Tics and Their Treatment

TICS OF THE LIPS – SUCKING TICS

The diversity of movement of which the buccal orifice is capable warrants the statement that the tics of this class are almost too numerous for detailed description. At times only the orbicularis oris is involved, unilaterally or bilaterally; at others, concomitant implication of the elevators and depressors of the lips, or of the chin muscles and the platysma, furnishes the basis for all sorts of pouting, biting, and sucking movements, and for every variety of smile and grin. Here again the clonic form of contraction is the most habitual, although that rapidity and abruptness which we commonly identify with such contractions may not always be conspicuous. Guinon says of a young patient of his, at one time addicted to innumerable tics, that the relative sluggishness with which she opened and shut her mouth served to inspire belief in the reality of the tonic tic of certain authors. As a matter of fact, tonic tics do exist, and are sometimes associated with another variety known as mental trismus, to the discussion of which we shall revert ere long.

The action of the muscles of the lips is manifold: whether in the expression of the emotions, or in the discharge of different functions, they come into play in miscellaneous modes that may be the forerunners of a multiplicity of tics. Of these, two types may be distinguished, according as expansion or occlusion of the labial orifice predominates. Under the one heading; come the caricatures of ordinary smiling or laughing, under the second those that exaggerate the pursing or pouting movements whereby we are wont to indicate chagrin, repugnance, disdain, etc. Labial tics of this nature may be styled tics of facial mimicry.

In the infant that has long been weaned, and a fortiori in the adult, the continuance of the act of sucking must of course be considered a functional anomaly; and while no doubt it is true we use our lips in imbibing a beverage through a straw, or in extracting the juice from a fruit, the action is different from that of the infant, and in any case not to be compared with incessant sucking of tongue or thumb, or of some object devoid of all nutritive value – merely a bad habit, perhaps, but frequently indistinguishable from tic.

The most fruitful source of the tics under consideration is to be found in labial cracks and dental mischief. More especially in children, towards the end of the first dentition, the torment of loose teeth calls forth interminable devices for relief, in seeking which tongue and lips pleasurably co-operate. Once the tooth is out, the lacuna it leaves provides a new sensation and a new reason for muscular activity. Irregularity of the permanent teeth may also be referred to as a potent factor in the causation of tic. It is therefore not superfluous systematically to examine the teeth of all patients suffering from tics of the mouth, and to extract any offender.

TICS OF THE CHIN

The muscles of the chin collaborate with other facial muscles in expressional movement, and are similarly liable to be the seat of tics.

Massaro73 has observed an interesting series of isolated "geniospasm" occurring in twenty-six individuals of the same family during five generations. The characteristic feature of these spasms was an involuntary intermittent clonic contraction of the transverse muscles of the chin, suggesting the look of one seized with fear or with cold. The will did not always effect their inhibition, while emotion appeared to aggravate and distraction to abate their intensity. With sleep they vanished entirely.

TICS OF THE TONGUE – LICKING TICS

Tics confined exclusively to the tongue are of rare occurrence. Moreover, they must be strictly differentiated from the tonic or clonic contractions of the tongue muscles met with in hysteria, epilepsy, and Sydenham's chorea, from the varying tremors that accompany organic disease of cerebral or bulbo-pontine origin, as well as from those "glosso-spasms" that may or may not be associated with twitches of the facial musculature.

Functional polymorphism is no less marked in the case of the tongue than in that of the lips; it participates in suction, mastication, deglutition, as well as in respiration, phonation, and articulation, while to "put out the tongue" at any one is equivalent to an expression of contempt. It is, accordingly, no surprise to find the number of tongue tics very considerable. Such, for instance, is the licking tic, where the tongue is constantly being passed over the free border of the lips, moistening them to excess; or the chewing tic, in which its perpetual motion inside the mouth in every direction conveys the impression that the subject is chewing something. Further, its contact with the palate or the upper lip may yield different clucking, whistling, or crowing sounds. Letulle remarks that the trick of producing a little inspiratory whistle by the passage of a column of air through an incompletely closed labial commissure – a common habit among people suffering from dental caries – is not slow in developing into an actual tic.

