Tics and Their Treatment Part 18

Intensity and frequency of movement, duration and deformity of att.i.tude, 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 p.r.o.ne 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 pa.s.s 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. d.u.c.h.enne 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 rea.s.sert 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 princ.i.p.ally 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 a.s.suming a fixed torticollis att.i.tude. 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 a.s.surance 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 att.i.tude 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 pa.s.ses from right to left, or vice versa; 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 circ.u.mstances, 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 fas.h.i.+on while he was writing, and the rotation gradually began to a.s.sert itself at other times, when he was reading, or eating, or b.u.t.toning his boots. Even apart from any other act, the rotatory movement soon became incessant, continuing while he was on his feet, but vanis.h.i.+ng 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 ch.o.r.eiform 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 a.s.sured 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 ch.o.r.ea.

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 repet.i.tion 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 pa.s.s into activity in the rhythmical salutation and balancing movements so common among idiots, movements bearing the most intimate a.n.a.logies to the tics, though their peculiarity of rhythm justifies their separate cla.s.sification.

Tonic contractions that find expression in att.i.tude tics of the body are generally a.s.sociated 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 circ.u.mspection 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 sequelae 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 princ.i.p.al 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 s.p.a.ce 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 att.i.tudes 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.