Tics and Their Treatment Part 17

In another case[78] 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 cla.s.s 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 repet.i.tion 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 d.u.c.h.enne of Boulogne, Trousseau, and Charcot. Some twelve years ago now, the term mental torticollis was applied by Brissaud[79] to a type of convulsion of the neck musculature whose a.s.sociation 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'etre_ 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 repet.i.tion 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 s.e.x 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 (Nogues 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.

Among personal antecedents may be noted hysterical attacks (s...o...b..), emotional unrest (de Buck[80]), migraine (Brissaud), neuralgia (Bompaire), irritability, eccentricity, caprice, absentmindedness, neurasthenia (Brissaud and Meige[81]). Other favouring circ.u.mstances are moral shook, intense and prolonged emotion, remorse, preoccupation (Bompaire, s...o...b.., Brissaud and Meige, Gra.s.set). Purely extraneous causes seem sometimes to be the starting-point; for instance, toothache and dental inflammation (Souques[*]), pain in the neck from carrying heavy loads (Amussat[*]), chill (Legouest, de Buck, Guibert[*]).

[*] Cited by BOMPAIRE, _These_.

At the Congress of Limoges a case was reported by Lannois where the onset of torticollis in a young girl was determined by an overpowering impulse to gaze at a little papilloma on her nose. The extirpation of the growth was followed by an amelioration of symptoms that amounted substantially to a cure.

Mental torticollis consecutive to anthrax of the neck has been described by Briand.

Other conditions that have been invoked as possible causes are the intoxications and infections, alcoholism, saturnism, mercury poisoning, typhus, pneumonia, paludism, etc. Oppenheim has signalised the reappearance, after several months of respite, of a torticollis secondary to an attack of influenza. Overwork, accident, occupation, have in their turn been suggested. In some cases, as a matter of fact, it does seem that the last is of some import, since the incidence of the torticollis is to a certain extent on those muscles that have been actively employed in the pursuit of a profession, and they thus acquire a sort of functional hyperkinesis.

Graff's[82] case of clonic convulsive contractions of the left splenius, left deep rotators, and right sternomastoid, occurred in an individual obliged, when carrying heavy loads, to maintain his head in a fixed position to the left, and unable thereafter to turn it to the right.

In some quarters no little importance is attached from the pathogenic point of view to the actual state of the muscles, and in particular to atrophy or hypertrophy of the sternomastoids. Fere holds that sometimes unilateral atrophy may occasion abnormal contraction of the opposite muscle, but such muscular changes are, in our opinion, much less likely to be the cause than the consequence of reiteration of movement or conservation of att.i.tude. Legenmann's case was one of tonic and clonic convulsion of the right sternomastoid where there was a cartilaginous tumour in the left.

The role played by ocular affections, by troubles of vision and of accommodation, in the genesis of wryneck is frequently no insignificant one, and it is curious how often patients attribute the mischief to the strain of overwork in bad light. Strabismus (Walton) and ocular palsies (Nieden) have also been known to lead to lateral deviation of the head and permanent torticollis. There has been described a variety _ab aure laesa_.

Albeit these factors have a share in determining the gesture and att.i.tude adopted by the patient, the resulting torticollis is not of necessity mental. That which, according to Romberg, is provoked by compression of supraclavicular nerve filaments is unmistakably a spasm.

To establish the diagnosis of mental torticollis, the existence of those psychical anomalies that are common to all who tic must first be substantiated, and then must one essay the reconstruction of its mechanism. The inquiry may at first prove fruitless, of course, but continuation of the search can scarcely fail to elicit tokens of mental infantilism. In pursuance of this quest we shall find ourselves face to face with the "big baby," the personification of childishness, obstinacy, and caprice; we shall encounter the peevish, the sulky, the whining; we shall see how their impotence in presence of their tic turns their nonchalance to profound despair, how their failure to adapt themselves to their malady convicts them remorselessly of volitional imperfection. The utter weakness of their will, according to Dejerine, justifies their being ranked as neurasthenics; but in the latter cla.s.s of case obsessional ideas are both fugitive and fluctuating, whereas mental torticollis is dependent on a fixed idea of peculiar tenacity.

There can be no doubt that such patients, however undimmed their intellectual powers may remain, ultimately fail before the everlasting obsession of their disease, and if in some cases interest in daily life and work continues unabated, a mult.i.tude of others become indifferent and apathetic, and sink into a state of physical and moral infirmity.