It has not fallen to our lot to observe the tonic variety of tongue tics, none the less must we believe in the possibility of their occurrence. Convulsive lingual movements, consecutive to disease of mouth or teeth, or to lesions of corresponding nerves, are in all probability spasms properly so called, to which disturbances of sensation and of nutrition are often superadded. The tonic contractions of tongue, lips, and masseters, which have been described in cases of hypochondriasis and puerperal psychosis, are much more nearly allied to the tonic type of tic, if, indeed, they are not to be identified with it. A case has been put on record by Lange of tonic contraction of the tongue during speaking and eating, each time that it touched the dental arches. No doubt the condition was a sort of tonic tic. Sometimes players of wind instruments are afflicted with a "professional cramp" of the tongue, as Strümpell has reported.

Generally speaking, however, it is particularly in tics of language, and in the various kinds of stammering, that the tongue muscles are concerned.

TICS OF THE JAWS – BITING TICS – TICS OF MASTICATION

When the muscles of mastication are the site of tics, a medley of nibbling and mumbling results, from which convulsive movements of the same muscles consequent on cerebro-spinal mischief must be scrupulously separated. A. von Sarbo's74 case of clonic maxillary spasm secondary to worry, depression, and an accident to the head, in a woman thirty-four years old, and otherwise free from stigmata – analogous cases are quoted by Strümpell and Ranschburg – was referred by him to a "spasm diathesis," akin to the "diathesis of contracture," but its etiology and evolution, together with a striking exaggeration of the knee jerks, negative the hypothesis of tic.

The masseters are chiefly but not exclusively affected. Unilateral implication of the pterygoids has been noted by Leube in a young girl who was also an hysteric and a choreic. A patient of ours prefaces every conversation by rapidly raising or lowering his inferior maxilla four or five times, and blinking at the same time; the performance has its variants, moreover, with the occasional addition of several nasal expirations.

Chattering or grinding of the teeth is a frequent accompaniment of the tics we are considering, and may have a disastrous issue in the loosening, cracking, or breaking of these structures, as in the case of O.

A still more common incident is injury to the buccal mucous membrane, a significant instance of which is furnished by an episode in the history of young J.

One day in June, 1900, J. experienced a feeling of discomfort in the articulation of the lower jaw – the sequel, as a matter of fact, to a slight alveolo-dental periostitis in the neighbourhood of a bad tooth – and, interpreting the sensation as a new and grave symptom in the march of his malady, forthwith proceeded to investigate its development by playing with his maxilla. Then ensued a perfect debauch of masticatory movements, in which agreeable repetition of every conceivable grimace was joined to protrusion and retraction of the jaw in the search after articular cracks. He became so wholly preoccupied with this tic of mastication that ere long he had begun to pinch the mucous membrane on the inside of the right cheek between the hindmost molars, and this fresh object of absorbing attention in its turn led quickly to some excoriation of the mucosa on both sides. No halt was called by the lower jaw to give the abrasions time for repair, with the natural outcome that they suppurated and paved the way for an attack of infective stomatitis with pain, fever, and malaise, which necessitated the application of the thermo-cautery to the ulcerated areas for its relief.

The explanation given by the patient of the evolution of the process was controlled by interrogation of the parents, and no doubt was left as to its genuineness. In the attempt to dispel the articular discomfort, he had accidentally bitten himself, but the consequent pain did not deter him from repeating and continuing the act until its execution was irresistible.

In these and similar cases, the infelicitous rehearsal of the movements of mastication is practically always associated with an imperative desire to experience a sensation at the place actually bitten. Cheilophagic children, who bite their lips unceasingly, usually commence by nibbling at some half-separated fragment of epithelium on the edge of a labial fissure, with the inevitable result that the erosion is enlarged and fresh particles of the mucous membrane are detached. Youthful candidates for tics can scarce escape from the vicious circle. A juvenile patient of ours, F., was in the habit of gnawing so vehemently at the most insignificant little irregularity of the mucosa that his lips were constantly chapped and bleeding, and as they were no less constantly being moistened by saliva, a succession of new cracks made their appearance, to be promptly torn apart by the teeth. Local applications of nauseous substances are not always sufficient to discourage these young "cheilophagics."

