• Email
  • Single Page
  • Print

Tics

Etude sur une affection nerveuse caracterisée par de l’incoordination motrice accompagnée d’echolalie et de copralalie”

by Georges Gilles de la Tourette
Arch. Neurol. Vol. 9, (Paris, 1885)

Gilles de la Tourette on Tourette Syndrome”

by C.G. Goetz, by H.L. Klawans. in Arnold J. Friedhoff and Thomas N. Chase, eds., Advances in Neurology, Vol. 35 (1982): Gilles de la Tourette Syndrome
Raven Press, 454 pp., $63.00

Postencephalitic Respiratory Disorders

by Smith Ely Jelliffe
Nervous and Mental Disease Publishing Company (Washington, DC, 1927, out of print)

Psychopathology of Forced Movements and the Oculogyric Crises of Lethargic Encephalitis

by Smith Ely Jelliffe
Nervous and Mental Disease Publishing Company (Washington, DC, 1932, out of print)

Tics and Related Disorders

by A.J Lees
Churchill Livingstone (New York, 1985), 276 pp., $45.00

Psychoanalytic Evaluation of Tic in Psychopathology of Children”

by Margaret S. Mahler. in Psychoanalytic Study of the Child
International University Press (New York, 1949, out of print)

Tics and Their Treatment

by H. Meige, by E. Feindel. translated and edited by S.A.K. Wilson from 1902 original
William Wood and Co. (1907, out of print)

Limbic Innervation of the Striatum”

by Walle J.H. Nauta. in Arnold J. Freidhoff and Thomas N. Chase, eds. Advances in Neurology, Vol. 35: Gilles de la Tourette Syndrome

Awakenings

by Oliver Sacks
Dutton (1983), 338 pp., $8.95 (paper)

Acquired Tourettism in Adult Life”

by Oliver Sacks. in Arnold J. Friedhoff and Thomas N. Chase, eds., Advances in Neurology, Vol. 35: Gilles de la Tourette Syndrome

The Possessed”

in The Man Who Mistook His Wife for a Hat and OtherClinical Tales
Harper & Row, 243 pp., $7.95 (paper)

Witty Ticcy Ray”

in The Man Who Mistook His Wife for a Hat and Other Clinical Tales

A Case of Gilles de la Tourette’s Disease After 10 Years’ Treatment with Haloperidol (R.1625)”

by Jean-N. Seignot. in F.S. Abuzzahab and F.O. Anderson, eds., Gilles de la Tourette’s Syndrome: Vol. 1, International Registry
Mason Publishing Co. (St. Paul, 1976)

1.

I want to edge into my subject indirectly and personally, by recalling my own education as a neurologist, and how this served—or failed to serve—me in later years, when I encountered the realities of various syndromes and afflictions, in particular encephalitis lethargica and Tourette’s syndrome,1 a syndrome of multiple convulsive tics. As a resident in neurology, I “rotated” through psychiatry, just as psychiatric residents “rotated” through neurology. These short rotations did nothing for us in terms of bringing about any unity of the two. One gained a little extraneous psychiatric knowledge, or a little extraneous neurological knowledge, but no real sense that the two were, or could be, related. I even think it encouraged, rather than prevented, some dissociation between neurological and psychiatric orientations, between body and mind, a dissociation which common experience, life itself, contradicts at every point.

When I emerged from residency to encounter the full reality of patients, I often found I had to be as much a psychiatrist as a neurologist. I felt this strongly when seeing patients with migraine, whose moods and feelings, attitudes and perceptions, could alter pari passu with their neurophysiologies: these patients showed me the absolute continuity of body and mind. But it was another affliction that was my real education, my education, that is, as a neuropsychiatrist. This was the lethargic encephalitis, the great sleeping sickness that affected nearly 5 million between 1918 and 1927. The moment of truth, or revelation, or “conversion” for me was when I encountered some eighty-odd postencephalitic patients at a hospital in New York. These patients had a myriad of disorders both “neurologic” and “psychiatric”: Parkinsonism, myoclonus, chorea, tics, strange compulsions, phobias, obsessions, gusts of passion. A “pure” neurologist or a “pure” psychiatrist with such patients would be utterly lost. The neurological, the psychiatric, had to be conjoined. One had to be as observant and knowledgeable about the psychological, the psychodynamic, as about the physiological, the neurodynamic.

