Part 12 (1/2)

To tell the truth, we are not averse to wagering that to-day the opinion of the surgeon would be invited on a similar case, where the motor reactions of the so-called tic are manifestly based on a Jacksonian type.

In a case recorded by Chipault and A. Chipault,[42] and characterised by brief epileptiform attacks involving the left side of the face, cerebral exploration proved ineffectual, but at the post-mortem a subcortical glioma of the size of a cherry was discovered underneath the posterior end of the second frontal convolution. Is a case of cerebral tumour to be labelled _tic_?

It is quite exceptional, in fact, for lesions of the cortical facial centres to give rise to muscular movements suggesting facial tic. Take another instance:

An interesting case (says Brissaud), and one that is everywhere quoted, is reported by Schultz, in which an aneurism of the vertebral artery, at the point where the basilar arises, compressed the trunk of the left facial nerve, and occasioned a ”tic” of ten years' duration. As a matter of fact, one could not have a better example of _spasm_ pure and simple.

Fere[43] cites the following incident in support of the contention that encephalic trauma may engender a tic:

A man in falling on his head sustained an injury to the cranial vault over the posterior section of the left parietal bone, at a spot exactly corresponding to the posterior part of the angular gyrus, and immediately became afflicted with a convulsive tic of the zygomatics and orbicularis palpebrarum on the right.

Conformably to Ferrier's experimental localisation of the motor centre for the eye muscles and lids in the angular gyrus, irritation of this centre by the cranial injury was the diagnosis made.

The proffered interpretation of the motor phenomena by cortical excitation is entirely justifiable, but no convulsion consecutive to traumatism can ever pa.s.s muster as a tic.

A no less frequently quoted experiment of Gilbert, Cadiot, and Roger,[44] supposed to confirm certain results obtained by Nothnagel, is now a standard case in the history of tic hypotheses. The animal in question was a dog affected with spasmodic twitches of the ear, which the successive removal of cortical facial centre, internal capsule, corpora striata, and cerebellum, signally failed to alleviate, and which disappeared only with the destruction of the corresponding nucleus in the pons. Their inability to find any anatomical change determined the experimenters in favour of the view that the trouble was functional, and they described it as a tic.

It would be foolhardy to deny the existence of a lesion on the ground that it was not discovered. Negative findings of this sort are valueless. The sole conclusion to draw from the incident is the all-important role played by the bulbar centres in the production of convulsive movements, which are in such circ.u.mstances, of course, nought else than spasms.

Compression of cranial nerves by tumours or aneurisms of the base has been the cause of symptoms imagined to be identical with those of tic.

The case of intracranial neoplasm mentioned by Oppenheim, in which irritation of the upper branch of the trigeminal was accompanied by h.o.m.olateral facial contraction, is wholly comparable to the so-called ”tic douloureux.”

No less positive is our refusal to accept as tics spasmodic contractions in a.s.sociation with or subsequent to facial palsy or contracture of peripheral or central origin. They are spasms, not tics.

Cruchet, for instance, describes indifferently as l.a.b.i.al tic or intermittent l.a.b.i.al hemispasm clonic elevation or depression of the oral aperture developing in central facial paralysis, especially in children.

As example he refers to the case of a child in whom an ictus at the age of three years was followed by a typical spastic hemiplegia on the left side, with athetoido-ch.o.r.eic movements chiefly in the arm.

At first the left side of the face was flaccid and deviated in the other direction, but at the time of examination it presented no unusual feature beyond a continual twitching, a real convulsive tic, of the upper lip.

Now, whatever a facial convulsion of apoplectic origin, secondary to facial palsy and accompanied with spastic hemiplegia and athetosis, may be, it is at all events no tic.

Take one more case, given by Buss[45] as ”convulsive tic of the left side of the face.”

The patient was an atheromatous subject, with cardiac hypertrophy, bronchitis, and emphysema. When he first came under observation at the hospital, his eyelids, cheek, and buccal commissure were the seat of painless clonic contractions, which a month later were complicated by giddiness, vomiting, inability to stand or walk, lancinating pain over the right side of the face, weakness of the right limbs, and left facial paresis, and had become fugitive and insignificant. Loss of consciousness was followed by flaccidity of all four extremities, hyperpyrexia, and death. The section showed a haemorrhage of the dimensions of a pigeon's egg which had destroyed the left half of the pons, and an atheromatous dilatation of the left posterior cerebellar artery, impinging at one spot on the seventh and eighth nerves of the same side. Microscopical examination of their trunks and of the facial area in the pons disclosed no abnormality.

The pathological anatomy of this case indicates its nature unmistakably, and its symptomatology and evolution, moreover, do not bear the remotest resemblance to those of tic.

In the opinion of Debrou,[46] convulsive tic is a functional derangement of a motor nerve, a.n.a.logous to the neuralgia of a sensory one. To strengthen his argument he relied on such cases as those of Romberg, Schultz, Rosenthal, Oppolzer, where disease of neighbouring structures (enlarged glands, ot.i.tis media, caries of the temporal bone, etc.) was the agent in the production of muscular twitches in the domain of the facial. In our view, however, they are simply spasms provoked by irritation on the centrifugal path of a reflex bulbar arc.

The slight contractions occasionally seen both on the paralysed and on the non-paralysed side in the secondary contracture stage of facial palsy--a condition noted by d.u.c.h.enne of Boulogne, Hitzig, and others, and distinct from fibrillary twitching--are nothing more than spasms, and the same obtains where the palsy is consecutive to affections of the ear.

Chipault and le Fur recently[47] communicated to the Academy of Medicine a case of intermittent attacks of acute pain in the right hypochondriac region, a.s.sociated with violent contractions of the muscles of the right abdominal wall, which they described as a tic comparable to tic douloureux of the face. It was seen at the subsequent operation that the eighth, ninth, and tenth posterior spinal roots on the right side were surrounded in their pa.s.sage through the meninges by a patch of matted and cicatricial arachnoiditis, dissection of which was instrumental in effecting immediate relief.

One could not desire a more typical example of reflex spasm, the area of irritation in this case being situated at a point on the centripetal arc close to the medullary centre.

We may be allowed to quote a last case from Cruchet:

A little phthisical girl, four and a half years old, began to complain of headache, and in the course of the next day became delirious. Three days later the delirium gave place to generalised convulsive seizures affecting chiefly the arms, and more p.r.o.nounced on the left side. Simultaneously a tic of the right side of the face was observed, distinguished by raising of the upper lip and closure of the palpebral aperture. Sleep brought no modification in its train. Up to this stage a very feeble degree of contracture of the jaw muscles had been noted, but this speedily became accentuated to such an extent that nasal feeding had to be adopted.