Tics and Their Treatment Part 28

Conditions such as these present the most intimate a.n.a.logies to our att.i.tude tics, though in the case of the latter there is always a more or less p.r.o.nounced exaggeration of muscular contraction, a certain degree of tonic convulsion.

Parakinetic stereotyped acts are of common occurrence, and embrace every variety of movement or gesture.

A former acrobat leaps staircases, climbs railings, exercises his arms rhythmically and regularly, etc.

A patient promenades untiringly in the same corner and at the same pace.

An old engraver, now a dement, pa.s.ses the day in reproducing in a more or less modified form certain actions a.s.sociated with his former profession.

Alike in tics and in stereotyped acts, a time comes when the motor habit establishes itself, for no apparent reason or purpose; hence the co-existence of the two cla.s.ses in chronic delusional insanity, in dementia prec.o.x, in catatonic states, in systematised mental disease of other forms, and in general paralysis.

Stereotyped acts may be the embodiment of ideas of persecution and of grandeur, or the outcome of mystical, hypochondriacal, and other states.

A patient with delusions of persecution writhes because he is being "electrified." A hypochondriac rests motionless because he believes himself made of gla.s.s. A mystic maintains an att.i.tude of genuflexion for hours at a time.

Obsessions also play a part in the genesis of the acts we have under consideration, but of all delusional ideas those of defence are the most fertile in this respect.

A patient under the care of A. Marie used to carry a fragment of gla.s.s between his teeth and other pieces beneath the soles of his feet, the idea being that they formed insulating cushions whereby to protect himself from the electricity of his enemies.

The suggestion was thrown out by Bresler that the movements of tic are often of a defensive character--that the disease, in fact, is a sort of "defence neurosis" linked to hyperexcitability of psych.o.m.otor centres.

This theory is not unlike the view of hysteria taken by Brener and Freud, and as the movements themselves are usually of the nature of mimicry, Bresler has proposed the term _mimische Krampfneurose_.

In some cases of mental torticollis, the att.i.tude a.s.sumed may be considered as a stereotyped act. Martin has recorded an example of torticollis in relation to melancholia. Another of his patients suffered from rotation of the head to the left, a position which could easily be rectified by asking the man to make the sign of the cross. The moment he put his finger on his forehead the displacement of the head was corrected. If, however, he were requested to look straight in front of him, he remained incapable of altering the vicious att.i.tude, the reason he advanced being that he could no longer see the sun.

One cannot but be struck with the remarkable a.n.a.logies to the cases given by Cohen. And it is worth remembering further, that sometimes mental torticollis degenerates into actual dementia.

TICS AND SPASMS

Nothing is more arduous, at first sight, than the differentiation of a tic from a spasm, the similarity of their external forms being a fertile source of confusion. Yet the establishment of a correct diagnosis is of prime importance, since in their case prognosis and treatment alike are diametrically opposed.

Tic is a psychical affection capable of being cured, if one can will to cure it: at the worst we may fail, but there is no idea that it is indicative of a grave organic lesion prejudicial to life. A spasm, on the contrary, though it appear in almost identical garb, is excited by a material lesion on which depends the degree of its gravity. The focus of disease may disappear, no doubt, but it is only too likely to persist and to occasion other disorders. Hence the desirability of making sure of one's diagnosis--a proceeding not necessarily of insuperable difficulty. If we apply the principles of diagnosis enunciated by Brissaud, to which our attention has already been directed, we shall not find the task beyond our powers.

Let us take a concrete instance.

Here is a cabman, forty-nine years of age, the left half of whose face is the seat of convulsive twitches. These commenced eighteen months ago by brief insignificant contractions of the left orbicularis palpebrarum, which have gradually spread to the whole of the muscular domain supplied by the left facial nerve. Their momentariness and rapidity, their apparent independence of extraneous stimuli, their indifference to treatment and resemblance to the twitches produced by electrical excitation, their occurrence in sleep, the fact of voluntary effort, of attention or distraction, serving so little to modify their range and intensity--all make clear the spasmodic nature of the condition.

The motor manifestation is the consequence of irritation at some point on a bulbo-spinal reflex arc; its abruptness and instantaneousness negative the possibility of recognising in it any sign of functional systematisation. It is not a co-ordinated act of a purposive nature, but a simple, unvarying, constant motor reaction to a particular stimulus. That its intensity should be in direct proportion to the intensity of the latter, changing from feeble contractions to a state of transient teta.n.u.s, is further proof of its spasmodic origin. When the excitation is at its maximum, there is sometimes involvement of the opposite side of the face, by virtue of the law of the generalisation of reflexes.

