THE DIFFERENT TICS
This chapter we shall devote to a review, necessarily incomplete, of the
principal sites in which tics are to be met with. We do not pretend to
have collated every known case observed up to the present, and we
foresee the likelihood, moreover, of new tics coming into being. Their
numbers are as unlimited as is the diversity of functional acts of which
they form the pathological expression. We must content ourselves, then,
with the consideration of the most familiar and most recent examples.
A rational classification would entail discussion of the various modes
of derangement to which functional acts are liable, and this would
demand in its turn a preliminary tabulation of function. How onerous
such a task is, is patent from the uniform imperfection of the attempts
already made, and the equivocal nature of their conclusions.
We have studiously avoided the designation of a tic by the muscle or
muscles that determine it. To specify the precise muscle involved is
sometimes attended with no little difficulty, while if several, as is
customary, are concerned, their association is rarely anatomical;
indeed, this is one of the chief aids to diagnosis between tics and
spasms. Should the convulsion chance to follow an anatomical
distribution, neighbouring muscles are apt to participate as well. Hence
it is advisable to name a tic after its morphological situation, or,
better still, from the functional act of which it is, in Charcot's
phrase, the caricature.
This is the plan we shall pursue in our successive examination of the
different parts of the body disposed to be the seat of tics.
FACIAL TICS--TICS OF MIMICRY
Of all tics, those of the face are the most frequent, and the most easy
to see. No other part is as rich in muscles whose functions are so
diversified--nictitation, mastication, suction, respiration,
articulation, etc. Moreover, the face is the abode of the mimic
expressions, each one of which is the revelation, by muscular play, of
some sentiment, or passion, or emotion. Hence the idea has been
entertained of adopting a physiological classification. In the smiling
tic of Bechterew, for an instance, the muscular contractions are framed
into a smile in the absence of any provocative to mirth; in a similar
fashion, the sniffing tic brings to mind the inhaling performances of
snuff-takers.
Facial tic is frequently unilateral. It is rare to find the whole
muscular distribution of one facial nerve involved, however, this being
a property rather of spasm, as is also the restriction to a particular
branch. A common event is the simultaneous abstention of some facial
muscles and implication of others belonging to a different nerve supply.
If the condition is bilateral, as a general rule only those muscles on
each side co-operate that are wont to act in concert for the
accomplishment of some function. In a case reported as bilateral facial
spasm by Claus and Sano,[61] in which both sides of the face and neck
were affected, the exaggeration of the convulsions by emotion, their
curtailment daring rest and disappearance in sleep, coupled with the
fact of their temporary arrest by recourse to subterfuge, suggest that
the condition is really one of tic.
The contractions of the facial muscles are usually associated to produce
a more or less complex grimace. Movements of forehead, eye, nose, or
mouth, may succeed each other or be superimposed one on the other
without any preconceived order, or the tic may consist in the
synchronous activity of two or more muscles.
Of course any and every facial tic may occur by itself, but careful
investigation will often reveal concomitant reactions of other muscular
groups. The sniff that accompanies puckering of the nose indicates the
engagement of the muscles of inspiration.
Facial tic, moreover, may be tonic as well as clonic, instances in point
being closure of the eyelids, wrinkling of the forehead, twisting of the
nose, distortion of the mouth, etc., of longer or shorter duration.
Any of the facial muscles may be attacked by tics. These commonly
furnish an illustration of functional disturbance of mimicry, as in
Oppenheim's cases of tic limited to the frontales, whereby astonishment
or dismay was expressed, or in contraction of the superciliary muscles,
which conveys a look of pain or of mournfulness. Spread to the scalp
muscles may take place, causing a perpetual to-and-fro movement of the
hair, of which O. and Miss R. supply examples. The platysma is sometimes
the seat of a tic. One of Oppenheim's patients was a child with
alternating twitches of his two platysmas; it is of interest to note he
was able to contract either voluntarily. This condition is generally
associated with similar contractions in other facial muscles, as in a
case of facial and palpebral tic with platysma involvement recorded by
Meirowitz,[62] or as in young M.
A not infrequent accompaniment is a shrug of one or both shoulders, due
to synergic contraction of the trapezius. The resulting complex may be
considered an act of mimicry in so far as it is an expression of
disdain.
TICS OF THE EAR--AUDITORY TICS
The muscles of the external ear come often into play. One of our
patients had a tic of the left ear, consisting in visible elevation of
the pinna. A case of tic of the ear muscles has been described by
Romberg, and another by Bernhardt, in the distribution of the occipital
and posterior auricular nerves. Reference is made by Seeligmüller[63] to
a ten-year-old girl suffering from unceasing involuntary contractions of
the eyelids and of various head and neck muscles, with wrinkling of the
forehead and movements of the ears. His original diagnosis of chorea was
discredited by his subsequently learning that the child, in common with
a younger sister and a brother, had for several years been exercising
herself by making faces, and in particular by attempting to move her
ears.
It is quite conceivable that certain middle-ear phenomena are comparable
to the tics. O. used often to complain of hearing noises in his right
ear, which came and went with his tics of face and neck. Now, it is well
known that the probable explanation of the humming sound attending
forcible closure of the orbiculares palpebrarum is the variation in
labyrinthine tension due to the synergic contraction of the stapedius.
This absolutely normal effect may be exaggerated by predisposed and
preoccupied individuals into a sort of auditory tic.
TICS OF THE EYES--NICTITATION AND VISION TICS
For the sake of precision, tics of the eyes may be subdivided into
eyelid tics and eyeball tics.
A. _Eyelid Tics._--These, perhaps the commonest of all tics, may be
either unilateral or bilateral. They consist simply in a palpitation of
the upper lid, repeated at irregular intervals, and differing from
ordinary blinking only in augmented frequency and abruptness. The form
they usually assume is that of a wink, attributable in the first
instance to contraction of the orbicularis, but supplemented by the
zygomatics and muscles of the nose.
The tonic variety of the same tic is constituted by a contraction of
inordinate length, the outcome of which is the all but permanent
maintenance of the eye in a half-closed position. The suspension of this
tonic tic by volitional effort accentuates its distinction from
contracture. In one of our patients a tic of this nature, which gave a
singularly sleepy cast to the features, was easily relieved by suitable
gymnastic treatment. The converse condition obtained in another case,
where excessive gaping of the palpebral fissure contributed an unwonted
fixity to the expression, which simultaneous contraction of the
corrugator supercilii served to heighten into one of wild anger. These
two tics corresponded to two diametrically opposed traits in their
subject's character--viz. nonchalance and impatience respectively, and
it is interesting to recall in this connection how the varying moods
depend for their physiognomical delineation chiefly on the degree of
curvature of the palpebral arc.
