Tics and Their Treatment

by Henry Meige; E. Feindel

The influence exerted on them by various circumstances is worthy of notice. Any emotion, or any reference on the part of the patient to the condition of his stomach, tended to exaggerate them, while, inversely, it was remarked by his wife that the distraction of conversation, or of a promenade, or of musical séances—to which he was passionately devoted—served to banish them instantaneously and for as long as the distraction endured. Sleep suspended their activity, but at any interruption of it they scarcely ever failed to reassert themselves.

These considerations determined my view of his trouble as a peculiar form of tic, which consisted in "muscular spasms systematically harmonised to produce the alternating deglutition and expulsion of a certain quantity of atmospheric air" (Pitres), which therefore might be denominated an aerophagic tic.

Different varieties of this tic exist, according as the air swallowed is derived from the exterior or from the lung, and depending on its penetration into the stomach or simply into the pharyngo-œsophageal canal; and further, the physiological mechanism of the condition varies with them.

Let us suppose that the swallowed air comes from the lung. In this case, a certain quantity of air is imprisoned at the beginning of expiration in the pharyngo-œsophageal cavity, whose orifices are firmly closed by simultaneous contraction of the muscles of the palate, glottis, and base of the tongue. At this moment a brisk contraction of the constrictors of the pharynx drives the accumulated air out by the mouth, setting the membranes surrounding the supero-anterior opening of the cavity into vibration in so doing, whereby the air escapes as a more or less noisy eructation.

Should the mouth not open at this juncture, however, the air is compressed and crowded back into the lower part of the œsophagus, whence it passes through the easily dilatable cardiac ring into the stomach, to be expelled again by the mouth in the same noisy way once it has accumulated in sufficient quantity.

The deglutition of external air is preceded by an aspiratory thoracic effort; closure of the glottis forces the œsophagus to open under the stress of increased negative intrathoracic pressure, and to suck air down. When aspiration ceases, this air is either driven out forthwith, or gathered in the stomach, as we have just seen.

One may sometimes notice that the act of suction is succeeded by movements of swallowing, in which case the probability is that at the moment of aspiration the closure both of glottis and of pharynx prevents the penetration of atmospheric air into either the trachea or the gullet, in spite of the differences of pressure, and that these movements allow its passage through the œsophagus.

Aerophagia is by no means, therefore, a simple involuntary movement, but a combination of systematised muscular actions. In fact, it is a tic, and as such has both a physical and a psychical side.

From the material point of view (to quote Séglas again), the predominant symptom is the eructation, and the object in determining the accessory symptoms is to distinguish it from gastric eructations properly so called, the consequence of improper fermentation. In our case the appetite is good, and the digestion normal—tympanites, splashing, and abdominal pain are all absent. The gases evolved are inodorous, and their analysis in different cases (Ponagen, Hoppe-Seyler, Pitres, Sabrazès and Rivière) has shown that so far from containing any abnormal constituent, they have almost the same composition as atmospheric air. Application of the ear to the vertebral column at the level of the stomach enables one to detect a noise that appears to correspond to the passage of air into that viscus, and less than a second later comes the eructation.

Facts of another kind indicate the participation of a psychical element. The activity of the tic increases under the influence of the emotions and decreases or disappears momentarily at the bidding of the will. Distraction, concentration of the attention on some particular thing, speaking, reading aloud, are also calculated to suspend its manifestations. In some cases, especially where there is an association with hysteria, support is given to the theory of its psychical origin by the observation that prolonged opening of the mouth, and the administration of mica panis pills or of distilled water tinted with methylene blue, have had a definite effect in controlling the spasm (Pitres). Moreover, the co-existence or pre-existence of intellectual troubles or mental peculiarities is often incontrovertibly proved by a painstaking psychological examination.