What I found for myself here was no more than a repetition of what had been found in the 1920s, when the epidemic encephalitis burst upon the world. And of all the pioneer observers of that time, I found Smith Ely Jelliffe and his writings the most penetrating and the most faithful to experience. Jelliffe was both a neurologist and an analyst,2 equally “Sherringtonian” and “Freudian” in outlook, as indeed one has to be if one is to observe such patients, for they are equally Sherringtonian and Freudian. Thus Jelliffe felt impelled to write in 1927:

In the monumental strides made by neuropsychiatry in the past ten years, no single advance has approached in importance that made through the study of epidemic encephalitis…. An entirely new orientation has been made imperative.

This “new orientation” of which Jelliffe spoke, and of which he himself was a notable exemplar, did not involve merely combining neurological and psychiatric knowledge (as every neurologist and psychiatrist does to some extent), but conjoining them, seeing them as inseparable, seeing how psychiatric phenomena might emerge from the physiological, or how, conversely, they might be transformed into it—and, thus, how both approaches had to be used, together, if one were to understand oculogyric crises, respiratory disorders, tics. Thus, although the respiratory disorders could in part be explained as the consequence of excitatory lesions in the respiratory systems of the upper and lower brain stem, they had also to be seen as “respiratory behavior.” This “new orientation,” it must be stressed, was thus something quite beyond the “old” neuropsychiatry, and also, to my mind, quite different from what we now call behavioral neurology or biological psychiatry (though both of these also stemmed from the experience with post-encephalitic patients, from the observation of dramatic behavioral disorders with a clear organic basis). And the difference lies in a sense of process, the dynamics, both neural and psychic, of the disorders.

When I gave my postencephalitic patients L-dopa they “awakened,” and their “awakenings” were simultaneously physical and mental: motor, intellectual, perceptual, affective, all at once and inseparably (see my Awakenings, 1983). I have to say that such a total awakening or animation was in contradiction to our concepts of neuroanatomy at the time (1969), a neuroanatomy that (as Professor Nauta has reminded us) was essentially compartmentalized in character, seeing the motor, the intellectual, and the affective in quite separate and noncommunicating compartments of the brain. The anatomist in me, subservient to this notion, said, “This can’t be. Such an ‘awakening’ should not happen”—but clearly it was happening, and common experience, furthermore, said it should. After some conflict, I deferred to my experience, and saw and described these awakenings as global, even though this meant abjuring various anatomical and physiological suppositions. Sooner or later, I thought, anatomy would catch up to reality.

One of the great delights of the last two decades is to have been present at a creative revolution, to have seen just such a “new” anatomy (and new orientation) emerge at the hands of Nauta and others. He has shown us, in innumerable ways, how the motor and affective and intellective parts of the brain are inseparably entwined and integrated at every point, so that, though separate, they act as a unity. I bring up this point because all of us who first saw the effects of L-dopa found ourselves in a situation of conflict, and many of us dealt with this by distorting or reducing or denying our own experience. We spoke of the motor effects of L-dopa as the effects and anything else (if we admitted it at all) as incidental, adventitious, mere “side” effects, neurologizing them, so to speak, out of existence.

But we could not perceive these “awakenings” in their totality without a neuropsychiatric, or Jelliffian, perspective. And if this was so for the initial “awakening,” how much more so was it of the later effects, the excitation not merely of motor excesses, but of perceptual, intellectual, and affective excesses. Parkinsonism itself is not “purely” motor; there is, for example, in many akinetic patients a corresponding “stickiness” of mind or bradyphrenia, the thought stream as slow and sluggish as the motor stream. The thought stream, the stream of consciousness, speeded up in these patients with L-dopa, often speeding too far, into a veritable tachyphrenia, with thoughts and associations almost too fast to follow. Again, there is not merely motor but perceptual inertia in Parkinsonism: a perspective drawing of a cube or a staircase, for example, which the normal mind perceives first this way and then that, in alternating perceptual configurations or hypotheses, may be absolutely frozen in one configuration for the Parkinsonian patient; it will unfreeze as he “awakens” and may then trust in the opposite direction, with a near delirium of perceptual hypotheses alternating many times a second. Again there may be, at least in postencephalitic patients, an apathy as profound as the lack or impoverishment of movement. This too is reversed by L-dopa, and they may then be thrust into the other direction, into a state of heightened, excessive, and (so to speak) convulsive emotion.