Valleix,[64] who employed the term "idiopathic facial convulsion" to
designate tic, cites a case where even in moments of tranquillity the
left eye seemed slightly smaller than its fellow, by reason of a feeble
contraction of the orbicularis. Persistent grimaces of this kind
resemble tics of attitude and stereotyped acts, and the possibility of
their occurrence must not be overlooked, once the diagnosis of facial
paralysis or spasm has been rigorously excluded.
The terms blepharospasm and blepharoclonus, sometimes applied to tonic
and to clonic involuntary palpebral contractions respectively, ought to
be strictly reserved for spasms and contractures properly so called. For
example, von Graefe's case of blindness consequent on permanent closure
of the eyelids in a child is undoubtedly one of blepharospasm. No tic
could have been attended with such a result, whereas compression of
branches of the trigeminal at their points of exit might determine
reflex tonic contraction of the orbicularis, and so, for that matter,
might a central lesion. Hence in these circumstances it is correct to
use the word spasm.
Palpebral tics are among those that ordinarily begin by a spasmodic
reaction to an extraneous source of irritation, such as that yielded by
a foreign body, a speck of dust, an eyelash, or by any form of
conjunctival inflammation.
Eyelid tics (says Parinaud[65]) are known to ophthalmologists as
clonic blepharospasms. Their starting-point is always some
peripheral stimulus, in particular an everyday variety of
conjunctivitis characterised by the presence of granulations in the
lower part of the sac. To discover these granulations it may be
necessary to explore the internal aspect of the lid. In my opinion,
they are a prolific cause of tic, especially in young children, and
their removal effects a cure in the vast majority of cases.
It is only when the blinking abides in spite of the suppression of the
exciting cause that it can be comprised in the category of tics,
otherwise the fact of its being contingent on the continuance of the
irritation shows it is a spasm.
A bright light sometimes suffices to initiate these conditions. During a
course of sittings for her portrait, G., a little girl eleven years of
age, acquired the habit of drooping one eyelid slightly to shield the
eye from the somewhat glaring light of the studio, but the persistence
of this movement in other surroundings was evidence of its degeneration
into a tonic tic.
Noir quotes the case of one of his colleagues who was for a long time
inconvenienced by a most disagreeable blinking, which he held to be a
tic; but a simple explanation was forthcoming in the unusual length of
some of the eyelashes on the outer part of the upper lid having caused
their entanglement with others in the under one, and when they were cut
off the spasm disappeared.
In the following instance, reported by Toby Cohn,[66] the diagnosis
remains undetermined:
The protracted use of a magnifying glass in the left eye was the
means, in a watchmaker, of inducing occasional localised twitches
of the orbicularis, which were not slow, however, in spreading to
the whole of the left half of the face. They may at first have been
an involuntary motor response to nipping of palpebral twigs of the
trigeminal, but at a later period their independence was constant
and pronounced. With certain associated movements such as
articulation or deglutition, or during the act of wiping the nose
or shutting the eyes, the form they assumed was tonic. There were
neither subjective nor objective sensory phenomena to note.
We have recently had the opportunity of observing a genuine case of
eyelid tic, of obscure origin perhaps, but one whose clinical features
eliminate the hypothesis of spasm.
Brif., a metal polisher, forty-seven years old, came on March 10,
1902, to Professor Brissaud's clinic at the Hotel Dieu, complaining
of involuntary closure of the eyes, especially when out walking. In
his family and in his personal antecedents there was little or no
neuropathic or psychopathic tendency. The sole trouble for which he
sought advice was this spasmodic shutting of his eyes, rare enough
under most circumstances, but aggravated instantly by a walk of
even a few paces.
The onset had been quite insidious eighteen months previously, and
at the first the average frequency was scarcely more than thrice or
four times daily. Whenever Brif. passed into direct sunlight the
movement was particularly liable to occur. As long as he remained
seated at his work he was free from it, while he had but to rise
and take a step or two for it to reappear and forthwith commence to
repeat itself. At home any effort engaging his attention inhibited
the tic, nor was there any sign of it in the course of our
interrogation and examination of him.
Even when he was on his feet, the incidence of the act was not
always uniform; if promenading with his wife and children, or
fishing along a river side, or running to catch a tram, he was not
hampered by his affliction. When he rose in the morning, it made
its appearance ere he could reach the window to look out. During
his journeys to and from his place of business, he was generally
unable to moderate the spasmodic movements, particularly towards
evening, whereas his professional pursuits in the daytime, and any
occupation--such as reading the newspaper--when at home again,
wholly counteracted the inclination to tic.
The production of this untimely gesture of his Brif. was disposed
to attribute to the action of sun or wind, though he acknowledged
the regularity of its occurrence irrespective of either. In its
actual nature the contraction was tonic in type and of several
seconds' duration, so that he used to cover some yards with eyes
shut. From the outset the will had always exercised a marked
influence on it, so much so that on certain days and for a certain
space he could check the convulsion, and even when it was prolonged
he contrived by volitional effort to open his eyes sufficiently to
pilot himself in avoiding obstacles.
Careful search by the ordinary tests at the Quinze-Vingts hospital
failed to reveal any abnormality whatever in his eyes. On our part,
we satisfied ourselves that there was no restriction of the visual
fields.
As far as his mental state was concerned, its chief peculiarity was a
somewhat childish turn of mind, a _soupçon_ of that psychic infantilism
so common in the subjects of tic; in addition, he was of an emotional
temperament, and prone to perspire or blush for no valid reason. He was
further a victim to a premature baldness which was hereditary in the
family, and which may be cited as a physical stigma of degeneration.
B. _Eyeball Tics._--The extrinsic muscles of the eye occasionally
participate in the tics we have just discussed. Assiduous observation of
patients suffering from blinking tics will enable the physician now and
then to detect movements of the eyeball behind the lowered upper lid.
In the case of F., for instance, with each tic of the lids the eyeballs
deviated briskly upwards and to the left. Similarly Miss R. turned her
head from right to left at the same time as the eye moved obliquely to
the left and in an upward direction. A patient mentioned by Otto
Lerch[67] used to open and shut his eyes while rotating the eyeballs and
throwing the head back. Occasionally he inclined his trunk to one or
other side, accompanying the act with disagreeable little grunts.
The eruption of these tics may equally be attributed to some foreign
body or minute conjunctival granulation, as was the case with a small
child of ten years under our care, who, in spite of the withdrawal of
the irritating particle, acquired the trick of tickling the inner
surface of his upper lid by rolling his eye about whenever he happened
to blink. The delight he took in this trivial manOEuvre led to its
mechanical reiteration, and was the means eventually of its developing
into a tic which required a sufficiently delicate muscle exercise and
drill for its repression.
Defects in the visual apparatus sometimes induce abnormal movements and
attitudes which may become tics if careful examination does not elicit
their explanation.
Tic of the eyeball is generally associated with other tics, ocular or
facial, but it may occur alone and bear a resemblance to nystagmus, a
peculiarity we have noticed in a patient perfectly free from any
cerebro-spinal disease. It is almost always bilateral, but in some cases
of unilateral palpebral tic it is more pronounced on the side of the
latter.
Fixity of the eyes is characteristic of tonic tics of the extrinsic
ocular muscles, and gives a somewhat haggard or maybe merely attentive
expression to the countenance. Very frequently it escapes observation,
and indeed cannot be considered a tic unless there be an incongruity
between it and the ideas at that moment uppermost in the patient's mind.
Reference has already been made to the historic example of an ocular tic
in the person of Peter the Great. A series of interesting discussions
has taken place recently at the Neurological Society of Paris in regard
to the question of a tic of elevation of the eyes.
The patient, who had come to consult Professor Marie at Bicêtre in
December, 1899, was presented to the Society in the first instance
by M. Crouzon.[68] He entered the room with his eyes fixed on the
floor, but in a few seconds they had resumed their normal position
in the horizontal plane. At frequent intervals he raised them
upwards, or inclined his head so as to bring the pupils into
contact with the upper lids, the natural position of rest of the
globes being regained by a voluntary effort after each
displacement. When interrogated, he complained of not being able to
distinguish objects in an area of his visual fields limited by an
imaginary line drawn from his eyes to strike the ground at a point
six feet in front of him; otherwise his sight was excellent. The
history he gave was to the effect that five months previously, in
the enjoyment of perfect mental and physical health, he had had a
sudden stroke, and been unconscious for seventeen hours. No
sinister results ensued till four days later, when he lost his
vision, began to articulate very indistinctly, and failed to
recognise his wife, continuing in that state for the next two
months. Gradual recovery of speech and sight then commenced, but
the habit of looking upwards persisted. The absence of injury to
the visual apparatus, coupled with the presence of admitted
psychical disorders, decided Crouzon in his consideration of the
condition as a functional disturbance of the ocular muscles
analogous to tic.
In this connection the significant observation was made by Joffroy
that in the recumbent position the patient's eyes assumed their
ordinary place, suggesting a comparison with those dolls whose eyes
open or close according as they are held vertically or
horizontally. In his opinion, the eye mobility negatived any idea
of contracture consequent on central lesions.
A few months later the same patient was submitted a second time to
the Society, on this occasion by M. Babinski,[69] who declared
himself in disagreement with the hypothesis of M. Crouzon. In all
cases of mental torticollis, so called, the contrary movement to
that the execution of which is impelled by the spasm can from time
to time be accomplished, whereas in the case under discussion
downward as opposed to upward deviation was never obtained.
Further, the acute onset, with loss of consciousness, militates
strongly against the tic theory, and indicates rather a variety of
paralysis of the inferior recti, or paralysis of conjugate downward
movement, secondary to organic disease of the nervous system. The
difficulty experienced by the patient in inducing his eyes to
resume the horizontal position after once elevating them is
explicable on the assumption that the action of the superior recti
is no longer controlled by their antagonists the inferior recti,
the former passing into a state of temporary spasm, which is,
however, strictly consecutive to the paralysis of the latter.
M. Parinaud expressed himself as being in accord with M. Babinski,
and recalled certain rare forms of associated ocular palsies
occurring with paralysis of convergence, a combination manifest in
the subject in question. Curiously enough, in these cases the
disturbance of function is always ushered in by a stroke, which
justifies the belief in the focal nature of the lesion.
On the other hand, it was noticed by M. Ballet that the range and
facility of downward deviation varied inversely with the attention
devoted to the patient by the examiner.
On yet a third occasion this identical case provided a subject of
discussion at the Society, after being under the observation of
Professor Pierre Marie in Bicêtre.
Professor Marie[70] had failed to satisfy himself of the paralytic
nature of the phenomenon, and demonstrated the ease with which the
eyeballs moved downwards if the patient was made to hold his head
in the position of maximum extension, while in the attempt to look
at his feet--the head being held normally--they were forthwith
inclined violently upwards, and were so maintained for thirty or
forty seconds. The only view tenable was that he was suffering from
a sort of neurosis whose outward expression was this spasmodic
elevation of the eyes. Additional confirmation of the accuracy of
this hypothesis was supplied by a consideration of the
circumstances attending the commencement of the illness. The sudden
and unexpected apoplexy, of seventeen hours' duration, had been
accompanied neither by stertor nor by relaxation of sphincters, and
had been followed by an equally sudden return to consciousness, the
faculty of speech and the desire for food reasserting themselves
unexpectedly. The ensuing three or four weeks the patient had spent
in a curious delirious state, not unlike the post-seizure stage of
hysteria, a trace of which remained in the guise of certain
eccentricities of mind. The difficulty in his speech bore a
resemblance to hysterical stammering; and, finally, his visual
fields were concentrically and bilaterally restricted.
Of the subsequent history of the case some information was
forthcoming at a later date,[71] corroborating the opinion
originally propounded by Professor Marie. Simultaneously with the
diminution in intensity of the ocular spasm there had been grave
deterioration of the patient's mental level, as evidenced by the
development of ideas of persecution.
In the subjects of tic, and especially in cases of mental
torticollis, we have noted an analogous symptom, consisting in
inability to look down at the feet, except perhaps by the aid of
innumerable contortions, in contrast to the consummate ease of
upward glances. By making the person write at a blackboard, and
observing his action according as his hand is above or below a
horizontal plane through his eyes, one can soon convince oneself of
the reality of the occurrence, yet search will fail to discover any
sign of ophthalmoplegia.
Patients of this class evince a remarkable aptitude for elevation
movements, and the trouble they experience in depressing the
eyeballs is not of necessity to be construed as denoting paralysis
of the depressors, but rather indicates the presence of a tic of
the elevators, as Professor Marie says--a tic born of a habit, and
nourished perhaps by the dread such persons feel of witnessing an
exaggeration of their convulsive movements whenever they cast their
eyes down.
Our object in summarising this discussion has been twofold: at once to
note the existence of tics of extrinsic eye muscles, and to illustrate
the intricacies of their diagnosis.
