Tics and Their Treatment

by Henry Meige; E. Feindel

Our lack of knowledge concerning the precise localisation of these functional centres is paralleled by our ignorance as to the manner of their involvement.

Noir has prudently observed that the manifestation of co-ordinated tics in cases of widespread cerebral disease, and the frequent occurrence of the most extensive and complex varieties in patients who have suffered from meningeal affections, suggest their cerebral origin. On these points, however, anatomo-pathological information is to seek, and for that matter the direct dependence of such an habitual movement as a co-ordinated tic upon one lesion is scarcely within the bounds of probability. Tic pertains to a psychical rather than to a motor sphere, and is to be regarded as a disease of the will.

With this statement, and with the expression of our hope that subsequent work will aid in the elucidation of the question, we shall close the chapter of the tic's pathological anatomy. It may not prove superfluous, however, to indicate why and how the facts gleaned from pathology and supposed to be in harmony with the clinical picture of tic should be allocated to other morbid entities.

In several cases considered to be tics of the face, cortical lesions have been discovered at the posterior end of the second frontal convolution, in the centre for voluntary and co-ordinated movements of the contra-lateral facial muscles. It has become classical to cite an example described as long ago as 1864 by Debrou[41] under the title "painless facial tic," but a glance at the observation suffices at once to negative its classification as a tic, and to justify the diagnosis of a spasm of a quite peculiar sort.

On February 26, 1862, a porter, aged forty-nine, was suddenly seized with an "attack of the nerves," and at its close lost his speech. When examined at the hospital two days later, he was found to have full use of his limbs, understood perfectly all that was said to him, and evinced great impatience at being unable to respond except in writing or by gesture. He made signs to indicate that his head was paining him, and that he had difficulty in swallowing. In addition, abrupt, forcible, and rapid movements of the facial muscles on the right side were taking place; the angle of the mouth and the outer angle of the palpebral aperture were being dragged on; the external ear was elevated, or moving to and fro; the platysma was twitching visibly and the hyoid bone so acted on as to pull up the larynx spasmodically. The exhibition was an exact replica of the effect produced in animals by intracranial galvanisation of the facial nerve. Moments of absolute repose alternated with periods of spasm of a few seconds' duration, which addressing or handling the patient seemed to aggravate. There was synchronous spasm in the masseter muscles, resulting in elevation of the inferior maxilla. No other region of the body was affected.

On the night of March 2 the attacks of spasm and of pain increased in intensity and frequency, without any other change in their nature. The patient's mind remained unclouded, and as he was still deprived of the faculty of speech, he again indicated in writing the severity of his sufferings. About eleven o'clock at night the situation became more distressing; he began to be profoundly agitated, then passed into a more or less maniacal state, in which his limbs were involved in powerful muscular spasms, his eyes rolled in their sockets, and his respiration commenced to be stertorous, while the violence of his struggles necessitated the intervention of two assistants to control him. An hour or two later, during one of these attacks the end came.

At the autopsy, under the arachnoid and spreading over the left hemisphere at the junction of its anterior and middle thirds, was a large blood-clot, dark, coagulated, and free in the cerebral substance, which it had penetrated for a depth of about one centimetre. It appeared to be of about four or six days' formation, and probably dated from the incipient "attack of the nerves." Painstaking scrutiny of the cerebellum and cranial nerves failed to reveal any further pathological condition.

To tell the truth, we are not averse to wagering that to-day the opinion of the surgeon would be invited on a similar case, where the motor reactions of the so-called tic are manifestly based on a Jacksonian type.

In a case recorded by Chipault and A. Chipault,[42] and characterised by brief epileptiform attacks involving the left side of the face, cerebral exploration proved ineffectual, but at the post-mortem a subcortical glioma of the size of a cherry was discovered underneath the posterior end of the second frontal convolution. Is a case of cerebral tumour to be labelled tic?

It is quite exceptional, in fact, for lesions of the cortical facial centres to give rise to muscular movements suggesting facial tic. Take another instance: