Tics and Their Treatment

by Henry Meige; E. Feindel

We have enjoyed the co-operation of M. Babinski in the examination of one of our patients, L., in whom we were able to determine a definite and symmetrical exaggeration of the patellar reflexes, a slight increase in the right triceps jerk, and, in making the subject rise from a prone to a sitting position with the arms folded, a very minor degree of flexion of the thigh on the trunk.

The first of these symptoms is of no pathognomonic value, and while the others no doubt are characteristic of organic disease, their development in this instance is too imperfect to warrant the deduction of pyramidal involvement. For the last ten years L.'s motor control has been very defective. The muscular activity of the right half of his body takes the form of irregular contractions, badly timed and inaccurate in range; in spite of the absence of pain, the timidity with which they are executed hinders their ever attaining a normal amplitude; and at the same time his inability to appreciate the direction and intensity of the motor reaction, the outcome of excessive muscular vigilance, illustrates a certain loss of the sense of position of his limbs.

The existence of an actual irritative lesion is therefore problematical, and it is scarcely conceivable that organic mischief of ten years' duration could have produced these clinical symptoms without creating graver disturbance of the reflexes, or effecting changes of a trophic nature in muscular and other tissues.

From the pathogenic and diagnostic point of view, the detection of conspicuous and persistent alterations in the reflexes is of deep significance. It is an important factor in the differentiation between tic and spasm.

Sometimes the task is unusually arduous, as when the unilateral distribution of the motor troubles recalls the clinical picture of lesions of the pyramidal paths. In L., for instance, the hemichorea and the torticollis were on the right side, and in a case published by Desterac a similar condition obtained, the writers' cramp, hip spasm, and head rotation being all confined to the right. Notwithstanding the fact that this patient had exaggerated knee jerks, ankle clonus, and a double extensor response, an opportunity for examination given to one of us made it clear that the untimely movements and bizarre attitudes were similar to what has been noted in certain cases of tic.

At the Neurological Society of Paris a case was shown by Babinski[56] of left spasmodic torticollis, with marked spasms of the left arm and left leg, and a homolateral extensor response, and it was contended that if one and the same cause underlay these phenomena—nor did there appear any adequate reason to doubt it—and if the reversal of the plantar reflex was, conformably to received opinion, to be interpreted as indicating a derangement in the function of the pyramidal system, then it was allowable to attribute the muscular spasms to the same derangement, in which circumstances the natural conclusion was that spasmodic torticollis itself might sometimes at least be dependent on pyramidal irritation of an as yet undetermined kind.

More recently still, another patient was exhibited by the same observer,[57] in whom the association of head rotation and convulsions of the arm on the left, with increase of the triceps reflex, was conceivably the outcome of pathological stimulation of the pyramidal tract. Yet the symptoms in each of these cases were curiously analogous to what we find in mental torticollis, in which abnormalities of the reflexes are conspicuous by their absence. We ought not on that account to reject the hypothesis of concurrent organic disease, inasmuch as a structural modification may be no longer the cause but the consequence of inordinate repetition of a motor reaction. Muscular hypertrophy or atrophy may be the sequel to tics born of ideas that find motor expression, and circulatory and even cellular changes may ensue on gesticulatory excess. The objective signs that reveal the existence of a point of irritation, on the presence of which the diagnosis of spasm depends, are commonly so trivial as to be wellnigh valueless, and should they be awanting, the motor disturbance appears to be purely functional, and may be considered a tic. At the same time we must admit the possibility of mixed forms, where the functional element is linked with primary or secondary organic disease, and perhaps their occurrence is more general than is ordinarily imagined. We repeat, however, that rigorous and lengthy investigation alike of the psychical and the somatic phases of the condition, embracing the state of the reflexes, will usually furnish sufficient information to facilitate the question of diagnosis and justify a positive statement.

ELECTRICAL REACTIONS

The examination of the electrical reactions of the muscles concerned in a tic is a clinical method seldom, if ever, resorted to, and we can scarcely expect it to yield decisive results from the symptomatological aspect. As with the reflexes, it may happen that we cannot afford to neglect its diagnostic significance in certain cases. For example, we have had occasion to test its worth in studying the case of young J., whose trouble consisted in a clonic tic of elevation of the left shoulder, and a tonic attitude tic of the left arm whereby it was firmly applied against the body. No important alteration in electrical contractility was discovered, although the response in the upper part of the left trapezius—which, by the way, was more voluminous than on the right—was brisker than in its fellow. On the other hand, the right deltoid, sternomastoid, and pectoral, were more excitable than on the left.

Here, of course, the evidence supplied by electrical examination only served to confirm the knowledge gathered from other clinical sources.