A case not unlike the preceding, recorded by Noguès and Sirol,[72] was
characterised by inability to look above a certain height without
simultaneous raising of the head. Paralysis of the associated movements
of elevation was excluded by the fact of the gradual onset, without an
ictus, and by the absence of paralysis of convergence and of impairment
of speech and intellect. Basing their conception of the case upon its
post-febrile origin and the knowledge of hysterical antecedents, the
authors were disposed to regard it as a neuropathic manifestation.
It is conceivable that some cases of strabismus in children are nothing
more than vicious habits transformed into tics, since, as a matter of
fact, attentive supervision is frequently sufficient to effect a cure,
although no doubt in other cases some visual abnormality is responsible
for the condition.
Finally, since accommodation is a function subservient to the will, tics
of accommodation are theoretically possible. Our information thereanent
must be sought from the ophthalmologists. We have met with genuine
professional cramps of accommodation in those who use the microscope, as
well as in opticians, watchmakers, etc.
TICS OF THE NOSE--SNIFFING TICS
The form these tics commonly take is a puckering of the nostrils to the
more or less noisy accompaniment of a nasal inspiration or expiration,
associated usually with curling of the upper lip. They are principally
the sequel to some coryza, or inflammation, or some little nasal fissure
or furuncle, and in their essence constitute a derangement of a complex
functional act intended to ensure the dislodgment of any obstruction in
the respiratory passages of the nose, in which act the muscles of
inspiration or of expiration bilaterally co-operate. Where the
contraction of the nose muscles is unilateral, it is generally part and
parcel of a facial grimace confined to that side, and therefore an
anomaly of mimicry.
As for the pathogenic mechanism of the sniffing tic, it is simple
enough. Some little passing obstacle in the air-ways, some minute,
irritating sore, supply the occasion for an expiratory reaction, in the
first instance, with wrinkling of the nose and dilatation of the
nostrils, the repetition of which with each fresh sensation of
discomfort or of pain speedily becomes automatic, and persists as a tic
when mucus or abrasion has disappeared. So far from being obstinate,
these tics are eminently amenable to treatment if they are
uncomplicated. We have remarked on their occurrence, by the way, in the
case of O. and his sister, in young J., in G., in the wife of S., etc.
TICS OF THE LIPS--SUCKING TICS
The diversity of movement of which the buccal orifice is capable
warrants the statement that the tics of this class are almost too
numerous for detailed description. At times only the orbicularis oris is
involved, unilaterally or bilaterally; at others, concomitant
implication of the elevators and depressors of the lips, or of the chin
muscles and the platysma, furnishes the basis for all sorts of pouting,
biting, and sucking movements, and for every variety of smile and grin.
Here again the clonic form of contraction is the most habitual, although
that rapidity and abruptness which we commonly identify with such
contractions may not always be conspicuous. Guinon says of a young
patient of his, at one time addicted to innumerable tics, that the
relative sluggishness with which she opened and shut her mouth served to
inspire belief in the reality of the tonic tic of certain authors. As a
matter of fact, tonic tics do exist, and are sometimes associated with
another variety known as mental trismus, to the discussion of which we
shall revert ere long.
The action of the muscles of the lips is manifold: whether in the
expression of the emotions, or in the discharge of different functions,
they come into play in miscellaneous modes that may be the forerunners
of a multiplicity of tics. Of these, two types may be distinguished,
according as expansion or occlusion of the labial orifice predominates.
Under the one heading; come the caricatures of ordinary smiling or
laughing, under the second those that exaggerate the pursing or pouting
movements whereby we are wont to indicate chagrin, repugnance, disdain,
etc. Labial tics of this nature may be styled tics of facial mimicry.
In the infant that has long been weaned, and _a fortiori_ in the adult,
the continuance of the act of sucking must of course be considered a
functional anomaly; and while no doubt it is true we use our lips in
imbibing a beverage through a straw, or in extracting the juice from a
fruit, the action is different from that of the infant, and in any case
not to be compared with incessant sucking of tongue or thumb, or of some
object devoid of all nutritive value--merely a bad habit, perhaps, but
frequently indistinguishable from tic.
The most fruitful source of the tics under consideration is to be found
in labial cracks and dental mischief. More especially in children,
towards the end of the first dentition, the torment of loose teeth calls
forth interminable devices for relief, in seeking which tongue and lips
pleasurably co-operate. Once the tooth is out, the lacuna it leaves
provides a new sensation and a new reason for muscular activity.
Irregularity of the permanent teeth may also be referred to as a potent
factor in the causation of tic. It is therefore not superfluous
systematically to examine the teeth of all patients suffering from tics
of the mouth, and to extract any offender.
TICS OF THE CHIN
The muscles of the chin collaborate with other facial muscles in
expressional movement, and are similarly liable to be the seat of tics.
Massaro[73] has observed an interesting series of isolated "geniospasm"
occurring in twenty-six individuals of the same family during five
generations. The characteristic feature of these spasms was an
involuntary intermittent clonic contraction of the transverse muscles of
the chin, suggesting the look of one seized with fear or with cold. The
will did not always effect their inhibition, while emotion appeared to
aggravate and distraction to abate their intensity. With sleep they
vanished entirely.
TICS OF THE TONGUE--LICKING TICS
Tics confined exclusively to the tongue are of rare occurrence.
Moreover, they must be strictly differentiated from the tonic or clonic
contractions of the tongue muscles met with in hysteria, epilepsy, and
Sydenham's chorea, from the varying tremors that accompany organic
disease of cerebral or bulbo-pontine origin, as well as from those
"glosso-spasms" that may or may not be associated with twitches of the
facial musculature.
Functional polymorphism is no less marked in the case of the tongue than
in that of the lips; it participates in suction, mastication,
deglutition, as well as in respiration, phonation, and articulation,
while to "put out the tongue" at any one is equivalent to an expression
of contempt. It is, accordingly, no surprise to find the number of
tongue tics very considerable. Such, for instance, is the licking tic,
where the tongue is constantly being passed over the free border of the
lips, moistening them to excess; or the chewing tic, in which its
perpetual motion inside the mouth in every direction conveys the
impression that the subject is chewing something. Further, its contact
with the palate or the upper lip may yield different clucking,
whistling, or crowing sounds. Letulle remarks that the trick of
producing a little inspiratory whistle by the passage of a column of air
through an incompletely closed labial commissure--a common habit among
people suffering from dental caries--is not slow in developing into an
actual tic.
