Part 13 (1/2)
Since the age of twelve she has been subject to various tics of the face and head. She wrinkles her forehead and moves her scalp to and fro, and sometimes she turns her head slowly and steadily towards the left side, raising her eyes up and to the left at the same moment. Head and eyes forthwith resume their normal position. The deliberateness of the act is altogether exceptional. If, however, she happens to be wearing her hat--which is remarkable for its size, weight, and unwieldiness--the gesture is repeated in a quick and jerky manner. Any diversion, such as reading, knitting, listening to a conversation, especially if she feels she is not being noticed, will augment the intensity of the movements, which the thought of being observed, or the awakening of her interest, or rest in bed, or sleep, has the effect of abbreviating or checking.
Our earliest step was to confiscate the offending hat, and this had the instantaneous result of diminis.h.i.+ng the violence and frequency of the tic, which the subsequent practice of appropriate exercises entirely dispelled.
If now we direct our attention to the psychical aspect of the case, we are struck with the goodness, devotion, and disinterestedness of our patient. Her one concern is for the welfare of others, and she is indifferent to the pleasures of literature, art, games, or even work. All that is required of her she performs with docility, but never with animation. The extent of her pa.s.siveness is seen in her childlike acceptance of her parents' wishes. Her temperament is neither gay nor sad, but merely dull. Indolence and maladroitness predominate in all her actions, and reveal themselves in the curious awkwardness and nonchalance that characterise the execution of even the simplest movement. She is essentially of a very unstable nature, but its torpidity is no less obvious than its instability. If there is no abruptness in her acts, it is equally true that she is never still. She cannot maintain any given att.i.tude; she cannot fix her gaze on any particular object. Her restlessness is such that her position is changed from moment to moment, however slowly and imperceptibly. Her eyes are only half opened; as she speaks, her lips are scarcely seen to move.
It has been a laborious and protracted task to teach her to sit motionless with her hands in front of her, and no less unremitting effort has been required to make her open her mouth properly, or turn her head naturally from side to side.
In some ways the endless movements of her hands and fingers--she never ceases playing with her dress or her gloves or her handkerchief--are vaguely reminiscent of those of athetosis, and on the left side especially, if they become a little brisker, there is slight hyperextension of the phalanges. She reads aloud in a low, colourless, monotonous tone of voice, without punctuation or accent, articulating the syllables defectively and slurring the ends of the words. At the finish of each paragraph comes a halt, as if from fatigue, and on command a fresh start is made with the same careless indifference. As for the lower extremities, the tale is identical. Mademoiselle R. cannot stand upright. She rests on either one leg or the other. Her left foot is never flat on the ground, but sometimes on the inner border, sometimes on the outer.
The faulty att.i.tude is readily enough corrected, though she declares she is ignorant of it. It is a sort of half clonic, half tonic, tic of the foot, whose slowness is on a par with that of all her other acts.
It is because clonic tics are so easily recognised that they are the most familiar, but we must not ignore another variety--viz. the _tonic tics_, corresponding to the tonic form of convulsion.
Tonic tic is of common occurrence in cases of mental torticollis. In that disease rotation of the head may be sustained for a considerable length of time without interruption, showing the permanent nature of the muscular contraction. Strictly speaking, we are concerned not with a sudden gesture, but with an att.i.tude. Abundant evidence is forthcoming to substantiate its mental origin, and it may therefore be described as an att.i.tude tic. Among other instances of tonic tics may be specified the affection of the ma.s.seters known as mental trismus (Raymond and Janet), or that continuous contraction of the orbicularis which keeps the eye half closed, though it may momentarily disappear under the influence of the will--a tonic blinking tic. O. and young J. have already supplied examples of att.i.tude tics, and reference may further be made to another of our patients[49]:
Sometimes the mouth is drawn directly and completely to the left, more usually to the right; at other times simultaneous contraction of the upper and lower lips takes place, const.i.tuting a sufficiently faithful reproduction of the grimace made by a child in the attempt to refrain from crying; at other times still, imperfect closure of the lids and upward deviation of the eyes bear a resemblance to children's imitation of a blind man. Displacement of the mouth to the right is the movement of longest duration, and while it persists the patient is capable of stuttering speech, without relaxing her lips. The other tics last but a few seconds, while all vanish if she laughs or opens her mouth wide to exhibit her tongue. They follow each other at irregular intervals, and during the moments of rest the face resumes its normal expression.
Cruchet, as has been already remarked, has criticised the use of the term att.i.tude tic, on the ground that the adoption of an att.i.tude, however vicious it be, need not be the outcome of a convulsion.
Doubtless; but it is no less true that a tonic convulsion may ”take shape”--_e.g._ the _arc de cercle_ of hysteria, the phenomena of catatonia and catalepsy, etc. Of course if the word tic is to be synonymous with _intermittent_ twitching, then it is inapplicable in this cla.s.s of case; but if our connotation of the term be accepted, we must find an expression that will serve to differentiate between tonic and clonic varieties. We are not aware of any particular advantage in describing the condition as a permanent contraction, for the obvious result of a permanent contraction, whether it be clenching of the jaws, occlusion of the eyelids, or rotation of the head, is the production of an att.i.tude, a ”position in which the body is kept” (Littre). No other designation could therefore be more appropriate than att.i.tude tic, or could indeed be imagined, seeing that Cruchet himself ranges mental torticollis among the tics, and describes it as ”an att.i.tude of defence and of repose.”