To retrace the steps in the evolution of mental torticollis is a task not always easy of accomplishment. Very commonly the affection supervenes as the sequel to the unhindered repet.i.tion of a once voluntary purposive act, a repet.i.tion become tyrannical through volitional debility. One or two extracts from published cases will serve to ill.u.s.trate the truth of our contention.

1. To escape the pain of a dental abscess on the right side, of only four or five days' duration, the patient had acquired the habit of turning the head to the right and maintaining it so for as long as possible at a time. Very shortly after the healing of the abscess, the head commenced to move involuntarily towards the same shoulder (Souques[83]).

2. Occipital neuralgia and pain in the neck led the patient to try various positions to allay the agony, in the course of which he found that rotation to the right brought transient relief. By dint of repet.i.tion the movement became involuntary (Brissaud and Meige[84]).

3. In this case the subject used to spend the whole evening inert, arms folded, without reading or working, tilting his head forwards or backwards to rediscover a "cracking" in his neck from which he suffered--a proceeding that gradually developed into a tic (Brissaud and Meige).

4. A schoolgirl was dissatisfied with the place allotted to her in the schoolroom, and pretended that she felt a draught on her neck coming from a window on her left. The initial movement was an elevation of the shoulder as if to bring her clothes a little more closely round her neck, then she commenced to depress her head and indicate her discomfort by facial grimaces, and these eventually pa.s.sed beyond voluntary control (Raymond and Janet[85]).

5. In order to deceive his friends, the patient a.s.sumed a forced att.i.tude of gaiety when really sick at heart, by inclining his head, raising his shoulders, and arching his back, and at the end of a few months a bantering remark revealed the surprising fact that he could not correct the position (Raymond and Janet[86]).

6. A woman used to pa.s.s the day sewing or knitting at her window and amusing herself from time to time by pensively looking out into the street. Not long afterwards she noticed how much more pleasant it was to allow her head to turn to the right, and how troublesome it was to keep it straight. At length she found this impossible, except with the aid of her hands (s...o...b..[87]).

7. Worried by severe occipital pains, an individual became so concerned to find they were being replaced by a feeling of great weakness, that he let his head rest by inclining it now and then to the left, an act which he is certain was the cause of his torticollis (Feindel[88]).

One further instance may be cited from Seglas,[89] where a neurasthenic lady, fifty years old, had been for three years a martyr to vague pains which finally settled in her neck, and a.s.serted themselves on the slightest exertion. She sought to mitigate her sufferings--a veritable topoalgic obsession--by leaning her head on her shoulder, and the desire thus to procure alleviation gradually became irresistible and the movement unconscious.

Multiplication of examples is unnecessary. It is abundantly evident from the above that the repet.i.tion of a deliberate and voluntary functional act, co-ordinated and systematised, is the first step in the genesis of mental torticollis.

The mere memory of a frequently repeated movement, especially if the latter occur in the prosecution of one's avocation, may determine the type of torticollis, as in Gra.s.set's "post-professional colporteur tic,"

to which reference has already been made.

In the case of one of our patients, N., the prolonged and almost exclusive use of certain muscles in the course of his business decided their involvement in the condition of practically permanent torticollis with which he was afflicted, and which was due to strong contraction of the right trapezius and sternomastoid. It appeared that for eighteen years he had been a cutter in a linen draper's, where it had been his duty, for hours at a stretch, to cut rolls of stuffs with a large and heavy pair of scissors, and in the execution of this work the right arm was extended, the hand firmly pressed on the table, the shoulder elevated, the head rotated and inclined to the left.

We cannot do better in this connection than recall the cases referred to by Brissaud[90] when directing attention for the first time to this variety of tics of the neck.

Here is a patient with energetic contraction of the muscles which depress the head on the neck. She holds her head in her hands to inhibit the movement, and succeeds. And she is quite convinced that the force requisite for rectifying the vicious att.i.tude is not simply the power of her will acting on the muscles concerned, but the strength of her hands. She has unconsciously doubled her physical personality; her hands obey her will, her neck does not.

At least, this would appear to be the key to the situation, for it can be well understood how much easier it would be to readjust the position by action of the antagonist cervical muscles than by the hands. The contraction, moreover, is entirely painless. It is a trivial act of obsessional insanity, provoked by some or other insignificant psych.o.m.otor hallucination.

Take this next man, who also must needs keep his head straight by means of his hand--obviously no irritation of the spinal accessory can be accused of originating the mischief, else would he be unable himself to replace his head. It is merely the idea that is urging him to its rotation. Try by force to prevent him from twisting his head round, or try to twist it against his will, and the difficulty of the thing will be at once comprehended. Or try to pull your own two hands apart to see which is the stronger, and you will never succeed, for the simple reason that abstraction of the will is impossible. One hand can prevail over the other only if both consent; the left cannot be in ignorance of what the right is doing. A "partial" or "local" will is inconceivable; there cannot be one for the head and another for the arm.