It has not fallen to our lot to observe the tonic variety of tongue
tics, none the less must we believe in the possibility of their
occurrence. Convulsive lingual movements, consecutive to disease of
mouth or teeth, or to lesions of corresponding nerves, are in all
probability spasms properly so called, to which disturbances of
sensation and of nutrition are often superadded. The tonic contractions
of tongue, lips, and masseters, which have been described in cases of
hypochondriasis and puerperal psychosis, are much more nearly allied to
the tonic type of tic, if, indeed, they are not to be identified with
it. A case has been put on record by Lange of tonic contraction of the
tongue during speaking and eating, each time that it touched the dental
arches. No doubt the condition was a sort of tonic tic. Sometimes
players of wind instruments are afflicted with a "professional cramp" of
the tongue, as Strümpell has reported.
Generally speaking, however, it is particularly in tics of language, and
in the various kinds of stammering, that the tongue muscles are
concerned.
TICS OF THE JAWS--BITING TICS--TICS OF MASTICATION
When the muscles of mastication are the site of tics, a medley of
nibbling and mumbling results, from which convulsive movements of the
same muscles consequent on cerebro-spinal mischief must be scrupulously
separated. A. von Sarbo's[74] case of clonic maxillary spasm secondary
to worry, depression, and an accident to the head, in a woman
thirty-four years old, and otherwise free from stigmata--analogous cases
are quoted by Strümpell and Ranschburg--was referred by him to a "spasm
diathesis," akin to the "diathesis of contracture," but its etiology and
evolution, together with a striking exaggeration of the knee jerks,
negative the hypothesis of tic.
The masseters are chiefly but not exclusively affected. Unilateral
implication of the pterygoids has been noted by Leube in a young girl
who was also an hysteric and a choreic. A patient of ours prefaces every
conversation by rapidly raising or lowering his inferior maxilla four or
five times, and blinking at the same time; the performance has its
variants, moreover, with the occasional addition of several nasal
expirations.
Chattering or grinding of the teeth is a frequent accompaniment of the
tics we are considering, and may have a disastrous issue in the
loosening, cracking, or breaking of these structures, as in the case of
O.
A still more common incident is injury to the buccal mucous membrane, a
significant instance of which is furnished by an episode in the history
of young J.
One day in June, 1900, J. experienced a feeling of discomfort in
the articulation of the lower jaw--the sequel, as a matter of fact,
to a slight alveolo-dental periostitis in the neighbourhood of a
bad tooth--and, interpreting the sensation as a new and grave
symptom in the march of his malady, forthwith proceeded to
investigate its development by playing with his maxilla. Then
ensued a perfect debauch of masticatory movements, in which
agreeable repetition of every conceivable grimace was joined to
protrusion and retraction of the jaw in the search after articular
cracks. He became so wholly preoccupied with this tic of
mastication that ere long he had begun to pinch the mucous membrane
on the inside of the right cheek between the hindmost molars, and
this fresh object of absorbing attention in its turn led quickly to
some excoriation of the mucosa on both sides. No halt was called by
the lower jaw to give the abrasions time for repair, with the
natural outcome that they suppurated and paved the way for an
attack of infective stomatitis with pain, fever, and malaise, which
necessitated the application of the thermo-cautery to the ulcerated
areas for its relief.
The explanation given by the patient of the evolution of the
process was controlled by interrogation of the parents, and no
doubt was left as to its genuineness. In the attempt to dispel the
articular discomfort, he had accidentally bitten himself, but the
consequent pain did not deter him from repeating and continuing the
act until its execution was irresistible.
In these and similar cases, the infelicitous rehearsal of the movements
of mastication is practically always associated with an imperative
desire to experience a sensation at the place actually bitten.
_Cheilophagic_ children, who bite their lips unceasingly, usually
commence by nibbling at some half-separated fragment of epithelium on
the edge of a labial fissure, with the inevitable result that the
erosion is enlarged and fresh particles of the mucous membrane are
detached. Youthful candidates for tics can scarce escape from the
vicious circle. A juvenile patient of ours, F., was in the habit of
gnawing so vehemently at the most insignificant little irregularity of
the mucosa that his lips were constantly chapped and bleeding, and as
they were no less constantly being moistened by saliva, a succession of
new cracks made their appearance, to be promptly torn apart by the
teeth. Local applications of nauseous substances are not always
sufficient to discourage these young "cheilophagics."
It is still more frequent to meet with _onychophagia_, a condition
rightly held to be a stigma of degeneration, and acknowledging the same
pathogenic mechanism as all biting tics.
So much for the clonic tics of mastication: we pass on to review the
tonic forms, the most curious of which has received the name of _mental
trismus_.
MENTAL TRISMUS
The characteristic feature of this tonic tic is an all but permanent
contraction of the masseters, which may, however, be completely relaxed
by making the subject put out his tongue, show his throat, etc. It may
be maintained during the act of speaking. Its intensity and its
persistence alike stand in rigorous relation to the nature and degree of
the mental affection that provides its occasion. In the insane it may
become so absolute an obstacle to nutrition that recourse must be made
to nasal feeding. Mental trismus resembles mental torticollis in that
any proceeding to which the patient attributes a special inhibitory
virtue is adequate to correct it, as, for instance, the insertion of a
cork between the teeth,[75] or the placing of a finger on the
incisors.[76]
It must of course be clearly understood that the diagnosis of mental
trismus can be arrived at only after previous elimination of every
possible source of confusion, such as tetanus, more rarely tetany,
meningitis, and acute bulbar paralysis, in addition to other
mesencephalic and perhaps also certain cortical lesions. One is inclined
to be less dogmatic where tonic or clonic convulsions of the jaws
succeed violent fright, as in a case of trismus of nine months' duration
recorded by Billot and Francotte. For that matter, trismus is met with
in hysteria, and may be regarded as a manifestation of that disease,
although this cannot always be invoked as its cause. We are not
attracted by Kocher's idea of assigning it to an "idiopathic spastic
neurosis," preferring to ally it to tics of the tonic variety.
Among the crowd of circumstances that reflexly give rise to trismus may
be enumerated abscess, caries, alveolo-dental periostitis, eruption of
the wisdom teeth, disease of the maxilla and the neighbouring soft
parts, and less commonly myositis or injury to the masseters. But so
long as any one of these causes is in operation, and especially if the
affection be attended with pain, we are dealing with a trismus spasm,
not a trismus tic.
S., whose psychical imperfections have already formed the subject of
remark, supplies an example of the combination of mental trismus and
torticollis, the former being the outcome of an inopportunely reiterated
voluntary act, and therefore comparable to the tics.
S. speaks with clenched teeth. His masseters are generally in a
state of contraction, yet when he is requested to put out his
tongue or to open his mouth, and when he is eating or engaged in an
animated conversation, any and every movement of the inferior
maxilla is accomplished with the greatest ease. According to his
story, this tonic tic of the masseters had its origin in the
forcible efforts he used to make to master his torticollis, in the
course of which he would close his mouth firmly; by dint of
continual repetition the habit developed into a tic, and persists
apart altogether from any endeavour of his to prevail against the
wryneck.