It may sometimes happen that the manifestations of stereotyped acts consist in the a.s.sumption of att.i.tudes, but in spite of their affinity to the tics we deem it preferable to reserve the term ”stereotyped att.i.tude” or ”akinetic stereotyped act” for cases where the motor reaction is clothed in the form of a normal movement. As it is inaccurate to describe as a tic a repeated gesture whose execution is normal in degree and in rapidity, so the mere immobility of a limb, or the prolonged contraction of a muscle, ought not to be called an att.i.tude tic if the muscular effort does not differ from that which a healthy person would make to preserve the same position. In such circ.u.mstances we say that it is a stereotyped gesture or att.i.tude. For the diagnosis of tic it is insufficient to establish the existence of a transient or permanent muscular contraction, and to note the inopportuneness of the movement; the contraction must be abnormal in itself, its abruptness unwonted and its intensity excessive--in short, it must be a convulsion; and finally, its repet.i.tion must be continued and exaggerated.
We have felt that some such explanation as the foregoing is required to justify our use of the term tonic or att.i.tude tic, to whose close intimacy and a.s.sociation with the better-known type pathogeny and clinical observation alike bear witness. In any case such terms as myotonus or myoclonus are too comprehensive, in view of our present-day knowledge, to specify the particular motor affection with which we are concerned.
As a general rule it is only one part or segment of the body that is immobilised by a tonic tic, but in regard to the possibility of a general involvement, the following instance[50] may be cited, although we do not think it can be considered decisive:
A man thirty-two years old, who had recovered from a first attack of mental torticollis, underwent a relapse in quite a different form. If when walking with his head perfectly straight he were asked to go round to the right, he instantly appeared to become rooted to the spot and could not turn even his head in the required direction; at the same time he felt a compression of his throat as if he were being strangled, and for a few seconds he experienced acute anguish. A moment later he was all right again, and his action unimpeded.
Without going so far as to cla.s.sify this incident as a tic, and without venturing to a.s.sert the existence of a _tic of immobility_, one cannot but be struck with its a.n.a.logy to the att.i.tude tics of which we have been speaking, and to catatonic conditions met with in the insane, of which too the pathogeny presents more than one point of similarity with that of this species of tic.
[In this connection reference may be made to certain conditions occasionally noted among those who tic--viz. a curious tendency to maintain abnormal positions of the limbs or trunks, and difficulty in or impossibility of relaxing various muscles (_catatonic apt.i.tudes_).
Patients are sometimes given to the exaggerated repet.i.tion of the ordinary movements of their members (_echokinesis_), as well as to imitation of the actions of others (_echomimia_). Such catatonic and echopraxic phenomena[51] are not confined to sufferers from tic, for they are encountered among psychopathic subjects generally, and indicate defect of cortical control--what is called by Brissaud ”pa.s.sive activity.” These catatonic apt.i.tudes may be discovered by resort to clinical tests, such as letting the arm fall from the horizontal position.[52]]
INTENSITY OF THE MOTOR REACTION
The muscular contraction varies considerably in intensity, in most cases exceeding that of the corresponding normal movement, and, especially in tonic tics, being often so powerful as to necessitate the exertion of great force to overcome it. Even though one's effort prove unavailing, however, it is only needful to distract the patient's attention to perform any and every pa.s.sive movement with consummate ease.
In the case of S., any attempt to budge the head from its torticollic position on the left evokes strong muscular resistance; but engage him in conversation or otherwise divert his mind, and the difficulty soon vanishes. By similar means, the resistance awakened by sudden change of the direction of pa.s.sive rotation will rapidly die down.
Occasionally the muscles brought into play surpa.s.s their fellows of the opposite side in size and power, this secondary hypertrophy being the natural sequel of repeated exercise. It was noted by Charcot that in rotatory tics the disused muscles atrophied, whereas the affected muscles hypertrophied, but they may do so only in appearance. The tonus of the muscles at the moment of examination may create differences inappreciable during relaxation. Sometimes one comes across such expressions as ”paresis” or even ”paralysis” of antagonistic muscles, and ”contracture” of those in which the tic is localised. To draw a distinction between slight contracture of the latter and mild paresis of the former is a problem practically always insoluble. Opinion has been ever divided on this point; yet some, in their desire to harmonise the two, take up an eclectic position and do not hesitate to speak[53] of ”paralytic contracture,” or ”mixed contracture, at once active and pa.s.sive,” a terminology by no means calculated to simplify the question, and one the discussion of which we do not care to pursue.
We should like, however, to allude to a matter of clinical observation that we frequently have had occasion to remark. What simulates muscular enfeeblement in the subject of tic is often nothing else than a want of accuracy and _adresse_ in the performance of a given movement. For instance:
S. enjoys robust health; his only trouble is a lack of accurate control over his limbs. His execution of the most elementary movements is incorrect. There is no tremor, no jerkiness, simply a loss of the sense of position. He never knows whether he is holding himself straight, whether his arms are exactly horizontal or his shoulders symmetrical. Often he confuses right and left, and when requested to perform some act on one side, he declares he is tempted to perform it simultaneously on both. The order to fold his arms and rotate the upper part of his body to the right evokes an inconceivable display of contortions. In the attempt to bend his head and body backward, fear of losing his balance causes him to twist and turn about most strangely, and the remark that all this he might avoid by merely putting one foot further back seems to cause him infinite surprise.
Or again:
The absence of precision in Mademoiselle R.'s movements, her habit of arresting the action before attaining the desired end, are not to be ascribed to any feeling of discomfort, but to her ignorance of the amplitude of her efforts, and of the position of her limbs.