Here is a third patient, presenting an identical muscular spasm. He is content to apply two fingers to his chin to overcome the otherwise irresistible bend of his head to the right. Such has been the situation for the last five years. No line of treatment has made any impression on this neurosis, to which two factors contribute, though one cannot say which predominates--an unconscious, imperious, motor impulse, and a conscious though ill-informed volition, powerless to arrest the convulsions by simple and normal media, and obliged to resort to a puerile artifice, to a sickly sort of deceit. The opposition furnished by two fingers only cannot be of any avail, yet, however feeble be the succour, the patient's imagination is thereby appeased.

Such (adds Brissaud), fas.h.i.+oned in the same mould, are the "mentals" of whom I have been speaking. Recollect the ungovernable impulse they feel to execute a convulsive movement that their will might thwart; remember, therefore, at the same time, their volitional enfeeblement.

Brissaud's earliest observations were followed at no long interval by various articles, first of all the thesis of his pupil Bompaire,[91]

then others in collaboration with ourselves. The more recent publications of Lentz,[92] s...o...b.., Nogues and Sirol, Raymond and Janet, Seglas, Etienne Martin, etc., may be mentioned, as well as a contribution by Gra.s.set,[93] notable alike for the case it contains and for the author's interpretations.

The view that considers of prime importance the psychical phenomena of this affection has received general confirmation. We have seen protracted cases of "spasm of the accessorius" cured, exactly as with the tics, by widely differing therapeutic agents. In numerous instances, according to Oppenheim, torticollis is not consecutive to any peripheral or central change in the nervous system, but rather indicates irritability of nerve centres. It is probable that the kinaesthetic centres in the cortex for the neck muscles are the seat of the lesion, and that their congenital and hereditary imperfection fixes the form the convulsion will take.

These and similar facts are well calculated to corroborate the opinion that mental torticollis is nought else than a form of tic. The subjects of the disease are satisfied of two things--that no one and no circ.u.mstance can hinder their torticollis from a.s.serting itself, and that their own antagonistic gesture is the sole efficacious preventative at their command. The attempt to put the displacement right evokes acute pain and stimulates opposition on their part. They prefer the display of considerable resistance to the renunciation of their satisfaction in their tic, and follow up any momentary restraint by a riot of inco-ordination, in recompense for the brief sacrifice they have made to preserve immobility.

The muscular contraction that deviates the head may be either clonic or tonic, bringing it to one side by a series of convulsions and allowing it to resume its original position in the intervals, or forcing it to maintain a vicious att.i.tude for hours. Innumerable variants may occur, indeed are the rule, even in the same patient. In short, though mental torticollis may generally be cla.s.sed as a tic of att.i.tude, it matters but little whether the adoption of the att.i.tude or the att.i.tude adopted const.i.tutes the tic. They are simply two successive phases in the same abnormal muscular act. The most elementary movement is rotation of the head; it may equally well be inclined on one shoulder, or be both inclined and rotated to one side, or it may be inclined in one direction and rotated in the other. There may be accompanying elevation of the shoulder, or the act may become a much more complex one, involving neck, shoulder, and arm.

Each and all of the neck muscles may take a share in the torticollic movement, but some are more commonly affected than others, in particular the sternomastoid, whose contraction may either be isolated,[94] or modified by trapezius, splenius, levator anguli scapulae, etc., of the same or the contralateral side. It is frequent to find the head inclined to one side and rotated to the other by the action of the sternomastoid, or displaced backwards and slightly turned to the side of the contraction by means of the splenius. If the sternomastoid and h.o.m.olateral trapezius are acting together, torsion of the neck is very p.r.o.nounced and the skin over that area is deeply lined.[95] It may happen that the head is rotated and inclined to the same side, as in Gra.s.set's case, where the curious combination occurred of clonic convulsion of left trapezius and pectoralis major with right pectoralis major and sternomastoid. In the same patient the left arm was pressed against the trunk and the right extended posteriorly.

There are other instances where it would be more accurate to speak of _retrocollis_, as in a case recorded by Brissaud, or _procollis_, the two sternomastoids contracting synchronously, as in another case due to d.u.c.h.enne of Boulogne. The extreme degree of flexion induced in this way was neutralised immediately by supporting the head; the adoption by the patient of a reclining position sufficed to inhibit the tic's manifestation.