One of us has had a recent opportunity of examining a young woman whose
obsessions and fixed ideas, and tics of face and neck, indicated an
extreme degree of mental instability, in spite of intellectual power
above the average, in whom trismus of this type was very obvious during
eating and speaking. No effort, however concentrated, to open the mouth
was then of any avail; yet, on the other hand, she could sing to
perfection, and she could yawn, or show her tongue or her throat, in an
entirely easy and normal fashion.
The appearance of this trismus during the performance of certain
functional acts, and of these alone, is unequivocal evidence of its
mental derivation.
TICS OF THE NECK--NODDING AND TOSSING TICS--TICS OF AFFIRMATION,
NEGATION, AND SALUTATION
Regionally considered, the neck is second only to the face in furnishing
the greatest number of tics. Convulsive movements of the neck muscles
produce displacement of the head in all sorts of ways and directions,
giving rise to clonic tics of affirmation, negation, and salutation, and
to nodding tics, as well as to an important group of tonic tics which
find expression in differing forms of torticollis. The latter are so
distinctive in symptomatology and evolution, and have been the centre
round which so much discussion has raged, that a chapter must be set
apart for their special study.
Restricting ourselves for the present to such as are included in the
category of clonic convulsions, we find here abrupt vertical or
horizontal movements, as well as intermediate varieties compounded of
elevation, depression, inclination, or rotation. The most ordinary kind
is a sudden, brief jerk or toss of the head, repeated at irregular
intervals, and followed by instantaneous resumption of the primary
position.
Certain convulsive affections--for instance, the _spasmus nutans_ of
young children, the salaam tic, and what are known as "baboon
movements"--are still rather obscure and in many cases seemingly not
equivalent to tics. Their occasional association with strabismus or
nystagmus constitutes a plea for their possible dependence on some
encephalic lesion. In two cases under Oppenheim's observation the
nodding spasm appeared solely in the hours of the night and during
sleep. From want of more precise knowledge we must confine ourselves to
the remark that conditions analogous to, though not identical with, the
tics, in addition to others more specifically hysterical, have probably
been incorporated with them.
It is a task of peculiar difficulty to determine the share in the final
product to be apportioned to individual muscles, of which the
sternomastoids, as being the most superficial and the most obvious, are
apparently comprised the oftenest, though the trapezius and the muscles
of the underlying strata, such as the splenius, complexus, and other
smaller ones, may also assist.
According to Guinon, isolated contraction of one sternomastoid,
whereby the head is rotated and inclined once or twice or several
times consecutively, to the usual accompaniment of facial
contortions, is very frequently to be noted. If there occur
simultaneous contraction of the platysma, its fibres will be seen
to line the cervical integuments longitudinally from the chin to
the infraclavicular fossa. Synchronous involvement of the two
sternomastoids will flex the head and approximate the chin almost
to the sternum, but more commonly there is only a slight forward
inclination of the head exactly similar to a gesture of assent.
Extension and lateral deviation are less generally encountered.
Extreme variability characterises the exciting causes of these tics. It
has been remarked more than once that insecurity of the headgear the
subject happens to be wearing ought to be blamed; instead of
readjustment with the hand, a little toss of the head will make the hat
sit properly, and one need not search further afield for the germ of the
patient's tic. We have been able to trace this mode of inauguration
quite as conspicuously in young men as in young women. Prohibition of
unstable head coverings and resort to exercises of immobilisation
suffice for the tic's correction in early cases.
A not infrequent accessory symptom--viz. elevation of the corresponding
shoulder--may have a similar origin in peripheral excitation connected
with the patient's clothing. To escape the annoyance of a high and
narrow collar, or, on the other hand, to experience an agreeable
sensation by rubbing the skin, it is a very simple and a very easy
matter to lean the head on the shoulder, and to raise the latter at the
same time. The automatic reproduction of this gesture eventually ends in
the formation of a tic which removal of the collar entirely fails to
suppress. The first therapeutic indication, nevertheless, is to
interdict the wearing of the unsuitable collar, and to recommend the
adoption of others softer and more ample. Whatever be the opinion one
holds on the mechanism of tic, the influence of peripheral stimuli is,
according to Pierre Marie,[77] very considerable, and it is his
invariable practice, in the case of youthful subjects, to impress on the
parents the desirability of paying special attention to their
children's clothing, and of discarding any article that is either stiff
or heavy.
In one of our cases, a girl A., suffering from a nodding and
rotatory tic of the head, examination of the cervical region
revealed the existence of a line of cicatrices along the margin of
the sternomastoid, the vestiges of a previous operation for a
severe tuberculous adenitis. Some nerve filaments entering the
sternomastoid and trapezius had no doubt been cut, since these
muscles presented a minor degree of atrophy, and the irritation
arising therefrom, as well at that due to dragging on the adhesions
between the cicatrices and the underlying tissues, had been the
starting-point of a motor reaction primarily convulsive and
involuntary, but eventually habitual and automatic, and therefore,
with the subsidence of the excitation, a tic.
In another case[78] a month's systematic treatment served to curtail to
a noteworthy extent spasmodic head movements resembling those one makes
to get rid of a fly.
From another point of view, some of the tics of this class are merely
the exaggeration of certain functions destined for the expression of the
ideas of affirmation and negation. The nod of the head with which little
G. used to punctuate his "yes's" was logical enough, but he soon began
its repetition irrespective of his topic of conversation, and even when
saying "no"--a veritable tic of affirmation.
Numbers of people are in the habit of emphasising their words with those
to-and-fro movements of the head that we call gestures of approval. Now,
if the gesture be strictly appropriate to the thought present in the
mind, it cannot be identified with the tics. On the other hand, its
execution may be inopportune, in which case, provided the form remain
normal, it is merely a stereotyped act, and must exhibit the additional
features of abruptness and exaggeration ere it rank as a tic.
It is chiefly among the mentally infirm, such as idiots and imbeciles,
that the phenomenon of salutation occurs, and as its rhythm is an
element which is foreign to most ordinary tics, it is not likely to be
confounded with them.
These conditions apart, however, there is one highly specialised
clinical type that merits separate study--viz. mental torticollis.
MENTAL TORTICOLLIS
The medical world has long been familiar with various kinds of permanent
or intermittent torticollis presumably unconnected with muscular,
articular, or osseous lesions of the neck, and been as long divided on
the question of their tabulation.
