Part 15 (1/2)
Facial tic, moreover, may be tonic as well as clonic, instances in point being closure of the eyelids, wrinkling of the forehead, twisting of the nose, distortion of the mouth, etc., of longer or shorter duration.
Any of the facial muscles may be attacked by tics. These commonly furnish an ill.u.s.tration of functional disturbance of mimicry, as in Oppenheim's cases of tic limited to the frontales, whereby astonishment or dismay was expressed, or in contraction of the superciliary muscles, which conveys a look of pain or of mournfulness. Spread to the scalp muscles may take place, causing a perpetual to-and-fro movement of the hair, of which O. and Miss R. supply examples. The platysma is sometimes the seat of a tic. One of Oppenheim's patients was a child with alternating twitches of his two platysmas; it is of interest to note he was able to contract either voluntarily. This condition is generally a.s.sociated with similar contractions in other facial muscles, as in a case of facial and palpebral tic with platysma involvement recorded by Meirowitz,[62] or as in young M.
A not infrequent accompaniment is a shrug of one or both shoulders, due to synergic contraction of the trapezius. The resulting complex may be considered an act of mimicry in so far as it is an expression of disdain.
TICS OF THE EAR--AUDITORY TICS
The muscles of the external ear come often into play. One of our patients had a tic of the left ear, consisting in visible elevation of the pinna. A case of tic of the ear muscles has been described by Romberg, and another by Bernhardt, in the distribution of the occipital and posterior auricular nerves. Reference is made by Seeligmuller[63] to a ten-year-old girl suffering from unceasing involuntary contractions of the eyelids and of various head and neck muscles, with wrinkling of the forehead and movements of the ears. His original diagnosis of ch.o.r.ea was discredited by his subsequently learning that the child, in common with a younger sister and a brother, had for several years been exercising herself by making faces, and in particular by attempting to move her ears.
It is quite conceivable that certain middle-ear phenomena are comparable to the tics. O. used often to complain of hearing noises in his right ear, which came and went with his tics of face and neck. Now, it is well known that the probable explanation of the humming sound attending forcible closure of the orbiculares palpebrarum is the variation in labyrinthine tension due to the synergic contraction of the stapedius.
This absolutely normal effect may be exaggerated by predisposed and preoccupied individuals into a sort of auditory tic.
TICS OF THE EYES--NICt.i.tATION AND VISION TICS
For the sake of precision, tics of the eyes may be subdivided into eyelid tics and eyeball tics.
A. _Eyelid Tics._--These, perhaps the commonest of all tics, may be either unilateral or bilateral. They consist simply in a palpitation of the upper lid, repeated at irregular intervals, and differing from ordinary blinking only in augmented frequency and abruptness. The form they usually a.s.sume is that of a wink, attributable in the first instance to contraction of the orbicularis, but supplemented by the zygomatics and muscles of the nose.
The tonic variety of the same tic is const.i.tuted by a contraction of inordinate length, the outcome of which is the all but permanent maintenance of the eye in a half-closed position. The suspension of this tonic tic by volitional effort accentuates its distinction from contracture. In one of our patients a tic of this nature, which gave a singularly sleepy cast to the features, was easily relieved by suitable gymnastic treatment. The converse condition obtained in another case, where excessive gaping of the palpebral fissure contributed an unwonted fixity to the expression, which simultaneous contraction of the corrugator supercilii served to heighten into one of wild anger. These two tics corresponded to two diametrically opposed traits in their subject's character--viz. nonchalance and impatience respectively, and it is interesting to recall in this connection how the varying moods depend for their physiognomical delineation chiefly on the degree of curvature of the palpebral arc.
Valleix,[64] who employed the term ”idiopathic facial convulsion” to designate tic, cites a case where even in moments of tranquillity the left eye seemed slightly smaller than its fellow, by reason of a feeble contraction of the orbicularis. Persistent grimaces of this kind resemble tics of att.i.tude and stereotyped acts, and the possibility of their occurrence must not be overlooked, once the diagnosis of facial paralysis or spasm has been rigorously excluded.
