Part 28 (1/2)

Conditions such as these present the most intimate a.n.a.logies to our att.i.tude tics, though in the case of the latter there is always a more or less p.r.o.nounced exaggeration of muscular contraction, a certain degree of tonic convulsion.

Parakinetic stereotyped acts are of common occurrence, and embrace every variety of movement or gesture.

A former acrobat leaps staircases, climbs railings, exercises his arms rhythmically and regularly, etc.

A patient promenades untiringly in the same corner and at the same pace.

An old engraver, now a dement, pa.s.ses the day in reproducing in a more or less modified form certain actions a.s.sociated with his former profession.

Alike in tics and in stereotyped acts, a time comes when the motor habit establishes itself, for no apparent reason or purpose; hence the co-existence of the two cla.s.ses in chronic delusional insanity, in dementia prec.o.x, in catatonic states, in systematised mental disease of other forms, and in general paralysis.

Stereotyped acts may be the embodiment of ideas of persecution and of grandeur, or the outcome of mystical, hypochondriacal, and other states.

A patient with delusions of persecution writhes because he is being ”electrified.” A hypochondriac rests motionless because he believes himself made of gla.s.s. A mystic maintains an att.i.tude of genuflexion for hours at a time.

Obsessions also play a part in the genesis of the acts we have under consideration, but of all delusional ideas those of defence are the most fertile in this respect.

A patient under the care of A. Marie used to carry a fragment of gla.s.s between his teeth and other pieces beneath the soles of his feet, the idea being that they formed insulating cus.h.i.+ons whereby to protect himself from the electricity of his enemies.

The suggestion was thrown out by Bresler that the movements of tic are often of a defensive character--that the disease, in fact, is a sort of ”defence neurosis” linked to hyperexcitability of psych.o.m.otor centres.

This theory is not unlike the view of hysteria taken by Brener and Freud, and as the movements themselves are usually of the nature of mimicry, Bresler has proposed the term _mimische Krampfneurose_.

In some cases of mental torticollis, the att.i.tude a.s.sumed may be considered as a stereotyped act. Martin has recorded an example of torticollis in relation to melancholia. Another of his patients suffered from rotation of the head to the left, a position which could easily be rectified by asking the man to make the sign of the cross. The moment he put his finger on his forehead the displacement of the head was corrected. If, however, he were requested to look straight in front of him, he remained incapable of altering the vicious att.i.tude, the reason he advanced being that he could no longer see the sun.

One cannot but be struck with the remarkable a.n.a.logies to the cases given by Cohen. And it is worth remembering further, that sometimes mental torticollis degenerates into actual dementia.

TICS AND SPASMS

Nothing is more arduous, at first sight, than the differentiation of a tic from a spasm, the similarity of their external forms being a fertile source of confusion. Yet the establishment of a correct diagnosis is of prime importance, since in their case prognosis and treatment alike are diametrically opposed.

Tic is a psychical affection capable of being cured, if one can will to cure it: at the worst we may fail, but there is no idea that it is indicative of a grave organic lesion prejudicial to life. A spasm, on the contrary, though it appear in almost identical garb, is excited by a material lesion on which depends the degree of its gravity. The focus of disease may disappear, no doubt, but it is only too likely to persist and to occasion other disorders. Hence the desirability of making sure of one's diagnosis--a proceeding not necessarily of insuperable difficulty. If we apply the principles of diagnosis enunciated by Brissaud, to which our attention has already been directed, we shall not find the task beyond our powers.

Let us take a concrete instance.

Here is a cabman, forty-nine years of age, the left half of whose face is the seat of convulsive twitches. These commenced eighteen months ago by brief insignificant contractions of the left orbicularis palpebrarum, which have gradually spread to the whole of the muscular domain supplied by the left facial nerve. Their momentariness and rapidity, their apparent independence of extraneous stimuli, their indifference to treatment and resemblance to the twitches produced by electrical excitation, their occurrence in sleep, the fact of voluntary effort, of attention or distraction, serving so little to modify their range and intensity--all make clear the spasmodic nature of the condition.

The motor manifestation is the consequence of irritation at some point on a bulbo-spinal reflex arc; its abruptness and instantaneousness negative the possibility of recognising in it any sign of functional systematisation. It is not a co-ordinated act of a purposive nature, but a simple, unvarying, constant motor reaction to a particular stimulus. That its intensity should be in direct proportion to the intensity of the latter, changing from feeble contractions to a state of transient teta.n.u.s, is further proof of its spasmodic origin. When the excitation is at its maximum, there is sometimes involvement of the opposite side of the face, by virtue of the law of the generalisation of reflexes.

It is true there is no a.s.sociation of pain with his attacks, as in so-called tic douloureux, but the spasm is heralded by a tingling sensation below and to the inner side of the outer corner of the eye. This sensation, ”like an electric battery,” persists during the spasm and disappears in the intervals. Its occurrence suggests that the ascending branch of the infraorbital nerve, springing from the trigeminal, is affected, and indeed pressure over its point of emergence evokes a certain amount of pain. Moreover, there is occasionally a flow of tears when the spasm is at its height. It may be difficult to decide whether this is the result of mechanical compression of the lachrymal gland or an exaggerated secretion of tears under the influence of stimulation of the lachrymo-palpebral twig of the orbital nerve. In any case the pathogeny of this facial spasm is entirely comparable to that of tic douloureux of the face, and it is quite within the bounds of possibility that a minute haemorrhage--for the patient is of a very florid type--somewhere on the centrifugal path of the trigemino-facial reflex arc, may be giving rise to the phenomena.

What we wish to insist on, however, is the dissimilarity between this facial spasm and tic. In the movements we have been describing we fail to distinguish any purposive element, any co-ordination for the fulfilment of a particular function: they are not imitative in character, nor do they express any sentiment; no impulse precedes their execution, no satisfaction follows.

The patient's mental state presents no peculiarities, as far as we have been able to discover. There is no volitional debility or instability; if he cannot control the convulsions, it is to be remarked that he cannot control them even for a moment, whereas all sufferers from tic are capable of inhibiting it for a longer or shorter period by an effort of the will, by concentrating their attention on it.[169]

The following remarks on this case are due to Professor Joffroy:

If the patient be asked to open his mouth, the spasm of the left cheek remains in abeyance at long as it is open, but the platysma of the same side then begins to twitch spasmodically. Or if he be requested to shut his eyes, so long as they continue closed the cheek is quiescent; but, on the other hand, both orbiculares palpebrarum, as well as the pyramidal muscles and the adjacent fibres of the frontalis, are seen to contract irregularly. There is a sort of transference of spasm, and this is of peculiar interest, inasmuch at it affords evidence that the lesion is not so restricted as one might suppose.

The explanation no doubt is to be sought in the law of the diffusion of reflexes, confirming the diagnosis of an irritative lesion at some point on the trigemino-facial reflex arc.