Instances of this affection, bearing such widely differing names as
"hyperkinesis of the accessory of Willis," "spasmodic torticollis,"
"functional spasm of the neck muscles," "rotatory tic," etc., have
abounded in medical literature ever since the days of Duchenne of
Boulogne, Trousseau, and Charcot. Some twelve years ago now, the term
mental torticollis was applied by Brissaud[79] to a type of convulsion
of the neck musculature whose association with psychical disturbances
justified its description as a tic, and his opinions have been
abundantly confirmed by later observation.
As a matter of fact, mental torticollis is a tic which the patient can
ordinarily curb by some procedure of his own invention. It has its
_raison d'être_ in his mental imperfection. To obviate misunderstanding,
we must premise that the latter term is not synonymous with mental
alienation. It merely signifies that lack of mental balance, to
whatever extent, that is patent in all sufferers from tic.
From the motor aspect the tic under consideration may be characterised
as a functional disorder, consisting in the ill-timed, inapposite,
unceremonious, and exaggerated repetition of the function of head
rotation. Notwithstanding the large number of muscles involved, the
various modifications of movement possible, and the consequent
complexity of clinical types, each individual case is recognisable as a
tic. Let but momentary cessation of the muscular spasm be effected, and
the torticollis disappears without leaving a trace. Instantaneous and
total prevention is in practically every case attainable by resort to
some subterfuge, however vehement be the patient's contortions.
This device, whatever it be, may be called the "efficacious antagonistic
gesture," of which the simple placing of the index finger on the chin
may be cited as an example. Its field of operation is not limited to
mental torticollis, and we shall have opportunities of observing its
working in greater detail in other tics; but in the former affection the
constancy of its occurrence and the facility of its detection combine to
enhance its diagnostic value.
We hasten to remark, however, that conditions other than those we have
just mentioned are capable of producing convulsive movements in the
muscles of this region. In addition to such osseous, articular, and
muscular alterations as may determine a more or less permanent
torticollis, certain nervous lesions are apt to be succeeded by the
development of the spasmodic form, no longer as a tic, but as a true
neck spasm, the due recognition of which may be a matter of no little
perplexity.
Confining our attention for the present to torticollis tic--the mental
torticollis of Brissaud--we notice, in the first place, that it affects
either sex indifferently. The age of our youngest patient was eighteen,
though in a case of Raymond and Janet's the disease made its appearance
four years earlier. A hereditary neuropathic or psychopathic factor is
invariable, but similar heredity is the exception. Paternal alcoholism
has been quoted by Guibert as a possible predisposing cause, also a
rheumatic diathesis (Bompaire), family trembling (Feindel), hereditary
stammering (Noguès and Sirol), nervous and mental disease in the parents
(Feindel and Meige). One of Oppenheim's patients had a peculiarly
sinister family history: the grandparents were related by blood, one
being a diabetic as well, and the other a lunatic; the mother was
nervous, and the sisters either epileptic or psychically abnormal. This
case was characterised by the existence of generalised tics in
childhood, and by the development of torticollis soon after marriage.
Among personal antecedents may be noted hysterical attacks (Sgobbo),
emotional unrest (de Buck[80]), migraine (Brissaud), neuralgia
(Bompaire), irritability, eccentricity, caprice, absentmindedness,
neurasthenia (Brissaud and Meige[81]). Other favouring circumstances are
moral shook, intense and prolonged emotion, remorse, preoccupation
(Bompaire, Sgobbo, Brissaud and Meige, Grasset). Purely extraneous
causes seem sometimes to be the starting-point; for instance, toothache
and dental inflammation (Souques[*]), pain in the neck from carrying
heavy loads (Amussat[*]), chill (Legouest, de Buck, Guibert[*]).
[*] Cited by BOMPAIRE, _Thèse_.
At the Congress of Limoges a case was reported by Lannois where the
onset of torticollis in a young girl was determined by an overpowering
impulse to gaze at a little papilloma on her nose. The extirpation of
the growth was followed by an amelioration of symptoms that amounted
substantially to a cure.
Mental torticollis consecutive to anthrax of the neck has been described
by Briand.
Other conditions that have been invoked as possible causes are the
intoxications and infections, alcoholism, saturnism, mercury poisoning,
typhus, pneumonia, paludism, etc. Oppenheim has signalised the
reappearance, after several months of respite, of a torticollis
secondary to an attack of influenza. Overwork, accident, occupation,
have in their turn been suggested. In some cases, as a matter of fact,
it does seem that the last is of some import, since the incidence of the
torticollis is to a certain extent on those muscles that have been
actively employed in the pursuit of a profession, and they thus acquire
a sort of functional hyperkinesis.
Graff's[82] case of clonic convulsive contractions of the left splenius,
left deep rotators, and right sternomastoid, occurred in an individual
obliged, when carrying heavy loads, to maintain his head in a fixed
position to the left, and unable thereafter to turn it to the right.
In some quarters no little importance is attached from the pathogenic
point of view to the actual state of the muscles, and in particular to
atrophy or hypertrophy of the sternomastoids. Féré holds that sometimes
unilateral atrophy may occasion abnormal contraction of the opposite
muscle, but such muscular changes are, in our opinion, much less likely
to be the cause than the consequence of reiteration of movement or
conservation of attitude. Legenmann's case was one of tonic and clonic
convulsion of the right sternomastoid where there was a cartilaginous
tumour in the left.
The rôle played by ocular affections, by troubles of vision and of
accommodation, in the genesis of wryneck is frequently no insignificant
one, and it is curious how often patients attribute the mischief to the
strain of overwork in bad light. Strabismus (Walton) and ocular palsies
(Nieden) have also been known to lead to lateral deviation of the head
and permanent torticollis. There has been described a variety _ab aure
læsa_.
Albeit these factors have a share in determining the gesture and
attitude adopted by the patient, the resulting torticollis is not of
necessity mental. That which, according to Romberg, is provoked by
compression of supraclavicular nerve filaments is unmistakably a spasm.
To establish the diagnosis of mental torticollis, the existence of those
psychical anomalies that are common to all who tic must first be
substantiated, and then must one essay the reconstruction of its
mechanism. The inquiry may at first prove fruitless, of course, but
continuation of the search can scarcely fail to elicit tokens of mental
infantilism. In pursuance of this quest we shall find ourselves face to
face with the "big baby," the personification of childishness,
obstinacy, and caprice; we shall encounter the peevish, the sulky, the
whining; we shall see how their impotence in presence of their tic turns
their nonchalance to profound despair, how their failure to adapt
themselves to their malady convicts them remorselessly of volitional
imperfection. The utter weakness of their will, according to Déjérine,
justifies their being ranked as neurasthenics; but in the latter class
of case obsessional ideas are both fugitive and fluctuating, whereas
mental torticollis is dependent on a fixed idea of peculiar tenacity.
