Tics and Their Treatment Part 13

Since the age of twelve she has been subject to various tics of the face and head. She wrinkles her forehead and moves her scalp to and fro, and sometimes she turns her head slowly and steadily towards the left side, raising her eyes up and to the left at the same moment. Head and eyes forthwith resume their normal position. The deliberateness of the act is altogether exceptional. If, however, she happens to be wearing her hat--which is remarkable for its size, weight, and unwieldiness--the gesture is repeated in a quick and jerky manner. Any diversion, such as reading, knitting, listening to a conversation, especially if she feels she is not being noticed, will augment the intensity of the movements, which the thought of being observed, or the awakening of her interest, or rest in bed, or sleep, has the effect of abbreviating or checking.

Our earliest step was to confiscate the offending hat, and this had the instantaneous result of diminishing the violence and frequency of the tic, which the subsequent practice of appropriate exercises entirely dispelled.

If now we direct our attention to the psychical aspect of the case, we are struck with the goodness, devotion, and disinterestedness of our patient. Her one concern is for the welfare of others, and she is indifferent to the pleasures of literature, art, games, or even work. All that is required of her she performs with docility, but never with animation. The extent of her pa.s.siveness is seen in her childlike acceptance of her parents' wishes. Her temperament is neither gay nor sad, but merely dull. Indolence and maladroitness predominate in all her actions, and reveal themselves in the curious awkwardness and nonchalance that characterise the execution of even the simplest movement. She is essentially of a very unstable nature, but its torpidity is no less obvious than its instability. If there is no abruptness in her acts, it is equally true that she is never still. She cannot maintain any given att.i.tude; she cannot fix her gaze on any particular object. Her restlessness is such that her position is changed from moment to moment, however slowly and imperceptibly. Her eyes are only half opened; as she speaks, her lips are scarcely seen to move.

It has been a laborious and protracted task to teach her to sit motionless with her hands in front of her, and no less unremitting effort has been required to make her open her mouth properly, or turn her head naturally from side to side.

In some ways the endless movements of her hands and fingers--she never ceases playing with her dress or her gloves or her handkerchief--are vaguely reminiscent of those of athetosis, and on the left side especially, if they become a little brisker, there is slight hyperextension of the phalanges. She reads aloud in a low, colourless, monotonous tone of voice, without punctuation or accent, articulating the syllables defectively and slurring the ends of the words. At the finish of each paragraph comes a halt, as if from fatigue, and on command a fresh start is made with the same careless indifference. As for the lower extremities, the tale is identical. Mademoiselle R. cannot stand upright. She rests on either one leg or the other. Her left foot is never flat on the ground, but sometimes on the inner border, sometimes on the outer.

The faulty att.i.tude is readily enough corrected, though she declares she is ignorant of it. It is a sort of half clonic, half tonic, tic of the foot, whose slowness is on a par with that of all her other acts.

It is because clonic tics are so easily recognised that they are the most familiar, but we must not ignore another variety--viz. the _tonic tics_, corresponding to the tonic form of convulsion.

Tonic tic is of common occurrence in cases of mental torticollis. In that disease rotation of the head may be sustained for a considerable length of time without interruption, showing the permanent nature of the muscular contraction. Strictly speaking, we are concerned not with a sudden gesture, but with an att.i.tude. Abundant evidence is forthcoming to substantiate its mental origin, and it may therefore be described as an att.i.tude tic. Among other instances of tonic tics may be specified the affection of the ma.s.seters known as mental trismus (Raymond and Janet), or that continuous contraction of the orbicularis which keeps the eye half closed, though it may momentarily disappear under the influence of the will--a tonic blinking tic. O. and young J. have already supplied examples of att.i.tude tics, and reference may further be made to another of our patients[49]:

Sometimes the mouth is drawn directly and completely to the left, more usually to the right; at other times simultaneous contraction of the upper and lower lips takes place, const.i.tuting a sufficiently faithful reproduction of the grimace made by a child in the attempt to refrain from crying; at other times still, imperfect closure of the lids and upward deviation of the eyes bear a resemblance to children's imitation of a blind man. Displacement of the mouth to the right is the movement of longest duration, and while it persists the patient is capable of stuttering speech, without relaxing her lips. The other tics last but a few seconds, while all vanish if she laughs or opens her mouth wide to exhibit her tongue. They follow each other at irregular intervals, and during the moments of rest the face resumes its normal expression.

