this affection has received general confirmation. We have seen
protracted cases of "spasm of the accessorius" cured, exactly as with
the tics, by widely differing therapeutic agents. In numerous instances,
according to Oppenheim, torticollis is not consecutive to any peripheral
or central change in the nervous system, but rather indicates
irritability of nerve centres. It is probable that the kinæsthetic
centres in the cortex for the neck muscles are the seat of the lesion,
and that their congenital and hereditary imperfection fixes the form the
convulsion will take.
These and similar facts are well calculated to corroborate the opinion
that mental torticollis is nought else than a form of tic. The subjects
of the disease are satisfied of two things--that no one and no
circumstance can hinder their torticollis from asserting itself, and
that their own antagonistic gesture is the sole efficacious preventative
at their command. The attempt to put the displacement right evokes acute
pain and stimulates opposition on their part. They prefer the display of
considerable resistance to the renunciation of their satisfaction in
their tic, and follow up any momentary restraint by a riot of
inco-ordination, in recompense for the brief sacrifice they have made to
preserve immobility.
The muscular contraction that deviates the head may be either clonic or
tonic, bringing it to one side by a series of convulsions and allowing
it to resume its original position in the intervals, or forcing it to
maintain a vicious attitude for hours. Innumerable variants may occur,
indeed are the rule, even in the same patient. In short, though mental
torticollis may generally be classed as a tic of attitude, it matters
but little whether the adoption of the attitude or the attitude adopted
constitutes the tic. They are simply two successive phases in the same
abnormal muscular act. The most elementary movement is rotation of the
head; it may equally well be inclined on one shoulder, or be both
inclined and rotated to one side, or it may be inclined in one direction
and rotated in the other. There may be accompanying elevation of the
shoulder, or the act may become a much more complex one, involving neck,
shoulder, and arm.
Each and all of the neck muscles may take a share in the torticollic
movement, but some are more commonly affected than others, in
particular the sternomastoid, whose contraction may either be
isolated,[94] or modified by trapezius, splenius, levator anguli
scapulæ, etc., of the same or the contralateral side. It is frequent to
find the head inclined to one side and rotated to the other by the
action of the sternomastoid, or displaced backwards and slightly turned
to the side of the contraction by means of the splenius. If the
sternomastoid and homolateral trapezius are acting together, torsion of
the neck is very pronounced and the skin over that area is deeply
lined.[95] It may happen that the head is rotated and inclined to the
same side, as in Grasset's case, where the curious combination occurred
of clonic convulsion of left trapezius and pectoralis major with right
pectoralis major and sternomastoid. In the same patient the left arm was
pressed against the trunk and the right extended posteriorly.
There are other instances where it would be more accurate to speak of
_retrocollis_, as in a case recorded by Brissaud, or _procollis_, the
two sternomastoids contracting synchronously, as in another case due to
Duchenne of Boulogne. The extreme degree of flexion induced in this way
was neutralised immediately by supporting the head; the adoption by the
patient of a reclining position sufficed to inhibit the tic's
manifestation.
Intensity and frequency of movement, duration and deformity of attitude,
all alike may vary in the same individual at differing times. Solitude,
tranquillity, and repose favour the diminution and even the entire
disappearance of spasmodic movements which fatigue, anxiety, and emotion
are prone to exaggerate. An instructive case in point is one of van
Gehuchten's,[96] the subject being a labourer twenty-five years old, in
whom a tic of the right arm and right sternomastoid of seven years'
continuance disappeared whenever the patient was by himself, to burst
out afresh as soon as he was conscious of being observed.
Distraction is a valuable sedative. A patient of ours used to pass the
day in twisting his head round with ever-increasing violence, while at
night, amid the smiling gaiety of the theatre, hours slipped by without
his betraying the least suspicion of his malady.
Occupation, on the other hand, may provoke the condition. Duchenne has a
reference to a case where rotation of the head to the right commenced
whenever the subject started to read, and ceased only with the laying
down of the book. In one of our cases the head kept turning whenever and
as long as the two hands were simultaneously engaged in some pursuit. If
one hand was disengaged, there was no torticollis.
As a general rule, excitement invites or increases movement, whereas
sleep frustrates it, and after a good night's rest several minutes or
even an hour or two may elapse ere the convulsions reassert themselves.
Acute pain is rarely met with in the disease we are considering, but
sensations of discomfort, of tension, of strain in the muscles, form a
common subject of complaint.
By way of example may be cited the case of one of our patients:
L. is eighteen years old, and has been suffering from torticollis
for the last six weeks. The chief movement is abrupt rotation and
very slight inclination of the head to the right, and the muscles
principally concerned are the left sternomastoid and the right
splenius. The head is sunk between the shoulders, of which the
right one is elevated synchronously with the rotation, and remains
so as long as the latter persists.
The displacement is effected by a moderately brisk muscular
contraction that rotates the head to the right on its vertical
axis, and succeeding contractions only serve to accentuate the
deviation or to maintain it when the head is beginning to revert to
its original position. There are none of those upward or downward
oscillations, those hesitating, tentative little jerks that some
patients make before assuming a fixed torticollis attitude. In L.'s
case the duration of the wryneck is exceedingly variable; sometimes
the head returns spontaneously to its place, and deviates afresh
immediately after, but its periodicity changes with the days, and
even with the minutes.
The torticollis is accompanied by a rather disagreeable sensation,
a feeling of fatigue in the muscles concerned, of "dragging" in
their bellies as well as at their insertions. The site of this
sensation is over the left sternomastoid, on the right half of the
posterior aspect of the neck, and deep in the right shoulder,
whereas the upper parts of the trapezii, the left half of the neck
and its anterior surface, and the right sternomastoid, are areas
that are free from pain.
Here, further, as in all cases of the same nature, the subjective
sensations differ from day to day, and moment to moment. It is just
as perplexing to localise these pains exactly as to fix the
topoalgia of a neurasthenic. The lack of precision of the answers
is no doubt explicable by the variability of the muscular
contractions.
Emotion, apprehension, the presence of strangers, tend to intensify
the spasm, which tranquillity and rest will attenuate. On the other
hand, the most trivial incident--a sudden noise, an unexpected
question, the act of swallowing saliva, of putting out the tongue,
etc.--will reawaken the latent torticollis; any surprise, any
movement, or even the idea of a movement, suffices for its
ebullition.
Under the influence of the will, particularly after a time of rest,
the head may sometimes reoccupy the mid position spontaneously, a
result unfailingly obtained by distraction also, as when the
patient is hearkening thoughtfully to her father's conversation. On
her "bad days," however, the use of even considerable force fails
alike to hinder the head's turning and to effect its replacement.
