Professor Marie[70] had failed to satisfy himself of the paralytic nature of the phenomenon, and demonstrated the ease with which the eyeballs moved downwards if the patient was made to hold his head in the position of maximum extension, while in the attempt to look at his feet—the head being held normally—they were forthwith inclined violently upwards, and were so maintained for thirty or forty seconds. The only view tenable was that he was suffering from a sort of neurosis whose outward expression was this spasmodic elevation of the eyes. Additional confirmation of the accuracy of this hypothesis was supplied by a consideration of the circumstances attending the commencement of the illness. The sudden and unexpected apoplexy, of seventeen hours' duration, had been accompanied neither by stertor nor by relaxation of sphincters, and had been followed by an equally sudden return to consciousness, the faculty of speech and the desire for food reasserting themselves unexpectedly. The ensuing three or four weeks the patient had spent in a curious delirious state, not unlike the post-seizure stage of hysteria, a trace of which remained in the guise of certain eccentricities of mind. The difficulty in his speech bore a resemblance to hysterical stammering; and, finally, his visual fields were concentrically and bilaterally restricted.
Of the subsequent history of the case some information was forthcoming at a later date,[71] corroborating the opinion originally propounded by Professor Marie. Simultaneously with the diminution in intensity of the ocular spasm there had been grave deterioration of the patient's mental level, as evidenced by the development of ideas of persecution.
In the subjects of tic, and especially in cases of mental torticollis, we have noted an analogous symptom, consisting in inability to look down at the feet, except perhaps by the aid of innumerable contortions, in contrast to the consummate ease of upward glances. By making the person write at a blackboard, and observing his action according as his hand is above or below a horizontal plane through his eyes, one can soon convince oneself of the reality of the occurrence, yet search will fail to discover any sign of ophthalmoplegia.
Patients of this class evince a remarkable aptitude for elevation movements, and the trouble they experience in depressing the eyeballs is not of necessity to be construed as denoting paralysis of the depressors, but rather indicates the presence of a tic of the elevators, as Professor Marie says—a tic born of a habit, and nourished perhaps by the dread such persons feel of witnessing an exaggeration of their convulsive movements whenever they cast their eyes down.
Our object in summarising this discussion has been twofold: at once to note the existence of tics of extrinsic eye muscles, and to illustrate the intricacies of their diagnosis.
A case not unlike the preceding, recorded by Noguès and Sirol,[72] was characterised by inability to look above a certain height without simultaneous raising of the head. Paralysis of the associated movements of elevation was excluded by the fact of the gradual onset, without an ictus, and by the absence of paralysis of convergence and of impairment of speech and intellect. Basing their conception of the case upon its post-febrile origin and the knowledge of hysterical antecedents, the authors were disposed to regard it as a neuropathic manifestation.
It is conceivable that some cases of strabismus in children are nothing more than vicious habits transformed into tics, since, as a matter of fact, attentive supervision is frequently sufficient to effect a cure, although no doubt in other cases some visual abnormality is responsible for the condition.
Finally, since accommodation is a function subservient to the will, tics of accommodation are theoretically possible. Our information thereanent must be sought from the ophthalmologists. We have met with genuine professional cramps of accommodation in those who use the microscope, as well as in opticians, watchmakers, etc.
TICS OF THE NOSE—SNIFFING TICS
The form these tics commonly take is a puckering of the nostrils to the more or less noisy accompaniment of a nasal inspiration or expiration, associated usually with curling of the upper lip. They are principally the sequel to some coryza, or inflammation, or some little nasal fissure or furuncle, and in their essence constitute a derangement of a complex functional act intended to ensure the dislodgment of any obstruction in the respiratory passages of the nose, in which act the muscles of inspiration or of expiration bilaterally co-operate. Where the contraction of the nose muscles is unilateral, it is generally part and parcel of a facial grimace confined to that side, and therefore an anomaly of mimicry.