Cruchet, as has been already remarked, has criticised the use of the term att.i.tude tic, on the ground that the adoption of an att.i.tude, however vicious it be, need not be the outcome of a convulsion.

Doubtless; but it is no less true that a tonic convulsion may "take shape"--_e.g._ the _arc de cercle_ of hysteria, the phenomena of catatonia and catalepsy, etc. Of course if the word tic is to be synonymous with _intermittent_ twitching, then it is inapplicable in this cla.s.s of case; but if our connotation of the term be accepted, we must find an expression that will serve to differentiate between tonic and clonic varieties. We are not aware of any particular advantage in describing the condition as a permanent contraction, for the obvious result of a permanent contraction, whether it be clenching of the jaws, occlusion of the eyelids, or rotation of the head, is the production of an att.i.tude, a "position in which the body is kept" (Littre). No other designation could therefore be more appropriate than att.i.tude tic, or could indeed be imagined, seeing that Cruchet himself ranges mental torticollis among the tics, and describes it as "an att.i.tude of defence and of repose."

It may sometimes happen that the manifestations of stereotyped acts consist in the a.s.sumption of att.i.tudes, but in spite of their affinity to the tics we deem it preferable to reserve the term "stereotyped att.i.tude" or "akinetic stereotyped act" for cases where the motor reaction is clothed in the form of a normal movement. As it is inaccurate to describe as a tic a repeated gesture whose execution is normal in degree and in rapidity, so the mere immobility of a limb, or the prolonged contraction of a muscle, ought not to be called an att.i.tude tic if the muscular effort does not differ from that which a healthy person would make to preserve the same position. In such circ.u.mstances we say that it is a stereotyped gesture or att.i.tude. For the diagnosis of tic it is insufficient to establish the existence of a transient or permanent muscular contraction, and to note the inopportuneness of the movement; the contraction must be abnormal in itself, its abruptness unwonted and its intensity excessive--in short, it must be a convulsion; and finally, its repet.i.tion must be continued and exaggerated.

We have felt that some such explanation as the foregoing is required to justify our use of the term tonic or att.i.tude tic, to whose close intimacy and a.s.sociation with the better-known type pathogeny and clinical observation alike bear witness. In any case such terms as myotonus or myoclonus are too comprehensive, in view of our present-day knowledge, to specify the particular motor affection with which we are concerned.

As a general rule it is only one part or segment of the body that is immobilised by a tonic tic, but in regard to the possibility of a general involvement, the following instance[50] may be cited, although we do not think it can be considered decisive:

A man thirty-two years old, who had recovered from a first attack of mental torticollis, underwent a relapse in quite a different form. If when walking with his head perfectly straight he were asked to go round to the right, he instantly appeared to become rooted to the spot and could not turn even his head in the required direction; at the same time he felt a compression of his throat as if he were being strangled, and for a few seconds he experienced acute anguish. A moment later he was all right again, and his action unimpeded.

Without going so far as to cla.s.sify this incident as a tic, and without venturing to a.s.sert the existence of a _tic of immobility_, one cannot but be struck with its a.n.a.logy to the att.i.tude tics of which we have been speaking, and to catatonic conditions met with in the insane, of which too the pathogeny presents more than one point of similarity with that of this species of tic.

[In this connection reference may be made to certain conditions occasionally noted among those who tic--viz. a curious tendency to maintain abnormal positions of the limbs or trunks, and difficulty in or impossibility of relaxing various muscles (_catatonic apt.i.tudes_).