That is to say, the resistance offered by the torticollis to
reduction may at one moment be nil, at another, feeble, or
forcible, or even insuperable.
Some patients affected with mental torticollis seem to have lost the
sense of position of their head, others evince a want of precision and
assurance in the execution of different limb movements. Speaking
generally, it may be said that downward movements of the arms are less
good than upward ones, and that their synchronous and symmetrical
action is accomplished with greater ease than is the operation of one
only.
The debut of mental torticollis is usually insidious. Whether head or
shoulder be implicated first, the incipient motor reaction is
infrequent, inconsiderable, and transitory. Little by little its
frequency increases and its duration lengthens, till the end of a few
months sees the torticollis established.
It may happen that the onset is so stealthy that it eludes the subject's
own notice, and attention is called to his peculiar attitude by the
members of his circle. Not seldom the earliest localisation of the
condition in a particular muscle is abandoned in favour of some other,
and resumed at a subsequent stage. Occasionally the torticollis passes
from right to left, or vice versâ; occasionally, too, the clonic variety
may give way to the tonic after a few weeks or months.
It has been already remarked that at the outset the tic is infrequent,
and may depend for its manifestation on certain predetermined
circumstances, as, for instance, the exercise of the faculty of writing.
Such was the case with S., with P., and with N.
N. was a patient forty-eight years old, with a left torticollis
dating back twenty months. His account of its origin was to the
following effect: for some years he had been employed in a
commercial office, where from seven in the morning to eight at
night he was occupied in writing, head and body being turned to the
left. At the beginning of 1900, consequent on a succession of
troubles, he noticed that his head was twisting round to the left
in an exaggerated fashion while he was writing, and the rotation
gradually began to assert itself at other times, when he was
reading, or eating, or buttoning his boots. Even apart from any
other act, the rotatory movement soon became incessant, continuing
while he was on his feet, but vanishing completely if he lay down
or if the head was supported. At present he has the greatest
difficulty in writing, for his head at once deviates violently to
the right.
The spasmodic movements sometimes spread to the shoulder, arm, and
trunk, and, in one of our cases, to the leg. Should the condition be
advanced, it is frequently complicated by choreiform or athetotic
movements in the limbs, or by irregular and arhythmical tremors.
A case of this nature was shown at the Neurological Society of Paris by
Marie and Guillain[97]:
The patient, forty-nine years of age, was suffering from muscular
spasms that kept turning his head first to one side and then to the
other. Fixation of the head between the hands assured a few
moments' respite, but the convulsions were quick to reappear. The
left hand was constantly being brought up to the face in the
endeavour to procure immobility, while the arms were the seat of
abrupt jerking movements intermediate between tremor and chorea.
The various reflexes were normal; stimulation of the sole of the
foot evoked a flexor response on either side, and no symptom of
hysteria was forthcoming. The disease had made its appearance in
1879, when, without discoverable motive, the head had commenced to
tremble and to work round to the left. Section of the tendon of the
sternomastoid did not impede the development of the affection,
which two years ago increased in intensity, when the
above-mentioned movements in the arms were superadded. The
likelihood seemed to be that they were of the same nature and
origin as the torticollis itself.
In reference to this communication, the following remarks were offered
by Professor Brissaud:
It is true of all forms of functional hyperkinesis, that the
indefinitely prolonged repetition of the same act leads finally not
merely to muscular hypertrophy, but to a ceaseless over-activity of
contraction in all the muscles affected. That this hypertrophy and
hyperexcitability depend on some organic central lesion is not the
necessary sequel. A purely functional exasperation may entail
visible augmentation of movement, the cause of which is not
central, but lies in the external manifestation of muscular
over-activity.
The antagonistic gesture is, in some instances, contemporaneous with the
wryneck, although more usually it is not in evidence until months or
years after the distortion has become inveterate.
Mental torticollis is characterised by remarkable chronicity. We have
seen cases of ten or fifteen years' duration and more. Temporary
remissions have been known, however, and alternations with other tics or
with psychical affections. At the Congress of Limoges, the following
case was reported by Briand:
As the result of a bicycle accident, a young man developed a
torticollis which ordinary treatment was sufficient to cure, and it
remained in abeyance until he entered a government school, when its
place was taken by a tic of the shoulder, with twitching of the
mouth and eye. At the approach of the annual vacation the tic
disappeared, and the torticollis, for some simple reason or other,
became obvious again. The latter had once more been got under
control by the time the holidays were over, but on the patient's
re-entering school the shoulder tic again manifested itself, and
this sequence recurred several times. A permanent cure was
eventually effected, but he continued as psychasthenic as ever.
In another of Briand's cases torticollis alternated with astasia-abasia,
a sort of "mental paraplegia." The patient could not walk at all without
crutches, or without a little _minerve_, which he used either to steady
his gait or to keep his head straight.
No doubt facts such as these just given are rather uncommon, but there
is abundant reason for considering mental torticollis one of the most
tenacious and intractable of all tics.
TICS OF THE TRUNK
The rarity of isolated involvement of the thoracic muscles, and the
frequency of their inclusion in tics of the neck and limbs, arise from
the fact of their insertion into the bones of the extremities, and
consequently conditions affecting them will be dealt with in another
place. Omitting for the present all reference to the muscles of
respiration, we have to consider only the vertebral and abdominal
groups. These pass into activity in the rhythmical salutation and
balancing movements so common among idiots, movements bearing the most
intimate analogies to the tics, though their peculiarity of rhythm
justifies their separate classification.
Tonic contractions that find expression in attitude tics of the body are
generally associated with tonic tics of the neck and limbs, and in some
cases of mental torticollis the deformation they produce is extensive.
The material part played by the abdominal muscles in the function of
respiration explains their implication in respiratory tics. A curious
case of this kind has been published by Pierre Janet[98]:
A woman thirty-two years old had been afflicted for three years
with a respiratory tic that consisted in imitating with the lips
the neighing of a horse, and with a still more extraordinary tic of
the abdominal parietes. She appeared to "swallow her stomach"; in
other words, her abdomen, prominent enough in its ordinary state,
was flattened and retracted, and the skin so stretched and dragged
upwards that the umbilicus approached the costal margin. Just as it
seemed to be disappearing, to be "swallowed," relaxation of the
abdomen slowly took place, and this procedure was repeated ten or
twelve times a minute. Pressure on the epigastrium inhibited the
abdominal movement, but was accompanied by immediate renewal of the
neighing, whereas with the relief of the pressure the sequence of
events was inverted.
