Chapter IX: The Different Tics (3)

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.