It is still more frequent to meet with onychophagia, a condition rightly held to be a stigma of degeneration, and acknowledging the same pathogenic mechanism as all biting tics.

So much for the clonic tics of mastication: we pass on to review the tonic forms, the most curious of which has received the name of mental trismus.

MENTAL TRISMUS

The characteristic feature of this tonic tic is an all but permanent contraction of the masseters, which may, however, be completely relaxed by making the subject put out his tongue, show his throat, etc. It may be maintained during the act of speaking. Its intensity and its persistence alike stand in rigorous relation to the nature and degree of the mental affection that provides its occasion. In the insane it may become so absolute an obstacle to nutrition that recourse must be made to nasal feeding. Mental trismus resembles mental torticollis in that any proceeding to which the patient attributes a special inhibitory virtue is adequate to correct it, as, for instance, the insertion of a cork between the teeth,75 or the placing of a finger on the incisors.76

It must of course be clearly understood that the diagnosis of mental trismus can be arrived at only after previous elimination of every possible source of confusion, such as tetanus, more rarely tetany, meningitis, and acute bulbar paralysis, in addition to other mesencephalic and perhaps also certain cortical lesions. One is inclined to be less dogmatic where tonic or clonic convulsions of the jaws succeed violent fright, as in a case of trismus of nine months' duration recorded by Billot and Francotte. For that matter, trismus is met with in hysteria, and may be regarded as a manifestation of that disease, although this cannot always be invoked as its cause. We are not attracted by Kocher's idea of assigning it to an "idiopathic spastic neurosis," preferring to ally it to tics of the tonic variety.

Among the crowd of circumstances that reflexly give rise to trismus may be enumerated abscess, caries, alveolo-dental periostitis, eruption of the wisdom teeth, disease of the maxilla and the neighbouring soft parts, and less commonly myositis or injury to the masseters. But so long as any one of these causes is in operation, and especially if the affection be attended with pain, we are dealing with a trismus spasm, not a trismus tic.

S., whose psychical imperfections have already formed the subject of remark, supplies an example of the combination of mental trismus and torticollis, the former being the outcome of an inopportunely reiterated voluntary act, and therefore comparable to the tics.

S. speaks with clenched teeth. His masseters are generally in a state of contraction, yet when he is requested to put out his tongue or to open his mouth, and when he is eating or engaged in an animated conversation, any and every movement of the inferior maxilla is accomplished with the greatest ease. According to his story, this tonic tic of the masseters had its origin in the forcible efforts he used to make to master his torticollis, in the course of which he would close his mouth firmly; by dint of continual repetition the habit developed into a tic, and persists apart altogether from any endeavour of his to prevail against the wryneck.

One of us has had a recent opportunity of examining a young woman whose obsessions and fixed ideas, and tics of face and neck, indicated an extreme degree of mental instability, in spite of intellectual power above the average, in whom trismus of this type was very obvious during eating and speaking. No effort, however concentrated, to open the mouth was then of any avail; yet, on the other hand, she could sing to perfection, and she could yawn, or show her tongue or her throat, in an entirely easy and normal fashion.

The appearance of this trismus during the performance of certain functional acts, and of these alone, is unequivocal evidence of its mental derivation.

TICS OF THE NECK – NODDING AND TOSSING TICS – TICS OF AFFIRMATION, NEGATION, AND SALUTATION

Regionally considered, the neck is second only to the face in furnishing the greatest number of tics. Convulsive movements of the neck muscles produce displacement of the head in all sorts of ways and directions, giving rise to clonic tics of affirmation, negation, and salutation, and to nodding tics, as well as to an important group of tonic tics which find expression in differing forms of torticollis. The latter are so distinctive in symptomatology and evolution, and have been the centre round which so much discussion has raged, that a chapter must be set apart for their special study.

