Part 19 (1/2)

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.