Part 25 (1/2)

Following in the train of the tics may come a number of complications, insignificant enough as a general rule, the dread of which may in some cases actually be instrumental in stimulating the will's activity to rid the patient of his tic.

Dislocations have in violent cases been known to occur. Incessant repet.i.tion of a tic may lead alike to hypertrophy of certain muscles and atrophy of their antagonists, conditions which in aggravated instances may produce permanent malformation.

It is of course in cases of spasm and other convulsive phenomena dependent on structural disease of nerve centres or conductors that such trophic disturbances are most liable to occur. Gaupp[152] has described a case of partial congenital myotonia localised in the muscles of the forearm and hand, and a.s.sociated with atrophy, in a patient presenting certain stigmata of infantilism; but the condition can scarcely be cla.s.sed with the tics.

As for actual paralysis supervening on a tic, the case recorded by Gra.s.set[153] of a young girl in whom a tic of the right leg was succeeded by a trailing movement of the same limb in walking can hardly be considered conclusive, inasmuch as such incidents usually indicate hysteria or functional disturbances akin to tonic tics.

Biting tics are more apt to be accompanied by various sequelae, such as mutilations, excoriations, ulcerations of all sorts. By constant nibbling at his lip J. produced an erosion of the mucous membrane, which became infected and developed into an ulcerative stomat.i.tis. The accident, however, had a salutary effect on his tic.

We may quote another ill.u.s.tration from the history of the same patient to show how complications may sometimes be of curative value.

In January, 1901, in consequence of excessive cudgelling of one fist by the other, the back of the left wrist became inflamed and painful, but the bruise soon disappeared. In April of the same year, however, a large reddish ecchymosis made its appearance in the neighbourhood of the left elbow, with a painful swelling of the whole arm on the proximal side, and a few days later the discovery of a hard, cordlike ma.s.s along the border of the biceps made it clear that phlebitis had set in. With proper treatment the symptoms gradually diminished in intensity, but there can be no doubt of their origin in the reiterated violence of J.'s onslaught on his left arm.

The immediate outcome of the event was to put a brake on his exuberant gestures, and although the impulse was still sometimes urgent enough to tempt him to recommence, the thought of his phlebitis and fear of the dangers of a relapse were sufficient to recall him to his senses.

Apropos of complications the case of O. occurs to the mind, his biting tics ending in the premature loss of all his teeth, while his habit of rubbing his nose and his chin against the back of a chair led to the development of callosities. Tonic tics of the neck may in cases of long duration result in permanent deformities.

Apart from such complications, the vast majority of the accidents that accompany tics are attributable to various concurrent affections. A case reported by Fere[154] of rotatory movements of the head pa.s.sing some years later into the initial symptom of epileptiform convulsions ought not, in all probability, to be placed among the tics.

As for the grave mental affections that sometimes are superadded to long-standing tics, it is unjustifiable to cla.s.s them as complications; they are rather manifestations of psychical instability that have found a suitable medium for their evolution; in many instances they occur quite independently of the tics.

It may, however, be remarked that the persistence of a tic entails ceaseless preoccupation on the part of the subject, and may thus pave the way for obsessions or hypochondriacal ideas. The motor disturbance reacts adversely on the mental state of which it is the outcome. Hence an obsession may give rise to a motor display that has all the appearance of a tic, while the motor act in its turn may become an actual obsession.

CHAPTER XIV

THE RELATION OF TICS TO OTHER PATHOLOGICAL CONDITIONS

A vast number of disturbances of motility, distinguished as spasm, ch.o.r.ea, cramp, myoclonus, myotonia, etc., may be derived from the same pathological substratum as tic, and an equally vast number of psychical anomalies may spring from that psychopathic diathesis of which tic is merely the motor expression.

The frequency of these a.s.sociations is confirmed by innumerable clinical observations, many instances of which have been given already.

That the relations between tic and other diseases of the nervous system are very intimate is patent from every-day experience; such and such a tic may be succeeded, in the same individual, by a much graver condition in the shape of mental disease, general paralysis, tabes dorsalis, etc.

Inversely, some cases of ch.o.r.ea seem to terminate by leaving no trace of their occurrence beyond some little convulsive movement or tic. The position tic occupies is, then, a peculiarly interesting one, for it may be the starting-point of another affection, it may be an intercurrent phenomenon, or it may persist as the reminder of some previous disease.

For this reason it well merits attentive study.

In this chapter we shall examine the connections of tic with hysteria, neurasthenia, epilepsy, mental disease, and idiocy respectively.

TICS AND HYSTERIA

Our response to the question whether tics are hysterical in origin is a direct negative. Without attaching pathognomonic significance to stigmata, we may remark how seldom they are encountered among those who suffer from tic, and how rarely the latter exhibit any of the paroxysmal manifestations of hysteria.

Modifications of general sensibility such as anaesthesia or hyperaesthesia are unknown; the special senses are intact; in particular, contraction of the visual fields is never met with. Though these signs are negative, their importance from the point of view of diagnosis is none the less real.

The mental condition of patients with tic is no doubt a.n.a.logous to that of hysterical cases, but it is no less common in many others that present no sign of that neurosis. There is little or nothing in tic characteristic of hysteria, and one sometimes questions whether the _soi-disant_ hysteria of certain subjects of tic is the real disease.

In the same way as all who are predisposed, the sufferer from hysteria may develop a tic or tics, and although tic was held by Briquet, Axenfeld, Bouchut, and others, to be merely an accessory symptom of hysteria and _nervosism_, these doctrines were propounded prior to the a.n.a.lytic researches of Charcot.