Tics and Their Treatment

by Henry Meige; E. Feindel

Defects in the visual apparatus sometimes induce abnormal movements and attitudes which may become tics if careful examination does not elicit their explanation.

Tic of the eyeball is generally associated with other tics, ocular or facial, but it may occur alone and bear a resemblance to nystagmus, a peculiarity we have noticed in a patient perfectly free from any cerebro-spinal disease. It is almost always bilateral, but in some cases of unilateral palpebral tic it is more pronounced on the side of the latter.

Fixity of the eyes is characteristic of tonic tics of the extrinsic ocular muscles, and gives a somewhat haggard or maybe merely attentive expression to the countenance. Very frequently it escapes observation, and indeed cannot be considered a tic unless there be an incongruity between it and the ideas at that moment uppermost in the patient's mind.

Reference has already been made to the historic example of an ocular tic in the person of Peter the Great. A series of interesting discussions has taken place recently at the Neurological Society of Paris in regard to the question of a tic of elevation of the eyes.

The patient, who had come to consult Professor Marie at Bicêtre in December, 1899, was presented to the Society in the first instance by M. Crouzon.[68] He entered the room with his eyes fixed on the floor, but in a few seconds they had resumed their normal position in the horizontal plane. At frequent intervals he raised them upwards, or inclined his head so as to bring the pupils into contact with the upper lids, the natural position of rest of the globes being regained by a voluntary effort after each displacement. When interrogated, he complained of not being able to distinguish objects in an area of his visual fields limited by an imaginary line drawn from his eyes to strike the ground at a point six feet in front of him; otherwise his sight was excellent. The history he gave was to the effect that five months previously, in the enjoyment of perfect mental and physical health, he had had a sudden stroke, and been unconscious for seventeen hours. No sinister results ensued till four days later, when he lost his vision, began to articulate very indistinctly, and failed to recognise his wife, continuing in that state for the next two months. Gradual recovery of speech and sight then commenced, but the habit of looking upwards persisted. The absence of injury to the visual apparatus, coupled with the presence of admitted psychical disorders, decided Crouzon in his consideration of the condition as a functional disturbance of the ocular muscles analogous to tic.

In this connection the significant observation was made by Joffroy that in the recumbent position the patient's eyes assumed their ordinary place, suggesting a comparison with those dolls whose eyes open or close according as they are held vertically or horizontally. In his opinion, the eye mobility negatived any idea of contracture consequent on central lesions.

A few months later the same patient was submitted a second time to the Society, on this occasion by M. Babinski,[69] who declared himself in disagreement with the hypothesis of M. Crouzon. In all cases of mental torticollis, so called, the contrary movement to that the execution of which is impelled by the spasm can from time to time be accomplished, whereas in the case under discussion downward as opposed to upward deviation was never obtained. Further, the acute onset, with loss of consciousness, militates strongly against the tic theory, and indicates rather a variety of paralysis of the inferior recti, or paralysis of conjugate downward movement, secondary to organic disease of the nervous system. The difficulty experienced by the patient in inducing his eyes to resume the horizontal position after once elevating them is explicable on the assumption that the action of the superior recti is no longer controlled by their antagonists the inferior recti, the former passing into a state of temporary spasm, which is, however, strictly consecutive to the paralysis of the latter.

M. Parinaud expressed himself as being in accord with M. Babinski, and recalled certain rare forms of associated ocular palsies occurring with paralysis of convergence, a combination manifest in the subject in question. Curiously enough, in these cases the disturbance of function is always ushered in by a stroke, which justifies the belief in the focal nature of the lesion.

On the other hand, it was noticed by M. Ballet that the range and facility of downward deviation varied inversely with the attention devoted to the patient by the examiner.

On yet a third occasion this identical case provided a subject of discussion at the Society, after being under the observation of Professor Pierre Marie in Bicêtre.