ACCESSORY SYMPTOMS
REFLEXES
The question whether in cases of tic there is any alteration in
superficial or deep reflexes can be decisively answered only by an
appeal to statistics, the information afforded by which has hitherto
been too scanty and too incomplete. Judging from our own observations in
about thirty cases, we feel compelled to admit that disorders of this
kind are altogether exceptional. Careful and repeated examination has
convinced us that in patients suffering from tic the knee, ankle, wrist,
elbow, and other jerks, the plantar and fascia lata reflexes, as well as
those of the pharynx, eyes, etc., are all but universally normal, and
any trifling exaggeration or diminution not only varies from day to day,
but also in no wise exceeds the differences met with in health, and is
therefore symptomatologically negligible. In the manifold varieties of
tic represented by R., S., P., N., M., B., etc., whose cases are quoted
here in part, our inquiries have always been negative. Noir's research
on the state of the reflexes in idiocy complicated with tics failed to
expose any abnormality, and even where the knee jerks were increased no
departure from the usual manifestations of the tic was discoverable. It
is of course permissible to suppose that a combination of the latter
with organic disease of the nervous system might explain the
modification of the reflexes. In this connection it may be remembered
that on one occasion we found the customary diminution of O.'s knee
jerks had passed into actual loss, and although on the next day they
were present again, the occurrence was suspicious enough to justify one
in entertaining the idea of incipient tabes. Even if the existence of
other signs had corroborated this diagnosis, the incontestable
genuineness of O.'s tics would have remained, so that the attempt to
correlate the derangement of the reflexes with the existence of tics is
somewhat questionable.
We have enjoyed the co-operation of M. Babinski in the examination of
one of our patients, L., in whom we were able to determine a definite
and symmetrical exaggeration of the patellar reflexes, a slight increase
in the right triceps jerk, and, in making the subject rise from a prone
to a sitting position with the arms folded, a very minor degree of
flexion of the thigh on the trunk.
The first of these symptoms is of no pathognomonic value, and while the
others no doubt are characteristic of organic disease, their development
in this instance is too imperfect to warrant the deduction of pyramidal
involvement. For the last ten years L.'s motor control has been very
defective. The muscular activity of the right half of his body takes the
form of irregular contractions, badly timed and inaccurate in range; in
spite of the absence of pain, the timidity with which they are executed
hinders their ever attaining a normal amplitude; and at the same time
his inability to appreciate the direction and intensity of the motor
reaction, the outcome of excessive muscular vigilance, illustrates a
certain loss of the sense of position of his limbs.
The existence of an actual irritative lesion is therefore problematical,
and it is scarcely conceivable that organic mischief of ten years'
duration could have produced these clinical symptoms without creating
graver disturbance of the reflexes, or effecting changes of a trophic
nature in muscular and other tissues.
From the pathogenic and diagnostic point of view, the detection of
conspicuous and persistent alterations in the reflexes is of deep
significance. It is an important factor in the differentiation between
tic and spasm.
Sometimes the task is unusually arduous, as when the unilateral
distribution of the motor troubles recalls the clinical picture of
lesions of the pyramidal paths. In L., for instance, the hemichorea and
the torticollis were on the right side, and in a case published by
Desterac a similar condition obtained, the writers' cramp, hip spasm,
and head rotation being all confined to the right. Notwithstanding the
fact that this patient had exaggerated knee jerks, ankle clonus, and a
double extensor response, an opportunity for examination given to one of
us made it clear that the untimely movements and bizarre attitudes were
similar to what has been noted in certain cases of tic.
At the Neurological Society of Paris a case was shown by Babinski[56] of
left spasmodic torticollis, with marked spasms of the left arm and left
leg, and a homolateral extensor response, and it was contended that if
one and the same cause underlay these phenomena--nor did there appear
any adequate reason to doubt it--and if the reversal of the plantar
reflex was, conformably to received opinion, to be interpreted as
indicating a derangement in the function of the pyramidal system, then
it was allowable to attribute the muscular spasms to the same
derangement, in which circumstances the natural conclusion was that
spasmodic torticollis itself might sometimes at least be dependent on
pyramidal irritation of an as yet undetermined kind.
More recently still, another patient was exhibited by the same
observer,[57] in whom the association of head rotation and convulsions
of the arm on the left, with increase of the triceps reflex, was
conceivably the outcome of pathological stimulation of the pyramidal
tract. Yet the symptoms in each of these cases were curiously analogous
to what we find in mental torticollis, in which abnormalities of the
reflexes are conspicuous by their absence. We ought not on that account
to reject the hypothesis of concurrent organic disease, inasmuch as a
structural modification may be no longer the cause but the consequence
of inordinate repetition of a motor reaction. Muscular hypertrophy or
atrophy may be the sequel to tics born of ideas that find motor
expression, and circulatory and even cellular changes may ensue on
gesticulatory excess. The objective signs that reveal the existence of a
point of irritation, on the presence of which the diagnosis of spasm
depends, are commonly so trivial as to be wellnigh valueless, and should
they be awanting, the motor disturbance appears to be purely functional,
and may be considered a tic. At the same time we must admit the
possibility of mixed forms, where the functional element is linked with
primary or secondary organic disease, and perhaps their occurrence is
more general than is ordinarily imagined. We repeat, however, that
rigorous and lengthy investigation alike of the psychical and the
somatic phases of the condition, embracing the state of the reflexes,
will usually furnish sufficient information to facilitate the question
of diagnosis and justify a positive statement.