Patients are sometimes given to the exaggerated repet.i.tion of the ordinary movements of their members (_echokinesis_), as well as to imitation of the actions of others (_echomimia_). Such catatonic and echopraxic phenomena[51] are not confined to sufferers from tic, for they are encountered among psychopathic subjects generally, and indicate defect of cortical control--what is called by Brissaud "pa.s.sive activity." These catatonic apt.i.tudes may be discovered by resort to clinical tests, such as letting the arm fall from the horizontal position.[52]]

INTENSITY OF THE MOTOR REACTION

The muscular contraction varies considerably in intensity, in most cases exceeding that of the corresponding normal movement, and, especially in tonic tics, being often so powerful as to necessitate the exertion of great force to overcome it. Even though one's effort prove unavailing, however, it is only needful to distract the patient's attention to perform any and every pa.s.sive movement with consummate ease.

In the case of S., any attempt to budge the head from its torticollic position on the left evokes strong muscular resistance; but engage him in conversation or otherwise divert his mind, and the difficulty soon vanishes. By similar means, the resistance awakened by sudden change of the direction of pa.s.sive rotation will rapidly die down.

Occasionally the muscles brought into play surpa.s.s their fellows of the opposite side in size and power, this secondary hypertrophy being the natural sequel of repeated exercise. It was noted by Charcot that in rotatory tics the disused muscles atrophied, whereas the affected muscles hypertrophied, but they may do so only in appearance. The tonus of the muscles at the moment of examination may create differences inappreciable during relaxation. Sometimes one comes across such expressions as "paresis" or even "paralysis" of antagonistic muscles, and "contracture" of those in which the tic is localised. To draw a distinction between slight contracture of the latter and mild paresis of the former is a problem practically always insoluble. Opinion has been ever divided on this point; yet some, in their desire to harmonise the two, take up an eclectic position and do not hesitate to speak[53] of "paralytic contracture," or "mixed contracture, at once active and pa.s.sive," a terminology by no means calculated to simplify the question, and one the discussion of which we do not care to pursue.

We should like, however, to allude to a matter of clinical observation that we frequently have had occasion to remark. What simulates muscular enfeeblement in the subject of tic is often nothing else than a want of accuracy and _adresse_ in the performance of a given movement. For instance:

S. enjoys robust health; his only trouble is a lack of accurate control over his limbs. His execution of the most elementary movements is incorrect. There is no tremor, no jerkiness, simply a loss of the sense of position. He never knows whether he is holding himself straight, whether his arms are exactly horizontal or his shoulders symmetrical. Often he confuses right and left, and when requested to perform some act on one side, he declares he is tempted to perform it simultaneously on both. The order to fold his arms and rotate the upper part of his body to the right evokes an inconceivable display of contortions. In the attempt to bend his head and body backward, fear of losing his balance causes him to twist and turn about most strangely, and the remark that all this he might avoid by merely putting one foot further back seems to cause him infinite surprise.

Or again:

The absence of precision in Mademoiselle R.'s movements, her habit of arresting the action before attaining the desired end, are not to be ascribed to any feeling of discomfort, but to her ignorance of the amplitude of her efforts, and of the position of her limbs.

Her acts are always feeble, hesitating, and curtailed, a curious mixture of muscular languor and vigilance, "as if she were afraid of breaking herself." She appears to be constantly seeking some new position for herself, and to be as constantly oblivious of her actual att.i.tude. With eyes closed, however, she indicates the relation of her limbs exactly.

Another example is furnished by the case of L., to which reference is made on p. 135.

There is no call to multiply instances. Enough has been said to demonstrate the frequent occurrence, if not of motor inco-ordination, at least of faulty orientation in s.p.a.ce and of defective estimation in regard to the range and intensity of voluntary movements, among the subjects of tic. The topic is a very interesting and fruitful one, on which considerable light may be thrown by the application to it of the results of Pierre Bonnier's[54] remarkable studies on the sense of att.i.tudes, a subject that we intend to develop on another occasion.