Restricting ourselves for the present to such as are included in the category of clonic convulsions, we find here abrupt vertical or horizontal movements, as well as intermediate varieties compounded of elevation, depression, inclination, or rotation. The most ordinary kind is a sudden, brief jerk or toss of the head, repeated at irregular intervals, and followed by instantaneous resumption of the primary position.

Certain convulsive affections – for instance, the spasmus nutans of young children, the salaam tic, and what are known as "baboon movements" – are still rather obscure and in many cases seemingly not equivalent to tics. Their occasional association with strabismus or nystagmus constitutes a plea for their possible dependence on some encephalic lesion. In two cases under Oppenheim's observation the nodding spasm appeared solely in the hours of the night and during sleep. From want of more precise knowledge we must confine ourselves to the remark that conditions analogous to, though not identical with, the tics, in addition to others more specifically hysterical, have probably been incorporated with them.

It is a task of peculiar difficulty to determine the share in the final product to be apportioned to individual muscles, of which the sternomastoids, as being the most superficial and the most obvious, are apparently comprised the oftenest, though the trapezius and the muscles of the underlying strata, such as the splenius, complexus, and other smaller ones, may also assist.

According to Guinon, isolated contraction of one sternomastoid, whereby the head is rotated and inclined once or twice or several times consecutively, to the usual accompaniment of facial contortions, is very frequently to be noted. If there occur simultaneous contraction of the platysma, its fibres will be seen to line the cervical integuments longitudinally from the chin to the infraclavicular fossa. Synchronous involvement of the two sternomastoids will flex the head and approximate the chin almost to the sternum, but more commonly there is only a slight forward inclination of the head exactly similar to a gesture of assent. Extension and lateral deviation are less generally encountered.

Extreme variability characterises the exciting causes of these tics. It has been remarked more than once that insecurity of the headgear the subject happens to be wearing ought to be blamed; instead of readjustment with the hand, a little toss of the head will make the hat sit properly, and one need not search further afield for the germ of the patient's tic. We have been able to trace this mode of inauguration quite as conspicuously in young men as in young women. Prohibition of unstable head coverings and resort to exercises of immobilisation suffice for the tic's correction in early cases.

A not infrequent accessory symptom – viz. elevation of the corresponding shoulder – may have a similar origin in peripheral excitation connected with the patient's clothing. To escape the annoyance of a high and narrow collar, or, on the other hand, to experience an agreeable sensation by rubbing the skin, it is a very simple and a very easy matter to lean the head on the shoulder, and to raise the latter at the same time. The automatic reproduction of this gesture eventually ends in the formation of a tic which removal of the collar entirely fails to suppress. The first therapeutic indication, nevertheless, is to interdict the wearing of the unsuitable collar, and to recommend the adoption of others softer and more ample. Whatever be the opinion one holds on the mechanism of tic, the influence of peripheral stimuli is, according to Pierre Marie,77 very considerable, and it is his invariable practice, in the case of youthful subjects, to impress on the parents the desirability of paying special attention to their children's clothing, and of discarding any article that is either stiff or heavy.

In one of our cases, a girl A., suffering from a nodding and rotatory tic of the head, examination of the cervical region revealed the existence of a line of cicatrices along the margin of the sternomastoid, the vestiges of a previous operation for a severe tuberculous adenitis. Some nerve filaments entering the sternomastoid and trapezius had no doubt been cut, since these muscles presented a minor degree of atrophy, and the irritation arising therefrom, as well at that due to dragging on the adhesions between the cicatrices and the underlying tissues, had been the starting-point of a motor reaction primarily convulsive and involuntary, but eventually habitual and automatic, and therefore, with the subsidence of the excitation, a tic.

In another case78 a month's systematic treatment served to curtail to a noteworthy extent spasmodic head movements resembling those one makes to get rid of a fly.