This amplification, often sudden and convulsive, affecting motor, intellectual, perceptual, and affective life, might produce a peculiar hyperanimation, very similar to that of Tourette’s syndrome. It was indeed in such a context, with these overenergized, overcathected patients, that I first saw and spoke of “Tourettism,” two years before I actually saw a patient with Tourette’s syndrome. (See my “Acquired Tourettism in Adult Life,” 1982.) I need to stress that this was my own path to Tourette’s syndrome—it was, from the start, a neuropsychiatric path, brought about by observation of postencephalitic patients and syndromes. Thus I was neither tempted to “neurologize” nor “psychiatrize” Tourette’s, tendencies which have been all too common in this century.

2.

Tourette’s syndrome was described a century ago by Georges Gilles de la Tourette, a singularly imaginative and gifted pupil of Charcot, like his contemporaries Babinski and Freud. The atmosphere around Charcot and of Paris at that time was one of rare imaginativeness and excitement—an atmosphere in which natural history, clinical naturalism, flourished as it had never done before, and in a most heightened, and sometimes dramatic, form. Such an atmosphere was a prerequisite for the perception and delineation of such a syndrome. The compartmentalizing and conceptualizing characteristic of medicine today had only just started on their huge and arduous journey, and a free and untrammeled (at times almost novelistic) naturalism was still open to the clinical minds of the time. If Tourette, like so many of the superspecialists of our own time, had thought narrowly in terms of “motor disorders,” he could have described the movements but nothing else of what we now call Tourette’s syndrome.

Fortunately, he was able to describe the echolalia, the coprolalia, the imitations, the impulsions, all of the complex “mental” aspects of the syndrome. He described it, in short, as a neuropsychiatric syndrome, although no such portentous word would have occurred to him in this context. He simply considered himself a clinical naturalist, describing whatever he saw with an open, unbiased, undivided fullness. Tourette sketched the outlines of his syndrome; others were to add detail, flesh it out. Tourette made it possible to see the syndrome, by first seeing it—there always has to be someone who sees something first, and thereby makes it possible for everyone else to see what they had failed to see before. Following his description in 1885, new cases were seen and described by the score, often with a wonderful richness beyond anything that had hitherto existed in clinical medicine, and that was all too soon to vanish completely.

This was a time when medical descriptions were full of a precision, delicacy, and (not least) humor, a time when naturalism (or what we now call phenomenology) had not yet collapsed under the advances of science. It was, by the same token, a time in which patients and physicians still spoke the same language—and thus it was possible for both to collaborate, producing between them a perfect balance of description and comment. I want here to quote from one of the finest examples of such a collaboration I know, the anonymous “Confessions of a Ticqueur,” interlarded with the comments of his physicians, H. Meige and E. Feindel (1907). The ticqueur, O., introduces himself—at least, the tic or Tourette part of himself (we can judge later how deeply, and in what ways, this is related to, or has interacted with, his “real,” or non-Tourette, self):

I have always been conscious of a predilection for imitation.3 A curious gesture or bizarre attitude affected by anyone was the immediate signal for an attempt on my part at its reproduction, and is still. Similarly with words or phrases, pronunciation or intonation, I was quick to mimic any peculiarity.

When I was thirteen years old I remember seeing a man with a droll grimace of eyes and mouth, and from that moment I gave myself no respite until I could imitate it accurately…. For several months I kept repeating the old gentleman’s grimace involuntarily. I had, in short, begun to tic.

  1. 1

    Properly speaking, “Gilles de la Tourette syndrome,” but for brevity’s sake, often “Tourette’s syndrome” or just “Tourette’s.”

  2. 2

    It is of interest that Jelliffe could not be accepted as both, and tended to be seen by neurologists as an analyst, and by analysts as a neurologist. The notion of a neuropsychiatrist, apparently, was anathema to both.

  3. 3

    Imitation may become positively frenzied in that special and most severe form of Tourette’s I have called super-Tourette’s—I describe this in a short sketch, “The Possessed” (Sacks, 1985). One sees here every level of imitation from the echoic to the parodic, the mimic, the pantomimic. The very physiology of Tourette’s seems to dispose to hypermimia and histrionism—as is also seen in dopa-activated Parkinsonism and chorea.

  • Email
  • Single Page
  • Print