Part 9 (1/2)
Consciousness is maintained in its integrity both before and after, but not during, an obsessional attack, and this is equally true of tic, as are the preliminary discomfort and subsequent satisfaction that attend the obsession. Noir makes the appropriate remark that idiots affected with krouomania, in whom sensory disturbance is awanting, so far from suffering pain through sundry self-inflicted blows and mutilations, seem, on the contrary, to be thus afforded a certain feeling of relief, if not of actual relish.
Whenever Lam., who exhibits incessant balancing and rotatory movements of the head, is seated in proximity to a wall, he knocks his head sideways against it until a bruise results, and appears to find therein a source of genuine satisfaction.[24]
If, then, an obsession provokes a motor reaction at all, it may originate a tic, and, in the case of tonic tics, this is a very common mode of derivation, as one may well understand how an obsession may occasion an att.i.tude.
Gra.s.set cites the example of a young girl who would never lean backwards in a railway carriage or on any chair or bench, preferring to sit bolt upright on the edge. In this instance the adoption of a stereotyped att.i.tude was directly attributable to an obsession.
Another example of an att.i.tude tic is furnished by the case of young J.:
Standing or seated, he always has his half-flexed left arm firmly pressed against the body in the position a.s.sumed by hemiplegics.
Its pose and inertia and the awkwardness of its movements unite to suggest some real affection, the existence of which the constant use of the right arm and the elaboration by the patient of intricate devices to obviate disturbing the other tend to substantiate. Nevertheless, the impotence is entirely imaginary. To order he can execute any movement of the left arm with energy and accuracy; his left hand will b.u.t.ton or unb.u.t.ton his clothes, lace his boot, handle a knife, and even hold a pen and write.
It seems that the position of the arm was chosen deliberately to alleviate a supposed pain in the shoulder, and unceasing resort to this subterfuge of his own inventing, which he considered a sovereign remedy, ended in its voluntary adoption being succeeded by its automatic reproduction.
The a.s.sumption of this position for his arm was at first attended with satisfactory results, but, as might have been foreseen, its inhibitory value decreased gradually, so he had recourse to other means. It was then that the right hand was made to grip the left and press it more energetically than ever against the epigastrium.
In this complex att.i.tude both arms simultaneously partic.i.p.ated, but again its efficacy was purely transitory. Evidently dissatisfied with his methods of immobilisation, and convinced that experimentation would end in the discovery of the desired arrangement, J. proceeded to employ the right hand in impressing every variety of pa.s.sive movement on the left hand, wrist, forearm, and upper arm, and soon there was no checking these gymnastic exercises. He would suddenly grasp the wrist and pull and screw it, while the left shoulder and elbow resisted n.o.bly; or he would bend, or unbend, or twist his fingers, or seize the arm below the axilla and knead it or rub it, forcing it against or away from the thorax; he would pound the muscles and pinch the tendons, sometimes in a brutal fas.h.i.+on; in short, the situation degenerated into nothing more nor less than a pitched battle between the left arm and the right hand, in which the latter endeavoured by a thousand tricks to bring the former into subjection. Victory rested always with the affected arm.
Each time that this absurd combat recommenced, the patient experienced a sensation of relief; resignation to the imperious motor obsession was even followed by a sense of well-being. On the other hand, resistance was accompanied by actual anguish--he would fidget desperately in his chair, cross and uncross his legs, sigh, grimace, rub his eyes, bite his lips and nails, twist his mouth about, pull at his hair or his moustache, he would look anxious or alarmed, would become by turns red or pale, and beads of perspiration would gather on his face. At length he would be compelled to yield, and the bloodless battle of his upper limbs would close more furiously than ever.
In this case the typical features of obsession are excellently ill.u.s.trated--its irresistibility, as well as the concomitant distress and succeeding content.
Conversely, however, a tic may be said to develop into an obsession if the exciting cause of the latter be the motor reaction.
In various psychopathic conditions (says Dupre[25]), especially where the genito-urinary apparatus is concerned, this pathogenic mechanism is encountered. Some source of peripheral irritation in bladder, urethra, prostate, etc., provokes cortical reaction, and a reflex arc is established with centrifugal manifestations in the guise of motor phenomena, which in their turn originate all sorts of fixed ideas, impulsions, and obsessions, forming an integral part of the syndrome.
There is frequently no direct or obvious connection between a patient's obsession or obsessions and his tics. The former may consist, both in children and in adults, in extraordinary scrupulousness, perpetual fear of doing wrong, absolute lack of self-confidence, sometimes simply in excessive timidity, exaggerated daintiness, or interminable hesitation.
We have often seen youthful subjects betray in their disposition weak elements such as the above, which at a later stage have proved the starting-point for more definite obsessions. Their intelligence and capacity for work earn the approbation of their teacher, yet they are for ever dissatisfied, haunted by the dread of having overlooked some iota in their task; they dare not affirm that they know their lessons, they stammer over their answers, mistrust their memory, make no promises and take no pledges, and thus bear witness to an absence of confidence in themselves which affects them profoundly, for they are well enough aware of its consequences.