From another point of view, some of the tics of this class are merely the exaggeration of certain functions destined for the expression of the ideas of affirmation and negation. The nod of the head with which little G. used to punctuate his "yes's" was logical enough, but he soon began its repetition irrespective of his topic of conversation, and even when saying "no" – a veritable tic of affirmation.

Numbers of people are in the habit of emphasising their words with those to-and-fro movements of the head that we call gestures of approval. Now, if the gesture be strictly appropriate to the thought present in the mind, it cannot be identified with the tics. On the other hand, its execution may be inopportune, in which case, provided the form remain normal, it is merely a stereotyped act, and must exhibit the additional features of abruptness and exaggeration ere it rank as a tic.

It is chiefly among the mentally infirm, such as idiots and imbeciles, that the phenomenon of salutation occurs, and as its rhythm is an element which is foreign to most ordinary tics, it is not likely to be confounded with them.

These conditions apart, however, there is one highly specialised clinical type that merits separate study – viz. mental torticollis.

MENTAL TORTICOLLIS

The medical world has long been familiar with various kinds of permanent or intermittent torticollis presumably unconnected with muscular, articular, or osseous lesions of the neck, and been as long divided on the question of their tabulation.

Instances of this affection, bearing such widely differing names as "hyperkinesis of the accessory of Willis," "spasmodic torticollis," "functional spasm of the neck muscles," "rotatory tic," etc., have abounded in medical literature ever since the days of Duchenne of Boulogne, Trousseau, and Charcot. Some twelve years ago now, the term mental torticollis was applied by Brissaud79 to a type of convulsion of the neck musculature whose association with psychical disturbances justified its description as a tic, and his opinions have been abundantly confirmed by later observation.

As a matter of fact, mental torticollis is a tic which the patient can ordinarily curb by some procedure of his own invention. It has its raison d'être in his mental imperfection. To obviate misunderstanding, we must premise that the latter term is not synonymous with mental alienation. It merely signifies that lack of mental balance, to whatever extent, that is patent in all sufferers from tic.

From the motor aspect the tic under consideration may be characterised as a functional disorder, consisting in the ill-timed, inapposite, unceremonious, and exaggerated repetition of the function of head rotation. Notwithstanding the large number of muscles involved, the various modifications of movement possible, and the consequent complexity of clinical types, each individual case is recognisable as a tic. Let but momentary cessation of the muscular spasm be effected, and the torticollis disappears without leaving a trace. Instantaneous and total prevention is in practically every case attainable by resort to some subterfuge, however vehement be the patient's contortions.

This device, whatever it be, may be called the "efficacious antagonistic gesture," of which the simple placing of the index finger on the chin may be cited as an example. Its field of operation is not limited to mental torticollis, and we shall have opportunities of observing its working in greater detail in other tics; but in the former affection the constancy of its occurrence and the facility of its detection combine to enhance its diagnostic value.

We hasten to remark, however, that conditions other than those we have just mentioned are capable of producing convulsive movements in the muscles of this region. In addition to such osseous, articular, and muscular alterations as may determine a more or less permanent torticollis, certain nervous lesions are apt to be succeeded by the development of the spasmodic form, no longer as a tic, but as a true neck spasm, the due recognition of which may be a matter of no little perplexity.

Confining our attention for the present to torticollis tic – the mental torticollis of Brissaud – we notice, in the first place, that it affects either sex indifferently. The age of our youngest patient was eighteen, though in a case of Raymond and Janet's the disease made its appearance four years earlier. A hereditary neuropathic or psychopathic factor is invariable, but similar heredity is the exception. Paternal alcoholism has been quoted by Guibert as a possible predisposing cause, also a rheumatic diathesis (Bompaire), family trembling (Feindel), hereditary stammering (Noguès and Sirol), nervous and mental disease in the parents (Feindel and Meige). One of Oppenheim's patients had a peculiarly sinister family history: the grandparents were related by blood, one being a diabetic as well, and the other a lunatic; the mother was nervous, and the sisters either epileptic or psychically abnormal. This case was characterised by the existence of generalised tics in childhood, and by the development of torticollis soon after marriage.