TICS OF THE ARM AND OF THE SHOULDER
In the upper extremity tics may affect the various muscles of the
shoulder, arm, or forearm. Shoulder tics are of frequent occurrence, and
often owe their origin to the discomfort of a tight sleeve or of a badly
fitting collar. They are generally a concomitant of neck tics, in
particular of mental torticollis.
In this connection we may recall the case of O., and supplement it by a
description of another--viz. young J.
This boy J. had always been "nervous," and affected with "nervous
movements" of face or limbs. At the age of thirteen years, when
playing in the house one day, he knocked himself against an open
door and bruised the shoulder near the outer end of the left
clavicle. Three or four days later all pain and discolouration had
vanished, and the child's movements were perfectly unimpeded again.
His tics continued as before.
Two months after this little accident was over and forgotten, it
was remarked that at the seat of the contusion there was a slight
swelling, quite painless and scarcely even uncomfortable, but
disquieting enough to the parents and thought to require
applications of neapolitan ointment and the actual cautery. This
line of treatment effected no alteration in the local condition,
but it had other far-reaching consequences, for the boy noticed the
anxious interest aroused by the singular exostosis, and began to
devote attention to it himself. From the moment that his parents
manifested their apprehension by words of pity and by solicitous
examination, his tics developed a preference for the left shoulder,
though continuing to exhibit themselves in the face and the right
arm. He would unexpectedly elevate or depress his shoulder, would
shrug it forwards or brace it back, accompanying the performance
with inclination of the head or abduction of the upper extremity.
He was very positive as to the painless nature of his affection;
his sole complaint was of a certain stiffness in the joint, and at
the thought of it came an impulse to move the shoulder which there
was no resisting. The twitching would disappear for a time for no
fathomable reason, and reappear again. By the exercise of a little
circumspection he could temporarily overcome it, and during sleep
it subsided entirely.
The facts--duly controlled and confirmed by the parents--that
involuntary shoulder movements preceded not merely the application
of the counter-irritants, but the accident itself, and that the
unique difference lay in the similarity of his shoulder tic to all
his other tics before the trauma, and in its marked preponderance
in degree and frequency after, especially subsequent to the
treatment, are of weighty diagnostic significance. Plainly the
injury and its sequelæ did not exert any causative influence on the
tic, and while it is conceivable that the clavicle may have been
cracked and an exostosis ensued, we must repeat that the
pre-existence of the movements in question negatives the
possibility of their being attributable to nerve irritation from a
periosteal overgrowth. The only effect which the accident and its
consequences had was to intensify the patient's preoccupation and
to determine the incidence of the tic.
By the month of October, 1900, the latter was at its height, and
had reached a state where differentiation of the movements and of
their muscular counterparts was attended with no little difficulty.
They could be resolved into four principal groups, whereby the
shoulder was raised, lowered, advanced, or drawn back,
respectively. The first of these presented no unusual feature
except that with it the head was commonly inclined to the same
side; but the act of depression was rather peculiar, inasmuch as it
was achieved by a sudden contraction of the inferior muscles of
the scapula, together with the pectoralis, which drew the humeral
head downwards, elongated the capsule, and stretched the deltoid
fasciculi over it. The space thus left between the separated
articular surfaces was partly filled in by the neighbouring
ligamentous and muscular structures. Anterior or posterior
projection of the shoulder took place at the expense of an actual
subluxation, the head of the humerus bulging under the pectoral or
the scapular muscles. Each and every movement was accompanied by
articular cracking, sometimes so insignificant as scarcely to be
pathological, to which, nevertheless, the boy attached extravagant
importance and devoted methodical investigation.
Ordinary arm movements were, without exception, unimpaired, nor was
any bony malformation discoverable. The two shoulders were
practically symmetrical, though the upper border of the trapezius
on the left side was, if anything, thickened and more prominent
than its fellow, and the same applied to the left scapular muscles.
Horizontal extension of the left arm revealed a slight
tremulousness, quite distinguishable from pathological tremor and
from fibrillary twitching, and wholly comparable to what is seen
when, by reason of a fracture or otherwise, a limb is for a certain
length of time prevented from executing movements of extension.
[Beating or striking tics (the patient using his own fist against
himself) arise from the attempt to alleviate some insignificant pain or
irritation; but tics of this kind are in their turn the exciting cause
of local discomfort, and so of fresh tics. In spite of the obviousness
of this, it is often difficult to convince the patient that his
movements are prior, not consecutive, to the unpleasant sensations.[99]]
Finally, tonic tics of the upper extremity find expression in attitudes
that vary with the localisation of the contraction. We have already had
occasion to observe this, which is an almost constant phenomenon in
mental torticollis, in the case of young J., in Madame T., and in N.,
where, it will be remembered, the all but permanent elevation of the
right shoulder seemed traceable to the habit of cutting stuffs with a
pair of large scissors.
TICS OF THE HANDS--SCRATCHING TICS
Scratching movements are infinite in their variety, and since the
co-operating muscles vary in each case, the question of muscular
localisation is of secondary interest.
The object in view in the act of scratching is relief from some such
source of cutaneous irritation as a pimple, an abrasion, a burn, the
bite of an insect, etc., and so long as the cause persists, the function
is being rationally exercised; but to persevere mechanically,
involuntarily, immoderately, in the absence of pruritus or of other
paræsthesiæ, is a sign that the functional act is growing into a tic.
Innumerable tics are thus developed, and they are intimately associated
with biting tics.
S. passes his hand every instant over his forehead, O. over his eyes, T.
over her lips, P. over his moustache, young J. over his budding
whiskers, etc., etc. These elementary tics are scarcely more than
stereotyped acts, and may maintain the semblance indefinitely, though
there is also the likelihood of their becoming immeasurably more
pronounced.
M. scratches his lips with his nails till they are bleeding; E. suffers
from a facial tic, and scrapes at his forehead and temples to such an
extent that his complexion is perpetually blooming with a crop of little
bleeding excoriations; in some places, as a result of ceaseless rubbing
and tapping, the skin is thickened and discoloured--a condition that
might be known as "scratchers' corns." Madame W. used to tear at her toe
nails with her fingers whenever she had retired for the night; and at
the present time, as a result of incessantly passing a fine gold chain
between the pulp of her fingers and the nails, she has succeeded in half
detaching the latter from their bed.
A case reported by Raymond and Janet[100] is one of unusual severity.
