Part 26 (1/2)

Whatever be the variety of tic, the remarks we have made, based as they are on clinical observation, are applicable to it. In particular, they have a direct bearing on Cruchet's psycho-mental tic. To quote that author again:

Hysteria and neurasthenia are two diseases which we meet at every turn in our study; and if we remember that, according to Raymond, fibrillary ch.o.r.ea of Morvan, paramyoclonus multiplex of Friedreich, electric ch.o.r.ea of Henoch-Bergeron, painless facial tic of Trousseau, and disease of Gilles de la Tourette-Charcot, are all mere varieties of myoclonus, which is itself a product of neurasthenia and hysteria, we are forced to admit that it is these conditions which dominate our conception of psycho-mental convulsive tic.

Thus it comes to pa.s.s that tic is lost in a crowd of widely differing convulsive phenomena, and is threatened with the permanent loss of its distinctive characters, while hysteria itself is like to become a perfect Proteus once more. Neurasthenia too is again to sink to the level of a receptacle for all manner of ill differentiated conditions.

We, on the contrary, feel it more than ever inc.u.mbent on us to resist the tendency to cla.s.s in the same section facts which clinical observation distinguishes, otherwise hysteria and neurasthenia will soon signify nothing at all. If tic is to be considered one of the polymorphic manifestations of these diseases, we shall be transported back fifty years, to the time of the famous ”chaos of neuroses,” out of which, in some ways at least, Charcot finally produced order.

TIC AND EPILEPSY

The co-existence of epilepsy and tic has been noted sufficiently often to open the question of their possible relations.h.i.+p. Of course the mental state of epileptics is such as to favour the development of tics.

Usually, however, the convulsive phenomena supposed to be of the nature of tic merit some other description.

In the first place, they may be Jacksonian in type, and under these circ.u.mstances confusion is scarcely possible. It is not without interest to compare the gestures and stratagems of defence which sufferers from tic devise, with the procedures adopted by some Jacksonian patients, such as compression of the arm or wrist by the fingers, or by string or more elaborate apparatus. There might conceivably be some hesitation in making a diagnosis if it depended on these arrangements, but the mere observation of one actual attack will dispel all difficulties.

We may mention the convulsive seizures of idiopathic epilepsy only to dismiss them. Loss of consciousness is an unfailing criterion.

It is more especially the a.s.sociation of epilepsy with the ill-defined group of myoclonus that we propose to discuss.

According to Maurice Dide,[160] myoclonus, which he calls motor pet.i.t mal, occurs in five per cent. of cases of epilepsy. Attention has also been directed to this question by Mannini[161]:

After an attack of epilepsy the convulsive twitches are at a minimum, but during the next few days the myoclonus, or rather the polyclonus, becomes increasingly intense and varied, until it reaches a maximum, which is crowned by a second epileptic fit. The spasmodic contractions begin in the face and invade the rest of the musculature; they recur in the form of seizures at diminis.h.i.+ng intervals, leading to the epileptic attack, when the muscles pa.s.s into permanent contraction.

Sometimes the myoclonus takes the shape of fibrillary spasm, sometimes the whole of a muscle is involved; the twitches may be rhythmical and symmetrical, or arhythmical and asymmetrical, so much so that at a given moment the patient may present the clinical picture of convulsive facial tic, or paramyoclonus multiplex, of Gilles de la Tourette's disease, or electric ch.o.r.ea.

Mannini's view is that the varying convulsions known as myoclonus or polyclonus are akin to epilepsy, and are the outcome of the same cortical lesion, the nature of which has not as yet been fathomed--a lesion whose expression is hyperexcitability of the cells of the rolandic area. a.n.a.logous conclusions may be drawn from a case of epilepsy and myoclonus, with autopsy, reported by Rossi and Gonzales,[162] where a general ischaemic degeneration of the central nervous system was found, the greatest changes being discovered in the rolandic zones of each side, as well as in the extremities of the three frontal convolutions. Schupfer[163] has recorded cases of family myoclonus with epileptiform attacks.

We are content to note the facts. Any conclusion applicable to the tics is premature.

Various observers have drawn attention to the development of tics in persons formerly subject to epilepsy. Malm[164] has described a case of rotatory tic in a man who has been a known epileptic for ten years.

According to Fere,[165] epilepsy may supervene in patients who at one time suffered from tic. As an example, he quotes a case of tic localised in the left ear and dating from infancy; the patient had reached his thirty-fifth year when the recrudescence of the tic ushered in the first attack of epilepsy, which consisted of elevatory movements of the left ear and convulsions of the left half of the face, pa.s.sing thence to the right arm and the left leg, and becoming generalised. The fact that the twitches of the left ear could not be imitated voluntarily suggested that the original ”tic” may have been the result of some minute cortical irritation, the increase of which became eventually the determining cause of a Jacksonian attack.

Another case due to the same author concerns a woman of fifty-four years, subject from her youth to fixed ideas.

For the last four years she has had seizures which may be attributed to her idea that she must see the whole of the objects on her left. Under the impulse of this idea, she turns her eyes upwards and to the left, rotates her head in the same direction, and her body too, if she happens to be on her feet. The performance is gone through fifteen or twenty times a day.

In addition, she suffers from epileptiform attacks, which commence by this deviation of head and eyes to the left, and spread to the arms and to the left leg, leading to loss of consciousness as they become generalised. The patient finally succ.u.mbed to an apoplectic stroke followed by left hemiplegia.

In this instance the connection between the fixed idea and the patient's gesture favours the diagnosis of tic, but the subsequent history of the case makes one consider it with reserve. All such cases ought to be followed up carefully, and we may modify Fere's conclusions somewhat to declare that the appearance of a convulsive movement in an adult, or the aggravation of a similar movement of ancient date, should lead one to suspect epilepsy and to look for signs of it: ”The patient runs more chance than risk in being treated as an epileptic.”

We have had the opportunity of observing, in one of our mental torticollis cases, a condition not unlike what is known as _absence epileptique_. The term ”incantation” was applied by the parent to his daughter's habit.

On two occasions we noticed the patient's eyes turn upward and remain fixed for a moment or two, while her expression changed to one of tranquillity and unconcern--a sign of distraction, not of ecstasy. She merely appeared to be thinking of something other than the immediate topic of conversation, and after two or three seconds resumed her ordinary ways.

These brief ”absences” are trifling enough, of course, but their painstaking study is of inestimable aid in the matter of diagnosis.

They began at the age of seven or eight, and at first occurred as often as sixty times in a day. What the patient did was to raise her head, and turn up the whites of her eyes; in a second or two her countenance had resumed its ordinary expression. From their onset, the ”incantations”--to use her father's term--gradually increased in frequency and length, and attained a sort of maximum when she was eleven years old, slowly diminis.h.i.+ng thereafter till at present they have become rather exceptional. They proved to be a source of great tribulation to L., seeing that she was exposed to the practical jokes of her companions, who used to seize the occasion to relieve her of any books or toys she had in her hand.

During the ”absence” there is no change of colour, nor has there ever been any vertigo or sense of rotation. She has never actually fallen, though she has allowed things to drop out of her hands.

Once it is over, she is aware of it, but her memory of what has just taken place is very vague, though she usually can tell what preceded it. She can be aroused from the ”incantation,” to sink back into it an instant later, as though she had not dreamed enough. Sometimes a series of ”incantations” occurs, one following on the heels of another. Occasionally she utters such words as ”yes, yes!” or ”no, no!” in an impatient tone of voice, and plucks at her hair or clothes, or toys with the handkerchief which is never out of her hands.