Part 20 (1/2)

Such tics of genuflexion are not particularly uncommon. Oddo[105] has recently recorded a very instructive example, whose pathogeny he has been at pains to elucidate.

A little girl, Th., ten years of age, takes four or five perfectly normal paces when she starts to walk, then bends down quickly to the right, flexing her knee to an acute angle and inclining her trunk forward with the deflection of her pelvis, just as a child whose genuflexion in front of an altar has become mechanical by repet.i.tion. The performance is sometimes so altogether sudden that Th. actually falls on to her right side. One striking feature of the case is that if she makes a tour of the room in order to be observed at leisure, the inclination never fails to occur at exactly the same point in the circuit--namely, when she is opposite the observer. It is useless formally to interdict her from this routine, for before one has time to notice any irregularity in the gait her knee suddenly flexes at the bidding of an invincible impulse, and a moment later, without any deviation from her path, she has resumed her rhythmical step round the apartment.

This movement is not her only one, however. While she lies in bed she can, by flexing her thigh on her pelvis, crack her joints loud enough to be heard, and when she has been up a little while the same action is exhibited. The absence of these cracking sounds during ordinary walking, and their occurrence in the act of genuflexion, very properly explain, as Oddo thinks, the origin of the tic. It seems that the articulations at hip and knee on the right side were affected as the result of successive attacks of scarlatina and diphtheria two years ago, which necessitated a prolonged sojourn in bed, and were accompanied with severe pain. It is interesting to note that the tic made its appearance only after the latter had considerably subsided.

Raymond and Janet[106] have reported the case of a young woman who fell on her knees every few paces, rising again with facility and taking a few more steps, to come down on her knees once more with a loud noise. She never did herself any harm, however, and for that matter the accident never occurred on a staircase or in a unsuitable or dangerous spot.

Leaping tics are met with also.

Sometimes when walking, but more usually when standing quietly, according to Guinon, the patients make little jumps or leaps in their place, looking rather as if they were dancing than really springing into the air. Some actually bound along, others run for a yard or two.

Still more bizarre and complex tics have been described, in particular by Gilles de la Tourette. One patient used to commence to run, then kneel suddenly, then rise with equal abruptness. Another was in the habit of stooping down, as if to pick something off the ground, and smartly rising again.

The kins.h.i.+p of these and other similar conditions to the tics is undeniable, and such seems to be the case with the yet more extraordinary phenomena of _jumping_ in Maine (Beard), _latah_ among the Malays (O'Brien), _myriachit_ in Siberia (Hammond). All these affections show, among others, this peculiarity--that unexpected contact produces a spring (Guinon).

In a recent thesis Ramisiray has depicted the dancing mania (_ramaneniana_) of Madagascar, a condition allied to the latah of the Dutch Indies, but more intimately connected with hysteria, perhaps, and with the saltatory ch.o.r.eas, the saltatory cramps of Bamberger, St.

John's and St. Guy's dance, tarentism, etc. The exact nature of these convulsive disorders is still _sub judice_, but in any case they present more than a mere resemblance to the tics.

SPITTING, SWALLOWING, AND VOMITING TICS--TICS OF ERUCTATION AND OF WIND SUCKING

In some tics the palatal muscles are found to contract, but this contraction must not be confused with the spasmodic twitches of the same muscles a.s.sociated with facial spasm and due to central or peripheral irritation of the seventh nerve. One of us has had occasion to observe an excellent case in point in a young man afflicted with spasm of the orbicularis and zygomatics on the right side, in whom synchronous displacement of the uvula occurred with each twitch. The extreme abruptness and rapidity of the muscular discharges, the inadequacy of voluntary effort to check them, the absolute uselessness of prolonged and systematic treatment, left no doubt as to the accuracy of the diagnosis.

The occurrence of palatal spasm in intracranial lesions has, of course, been recognised--in cerebellar tumour (Oppenheim), in epidemic cerebro-spinal meningitis, in aneurism of the vertebral artery (Siemerling and Oppenheim). It is occasionally a.s.sociated with the emission of clucking sounds, and with convulsive action of hyoid and tongue muscles. In such cases the distinction between a tic and a spasm is not always easy to establish. We may, however, readily recognise that we are dealing with the former if the contractions of tongue, palate, and larynx are contemporaneous with the execution of a functional act, such as expectoration.