FREQUENCY AND RHYTHM--RHYTHMIC TIC

The frequency of the muscular contractions in tic is so very variable that it cannot be regarded as a distinctive feature, nor is there any evidence to show that it is rhythmical, as some would have us believe.

Contrary to what obtains in tremor, there is no periodicity in the motor phenomena, even when the tic is based on derangement of a function whose manifestations are rhythmical, such as the function of respiration.

Conditions described as rhythmic tics, or less well as rhythmic spasms, seem to form a group by themselves; probably they do not belong to the same family as the tics, indeed in some cases they are symptomatic of encephalic lesions, as in the _spasmus nutans_ of infants, or the rhythmic tics of idiots and imbeciles. In this connection the remarks of Noir are very pertinent:

We shall be well advised to refrain from drawing too absolute conclusions in questions so difficult, where even the framing of an hypothesis demands prolonged observation, but we cannot withstand the temptation to note the co-existence of certain of these tics with certain definite lesions recognisable post-mortem. This has been done before us by our master Bourneville, who has on several occasions made the diagnosis of chronic meningo-encephalitis, cerebral sclerosis, etc., from this a.s.sociation of rocking, rotation, and krouomanic movements with a special symptom-complex, and verified it at the autopsy. Nevertheless, there is not always an absolute correspondence between them, wherefore Bourneville, with an altogether praiseworthy scientific reserve, has hesitated to consider these tics as actual symptoms of the affections alluded to, and we shall follow his prudent example.

To the combination of various rhythmical acts with hysteria we shall revert at a later stage. Under the t.i.tle "rhythmic spasm" an interesting case has been reported at length by de Buck,[55] concerning a young woman, free of hysterical stigmata, in whom convulsive movements first appeared at the age of seven years.

When she had attained her nineteenth year she commenced to suffer from attacks of anguish of some hours' duration, but disappearing under the influence of sleep, in which she felt as though her breathing were going to stop and she herself were about to die. On the termination of these sensations some eighteen months later, their place was taken by convulsive movements of the tongue, lips, neck, trunk, left arm, diaphragm, pharynx, and muscles of respiration. These consisted of clonic rhythmical twitches, each preceded by an inspiration and succeeded by an expiratory e.j.a.c.u.l.a.t.i.o.n, repeated fifty or sixty times a minute. During the seizure the tongue was protruded and deviated to the left, the left arm was raised, the head and trunk bent down and forward. All day long the movements were continued with unflagging regularity. Rest in bed was without effect, but they were dispelled by sleep.

Distraction and occupation exercised an inhibitory influence on them, whereas voluntary control was both feeble and fleeting. In the condition of the patient there was nothing else abnormal with the exception of slow, monotonous, and syllabic speech. Her mental development was perhaps a little immature, but signs of hysteria were lacking, and all attempts at treatment by suggestion and hypnotism failed of their object. Death ensued from pulmonary tuberculosis.

De Buck observes that while the action of some of the muscular groups involved in the rhythmic spasm was, so to speak, purposive, the whole did not const.i.tute any known, conscious, and logical movement. It may have been a species of tic, but the rhythmical sequence of the convulsions imparts to it a quite peculiar character.

