept in the position just mentioned. Identical rules were to be observed when eating, etc, and a tepid bath was prescribed night and morning.

_October 21._--Some improvement has taken place. The patient is less uneasy and less discouraged. Dissociation of the movements of writing into their component parts and isolated execution of each are accomplished admirably at the first trial, less well the second, and at the third, rotation recommences. Fatigue rapidly increases, and P. sinks again into impatience, enervation, and despair. Occasionally his anguish is so extreme he is covered with perspiration even after the most elementary pencil drill, and is forced to mop his brows.

_November 21._--Improvement is maintained. He can now write various letters and short words at his ease, though he still feels uncomfortable in anything requiring a more sustained effort.

Otherwise, he is conscious of greater control over his head.

_December 15._--The amelioration has not persisted. While he was paying a visit to the barber's, and having his hair cut, rotation to the right began again, and when lifting his hat in the street to salute a friend, he repeated the movement. At table, too, he noticed it as he was in the act of bringing his gla.s.s to his mouth.

P. is consequently upset, and often plunged into tears.

_December 24._--The patient's condition is more than ever deplorable. On the slightest provocation--indeed, on no provocation at all--furious torsion movements force the head backwards and to the right, while the right shoulder rises.

Complete rest in bed was ordered, yet after two or three days of this repose the torticollis manifested itself even in the rec.u.mbent position. As a result, he was quite unnerved and talked of suicide.

Another physician called in consultation agreed with what had been done, confirmed the integrity of all the reflexes, including the plantars, and recommended a course of electricity.

_January 20, 1902._--There has been no further change. P. stays abed all morning, inventing endless arrangements of pillows and dictionaries to prop his head. When he goes out for a walk, he turns up the collar of his coat and leans his head on the point of it.

_January 27._--The electrical treatment has been relinquished. He has also taken one douche at a hydrotherapeutic establishment, but expressed his dissatisfaction and vowed never to return. He then departed to undergo a "water cure" in the country, since when he has vanished entirely from observation.

More than once we have had occasion to notice that the degree and extent of such neck and arm convulsions as are provoked or exaggerated by the act of writing vary with the level at which the patient has to write.

With elevation of the arm the movements are weak and easily mastered; conversely, lowering of the arm augments them in a marked manner. We repeat, however, that in all these cases the handwriting itself is not interfered with.

It is quite otherwise with writers' cramp, the so-called "graphospasm"

or "mogigraphia." This condition is purely and exclusively a disorder of the function of writing, depending for its exhibition on the exercise of this function, else is its existence concealed. For this reason it ought to be differentiated from the tics, although, by its development in obvious neuropathic or psychopathic subjects, it is closely linked to them.

One of Oppenheim's cases was a lady whose husband suffered from paralysis agitans; in her case, fear of becoming affected with the same disease led to the development of writers' cramp. Sometimes it occurs in families, and it may be a concomitant of genuine tics. In spite of the affinity between these two sorts of functional disturbance, we do not feel it inc.u.mbent on us to enter on a detailed study of scriveners'

palsy in this place.

TICS OF THE LOWER EXTREMITIES--WALKING AND LEAPING TICS

Tics of the lower limbs are infrequent, and seldom isolated. One of the most habitual of these is the "kicking tic." Sometimes one leg knocks against the other, as in O.'s case, or it is kicked out in front, or to the side, or even backwards, after the manner of a horse. Tonic convulsions of the leg muscles have been observed to give rise to phenomena a.n.a.logous to tonic tics. Tonic contractions restricted to a particular muscle, or group of muscles, and accompanied by relaxation of the antagonists, have been christened by Ehret[103] "habit contractures"

and "habit paralyses." Their characteristic feature is the fact of the contracture being voluntary in origin. For instance, an individual wounds the inner margin of his foot, and learns to escape the pain by throwing his weight on the outer side. Voluntary contraction of the adductors of the foot pa.s.ses gradually into an involuntary stage, giving place to spasmodic contraction, and the simultaneous inactivity of the antagonists--in this case the peronei--leads ultimately to their atrophy.

In Ehret's view the fact of loss of volitional control argues the psychical nature of the affection, and a similar opinion is held by Thiem, Jacoby, and Wolff, who attribute the a.n.a.logous cases they report to a sort of traumatic neurosis in which the psychical element is preponderant. Needless to remark, the patients in question were not suffering from hysteria.

In this connection ought to be recalled the cases described by Raymond and Janet[104] under the t.i.tle of "tics of the foot."

The first was a woman thirty-seven years old, who as she walked used slightly to invert her left foot, forcibly dorsiflex the great toe, and separate the remaining toes widely one from the other.

Notwithstanding its painful nature, the condition had persisted for seven years, and had originated in a very interesting way. She happened to be undergoing a course of mercurial inunction at the same time as she was troubled with a corn. The idea struck her that perhaps the application of the ointment to the corn might prove efficacious, but while tr.i.m.m.i.n.g the latter some days later, she had the misfortune to cut herself. Dread of the possible evil effects of the injury was followed on the morrow by an accession of cramps in the foot, the continuance of which led to the deformity that ever since had made walking a misery.

The other patient was a young man twenty years of age, whose gait used to be arrested, after a walk of ten minutes, by sudden and vigorous plantar flexion of his right toes. Momentary repose sufficed to make the spasm disappear, but it constantly recurred.

Re-education and psychotherapy effected a cure in each instance, so that their psychical nature cannot be called in question, nevertheless the painful character of the affections must not be forgotten, and since the occasions of their manifestation were confined to the act of walking, they correspond rather to "functional" or "professional cramps." In any case, they cannot be confounded with the painful cramps of the calf muscles that characterise certain toxaemias and infections (alcoholism, cholera, etc.).

On the other hand, there can be no doubt of the existence of definite tics of walking--widely varying functional derangements of tonic or clonic type, distinguished by the unexpected interruption of ambulatory rhythm.

We have met with a patient (says Guinon) who would abruptly halt and bend his knees at though he had just received a violent blow on the hock for which he was unprepared. To see him, one would have thought he was about to sink to the ground.