It is true there is no a.s.sociation of pain with his attacks, as in so-called tic douloureux, but the spasm is heralded by a tingling sensation below and to the inner side of the outer corner of the eye. This sensation, "like an electric battery," persists during the spasm and disappears in the intervals. Its occurrence suggests that the ascending branch of the infraorbital nerve, springing from the trigeminal, is affected, and indeed pressure over its point of emergence evokes a certain amount of pain. Moreover, there is occasionally a flow of tears when the spasm is at its height. It may be difficult to decide whether this is the result of mechanical compression of the lachrymal gland or an exaggerated secretion of tears under the influence of stimulation of the lachrymo-palpebral twig of the orbital nerve. In any case the pathogeny of this facial spasm is entirely comparable to that of tic douloureux of the face, and it is quite within the bounds of possibility that a minute haemorrhage--for the patient is of a very florid type--somewhere on the centrifugal path of the trigemino-facial reflex arc, may be giving rise to the phenomena.

What we wish to insist on, however, is the dissimilarity between this facial spasm and tic. In the movements we have been describing we fail to distinguish any purposive element, any co-ordination for the fulfilment of a particular function: they are not imitative in character, nor do they express any sentiment; no impulse precedes their execution, no satisfaction follows.

The patient's mental state presents no peculiarities, as far as we have been able to discover. There is no volitional debility or instability; if he cannot control the convulsions, it is to be remarked that he cannot control them even for a moment, whereas all sufferers from tic are capable of inhibiting it for a longer or shorter period by an effort of the will, by concentrating their attention on it.[169]

The following remarks on this case are due to Professor Joffroy:

If the patient be asked to open his mouth, the spasm of the left cheek remains in abeyance at long as it is open, but the platysma of the same side then begins to twitch spasmodically. Or if he be requested to shut his eyes, so long as they continue closed the cheek is quiescent; but, on the other hand, both orbiculares palpebrarum, as well as the pyramidal muscles and the adjacent fibres of the frontalis, are seen to contract irregularly. There is a sort of transference of spasm, and this is of peculiar interest, inasmuch at it affords evidence that the lesion is not so restricted as one might suppose.

The explanation no doubt is to be sought in the law of the diffusion of reflexes, confirming the diagnosis of an irritative lesion at some point on the trigemino-facial reflex arc.

In the differential diagnosis of spasm a.s.sistance may be obtained by a consideration of the following points:

The extreme abruptness of the movement recalls the contractions produced by electrical stimulation.

There is no purposive or co-ordinated feature in the spasm, which is confined to some nerve area anatomically limited.

Volition, attention, distraction, emotion, all fail to effect any modification of the phenomena.

No irresistible impulse precedes their manifestation, nor is it succeeded by a feeling of satisfaction. Sometimes the spasm is accompanied by severe pain.

As a general rule the patient's mental state does not present the anomalies met with so frequently among those who tic.

Important information may be gleaned from a scrutiny of the condition during sleep. Should the convulsive movement persist, it may be said with confidence to be a spasm; whereas if it completely disappear, it is probably a tic. Whether a spasm may vanish in sleep, however, is another question, which clinical observation has not yet satisfactorily answered, and if no other indication of organic disease be forthcoming, the problem must in the present state of our knowledge be left unsolved.

A. Tic or Spasm of the Face

In cases where the face is the seat of the convulsive movements this problem of diagnosis becomes one of the utmost nicety. That a distinction may be drawn, however, is universally admitted.

Hallion,[170] for instance, specifically separates clonic spasms due to structural changes from the "nervous movements" of neuroses such as ch.o.r.ea or tic. Facial spasm is rigorously limited to the distribution of the nerve, and is commonly the result of some alteration in it effected by causes similar to those that occasion facial paralysis.

Clonic spasms of the face are occasionally a sequel to local traumatism--that is to say, they are the result not of direct but of reflex excitation of the facial nerve. Tic douloureux belongs to this cla.s.s. Tic non-douloureux also is sometimes merely a simple reflex spasm.