ATTACKS

A further mark of the motor reaction is the circ.u.mstance that it ceases for a longer or shorter interval, independently of the tic's localisation, intensity, or form, the result being an alternating series of "attacks" and periods of respite. In different patients, and in the same patient, the number and the length of these attacks are as variable as are the s.p.a.ces of rest that separate them. We remember a girl with a tic consisting in a toss of the head repeated perhaps fifteen times a minute, three or four occurring together at intervals of one or two seconds, and being succeeded by a relatively long pause. The effect of treatment was to modify the sequence entirely, and to reduce the tic to an isolated jerk reappearing not oftener than once in a quarter of an hour, and in itself const.i.tuting the attack. In another case the patient's head used to turn to the left, remain so for a moment, then resume its ordinary place. After a time of repose the tic began again, and even when the movements followed each other more rapidly, the intervening period was always appreciable. On the other hand, we have seen a youth afflicted with multiple tics which continued without intermission the whole day long; the attack lasted, strictly speaking, from morning to night, and any break in its continuity was altogether exceptional. It might then be more exact, perhaps, to use the epithet paroxysmal in reference to the external manifestations of tics, but it signifies little what word we employ provided we are familiar with the clinical facts.

The attacks vary with circ.u.mstances and environment. One of our patients remained quite free from them during a visit to the theatre. Tissie had a young patient who did not tic at all while on holiday, but the reopening of his cla.s.ses was the signal for a fresh outbreak. Similarly, no rule whatever seems to govern the duration of the times of relief; they may never be longer than a few seconds, or they may run into months. In the face of these data we cannot supply further generalisations; it will be sufficient if we impress on ourselves the importance of one fundamental element in the const.i.tution of tic--viz.

its repet.i.tion.

LOCALISATION OF THE MOTOR REACTION--VARIABLE TICS--FIXED TICS

The localisation of the motor reaction in cases of tic is essentially physiological. In rare instances its sphere may be limited to a single muscle, if one muscle only be requisitioned for the performance of a functional act; but it is very much more usual to find several muscles contributing, whose synergic contractions fashion the movement of which the tic is a caricature. If the same effect is yielded by the action of either of two different muscles or groups of muscles, as in rotation of the head, and if one be hindered from fulfilling its function, the incidence of a tic originally located in it will promptly be transferred to the other. This is the explanation of the persistence of rotatory tics after exclusion of the sternomastoids by surgical means.

Two symmetrical muscles may be affected, as in tics of blinking and of affirmation, or a median muscle, such as the orbicularis oris. Much more frequently the tic is unilateral in its distribution, as, for instance, when it involves the face; in this respect its figuration as a functional disturbance is well exemplified, for expressional movements of the face are normally bilateral. A tic may settle itself on two mutually antagonistic muscles, and manifest its presence in the immobilisation of a limb or segment of a limb; or only a portion of a muscle may contract, as in the case of the deltoid or trapezius, which are composed of bundles anatomically a.s.sociated but physiologically independent, and so capable of being functionally differentiated by voluntary education. Fibrillary contraction and tic have nothing in common.

Inasmuch as the muscles concerned are under voluntary control, and their contractions such as the will can effect, it follows that with adequate practice the movement of a tic can always be imitated, and in predisposed soil imitation tics may thus take root; it is not always feasible, on the other hand, to counterfeit a spasm.

Several functional muscular territories may be simultaneously affected, and several tics may follow one another in quick succession, the duration of any one tic on any one site being a more or less varying quant.i.ty.

We have already noted the occurrence of variable tics. They appear one day to disappear a few days later, and reappear again after another s.p.a.ce. Weeks or months may elapse without any vestige of them, until they suddenly break forth again unheralded. As a general though not absolute rule, the younger the patient, the less stable his tics.

Occasionally they are isolated, limited, and stationary, one of the most frequent of this kind being a tic of blinking, but the intimate alliance between the motor troubles and the mental level of the subject helps to explain why these tics of children are so changeable.

In the case of young J., for instance, it was shortly after attaining his tenth year and entering school that first he began to tic, and thenceforward, at unequal intervals, trunk, arms, shoulders, legs, became in turn the seat of "movements of the nerves," while other more definite tics were not slow in developing.

When only six years old B. exhibited a respiratory tic, which changed a year later to one of the tongue, and after another year to one of the leg; at the age of twelve he used to nod his head in affirmation, and this was eventually succeeded by movements of negation, etc. He has since started a salaam tic, and finally a torticollis with deviation of the eyes.