A little girl ten years old was covered from head to foot with
scabs and sores, some of which on the body were several centimetres
in diameter and looked very ugly. These she had contrived to
inflict on herself, in spite of every precaution and admonition. It
appeared that successive attacks of measles and of whooping-cough
at the age of five had entailed long rest in bed, and had been
followed by a tardy convalescence, in the course of which the
development of a few pimples on the forehead was the signal for her
to commence scratching them and any other part of her body where
there was the least discomfort, or where the skin was at all
roughened. This merciless self-mutilation ended in the production
of large and painful excoriated areas; nevertheless a tic had
sprung from the habit, and it remained inveterate.
Another analogous case is quoted by the same observers[101]:
In this instance, apart from the obvious existence of a confirmed
tic, the patient had a curious look about the eyes which a nearer
glance showed was caused by complete absence of the eyelashes. He
had a trick when speaking or talking of lifting his right hand and
running his finger carefully along the margin of the lids, and if
it encountered an eyelash projecting beyond the skin, he promptly
plucked it out. The endless repetition of this toilette rendered
the eyelids barren of lashes.
TICS AND WRITING
Are writing tics to be recognised?
Tricks and turns of writing, however ridiculous, involuntary, and
ingrained they be, scarcely deserve to be called tics. Those flourishes
and ornaments that some people take delight in adding to their letters
can no more be considered the expression of a pathological state than
the superabundant gestures, the redundant words, the exuberant mimicry,
of which others are so prodigal. They are simply modes of
exteriorisation peculiar to the individual, and if in their superfluity
and excess they go beyond the strict requirements of the case, still,
they are only mannerisms of writing or of speech. Their manifestation is
rigorously dependent on the performance of some function, and is not
preceded by an imperious need of execution.
More akin to the tics is stereotypy of written language, so common an
appanage of mental disease. The term is intended to include such habits
as repetition of a particular formula, underlining of words, constant
use of hyphens in the same way, writing of certain pages in a hand
differing from the rest of the manuscript. Séglas[102] has done
excellent work in the analysis and interpretation of these troubles. One
of his patients used every week to write letters bearing the same
complicated address, and signed invariably with the following rigmarole:
De Senez de Mesange, great Prince Napoleon, great Prince of the
Blood Royal and Imperial of the Universe, great Admiral, great
Marshal of my armies, ... great Procurator of the Republic, Royal
and Imperial, great President of the Republic, Royal and Imperial,
great Pope, great Duke, great King, great Emperor--Jupiter, Louis
XIV. and Louis XV.
Another would write after almost every sentence:
_Dieu et son droit_, let him be cursed in all that is most cursed
_qui mal y pense_.
This was a sort of exorcism, a cabalistic formula enabling the
persecuted unfortunate to defend herself against the wiles of the evil
spirit.
A tic of writing, however, is of a totally different nature. He who,
without pen or pencil, is constrained by irrepressible impulse to go
through the movements of writing with his fingers, convulsively,
impetuously; and he who, without rhyme or reason, feverishly traces
characters utterly at variance with the ideas he would express, are
alike subjects of a writing tic. Of the former, we know no
characteristic example, while in the latter case the study of the
phenomenon would lead us too far into the realm of automatic writing and
graphic impulsions. We must content ourselves with recalling its
occurrence in an undeveloped form in the case of O.
Among those who are affected with tics, disorders of writing are very
infrequent, even where the tic's exhibition is displayed in the upper
extremities. One of the distinctive features of tics, in fact, is the
brevity of the interruption they cause in the performance of any
voluntary act on the part of the patient. Tics of arm or hand effect but
little modification of his writing. He is rarely taken aback by his
tic's convulsive demonstration. He can permit the co-existence, on a
perfect understanding, of two automatic acts, normal and abnormal,
writing and tic.
One of Guinon's patients was wont to proceed in the following way:
if asked to write, he would lean on the table, pick up his pen, and
just ai it was about to touch the paper, make several little
movements of circumduction with his right hand, as a child does.
Thereafter, he would sometimes pass on at once to trace the
letters; at other times he would have to grind his teeth, contort
the right half of his face, put out his tongue, pucker his nose, or
dip his pen spasmodically into the ink ten consecutive
times--ejaculating ahem! ahem! the while--before being able to
commence. He would often cease altogether, to make one or two
grimaces, or to wave his hand about. As far as the actual writing
was concerned, its distinctness and evenness were no less
praiseworthy than its style and content, and though a glance at his
gesticulations led one to expect blots and irregularities in his
manuscript, he conducted his task with assurance and correctness.
Of course, if the tic, whatever it be, exceed a certain limit of
frequency and violence, accurate writing may amount almost to a physical
impossibility, in which case the patient usually discontinues, although
if called on to exercise his will he can always pen a few words and
even a few lines. However this may be, the spots and scrawls and zigzags
and shaky cramped characters we associate with such organic affections
as tabes, Friedreich's disease, paralysis agitans, etc., are wholly
exceptional in the case of tic.
While, then, disturbances of the function of writing are seldom
ascertainable in those who tic, we have convinced ourselves on more than
one occasion of the truth of the converse, that the exercise of the
faculty is sometimes intimately combined with the evolution of tics of
neck and shoulder.
S. dated his mental torticollis from the time when he used to copy
figures for several hours a day. As a matter of fact, he wrote an
excellent hand, and experienced no difficulty in performing the
necessary movements, but continued writing increased the rotation. N.'s
torticollis was the sequel to long spells of office work, during which
he never laid down his pen. In the case of L., the wryneck and the
convulsions of the right arm were preceded by a sort of writers' cramp
of the right hand, and subsequently of the left.
In the accompanying instance, the development of which one of us has had
the opportunity of observing, the appearance of the torticollis was at
first confined to occasions of writing, but gradually it came into
evidence with other arm actions, and eventually established itself in a
permanent fashion.
P., fifty years old, occupies a responsible position in a big
railway company, is director in a large office, and performs his
duties with peculiar conscientiousness and zeal. Naturally an
emotional man, he was much distressed by an unusually sad family
bereavement about the middle of 1900, which coincided with a period
of great overwork. As he was obliged every day to arrange
innumerable papers and affix his signature to them, he began to
notice that each time he wrote his name his head turned to the
right involuntarily, and he felt a sensation of discomfort in the
neck and right shoulder. He tried to remedy the faulty position by
holding his chin with his left hand; nevertheless, in the course
of the next few months the movement began to assert itself not
merely as he wrote his signature, but also when he cut his food at
table, or sharpened a pencil, or trimmed his finger nails.
