Tics and Their Treatment. Feindel Eugène

From the ranks of these spoiled children is recruited the company of those who tic, for tics, generally speaking, are nothing more than bad habits, which, in the absence of all restraining influence, negligence and weakness on the side of the parents have allowed to degenerate into veritable infirmities. These the patients themselves are incapable of inhibiting, for whatever be their age, they remain "big children," badly bred and capricious, and ignorant of any self-control. Hence one of the first indications in their treatment is to submit them to a firm psychical discipline, calculated specially to strengthen their hold over their voluntary acts. Take the following case:

      J. is nineteen years old, intelligent, educated, ready to graduate were it not for the interruptions his studies have undergone, and to all appearance arrived at manhood's estate. None the less he presents to-day the mental condition of nine years ago: he is fickle, pusillanimous, naïve, emotional; he laughs at trifles and is provoked to tears at the first harsh word; his nature is restless, his mind inconsequential; he is by turns elated or depressed for the most trivial of reasons. Notwithstanding his seventy-one inches, he must still be fed, dressed, and put to bed by his mother!

      An identical mental state obtains in infantilism, properly so called, where to arrest of mental development physical imperfection is superadded. In cases of infantilism the psychical level corresponds more or less intimately to the somatic level, an observation borne out in the case of J.:

      From the morphological point of view he shows one or two stigmata of infantilism: his great height need not be held to disprove this, for gigantism and retardation of sexual development are often in association. In spite of his nineteen years, J. has still a eunuch's voice and a minimum of axillary and pubic hair – in fact, one might say that physically he is thirteen years old, and mentally ten.

      Or take Mademoiselle R., aged twenty-six:

      Her intellectual attainments are those of a child of twelve, her age when her first tics made their appearance. Her artlessness and timidity are simply childish, and at the same time she lacks womanly charm and feminine ways.

      Or again:

      Young thirteen-year-old M. has been afflicted with tics of face, head, and shoulders for the last three years. Though small, he is well enough built, and has no obvious physical anomaly except an odd admixture of blonde and brown in his hair and eyebrows. His teeth are bad and misplaced, and several of the first dentition persist. There is no sign of pubic or axillary growth. As a general rule he is mild-mannered and docile; sometimes, however, he is irritable, impatient, emotional beyond his years. His degree of intelligence is very fair, but idleness and inconstancy are prominent traits in his character. The ease with which he apprehends is counterbalanced by the readiness with which he forgets, while his reason and judgment are those of a child of seven. The discordance between his actual age and his mental standard is therefore striking enough.

      Another of our patients is L.:

      Her intellect is quite up to the average, but the exaggerated importance attached by her parents to her "nervous movements" has only served to intensify her whims. Her eighteen years do not prevent her from revealing signs of mental infantilism in every action of her daily life, but, thanks to suitable treatment, she has been astonishing her father by unheard-of audacities – has she not recently ventured to cross the street alone, and alone to go an errand to a neighbouring shop?

      X. has a tic of the eyes and has reached the age of forty-eight, yet he told us he was not so much his children's father as their playmate. At the age of fifty-four O. could still remark on his youthfulness of character. The same is true of S., who has attained his thirty-eighth year.

      It is as arduous a task to define the term "stability of the will," as it is to explain what is meant by physical or mental health. But as it is not essential to preface descriptions of disease with a disquisition on the signs of good health, so anomalies of voluntary activity may surely be noted without a preliminary excursus on normal volition.

      Will power may deviate from the normal in either of two directions – in the direction of excess or of insufficiency. To both of these two forms of volitional disturbance the subjects of tic have become slaves. Weakness of will is seen in irresoluteness of mind, flight of ideas, want of perseverance; exuberance of will in sudden vagary or imperious caprice. The man who tics has both the debility and the impulsiveness of the child; to his impatience his incapacity for sustained effort acts as a set-off; he is impressionable, wavering, thoughtless, even as he is mettlesome and irascible. He does not know how to will; he wills too much or too little, too quickly, too restrictedly.

      As a single example of volitional activity, let us take the attention. Diminution of attention on the part of tic patients has been judiciously commented on by Guinon:

      It is impossible for them to address themselves to any subject: they skip unceasingly from one idea to another, and apply themselves with zest to some occupation only to forget it immediately. No further proof of this need be sought than the inability of the patient, if he be at all severely affected, to read, a proceeding at once intellectual and mechanical, and absolutely familiar to most. Read the patient cannot, and though the attempt to concentrate the attention diminishes or inhibits the tic at once, there is no sequence in his effort; his eye jumps erratically from one line to another, and his many unavailing trials end in his throwing the book away.

      Excess of voluntary activity is disclosed in the whole series of impulsions.

      The germ of homicidal or suicidal tendencies, which we have indicated in the case of O., is discoverable also in one of Charcot's patients.23

      M. Charcot (to the patient) – Tell us what you said the other day about razors.

       The Patient– Whenever I see a razor or a knife, I begin to thrill and feel afraid. I imagine I am going to kill some one, or that some one is going to kill me. I have the same sensation when I see a gun, or even if the notion of a gun comes to my mind. The mere thought of it agonises me. The fancy of murdering some one strikes me, and up to a certain point I am envious of fulfilling the desire. Often I am conscious of an irresistible longing to fight somebody, and I am frequently impelled to it by the sight of a cabman. Why a cabman more than any one else, I have not the remotest idea.

      We have already touched on the close affinity between an act and the idea of the act, and we have emphasised the absence of any appreciable interval between the idea and its execution, unless the brake of volitional interference be put on at the proper moment. It is in these circumstances that the feeble of will betray their debility; the inadequateness or inopportuneness of their will's activity allows the performance of the act they would fain repress.

      A no less characteristic feature of the subject of tic is his impatience.

      J. bolts his food without waiting to masticate it, and the instant his plate is empty jumps up from the table to walk about the house. He returns for the next course, which he swallows as precipitately; delay makes him impatient, and all are forced to rush as he does. Meal time for the whole family has become a perfect punishment. Alarmed enough already at his tics, the parents are terror-stricken by the tyrannical caprices of this big baby, who outvies the worst of spoilt children in his behaviour.

      Mental instability is not uncommonly associated with a general restlessness and fidgetiness during intervals of respite from the actual tics. The patient experiences a singular difficulty in maintaining repose. Every minute he is moving his finger, his foot, his arm, his head. He passes his hand over his forehead, runs his fingers through his hair, rubs his eyes or his lips, ruffles his clothes, plays with his handkerchief or with anything within reach, crosses and uncrosses his legs, etc. None of these gestures can properly be considered a tic, for, however frequent be its repetition, it is neither inevitable nor invariable. If they are superfluous and out of place, the absence of exaggeration or absurdity negatives their classification as choreic. They are a sign not so much of motor hyperactivity as of volitional inactivity. They are tics in embryo.

      The patient's emotions are similarly ill balanced. Any rearrangement in his habits he finds disconcerting; he is upset by an unexpected word, a deed, a look; his timidity and sensitiveness are extreme – fertile soil for the development of tics.

      So, too, with his affections, his likes

23

CHARCOT, Leçons du mardi, October 23, 1889.