We have recently had the opportunity of observing a genuine case of eyelid tic, of obscure origin perhaps, but one whose clinical features eliminate the hypothesis of spasm.
Brif., a metal polisher, forty-seven years old, came on March 10, 1902, to Professor Brissaud's clinic at the Hotel Dieu, complaining of involuntary closure of the eyes, especially when out walking. In his family and in his personal antecedents there was little or no neuropathic or psychopathic tendency. The sole trouble for which he sought advice was this spasmodic shutting of his eyes, rare enough under most circumstances, but aggravated instantly by a walk of even a few paces.
The onset had been quite insidious eighteen months previously, and at the first the average frequency was scarcely more than thrice or four times daily. Whenever Brif. passed into direct sunlight the movement was particularly liable to occur. As long as he remained seated at his work he was free from it, while he had but to rise and take a step or two for it to reappear and forthwith commence to repeat itself. At home any effort engaging his attention inhibited the tic, nor was there any sign of it in the course of our interrogation and examination of him.
Even when he was on his feet, the incidence of the act was not always uniform; if promenading with his wife and children, or fishing along a river side, or running to catch a tram, he was not hampered by his affliction. When he rose in the morning, it made its appearance ere he could reach the window to look out. During his journeys to and from his place of business, he was generally unable to moderate the spasmodic movements, particularly towards evening, whereas his professional pursuits in the daytime, and any occupation—such as reading the newspaper—when at home again, wholly counteracted the inclination to tic.
The production of this untimely gesture of his Brif. was disposed to attribute to the action of sun or wind, though he acknowledged the regularity of its occurrence irrespective of either. In its actual nature the contraction was tonic in type and of several seconds' duration, so that he used to cover some yards with eyes shut. From the outset the will had always exercised a marked influence on it, so much so that on certain days and for a certain space he could check the convulsion, and even when it was prolonged he contrived by volitional effort to open his eyes sufficiently to pilot himself in avoiding obstacles.
Careful search by the ordinary tests at the Quinze-Vingts hospital failed to reveal any abnormality whatever in his eyes. On our part, we satisfied ourselves that there was no restriction of the visual fields.
As far as his mental state was concerned, its chief peculiarity was a somewhat childish turn of mind, a soupçon of that psychic infantilism so common in the subjects of tic; in addition, he was of an emotional temperament, and prone to perspire or blush for no valid reason. He was further a victim to a premature baldness which was hereditary in the family, and which may be cited as a physical stigma of degeneration.
B. Eyeball Tics.—The extrinsic muscles of the eye occasionally participate in the tics we have just discussed. Assiduous observation of patients suffering from blinking tics will enable the physician now and then to detect movements of the eyeball behind the lowered upper lid.
In the case of F., for instance, with each tic of the lids the eyeballs deviated briskly upwards and to the left. Similarly Miss R. turned her head from right to left at the same time as the eye moved obliquely to the left and in an upward direction. A patient mentioned by Otto Lerch[67] used to open and shut his eyes while rotating the eyeballs and throwing the head back. Occasionally he inclined his trunk to one or other side, accompanying the act with disagreeable little grunts.
The eruption of these tics may equally be attributed to some foreign body or minute conjunctival granulation, as was the case with a small child of ten years under our care, who, in spite of the withdrawal of the irritating particle, acquired the trick of tickling the inner surface of his upper lid by rolling his eye about whenever he happened to blink. The delight he took in this trivial manœuvre led to its mechanical reiteration, and was the means eventually of its developing into a tic which required a sufficiently delicate muscle exercise and drill for its repression.