There can be no doubt that such patients, however undimmed their
intellectual powers may remain, ultimately fail before the everlasting
obsession of their disease, and if in some cases interest in daily life
and work continues unabated, a multitude of others become indifferent
and apathetic, and sink into a state of physical and moral infirmity.
To retrace the steps in the evolution of mental torticollis is a task
not always easy of accomplishment. Very commonly the affection
supervenes as the sequel to the unhindered repetition of a once
voluntary purposive act, a repetition become tyrannical through
volitional debility. One or two extracts from published cases will serve
to illustrate the truth of our contention.
1. To escape the pain of a dental abscess on the right side, of
only four or five days' duration, the patient had acquired the
habit of turning the head to the right and maintaining it so for as
long as possible at a time. Very shortly after the healing of the
abscess, the head commenced to move involuntarily towards the same
shoulder (Souques[83]).
2. Occipital neuralgia and pain in the neck led the patient to try
various positions to allay the agony, in the course of which he
found that rotation to the right brought transient relief. By dint
of repetition the movement became involuntary (Brissaud and
Meige[84]).
3. In this case the subject used to spend the whole evening inert,
arms folded, without reading or working, tilting his head forwards
or backwards to rediscover a "cracking" in his neck from which he
suffered--a proceeding that gradually developed into a tic
(Brissaud and Meige).
4. A schoolgirl was dissatisfied with the place allotted to her in
the schoolroom, and pretended that she felt a draught on her neck
coming from a window on her left. The initial movement was an
elevation of the shoulder as if to bring her clothes a little more
closely round her neck, then she commenced to depress her head and
indicate her discomfort by facial grimaces, and these eventually
passed beyond voluntary control (Raymond and Janet[85]).
5. In order to deceive his friends, the patient assumed a forced
attitude of gaiety when really sick at heart, by inclining his
head, raising his shoulders, and arching his back, and at the end
of a few months a bantering remark revealed the surprising fact
that he could not correct the position (Raymond and Janet[86]).
6. A woman used to pass the day sewing or knitting at her window
and amusing herself from time to time by pensively looking out into
the street. Not long afterwards she noticed how much more pleasant
it was to allow her head to turn to the right, and how troublesome
it was to keep it straight. At length she found this impossible,
except with the aid of her hands (Sgobbo[87]).
7. Worried by severe occipital pains, an individual became so
concerned to find they were being replaced by a feeling of great
weakness, that he let his head rest by inclining it now and then to
the left, an act which he is certain was the cause of his
torticollis (Feindel[88]).
One further instance may be cited from Séglas,[89] where a
neurasthenic lady, fifty years old, had been for three years a
martyr to vague pains which finally settled in her neck, and
asserted themselves on the slightest exertion. She sought to
mitigate her sufferings--a veritable topoalgic obsession--by
leaning her head on her shoulder, and the desire thus to procure
alleviation gradually became irresistible and the movement
unconscious.
Multiplication of examples is unnecessary. It is abundantly evident from
the above that the repetition of a deliberate and voluntary functional
act, co-ordinated and systematised, is the first step in the genesis of
mental torticollis.
The mere memory of a frequently repeated movement, especially if the
latter occur in the prosecution of one's avocation, may determine the
type of torticollis, as in Grasset's "post-professional colporteur tic,"
to which reference has already been made.
In the case of one of our patients, N., the prolonged and almost
exclusive use of certain muscles in the course of his business decided
their involvement in the condition of practically permanent torticollis
with which he was afflicted, and which was due to strong contraction of
the right trapezius and sternomastoid. It appeared that for eighteen
years he had been a cutter in a linen draper's, where it had been his
duty, for hours at a stretch, to cut rolls of stuffs with a large and
heavy pair of scissors, and in the execution of this work the right arm
was extended, the hand firmly pressed on the table, the shoulder
elevated, the head rotated and inclined to the left.
We cannot do better in this connection than recall the cases referred to
by Brissaud[90] when directing attention for the first time to this
variety of tics of the neck.
Here is a patient with energetic contraction of the muscles which
depress the head on the neck. She holds her head in her hands to
inhibit the movement, and succeeds. And she is quite convinced that
the force requisite for rectifying the vicious attitude is not
simply the power of her will acting on the muscles concerned, but
the strength of her hands. She has unconsciously doubled her
physical personality; her hands obey her will, her neck does not.
At least, this would appear to be the key to the situation, for it
can be well understood how much easier it would be to readjust the
position by action of the antagonist cervical muscles than by the
hands. The contraction, moreover, is entirely painless. It is a
trivial act of obsessional insanity, provoked by some or other
insignificant psychomotor hallucination.
Take this next man, who also must needs keep his head straight by
means of his hand--obviously no irritation of the spinal accessory
can be accused of originating the mischief, else would he be unable
himself to replace his head. It is merely the idea that is urging
him to its rotation. Try by force to prevent him from twisting his
head round, or try to twist it against his will, and the difficulty
of the thing will be at once comprehended. Or try to pull your own
two hands apart to see which is the stronger, and you will never
succeed, for the simple reason that abstraction of the will is
impossible. One hand can prevail over the other only if both
consent; the left cannot be in ignorance of what the right is
doing. A "partial" or "local" will is inconceivable; there cannot
be one for the head and another for the arm.
Here is a third patient, presenting an identical muscular spasm. He
is content to apply two fingers to his chin to overcome the
otherwise irresistible bend of his head to the right. Such has been
the situation for the last five years. No line of treatment has
made any impression on this neurosis, to which two factors
contribute, though one cannot say which predominates--an
unconscious, imperious, motor impulse, and a conscious though
ill-informed volition, powerless to arrest the convulsions by
simple and normal media, and obliged to resort to a puerile
artifice, to a sickly sort of deceit. The opposition furnished by
two fingers only cannot be of any avail, yet, however feeble be the
succour, the patient's imagination is thereby appeased.
Such (adds Brissaud), fashioned in the same mould, are the
"mentals" of whom I have been speaking. Recollect the ungovernable
impulse they feel to execute a convulsive movement that their will
might thwart; remember, therefore, at the same time, their
volitional enfeeblement.
Brissaud's earliest observations were followed at no long interval by
various articles, first of all the thesis of his pupil Bompaire,[91]
then others in collaboration with ourselves. The more recent
publications of Lentz,[92] Sgobbo, Noguès and Sirol, Raymond and Janet,
Séglas, Etienne Martin, etc., may be mentioned, as well as a
contribution by Grasset,[93] notable alike for the case it contains and
for the author's interpretations.