An admirable instance of this is furnished by the case of young F., or by little G., ten years old, who suffers from a facial tic, and constantly hesitates when asked to give a measurement, an hour, a date, a figure, solely by reason of a conscientious fear of not being absolutely accurate in his reply.
In children the emotional excitement of their first Communion often favours the development of religious scruples. By a sort of metastasis, diminution of the convulsive movements goes _pari pa.s.su_ with aggravation of the mental phenomena, until such a time as the devotional exercises are done with, when there is a return to the previous state.
Arithmomania betokens an a.n.a.logous turn of mind. Certain patients are compelled to count up to some number before performing any act. One cannot rise from his seat without counting one, two, three, four, five, seven, leaving out six since it is disagreeable to him. Another must repeat the same movement two, three, ten times, must turn the door-handle ten times ere opening it, must take five steps in a circle before beginning to walk (Guinon). A patient of Charcot's used insanely to count one, two, three, four, used to look under his bed three or four times, and could not lie down until a.s.sured that his door was bolted. A further example is reported by Dubois:
A young woman twenty years of age first began to suffer from convulsive tics five years ago. Without any warning she used to bend down as if with the intention of picking up something, but she had to touch the ground with the back of her hand, else the performance was repeated. Twenty or thirty times a day this act was gone through; in the intervals she kept turning her head to the right, looking up at the curtains in a corner of the window, and at the same time making a low clucking sound that attracted the attention of those in the room. For nine or ten years these two tics have prevailed, and have been accompanied with certain obsessions, such as the impulse to count up to three, to regard any person or object three times, etc. With the generalisation of the convulsive movements various phobias have made their appearance--viz. fear of horned animals, of earthworms, of cats, of blight, etc.
Onomatomania is another form of obsession which may be mentioned, exemplified by the dread of uttering some forbidden word, or by the impulse to intercalate some other. The term _folie du pourquoi_ has been applied to the irresistible habit of some to unearth an explanation for the most commonplace of facts: ”Why has this coat six b.u.t.tons?” ”Why is so-and-so blonde?” ”Why is Paris on the Seine?” etc. This mode of obsession is frequent among those who tic, and is curiously reminiscent of a familiar trait in the character of children, thereby supporting our contention of the mental infantilism of all affected with tics.
Prominent among the mental anomalies of the subjects of tic are found different sorts of phobia: fear of death or of sickness, of water, knives, firearms--topophobia, agoraphobia, claustrophobia, etc.
The following most instructive case has been observed by one of us over a period of several months:
S.'s earliest attack of torticollis, of two or three days' duration merely, occurred when he was fifteen years old, and was attributed by his mother--whose mental peculiarities, in especial her fear of draughts, are no less salient than those of her son--to a chill occasioned by a flake of snow falling on his neck. S. is so blindly submissive that he accepts this pathogeny without reserve. Five years ago a second torticollis supervened, which still persists to-day, and of which his explanation is that he was obliged, when standing at a desk, to turn his head constantly to the left for two hours at a time in order to see the figures that he had to copy, and was forced, after the elapse of some months, to relinquish his work owing to pain in the occipital region and neck. From that moment dates the rotation of his head to the left.
At the present time his head is turned to the left to the maximum extent, the h.o.m.olateral shoulder is elevated somewhat, and the trunk itself inclines a little in the same direction. The permanent nature of this att.i.tude necessitates his rotating through a quarter of a circle on his own axis if he wishes to look to the right. On the latter side the sternomastoid stands out very prominently, and effectually prevents his bringing the head round; nevertheless he is greatly apprehensive of this happening, and as he walks along a pavement with houses on his right he keeps edging away from them, since he is afraid of knocking himself against them. By a curious inversion, common enough in this cla.s.s of phobia, he feels himself impelled to approach, with the result that he cannons against the wall on his right as he proceeds.
Contrary to the habit some patients with mental torticollis have of endeavouring to ameliorate the vicious position by the aid of high starched collars, S. has progressively reduced the height of his until he has finished by discarding them altogether. As a matter of fact, it is the ”swelling” in the neck caused by the right sternomastoid that is at the root of his nervousness, for he is convinced that it preceded the onset of the torticollis, and he has a mortal dread of aggravating it by compression.
Hence one may perhaps understand what line of erroneous reasoning has led to the establishment of the wryneck. The fear of draughts, instilled in his youthful mind by his mother, had the effect of driving him to half-strangle himself with a tightly drawn neckerchief, to hinder the inlet of air and minimise the risk of catching cold, and when he commenced to turn his head to the left at his work, the pressure of the band round his neck was felt most of all on the contracted right sternomastoid. A glance at a mirror convinced him that the unusual sensation was due to an abnormal muscular ”swelling,” whereat he was vastly alarmed; he hastened to change his collar, but all to no purpose. By dint of feverish examination and palpation of the muscle, he soon acquired the habit of contracting it in season and out of season, till at length an unmistakable mental torticollis supervened.