Tics and Their Treatment

by Henry Meige; E. Feindel

SPITTING, SWALLOWING, AND VOMITING TICS—TICS OF ERUCTATION AND OF WIND SUCKING

In some tics the palatal muscles are found to contract, but this contraction must not be confused with the spasmodic twitches of the same muscles associated with facial spasm and due to central or peripheral irritation of the seventh nerve. One of us has had occasion to observe an excellent case in point in a young man afflicted with spasm of the orbicularis and zygomatics on the right side, in whom synchronous displacement of the uvula occurred with each twitch. The extreme abruptness and rapidity of the muscular discharges, the inadequacy of voluntary effort to check them, the absolute uselessness of prolonged and systematic treatment, left no doubt as to the accuracy of the diagnosis.

The occurrence of palatal spasm in intracranial lesions has, of course, been recognised—in cerebellar tumour (Oppenheim), in epidemic cerebro-spinal meningitis, in aneurism of the vertebral artery (Siemerling and Oppenheim). It is occasionally associated with the emission of clucking sounds, and with convulsive action of hyoid and tongue muscles. In such cases the distinction between a tic and a spasm is not always easy to establish. We may, however, readily recognise that we are dealing with the former if the contractions of tongue, palate, and larynx are contemporaneous with the execution of a functional act, such as expectoration.

Among those who labour under obsessions, tics of expectoration are well known. One of Guinon's patients, while making forced expirations, used to bring his hand up over his mouth convulsively as though he were afraid of spitting on some one in his neighbourhood.

A case of Séglas', from whom stigmata of hysteria were absent, was possessed, among other things, with the fear of having swallowed certain objects, such as pins, knives, etc. The obsession eventually became so vivid and so intense at certain moments, that it began to be accompanied with a sensation as of a foreign body arrested in the œsophagus, 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-œsophageal 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-œsophageal 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 œsophagus, 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 œsophagus 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 œsophagus.

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.