_October 14, 1901._--Whenever P. proceeds to write, his head is
immediately rotated to the right and maintained in that attitude by
successive contractions. Simultaneously, the right side of the face
is distorted by a grimace, the right eye blinks, and the right
corner of the mouth is drawn down by a strong effort of the
platysma. The state of affairs is unaltered so long as he is
handling a pen, though, curiously enough, his caligraphy itself is
flawless. The more firmly he grasps his pen, the more violent the
spasms; the substitution of a pencil abates them somewhat, as does
writing on the floor with a cane, while if he traces letters in the
air in front of him with his finger, they do not occur at all. When
both hands are occupied in writing, the head still turns to the
right.
He was advised to incline his head on his right shoulder as he
wrote, and to force his right sternomastoid to contract, in
carrying out which instructions he managed to form several hooks
and rods correctly without any torticollic movement, and was both
elated at the success of the experiment and dejected by the thought
of his infirmity. Accordingly all writing was prohibited, all
signature making reduced to a minimum, and he was recommended a
simple pencil exercise, to be performed with slowness and
deliberation while the head was kept in the position just
mentioned. Identical rules were to be observed when eating, etc,
and a tepid bath was prescribed night and morning.
_October 21._--Some improvement has taken place. The patient is
less uneasy and less discouraged. Dissociation of the movements of
writing into their component parts and isolated execution of each
are accomplished admirably at the first trial, less well the
second, and at the third, rotation recommences. Fatigue rapidly
increases, and P. sinks again into impatience, enervation, and
despair. Occasionally his anguish is so extreme he is covered with
perspiration even after the most elementary pencil drill, and is
forced to mop his brows.
_November 21._--Improvement is maintained. He can now write various
letters and short words at his ease, though he still feels
uncomfortable in anything requiring a more sustained effort.
Otherwise, he is conscious of greater control over his head.
_December 15._--The amelioration has not persisted. While he was
paying a visit to the barber's, and having his hair cut, rotation
to the right began again, and when lifting his hat in the street to
salute a friend, he repeated the movement. At table, too, he
noticed it as he was in the act of bringing his glass to his mouth.
P. is consequently upset, and often plunged into tears.
_December 24._--The patient's condition is more than ever
deplorable. On the slightest provocation--indeed, on no provocation
at all--furious torsion movements force the head backwards and to
the right, while the right shoulder rises.
Complete rest in bed was ordered, yet after two or three days of
this repose the torticollis manifested itself even in the recumbent
position. As a result, he was quite unnerved and talked of suicide.
Another physician called in consultation agreed with what had been
done, confirmed the integrity of all the reflexes, including the
plantars, and recommended a course of electricity.
_January 20, 1902._--There has been no further change. P. stays
abed all morning, inventing endless arrangements of pillows and
dictionaries to prop his head. When he goes out for a walk, he
turns up the collar of his coat and leans his head on the point of
it.
_January 27._--The electrical treatment has been relinquished. He
has also taken one douche at a hydrotherapeutic establishment, but
expressed his dissatisfaction and vowed never to return. He then
departed to undergo a "water cure" in the country, since when he
has vanished entirely from observation.
More than once we have had occasion to notice that the degree and extent
of such neck and arm convulsions as are provoked or exaggerated by the
act of writing vary with the level at which the patient has to write.
With elevation of the arm the movements are weak and easily mastered;
conversely, lowering of the arm augments them in a marked manner. We
repeat, however, that in all these cases the handwriting itself is not
interfered with.
It is quite otherwise with writers' cramp, the so-called "graphospasm"
or "mogigraphia." This condition is purely and exclusively a disorder of
the function of writing, depending for its exhibition on the exercise of
this function, else is its existence concealed. For this reason it ought
to be differentiated from the tics, although, by its development in
obvious neuropathic or psychopathic subjects, it is closely linked to
them.
One of Oppenheim's cases was a lady whose husband suffered from
paralysis agitans; in her case, fear of becoming affected with the same
disease led to the development of writers' cramp. Sometimes it occurs in
families, and it may be a concomitant of genuine tics. In spite of the
affinity between these two sorts of functional disturbance, we do not
feel it incumbent on us to enter on a detailed study of scriveners'
palsy in this place.
TICS OF THE LOWER EXTREMITIES--WALKING AND LEAPING TICS
Tics of the lower limbs are infrequent, and seldom isolated. One of the
most habitual of these is the "kicking tic." Sometimes one leg knocks
against the other, as in O.'s case, or it is kicked out in front, or to
the side, or even backwards, after the manner of a horse. Tonic
convulsions of the leg muscles have been observed to give rise to
phenomena analogous to tonic tics. Tonic contractions restricted to a
particular muscle, or group of muscles, and accompanied by relaxation of
the antagonists, have been christened by Ehret[103] "habit contractures"
and "habit paralyses." Their characteristic feature is the fact of the
contracture being voluntary in origin. For instance, an individual
wounds the inner margin of his foot, and learns to escape the pain by
throwing his weight on the outer side. Voluntary contraction of the
adductors of the foot passes gradually into an involuntary stage, giving
place to spasmodic contraction, and the simultaneous inactivity of the
antagonists--in this case the peronei--leads ultimately to their
atrophy.
In Ehret's view the fact of loss of volitional control argues the
psychical nature of the affection, and a similar opinion is held by
Thiem, Jacoby, and Wolff, who attribute the analogous cases they report
to a sort of traumatic neurosis in which the psychical element is
preponderant. Needless to remark, the patients in question were not
suffering from hysteria.
In this connection ought to be recalled the cases described by Raymond
and Janet[104] under the title of "tics of the foot."
The first was a woman thirty-seven years old, who as she walked
used slightly to invert her left foot, forcibly dorsiflex the great
toe, and separate the remaining toes widely one from the other.
Notwithstanding its painful nature, the condition had persisted for
seven years, and had originated in a very interesting way. She
happened to be undergoing a course of mercurial inunction at the
same time as she was troubled with a corn. The idea struck her that
perhaps the application of the ointment to the corn might prove
efficacious, but while trimming the latter some days later, she had
the misfortune to cut herself. Dread of the possible evil effects
of the injury was followed on the morrow by an accession of cramps
in the foot, the continuance of which led to the deformity that
ever since had made walking a misery.
The other patient was a young man twenty years of age, whose gait
used to be arrested, after a walk of ten minutes, by sudden and
vigorous plantar flexion of his right toes. Momentary repose
sufficed to make the spasm disappear, but it constantly recurred.
