Tics and Their Treatment

by Henry Meige; E. Feindel

One cannot but be struck with the remarkable analogies to the cases given by Cohen. And it is worth remembering further, that sometimes mental torticollis degenerates into actual dementia.

TICS AND SPASMS

Nothing is more arduous, at first sight, than the differentiation of a tic from a spasm, the similarity of their external forms being a fertile source of confusion. Yet the establishment of a correct diagnosis is of prime importance, since in their case prognosis and treatment alike are diametrically opposed.

Tic is a psychical affection capable of being cured, if one can will to cure it: at the worst we may fail, but there is no idea that it is indicative of a grave organic lesion prejudicial to life. A spasm, on the contrary, though it appear in almost identical garb, is excited by a material lesion on which depends the degree of its gravity. The focus of disease may disappear, no doubt, but it is only too likely to persist and to occasion other disorders. Hence the desirability of making sure of one's diagnosis—a proceeding not necessarily of insuperable difficulty. If we apply the principles of diagnosis enunciated by Brissaud, to which our attention has already been directed, we shall not find the task beyond our powers.

Let us take a concrete instance.

Here is a cabman, forty-nine years of age, the left half of whose face is the seat of convulsive twitches. These commenced eighteen months ago by brief insignificant contractions of the left orbicularis palpebrarum, which have gradually spread to the whole of the muscular domain supplied by the left facial nerve. Their momentariness and rapidity, their apparent independence of extraneous stimuli, their indifference to treatment and resemblance to the twitches produced by electrical excitation, their occurrence in sleep, the fact of voluntary effort, of attention or distraction, serving so little to modify their range and intensity—all make clear the spasmodic nature of the condition.

The motor manifestation is the consequence of irritation at some point on a bulbo-spinal reflex arc; its abruptness and instantaneousness negative the possibility of recognising in it any sign of functional systematisation. It is not a co-ordinated act of a purposive nature, but a simple, unvarying, constant motor reaction to a particular stimulus. That its intensity should be in direct proportion to the intensity of the latter, changing from feeble contractions to a state of transient tetanus, is further proof of its spasmodic origin. When the excitation is at its maximum, there is sometimes involvement of the opposite side of the face, by virtue of the law of the generalisation of reflexes.

It is true there is no association of pain with his attacks, as in so-called tic douloureux, but the spasm is heralded by a tingling sensation below and to the inner side of the outer corner of the eye. This sensation, "like an electric battery," persists during the spasm and disappears in the intervals. Its occurrence suggests that the ascending branch of the infraorbital nerve, springing from the trigeminal, is affected, and indeed pressure over its point of emergence evokes a certain amount of pain. Moreover, there is occasionally a flow of tears when the spasm is at its height. It may be difficult to decide whether this is the result of mechanical compression of the lachrymal gland or an exaggerated secretion of tears under the influence of stimulation of the lachrymo-palpebral twig of the orbital nerve. In any case the pathogeny of this facial spasm is entirely comparable to that of tic douloureux of the face, and it is quite within the bounds of possibility that a minute hæmorrhage—for the patient is of a very florid type—somewhere on the centrifugal path of the trigemino-facial reflex arc, may be giving rise to the phenomena.

What we wish to insist on, however, is the dissimilarity between this facial spasm and tic. In the movements we have been describing we fail to distinguish any purposive element, any co-ordination for the fulfilment of a particular function: they are not imitative in character, nor do they express any sentiment; no impulse precedes their execution, no satisfaction follows.

The patient's mental state presents no peculiarities, as far as we have been able to discover. There is no volitional debility or instability; if he cannot control the convulsions, it is to be remarked that he cannot control them even for a moment, whereas all sufferers from tic are capable of inhibiting it for a longer or shorter period by an effort of the will, by concentrating their attention on it.[169]