Chapter IX: The Different Tics (1)

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.