Re-education and psychotherapy effected a cure in each instance, so that
their psychical nature cannot be called in question, nevertheless the
painful character of the affections must not be forgotten, and since the
occasions of their manifestation were confined to the act of walking,
they correspond rather to "functional" or "professional cramps." In any
case, they cannot be confounded with the painful cramps of the calf
muscles that characterise certain toxæmias and infections (alcoholism,
cholera, etc.).
On the other hand, there can be no doubt of the existence of definite
tics of walking--widely varying functional derangements of tonic or
clonic type, distinguished by the unexpected interruption of ambulatory
rhythm.
We have met with a patient (says Guinon) who would abruptly halt
and bend his knees at though he had just received a violent blow on
the hock for which he was unprepared. To see him, one would have
thought he was about to sink to the ground.
Such tics of genuflexion are not particularly uncommon. Oddo[105] has
recently recorded a very instructive example, whose pathogeny he has
been at pains to elucidate.
A little girl, Th., ten years of age, takes four or five perfectly
normal paces when she starts to walk, then bends down quickly to
the right, flexing her knee to an acute angle and inclining her
trunk forward with the deflection of her pelvis, just as a child
whose genuflexion in front of an altar has become mechanical by
repetition. The performance is sometimes so altogether sudden that
Th. actually falls on to her right side. One striking feature of
the case is that if she makes a tour of the room in order to be
observed at leisure, the inclination never fails to occur at
exactly the same point in the circuit--namely, when she is opposite
the observer. It is useless formally to interdict her from this
routine, for before one has time to notice any irregularity in the
gait her knee suddenly flexes at the bidding of an invincible
impulse, and a moment later, without any deviation from her path,
she has resumed her rhythmical step round the apartment.
This movement is not her only one, however. While she lies in bed
she can, by flexing her thigh on her pelvis, crack her joints loud
enough to be heard, and when she has been up a little while the
same action is exhibited. The absence of these cracking sounds
during ordinary walking, and their occurrence in the act of
genuflexion, very properly explain, as Oddo thinks, the origin of
the tic. It seems that the articulations at hip and knee on the
right side were affected as the result of successive attacks of
scarlatina and diphtheria two years ago, which necessitated a
prolonged sojourn in bed, and were accompanied with severe pain. It
is interesting to note that the tic made its appearance only after
the latter had considerably subsided.
Raymond and Janet[106] have reported the case of a young woman who
fell on her knees every few paces, rising again with facility and
taking a few more steps, to come down on her knees once more with a
loud noise. She never did herself any harm, however, and for that
matter the accident never occurred on a staircase or in a
unsuitable or dangerous spot.
Leaping tics are met with also.
Sometimes when walking, but more usually when standing quietly,
according to Guinon, the patients make little jumps or leaps in
their place, looking rather as if they were dancing than really
springing into the air. Some actually bound along, others run for a
yard or two.
Still more bizarre and complex tics have been described, in particular
by Gilles de la Tourette. One patient used to commence to run, then
kneel suddenly, then rise with equal abruptness. Another was in the
habit of stooping down, as if to pick something off the ground, and
smartly rising again.
The kinship of these and other similar conditions to the tics is
undeniable, and such seems to be the case with the yet more
extraordinary phenomena of _jumping_ in Maine (Beard), _latah_ among the
Malays (O'Brien), _myriachit_ in Siberia (Hammond). All these affections
show, among others, this peculiarity--that unexpected contact produces a
spring (Guinon).
In a recent thesis Ramisiray has depicted the dancing mania
(_ramaneniana_) of Madagascar, a condition allied to the latah of the
Dutch Indies, but more intimately connected with hysteria, perhaps, and
with the saltatory choreas, the saltatory cramps of Bamberger, St.
John's and St. Guy's dance, tarentism, etc. The exact nature of these
convulsive disorders is still _sub judice_, but in any case they present
more than a mere resemblance to the tics.
SPITTING, SWALLOWING, AND VOMITING TICS--TICS OF ERUCTATION AND OF WIND
SUCKING
In some tics the palatal muscles are found to contract, but this
contraction must not be confused with the spasmodic twitches of the same
muscles associated with facial spasm and due to central or peripheral
irritation of the seventh nerve. One of us has had occasion to observe
an excellent case in point in a young man afflicted with spasm of the
orbicularis and zygomatics on the right side, in whom synchronous
displacement of the uvula occurred with each twitch. The extreme
abruptness and rapidity of the muscular discharges, the inadequacy of
voluntary effort to check them, the absolute uselessness of prolonged
and systematic treatment, left no doubt as to the accuracy of the
diagnosis.
The occurrence of palatal spasm in intracranial lesions has, of course,
been recognised--in cerebellar tumour (Oppenheim), in epidemic
cerebro-spinal meningitis, in aneurism of the vertebral artery
(Siemerling and Oppenheim). It is occasionally associated with the
emission of clucking sounds, and with convulsive action of hyoid and
tongue muscles. In such cases the distinction between a tic and a spasm
is not always easy to establish. We may, however, readily recognise that
we are dealing with the former if the contractions of tongue, palate,
and larynx are contemporaneous with the execution of a functional act,
such as expectoration.
Among those who labour under obsessions, tics of expectoration are well
known. One of Guinon's patients, while making forced expirations, used
to bring his hand up over his mouth convulsively as though he were
afraid of spitting on some one in his neighbourhood.
A case of Séglas', from whom stigmata of hysteria were absent, was
possessed, among other things, with the fear of having swallowed
certain objects, such as pins, knives, etc. The obsession
eventually became so vivid and so intense at certain moments, that
it began to be accompanied with a sensation as of a foreign body
arrested in the OEsophagus, and the anguish thus created revealed
itself by various reactions, one of which consisted in excessive
salivation and ceaseless expectoration, entailing the carrying
about and use of numbers of handkerchiefs.
It is scarcely possible for the mechanism of deglutition, the orderly
succession of muscular contractions, to be interfered with by the will,
but increased frequency of these movements may constitute an
abnormality. Hartenberg's[107] case of deglutition tic was characterised
by a continual desire of swallowing saliva; the patient, it is true, was
an hysteric.
Rossolimo[108] has called attention to what he distinguishes as
amyotaxic troubles of deglutition, a dysphagia of which three types,
motor, sensory, and psychic, may be specified. Cases of the last form
had already been described by Bechterew.[109] The patient either suffers
from a genuine obsession, or is ever at the mercy of an involuntary or
even an unconscious dread of choking as he eats, a dread with which he
is powerless to cope, though in the case of others the phobia and the
dysphagia may alike be intermittent. In the majority of instances there
are grave hereditary or personal neuropathic antecedents.
Some people are afflicted with eructations so continual that they amount
to tics. One of us is acquainted with a family several of whose members
present this peculiarity in different degrees, yet none of them suffers
from hysteria.
Otto Lerch[110] has published a case of multiple tics, among which may
be enumerated opening and closing the eyes, rolling of the ocular
globes, tilting back of the head, with instantaneous recovery of
position, inclination of the whole trunk to right or left--each and all
of which movements are frequently attended, especially at night and in
the morning, by profound eructations.
Of course, the prominent place occupied by these signs in hysteria is
well recognised: the demonologues of old regarded them as an index of
the departure of the devils that dwelt in the possessed. In a case of
hysteria that came under the notice of Raymond and Janet,[111] a general
tremulousness of the whole body was replaced by a chorea of the right
arm, which in its turn was succeeded by the perpetual emission of
sonorous eructations. In another instance[112] inspiratory hiccoughs and
expiratory eructations co-existed. A similar example is cited by Cruchet
in his thesis.
In the same category of facts are included those to which the name of
_aerophagic tic_ has been applied. Various cases have been narrated by
Pitres and by Séglas,[113] the latter of whom, in a remarkably complete
analysis of the condition, has demonstrated its identity with the tics,
and written very instructive commentaries on his observations.
I was consulted (says Séglas) by a man thirty-four years of age,
who was sent to me as a hypochondriacal neurasthenic. No sooner had
he entered my consulting-room than I was astonished to find he was
giving vent to repeated sonorous eructations at very brief
intervals. His story was to the effect that several weeks
previously he had been suddenly seized in the middle of a meal by a
sort of vertigo, and had lost consciousness. A consideration of
subsequent events made it more than probable that he had had an
ictus; the patient, however, was for no apparent reason persuaded
that he had been poisoned by badly cooked food, and from that
moment became despondently preoccupied with the state of his
stomach. A few days later the eructations made their appearance.
A closer examination very soon dispelled the idea of their gastric
origin, seeing that the digestive functions were in every respect
normal, whereas the symptom in question occurred at any moment,
independently of the stage of digestion, and the gases evolved
were absolutely inodorous. On the other hand, one could easily
satisfy oneself that the eructations were preceded by an
inspiratory effort and by two or three very obvious movements of
deglutition, accompanied by a low, rumbling, pharyngeal noise, and
followed almost immediately by the expulsion of gas. Their
reproduction several times a minute was spasmodic in character and
irregular in rhythm, and continued, it might be, for hours.
Of this series of phenomena the patient had conscious knowledge
only of the last--viz. the eructations--and affirmed their
involuntary nature and his desire to be rid of them.
The influence exerted on them by various circumstances is worthy of
notice. Any emotion, or any reference on the part of the patient to
the condition of his stomach, tended to exaggerate them, while,
inversely, it was remarked by his wife that the distraction of
conversation, or of a promenade, or of musical séances--to which he
was passionately devoted--served to banish them instantaneously and
for as long as the distraction endured. Sleep suspended their
activity, but at any interruption of it they scarcely ever failed
to reassert themselves.
These considerations determined my view of his trouble as a
peculiar form of tic, which consisted in "muscular spasms
systematically harmonised to produce the alternating deglutition
and expulsion of a certain quantity of atmospheric air" (Pitres),
which therefore might be denominated an _aerophagic tic_.
Different varieties of this tic exist, according as the air swallowed is
derived from the exterior or from the lung, and depending on its
penetration into the stomach or simply into the pharyngo-OEsophageal
canal; and further, the physiological mechanism of the condition varies
with them.
Let us suppose that the swallowed air comes from the lung. In this
case, a certain quantity of air is imprisoned at the beginning of
expiration in the pharyngo-OEsophageal cavity, whose orifices are
firmly closed by simultaneous contraction of the muscles of the
palate, glottis, and base of the tongue. At this moment a brisk
contraction of the constrictors of the pharynx drives the
accumulated air out by the mouth, setting the membranes surrounding
the supero-anterior opening of the cavity into vibration in so
doing, whereby the air escapes as a more or less noisy eructation.
Should the mouth not open at this juncture, however, the air is
compressed and crowded back into the lower part of the
OEsophagus, whence it passes through the easily dilatable cardiac
ring into the stomach, to be expelled again by the mouth in the
same noisy way once it has accumulated in sufficient quantity.
The deglutition of external air is preceded by an aspiratory
thoracic effort; closure of the glottis forces the OEsophagus to
open under the stress of increased negative intrathoracic pressure,
and to suck air down. When aspiration ceases, this air is either
driven out forthwith, or gathered in the stomach, as we have just
seen.
One may sometimes notice that the act of suction is succeeded by
movements of swallowing, in which case the probability is that at
the moment of aspiration the closure both of glottis and of pharynx
prevents the penetration of atmospheric air into either the trachea
or the gullet, in spite of the differences of pressure, and that
these movements allow its passage through the OEsophagus.
Aerophagia is by no means, therefore, a simple involuntary movement, but
a combination of systematised muscular actions. In fact, it is a tic,
and as such has both a physical and a psychical side.
From the material point of view (to quote Séglas again), the
predominant symptom is the eructation, and the object in
determining the accessory symptoms is to distinguish it from
gastric eructations properly so called, the consequence of improper
fermentation. In our case the appetite is good, and the digestion
normal--tympanites, splashing, and abdominal pain are all absent.
The gases evolved are inodorous, and their analysis in different
cases (Ponagen, Hoppe-Seyler, Pitres, Sabrazès and Rivière) has
shown that so far from containing any abnormal constituent, they
have almost the same composition as atmospheric air. Application of
the ear to the vertebral column at the level of the stomach enables
one to detect a noise that appears to correspond to the passage of
air into that viscus, and less than a second later comes the
eructation.
Facts of another kind indicate the participation of a psychical
element. The activity of the tic increases under the influence of
the emotions and decreases or disappears momentarily at the bidding
of the will. Distraction, concentration of the attention on some
particular thing, speaking, reading aloud, are also calculated to
suspend its manifestations. In some cases, especially where there
is an association with hysteria, support is given to the theory of
its psychical origin by the observation that prolonged opening of
the mouth, and the administration of mica panis pills or of
distilled water tinted with methylene blue, have had a definite
effect in controlling the spasm (Pitres). Moreover, the
co-existence or pre-existence of intellectual troubles or mental
peculiarities is often incontrovertibly proved by a painstaking
psychological examination.