ELECTRICAL REACTIONS
The examination of the electrical reactions of the muscles concerned in
a tic is a clinical method seldom, if ever, resorted to, and we can
scarcely expect it to yield decisive results from the symptomatological
aspect. As with the reflexes, it may happen that we cannot afford to
neglect its diagnostic significance in certain cases. For example, we
have had occasion to test its worth in studying the case of young J.,
whose trouble consisted in a clonic tic of elevation of the left
shoulder, and a tonic attitude tic of the left arm whereby it was firmly
applied against the body. No important alteration in electrical
contractility was discovered, although the response in the upper part of
the left trapezius--which, by the way, was more voluminous than on the
right--was brisker than in its fellow. On the other hand, the right
deltoid, sternomastoid, and pectoral, were more excitable than on the
left.
Here, of course, the evidence supplied by electrical examination only
served to confirm the knowledge gathered from other clinical sources.
VASOMOTOR AND SECRETORY AFFECTIONS
Disorders of the vasomotor system rarely fail to assert themselves in
the subjects of tic, but they do not in any wise differ from such as are
met with in the majority of "nervous" individuals. The average sufferer
from tic is emotional, and apt to betray his emotion by blushing for the
most childish reason. This symptom may be in itself trifling enough, yet
it may afford the earliest indication of mental instability the nature
and extent of which subsequent research will determine. It is even
conceivable that fear of blushing--the _ereutophobia_ of Regis--may be
at the bottom of certain gestures intended to conceal the heightened
colour the apparition of which is so humiliating. The form they assume
is generally a movement of the arm or hand over the face, to mask the
momentary discomfort, and while in most instances they are no more than
stereotyped acts, they may develop into full-blown tics.
In regard to secretory affections, we have frequently observed the
concurrence of hyperidrosis and emotional phenomena in those who tic.
Young J., S., P., are cases in point. The slightest exertion, the least
effort of attention, are followed by an extraordinary secretion of
sweat, entailing constant carrying of a handkerchief in the hand, and
ceaseless mopping of the forehead or temples. This performance becomes
stereotyped, and is gone through even when there is no perspiration at
all. Suppression of the handkerchief sometimes causes actual malaise,
but this injunction must never be forgotten if a cure is to be effected.
[Persons afflicted with tic often develop a sort of visceral instability
which betrays itself in indigestion, dyspepsia, constipation,
diarrhOEa, and in every variety of dietetic and alimentary caprice.
It is rare to meet with troubles of micturition, nocturnal enuresis
scarcely deserving mention owing to its frequency among all young
degenerates and to its being so commonly the outcome of neglect.
Oppenheim,[58] however, considers diurnal enuresis worth including in
the symptomatology, and Brissaud[59] has described polyuria and
pollakiuria in association with obsessional preoccupation. These are
really functional disturbances in which increased desire is followed by
increased vesical action, and may be regarded, if one likes, as
micturition or sphincter tics.[60]]
AFFECTIONS OF SENSATION
Generally speaking, objective disturbances of sensibility do not occur,
and while subjective changes are more frequent, they may be entirely
lacking even in long-standing and aggravated cases. What the patients
usually complain of is a more or less persistent, disagreeable,
uncomfortable sensation, rarely described as painful, and often compared
with a feeling of stiffness or fatigue. Or, again, they may be conscious
of a sense of constriction or of dragging in the affected muscles,
either at their insertions or in the muscle belly, or sometimes in the
joints concerned. These subjective sensations are characterised by
extreme variability in time and in degree. Moreover, the accounts given
by patients of their own sufferings ought to be accepted with reserve.
Not merely are they ready to exaggerate and incapable of accurately
depicting and localising their sensations, but they also exhibit a
curious tendency to false interpretation: they attribute an erroneous
pathological significance to their feelings, and proceed to elaborate a
thousand ridiculous variations, thereby inviting in a sense the eruption
of fresh tics. In all this behaviour their mental imperfections are
abundantly manifest.
We may remind ourselves in this connection how O.'s various inventions
had no other effect than that of provoking new tics, and another
illustration is to hand in the case of S., an account of whose mental
torticollis will be found in a previous chapter.
Any trifling item of passing interest used to make S. forget
altogether the more or less acute pain he experienced in his neck
and shoulders, and reacted no less successfully on his torticollis.
When systematic and methodical exercise of the muscles was ordered,
nothing was more natural than that their long period of inactivity
should have the result of causing a vague feeling of stiffness in
them with the unwonted action. Yet S. never dreamed of such an
ordinary explanation, but pessimistically exaggerated the
sensation, and deemed it an infallible sign of the spread of the
disease. It proved to be a simple enough matter, however, to
convince him of its harmlessness, for it was sufficient to remind
him of the corresponding stiffness he had felt after his first
attempts at riding and fencing, and from that moment he ceased to
pay any attention to it and therefore to complain.
With spasm, on the other hand, pain is more frequently, though not
always, associated. It may be said, of course, that since a tic may be
evolved from a spasm, the pain of the latter is really the exciting
cause of the former, but in the tic as it is constituted all these
initial disturbances have disappeared, and what the patient does feel is
the consequence of excess of muscular action or of articular
displacement. His dolorous sensations form the sequel, not the prelude;
they are not symptoms, but, so to speak, complications.