Tics and Their Treatment

by Henry Meige; E. Feindel

After an attack of epilepsy the convulsive twitches are at a minimum, but during the next few days the myoclonus, or rather the polyclonus, becomes increasingly intense and varied, until it reaches a maximum, which is crowned by a second epileptic fit. The spasmodic contractions begin in the face and invade the rest of the musculature; they recur in the form of seizures at diminishing intervals, leading to the epileptic attack, when the muscles pass into permanent contraction.

Sometimes the myoclonus takes the shape of fibrillary spasm, sometimes the whole of a muscle is involved; the twitches may be rhythmical and symmetrical, or arhythmical and asymmetrical, so much so that at a given moment the patient may present the clinical picture of convulsive facial tic, or paramyoclonus multiplex, of Gilles de la Tourette's disease, or electric chorea.

Mannini's view is that the varying convulsions known as myoclonus or polyclonus are akin to epilepsy, and are the outcome of the same cortical lesion, the nature of which has not as yet been fathomed—a lesion whose expression is hyperexcitability of the cells of the rolandic area. Analogous conclusions may be drawn from a case of epilepsy and myoclonus, with autopsy, reported by Rossi and Gonzales,[162] where a general ischæmic degeneration of the central nervous system was found, the greatest changes being discovered in the rolandic zones of each side, as well as in the extremities of the three frontal convolutions. Schupfer[163] has recorded cases of family myoclonus with epileptiform attacks.

We are content to note the facts. Any conclusion applicable to the tics is premature.

Various observers have drawn attention to the development of tics in persons formerly subject to epilepsy. Malm[164] has described a case of rotatory tic in a man who has been a known epileptic for ten years. According to Féré,[165] epilepsy may supervene in patients who at one time suffered from tic. As an example, he quotes a case of tic localised in the left ear and dating from infancy; the patient had reached his thirty-fifth year when the recrudescence of the tic ushered in the first attack of epilepsy, which consisted of elevatory movements of the left ear and convulsions of the left half of the face, passing thence to the right arm and the left leg, and becoming generalised. The fact that the twitches of the left ear could not be imitated voluntarily suggested that the original "tic" may have been the result of some minute cortical irritation, the increase of which became eventually the determining cause of a Jacksonian attack.

Another case due to the same author concerns a woman of fifty-four years, subject from her youth to fixed ideas.

For the last four years she has had seizures which may be attributed to her idea that she must see the whole of the objects on her left. Under the impulse of this idea, she turns her eyes upwards and to the left, rotates her head in the same direction, and her body too, if she happens to be on her feet. The performance is gone through fifteen or twenty times a day.

In addition, she suffers from epileptiform attacks, which commence by this deviation of head and eyes to the left, and spread to the arms and to the left leg, leading to loss of consciousness as they become generalised. The patient finally succumbed to an apoplectic stroke followed by left hemiplegia.

In this instance the connection between the fixed idea and the patient's gesture favours the diagnosis of tic, but the subsequent history of the case makes one consider it with reserve. All such cases ought to be followed up carefully, and we may modify Féré's conclusions somewhat to declare that the appearance of a convulsive movement in an adult, or the aggravation of a similar movement of ancient date, should lead one to suspect epilepsy and to look for signs of it: "The patient runs more chance than risk in being treated as an epileptic."

We have had the opportunity of observing, in one of our mental torticollis cases, a condition not unlike what is known as absence épileptique. The term "incantation" was applied by the parent to his daughter's habit.