In reality this aerophagic tic is a symptom-complex encountered in
very different pathological conditions. No doubt its frequency is
greatest and its development highest in hysteria, but we are in
error if we suppose that it is the exclusive appurtenance of that
disease: its occurrence in our case of general paralysis is
evidence to the contrary. I have noted it where there was not the
slightest suspicion of hysterical antecedents. Nevertheless its
relation to pathological mental states of some form or another is
invariable.
It is often found in cases of insanity of the obsessional or of some
other type.
I have had an opportunity (says Séglas) of observing an instance of
aerophagia in a woman of fifty-four years, who for the last fifteen
years has been suffering from hypochondriasis in a delusional form.
She believes she has a hole in her head, and that her brain is
gangrenous; she is no longer conscious of her body, nor of her food
as it passes through. "It is like a cupboard empty of everything
but air." Grafted on this delusion is an aerophagic tic, upon which
the patient relies in support of her contentions. So little is she
able to withstand its ceaseless repetition that the sequence of
muscular actions continues though the tongue be held outside the
mouth or fixed with a spoon.
I have seen the same phenomenon in another woman, forty-six years
of age, afflicted with fixed and systematised delusions of
persecution. She imagined that she was being pursued by sorcerers,
who had cast a spell on her and were about to poison her, torture
her, break her on the wheel, etc. In addition to very distinct and
frequent verbal hallucinations and disorders of general
sensibility, she exhibited several tics, one of which consisted in
spasmodically closing her eyes, brandishing her right arm, and
uttering a string of incomprehensible words; the other was this
aerophagic tic, characterised by a jumble of quick swallowing
movements, pharyngeal grunts, and long-drawn-out, sonorous
eructations. All this performance was rehearsed two or three times
a minute as a sort of convulsive discharge, which she alleged the
sorcerers forced her to emit in spite of herself, exactly as they
coerced her into uttering a jargon she did not understand, and
wagged her tongue at their own sweet will.
To quote Séglas again in conclusion:
The air-swallowing tic is merely a syndrome common to various
pathological conditions differing widely enough, but all alike in
being associated with some degree of mental impairment, in which
perhaps may be discovered the actual cause of the condition. It
cannot therefore be looked upon as a simple spasm, based
anatomically on a reflex arc, but must be regarded as a reaction
whose substratum is a cortico-spinal anastomosis--that is to say,
it is a tic.
Tics of vomiting may be produced if the diaphragm be affected. Noguès
and Sirol[114] have reported the case of a woman with a
pharyngo-laryngeal derangement resembling vomiting, except as far as the
actual ejection of alimentary matters was concerned. She used to become
conscious of a sensation of constriction, and to feel the tickling of a
foreign body in the gullet; at this point the slightest pressure on the
neck provoked a convulsive attack, in which all the pantomime of
vomiting was gone through without the actual emesis taking place.
It is possible, as Noguès and Sirol think, that the trouble may have
originated in a reflex spasm, and that with the disappearance of the
primary irritation a new psychical factor operated to effect its
repetition and prolongation.
The designation of all these functional disorders as tics is not always
justifiable, and their separation from the corresponding normal act is
frequently a task of delicate diagnosis, but patient search for the
exciting cause and study of the concomitant mental anomalies will supply
the necessary indications.
TICS OF RESPIRATION--SNORING, SNIFFING, BLOWING, WHISTLING, COUGHING,
SOBBING, AND HICCOUGHING TICS
Respiratory tics are exceedingly numerous. They concern the diaphragm
and the muscles of inspiration or expiration, and are accompanied by
synergic movements of the muscles of the nose, lips, tongue, palate,
pharynx, as well as by laryngeal noises or by tics of the face and
limbs. They embody disturbances of various functional acts, and may be
subdivided into inspiratory and expiratory tics.
It is only as regards their frequency that such reflex mechanisms as
yawning and sneezing are liable to be modified by the intervention of
the will. Saenger[115] records the case of a woman twenty-nine years
old, not affected with hysteria, who used to suffer from attacks of
yawning and of stiffness in the arms, followed by rapid contractions of
the tongue lasting for about a minute. He describes the condition as one
of "idiopathic spasm"--probably a species of tic. It is in hysteria,
however, that functional variations in sneezing and yawning are most
commonly found, and the latter, moreover, may constitute the aura of an
epileptic fit. Yawning occurs in a most intractable form in meningeal
affections, and in cerebral and cerebellar tumours.
"Rhincho-spasm," a snoring tic, has been observed by Oppenheim in a case
of neurofibromatosis. In certain tics of this nature, and in sniffing
tics, the onset is sometimes attributable to the presence of adenoids.
Among various expiratory tics may be enumerated the habit of blowing
through one's nose or mouth. Schapiro has reported a case of expiratory
"spasm" due to contraction of the buccinators. Whistling ought to be
considered a stereotyped act, rather than a tic, as Letulle maintains.
Spasmodic troubles of respiration, defined indifferently as "spasmodic
dyspnOEa," "spasmodic asthma," "spasmodic cough," "asphyxial spasm,"
"nervous cough," etc., ought not to be classified as tics; in many cases
they are genuine spasms, arising from some irritation in sensory paths.
At the instant of any contact, or under the influence of a sudden noise
or a bright light, a patient of Edel's used to become distressingly
dyspnOEic. Evidently the condition was one of spasm.
Coughing tics also are of remarkably common occurrence. Many
individuals ceaselessly interrupt the thread of their conversation to
make more or less audible explosive expirations, for which there is
neither reason nor necessity, since the respiratory paths are free from
all irritation or obstruction. These useless little coughs do not always
deserve the appellation of tics; in many instances they are mannerisms
comparable to the gestures of conversation or reflection, although in
some people their insistence, abruptness, and irresistibility might
justify their incorporation in the other category. Their co-existence
with tics of face and limbs has been noted, as in a case published by
Tissié[116] of an eight-year-old child, with ocular and facial tic and
spasmodic cough.
Clonic contraction of the diaphragm gives rise to conditions imitated or
caricatured by the tics, in particular sobbing and hiccoughing. It must
not, of course, be forgotten that these are apt to occur in hysteria, as
well as in organic disease of the nervous system, and in grave
infectious states. Careful and searching inquiry must therefore precede
any expression of diagnosis.
Tonic diaphragmatic contraction is of very much greater rarity. In such
cases abdominal respiration comes to a momentary standstill, whereas
thoracic respiration is accelerated. The patient is in imminent danger
of being asphyxiated, and the insertions of the diaphragm sometimes
become painful. What is known as acute pulmonary eructation is
occasionally the sequel to this convulsive affection. Tonic contraction
of the diaphragm is nearly always of an hysterical nature, and is
doubtless akin to the aerophagic type.