When only six years old B. exhibited a respiratory tic, which changed a year later to one of the tongue, and after another year to one of the leg; at the age of twelve he used to nod his head in affirmation, and this was eventually succeeded by movements of negation, etc. He has since started a salaam tic, and finally a torticollis with deviation of the eyes.
We may cite an analogous case from Grasset:
A young girl, who had had eye and mouth tics in childhood, commenced at the age of fifteen to advance her right leg involuntarily—a sort of tic which lasted several months and gave place to paralysis of the same limb; for this affection was next substituted a whistling tic, and then for a whole year she used from time to time to give vent to a loud "Ah!" When she came under observation she was suffering from a tic of salutation, with retrocollic jerking of the head and shrugging of the right shoulder.
One of our own patients furnished us with the following story:
The disease made its debut by a blinking tic of both eyes, whose origin in the absence of any visual defect remained undetermined; grimacing and distortion of the mouth were the next to appear, as well as wrinkling of the nose and forehead, twitching of the eyebrows and contraction of one platysma, sometimes even of the ear muscles and the entire scalp. Then ensued up-and-down tossing of the head, or rotation of it from right to left, and, later, elevation and advancement of the shoulders, with restless agitation of hands and arms. A former trick of his of biting his nails is quite in abeyance at present; instead, he catches hold of his under lip every moment and abrades its mucous membrane with his nails, so much so that the lip is swollen and cracked like those of children with nibbling tics. Some months ago he acquired the habit of giving utterance to a soft little cry not unlike the sound made by a guinea-pig.
One tic has succeeded another in an unbroken series. The facial tics were more of the nature of grimaces, which the child amused itself in repeating; no doubt the scratching of the lip was a sequel to the desire of experiencing a new sensation, while the movements of hands, arms, and shoulders were very variable and different enough from the accompanying phenomena. No one of the tics was at all of protracted duration; on the contrary, each was fugitive and changeable, and therein presented a resemblance to the child's mental status. In sleep they completely disappeared; in the presence of strangers or if his interest was in any way aroused, they quieted down, while they increased on holidays, during games, or with physical fatigue.
It is clear that determination of the tic's localisation and mode can come only with the mental evolution of the patient, and that the transformation from the psychical inconsistency of childhood to the stability of the adult is paralleled by the change in the tic's manifestations as the scale of age is ascended. Any individual, whatever his years, who is in the stage of mental infantilism, will tic after the manner of a child, for the characters of a tic are dependent on the state of mind of its subject.
CHAPTER VIII
ACCESSORY SYMPTOMS
REFLEXES
THE question whether in cases of tic there is any alteration in superficial or deep reflexes can be decisively answered only by an appeal to statistics, the information afforded by which has hitherto been too scanty and too incomplete. Judging from our own observations in about thirty cases, we feel compelled to admit that disorders of this kind are altogether exceptional. Careful and repeated examination has convinced us that in patients suffering from tic the knee, ankle, wrist, elbow, and other jerks, the plantar and fascia lata reflexes, as well as those of the pharynx, eyes, etc., are all but universally normal, and any trifling exaggeration or diminution not only varies from day to day, but also in no wise exceeds the differences met with in health, and is therefore symptomatologically negligible. In the manifold varieties of tic represented by R., S., P., N., M., B., etc., whose cases are quoted here in part, our inquiries have always been negative. Noir's research on the state of the reflexes in idiocy complicated with tics failed to expose any abnormality, and even where the knee jerks were increased no departure from the usual manifestations of the tic was discoverable. It is of course permissible to suppose that a combination of the latter with organic disease of the nervous system might explain the modification of the reflexes. In this connection it may be remembered that on one occasion we found the customary diminution of O.'s knee jerks had passed into actual loss, and although on the next day they were present again, the occurrence was suspicious enough to justify one in entertaining the idea of incipient tabes. Even if the existence of other signs had corroborated this diagnosis, the incontestable genuineness of O.'s tics would have remained, so that the attempt to correlate the derangement of the reflexes with the existence of tics is somewhat questionable.