Part 24 (1/2)

Notwithstanding its slow evolution (says Brissaud), the neurosis, in so far as it was a disorder of motility, seems to have completely disappeared. The importance of this for prognosis is fundamental, but from the point of view of diagnosis it is no less significant, seeing that the nature and form of the movements suggested chronic or Huntington's ch.o.r.ea.

A case described by Gilles de la Tourette[139] as disease of the tics seems really to have been one of variable ch.o.r.ea.

A woman of twenty-two, who had never been very strong, had an attack, at eight years, of involuntary movements of face and arms which prevented her feeding herself, and at the hospital a diagnosis of ch.o.r.ea was made. Two months later cessation of the movements allowed of her return to school, but a second attack followed after two years, and a third a year later. At the time of observation she was in the throes of her sixth relapse. Every one who had seen her considered the condition as ch.o.r.ea.

Tourette, however, was dissatisfied with the diagnosis. There was no suggestion of its being Sydenham's ch.o.r.ea, or hysterical ch.o.r.ea, still less of its belonging to Huntington's variety. According to the author, the muscular twitches were amorphous and indefinite, and characterised by extreme variability in form, expression, and intensity.

In our opinion the clinical picture is that of variable ch.o.r.ea, and we are confirmed in our opinion by a consideration of the patient's mental condition.

She comes of a p.r.o.nounced neuropathic stock. One of her two sisters is nervous and impressionable, and probably a neurasthenic, while the other is subject to hysterical attacks. She herself is of a profoundly nervous temperament; she cannot go to bed without a.s.suring herself several times that no one is concealed beneath it; she suffers from fears and dreads and obsessions of all sorts; she is, in fact, an ”unstable,” a degenerate.

In one of our patients the symptoms were unilateral, const.i.tuting a variable hemich.o.r.ea.

It is a matter of some difficulty to furnish an adequate description of the movements of the right arm. We note, first of all, that their activity depends on whether the arm is free or held in a fixed position. Voluntary movements are carried out stiffly, but are interrupted by sudden deviations, sometimes of rather a wide range, and highly irregular in distribution. Notwithstanding these breaks, the end to which the movement is directed is always attained with precision.

While L. was an apprentice dressmaker, she occasionally used to make various contortions with her arm, though if her attention was diverted they did not occur, and as a matter of fact she did her work well enough. Once she became familiar with the mechanical act of sewing, the involuntary performances ceased. Before her disease a.s.serted itself, she had commenced to learn the piano, and she continued to make unimpeded progress, as her teacher discovered a method of holding her elbow which checked all convulsive twitches.

The involuntary movements of the right leg were so insignificant as to be almost negligible; they united to produce a sort of irregular tremor which became appreciable only when the patient was very tired or very annoyed. Sometimes a long walk was followed by a certain hesitation in putting the right foot to the ground, and by defective inhibition of the antagonists of the desired movement.

Sometimes one foot was knocked against the other, and sometimes the right appeared to a.s.sume an equinovarus position. On the other hand, we have seen L. walking in the street with her father, when no anomaly could be detected in her gait. The distraction of any occupation such as dancing or playing a game has the effect, for the time being, of banis.h.i.+ng the greater part, if not all, of the spasmodic phenomena.

This is undoubtedly a case of Brissaud's variable ch.o.r.ea of a unilateral type, and a consideration of the symptoms confirms the intimate relations.h.i.+p between it and tic.

Various intermediate forms have been noted. In one of Brissaud's cases, variable ch.o.r.ea and multiple tics co-existed. Fere[140] reports a case of variable ch.o.r.ea preceded by tic, and Bernard another in which starting, trembling, facial tic, variable ch.o.r.ea, etc., were a.s.sociated.

Tics of phonation are often superadded to the gesticulations of variable ch.o.r.ea. Brissaud refers to the case of a girl of sixteen in whom involuntary movements resembling those of this type of ch.o.r.ea were coincident with a sort of hiccough, and a more or less inarticulate cry; at a later stage the movements became very infrequent, the hiccough was more constant, and the cry developed into a coprolalic e.j.a.c.u.l.a.t.i.o.n.

Variable ch.o.r.ea and variable tic are obviously very closely allied. The movements of the latter, however, are distinguished by their greater abruptness and smaller variety. They are tics by reason of their systematisation and co-ordination; they are variable because they pa.s.s from one region of the body to another. There is no necessary relation between them; each has an individuality of its own and is independent of the rest. In variable ch.o.r.ea, on the other hand, one movement pa.s.ses insensibly into another, and the variants of any particular one are legion.

However easy it is, then, to separate the two clinically, it is none the less true that they spring from the same soil of mental defect. Variable ch.o.r.ea differs in nature from other ch.o.r.eas, though its form is the same; it may be distinguished from tic by the type of movement, but in essence it is identical.

CHAPTER XII

ANTAGONISTIC GESTURES AND STRATAGEMS

However harmless and insignificant a tic may be, it is a source of annoyance to its subject of which he constantly seeks to disembarra.s.s himself. But the feebleness of his will militates against any sustained effort, and if for a brief s.p.a.ce he can conserve his immobility, victory eludes his grasp, for his tics resume the offensive and increase in violence. More than ever convinced of his helplessness, he resorts to measures that serve but to accentuate the mischief. Thus it comes to pa.s.s that he desists from his attempts at repression and admits himself vanquished.

Some there are, nevertheless, whose inventive faculty leads them to adopt singular att.i.tudes, to execute curious gestures, to utilise elaborate apparatus--proceedings always more or less childish, whose employment is usually followed by success, but only for a time. The history of O. acquaints us with a whole series of these subterfuges, for which the expressive name of para-tics was invented by him, tricks intended to mask or to modify existing tics, but they soon themselves became as involuntary and as inevitable.

Not all who tic are imaginative enough to conceive such plans, and many have no thought of showing fight at all, but it is worth while dwelling on this point for a little, especially in view of the frequency with which certain tics are accompanied by methods of correction evolved by the patient.

To begin with, we may quote the case of mental torticollis. The sufferer's head is irresistibly driven to the right, say, yet he replaces it immediately by the mere application of his right forefinger to his chin, and the correct att.i.tude is maintained so long as the finger is applied. Of the variants of this efficacious antagonistic gesture the most common is the grasping of the head in the hands, or its support in the palm, or the simple contact of the fingers with chin, or cheek, or temple. In some cases the mere threat of this gesture suffices for the purpose. S. approximates his hand to his left ear, but before he has actually touched it his head turns spontaneously to the right. It would be difficult to find more conclusive evidence of the purely psychical value of such corrective acts.

Sometimes the resources at the patient's disposal are confined to one measure, though more frequently he avails himself of several, as in a case recorded by s...o...b...[141] The antagonistic gesture may fail of its object if some one other than the patient put it to the test. Even with the expenditure of considerable force he may make no impression on the tonic contraction; this rule, however, is by no means general.

One of our patients, whose head used to be strongly tilted on to his elevated right shoulder, while his right arm was flexed, his left shoulder depressed, and his whole trunk deviated to the former side, was able instantaneously to resume his normal att.i.tude by merely placing his thumbs one on either side of his head. If any one else sought to correct his vicious position he could do so by applying his fingers to two well-defined spots on the occiput, towards the base of the mastoid processes.[142]

Occasionally the antagonistic gesture is of the nature of a paradox. We may cite an example from Raymond and Janet.[143]