One of the most pregnant of Brissaud's lessons is devoted to the elucidation of this part of our subject, and we have already made several quotations from it. In many cases he is forced to say, "I decline to hazard a diagnosis when etiology is silent." We too have been face to face with this diagnostic difficulty on several occasions, and it may be instructive to give the details of one or two cases where no definite conclusion could be arrived at.

A man thirty-seven years of age had been suddenly seized with facial paralysis on the left side thirteen years before, accompanied after an interval of eight days by bilateral fronto-temporal cephalalgia, nausea, vomiting, and disturbances of vision. These attacks recurred irregularly during the next four years, since when they have ceased, although the palsy persists.

Recently the patient woke up abruptly in the middle of the night to find that the left side of the face was in a state of spasmodic contraction, a condition which has continued absolutely without intermission. There is no pain in relation to the spasm, merely a peculiar sensation at the site of the muscular twitches. Of what nature are they?

If we a.n.a.lyse the muscular play somewhat more closely, we observe that with the exception of the frontalis all the muscles of the left face, including the platysma, contribute. On a background of more or less permanent contraction are outlined short, incomplete, greatly varying twitches, affecting one muscle after another, and sometimes only a few fibres, in a highly erratic way. The march of the movements obeys no law, either of s.p.a.ce or time, nor is there any co-ordination in their activity. That the condition is one of tic, therefore, is scarcely conceivable. No purposive element is discoverable in the phenomena, no systematisation, no expression of emotional excess. All is disorder, confusion, contradiction.

We should, accordingly, be content to make a diagnosis of spasm, but an examination of the patient's mental condition must not be neglected, and in this particular case it is very instructive.

It appears that his imagination has always been singularly fertile, amounting indeed to eccentricity. The picturesque description he furnished of the unusual sensations in face and neck lent support to the view that his muscular activity was intended, consciously or unconsciously, to free himself from their insistence, so that his grimacing may have been but a gesture of defence.

But however much his lack of psychical equilibrium may favour the relegation of his affection to the category of tic, certain considerations make one question the validity of the hypothesis.

In the first place, it is rather an uncommon functional adaptation of the facial muscles to utilise them in an attempt to disembarra.s.s oneself of disagreeable sensations; and in the second it is no less uncommon for the sufferer from tic to be unable to restrain his muscles even momentarily, as our patient appears to be. The actual time of onset of the movements is significant enough, but of supreme importance is the fact of their supervention in an area previously the seat of paralysis. To our mind this is more than a coincidence; from the history supplied by the patient it is plain that the paralysis was peripheral and that the lesion involved the facial trunk somewhere in its intracranial course after its emergence from the side of the pons. Thirteen years later, convulsive movements appear in the same domain. Taking all the circ.u.mstances into consideration, we think the hypothesis tenable that the trigeminal is implicated in the pathogeny of the spasm, although the condition is not strictly comparable to the cla.s.sic tic douloureux.

The exact nature of the lesion is more difficult to determine. A review of the details of the facial palsy suggests its vascular origin, to which theory the headache, nausea, and photophobia of succeeding days and months--indicating, as they do, a circulatory disturbance in the basilar region--lend support. With the gradual restoration of vascular equilibrium the migrainous attacks lessened in frequency and severity, though the facial trunk remained compressed, till the spasm appeared, no less suddenly than had the paralysis. It is feasible that the former, too, is the derivative of a minute haemorrhage irritating either the centrifugal or the centripetal arm of the facial reflex arc, probably the latter, which would explain the paraesthesiae.

The possibility of this explanation being accurate is confirmed by a case reported by Schultz, where facial spasm of ten years'

duration was shown at the autopsy to have been caused by an aneurism of the left vertebral artery impinging on the facial nerve in the neighbourhood of the basilar trunk.

The arguments, therefore, which plead in favour of the spasmodic nature of the condition seem to us so cogent that the hypothesis of tic must be rejected. We ought not to forget, on the other hand, that a spasm, of whatsoever origin, may be transformed into a tic by the perpetuation of a morbid habit.

Let us take a second case, no less instructive than the preceding.

Madame L. was sent to one of us by Professor Pierre Marie. She had always been nervous, impressionable, and high-spirited, but had never suffered from fits. At the age of eight years, during convalescence from one of the exanthemata, she got a chill, and the very next day developed an acutely painful torticollis, the head resting on the right shoulder and the chin touching the left clavicle. A complete cure ensued, but from that time a certain degree of facial asymmetry was remarked. At the age of eight and a half menstruation commenced, and it still continues, at the age of fifty-nine.