Among those who labour under obsessions, tics of expectoration are well known. One of Guinon's patients, while making forced expirations, used to bring his hand up over his mouth convulsively as though he were afraid of spitting on some one in his neighbourhood.

A case of Seglas', from whom stigmata of hysteria were absent, was possessed, among other things, with the fear of having swallowed certain objects, such as pins, knives, etc. The obsession eventually became so vivid and so intense at certain moments, that it began to be accompanied with a sensation as of a foreign body arrested in the sophagus, and the anguish thus created revealed itself by various reactions, one of which consisted in excessive salivation and ceaseless expectoration, entailing the carrying about and use of numbers of handkerchiefs.

It is scarcely possible for the mechanism of deglut.i.tion, the orderly succession of muscular contractions, to be interfered with by the will, but increased frequency of these movements may const.i.tute an abnormality. Hartenberg's[107] case of deglut.i.tion tic was characterised by a continual desire of swallowing saliva; the patient, it is true, was an hysteric.

Rossolimo[108] has called attention to what he distinguishes as amyotaxic troubles of deglut.i.tion, a dysphagia of which three types, motor, sensory, and psychic, may be specified. Cases of the last form had already been described by Bechterew.[109] The patient either suffers from a genuine obsession, or is ever at the mercy of an involuntary or even an unconscious dread of choking as he eats, a dread with which he is powerless to cope, though in the case of others the phobia and the dysphagia may alike be intermittent. In the majority of instances there are grave hereditary or personal neuropathic antecedents.

Some people are afflicted with eructations so continual that they amount to tics. One of us is acquainted with a family several of whose members present this peculiarity in different degrees, yet none of them suffers from hysteria.

Otto Lerch[110] has published a case of multiple tics, among which may be enumerated opening and closing the eyes, rolling of the ocular globes, tilting back of the head, with instantaneous recovery of position, inclination of the whole trunk to right or left--each and all of which movements are frequently attended, especially at night and in the morning, by profound eructations.

Of course, the prominent place occupied by these signs in hysteria is well recognised: the demonologues of old regarded them as an index of the departure of the devils that dwelt in the possessed. In a case of hysteria that came under the notice of Raymond and Janet,[111] a general tremulousness of the whole body was replaced by a ch.o.r.ea of the right arm, which in its turn was succeeded by the perpetual emission of sonorous eructations. In another instance[112] inspiratory hiccoughs and expiratory eructations co-existed. A similar example is cited by Cruchet in his thesis.

In the same category of facts are included those to which the name of _aerophagic tic_ has been applied. Various cases have been narrated by Pitres and by Seglas,[113] the latter of whom, in a remarkably complete a.n.a.lysis of the condition, has demonstrated its ident.i.ty with the tics, and written very instructive commentaries on his observations.

I was consulted (says Seglas) by a man thirty-four years of age, who was sent to me as a hypochondriacal neurasthenic. No sooner had he entered my consulting-room than I was astonished to find he was giving vent to repeated sonorous eructations at very brief intervals. His story was to the effect that several weeks previously he had been suddenly seized in the middle of a meal by a sort of vertigo, and had lost consciousness. A consideration of subsequent events made it more than probable that he had had an ictus; the patient, however, was for no apparent reason persuaded that he had been poisoned by badly cooked food, and from that moment became despondently preoccupied with the state of his stomach. A few days later the eructations made their appearance.

A closer examination very soon dispelled the idea of their gastric origin, seeing that the digestive functions were in every respect normal, whereas the symptom in question occurred at any moment, independently of the stage of digestion, and the gases evolved were absolutely inodorous. On the other hand, one could easily satisfy oneself that the eructations were preceded by an inspiratory effort and by two or three very obvious movements of deglut.i.tion, accompanied by a low, rumbling, pharyngeal noise, and followed almost immediately by the expulsion of gas. Their reproduction several times a minute was spasmodic in character and irregular in rhythm, and continued, it might be, for hours.

Of this series of phenomena the patient had conscious knowledge only of the last--viz. the eructations--and affirmed their involuntary nature and his desire to be rid of them.

The influence exerted on them by various circ.u.mstances 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 seances--to which he was pa.s.sionately 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 rea.s.sert 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 deglut.i.tion and expulsion of a certain quant.i.ty of atmospheric air” (Pitres), which therefore might be denominated an _aerophagic tic_.