The terms blepharospasm and blepharoclonus, sometimes applied to tonic and to clonic involuntary palpebral contractions respectively, ought to be strictly reserved for spasms and contractures properly so called. For example, von Graefe's case of blindness consequent on permanent closure of the eyelids in a child is undoubtedly one of blepharospasm. No tic could have been attended with such a result, whereas compression of branches of the trigeminal at their points of exit might determine reflex tonic contraction of the orbicularis, and so, for that matter, might a central lesion. Hence in these circ.u.mstances it is correct to use the word spasm.
Palpebral tics are among those that ordinarily begin by a spasmodic reaction to an extraneous source of irritation, such as that yielded by a foreign body, a speck of dust, an eyelash, or by any form of conjunctival inflammation.
Eyelid tics (says Parinaud[65]) are known to ophthalmologists as clonic blepharospasms. Their starting-point is always some peripheral stimulus, in particular an everyday variety of conjunctivitis characterised by the presence of granulations in the lower part of the sac. To discover these granulations it may be necessary to explore the internal aspect of the lid. In my opinion, they are a prolific cause of tic, especially in young children, and their removal effects a cure in the vast majority of cases.
It is only when the blinking abides in spite of the suppression of the exciting cause that it can be comprised in the category of tics, otherwise the fact of its being contingent on the continuance of the irritation shows it is a spasm.
A bright light sometimes suffices to initiate these conditions. During a course of sittings for her portrait, G., a little girl eleven years of age, acquired the habit of drooping one eyelid slightly to s.h.i.+eld the eye from the somewhat glaring light of the studio, but the persistence of this movement in other surroundings was evidence of its degeneration into a tonic tic.
Noir quotes the case of one of his colleagues who was for a long time inconvenienced by a most disagreeable blinking, which he held to be a tic; but a simple explanation was forthcoming in the unusual length of some of the eyelashes on the outer part of the upper lid having caused their entanglement with others in the under one, and when they were cut off the spasm disappeared.
In the following instance, reported by Toby Cohn,[66] the diagnosis remains undetermined:
The protracted use of a magnifying gla.s.s in the left eye was the means, in a watchmaker, of inducing occasional localised twitches of the orbicularis, which were not slow, however, in spreading to the whole of the left half of the face. They may at first have been an involuntary motor response to nipping of palpebral twigs of the trigeminal, but at a later period their independence was constant and p.r.o.nounced. With certain a.s.sociated movements such as articulation or deglut.i.tion, or during the act of wiping the nose or shutting the eyes, the form they a.s.sumed was tonic. There were neither subjective nor objective sensory phenomena to note.
We have recently had the opportunity of observing a genuine case of eyelid tic, of obscure origin perhaps, but one whose clinical features eliminate the hypothesis of spasm.
Brif., a metal polisher, forty-seven years old, came on March 10, 1902, to Professor Brissaud's clinic at the Hotel Dieu, complaining of involuntary closure of the eyes, especially when out walking. In his family and in his personal antecedents there was little or no neuropathic or psychopathic tendency. The sole trouble for which he sought advice was this spasmodic shutting of his eyes, rare enough under most circ.u.mstances, but aggravated instantly by a walk of even a few paces.
The onset had been quite insidious eighteen months previously, and at the first the average frequency was scarcely more than thrice or four times daily. Whenever Brif. pa.s.sed into direct sunlight the movement was particularly liable to occur. As long as he remained seated at his work he was free from it, while he had but to rise and take a step or two for it to reappear and forthwith commence to repeat itself. At home any effort engaging his attention inhibited the tic, nor was there any sign of it in the course of our interrogation and examination of him.
Even when he was on his feet, the incidence of the act was not always uniform; if promenading with his wife and children, or fis.h.i.+ng along a river side, or running to catch a tram, he was not hampered by his affliction. When he rose in the morning, it made its appearance ere he could reach the window to look out. During his journeys to and from his place of business, he was generally unable to moderate the spasmodic movements, particularly towards evening, whereas his professional pursuits in the daytime, and any occupation--such as reading the newspaper--when at home again, wholly counteracted the inclination to tic.
The production of this untimely gesture of his Brif. was disposed to attribute to the action of sun or wind, though he acknowledged the regularity of its occurrence irrespective of either. In its actual nature the contraction was tonic in type and of several seconds' duration, so that he used to cover some yards with eyes shut. From the outset the will had always exercised a marked influence on it, so much so that on certain days and for a certain s.p.a.ce he could check the convulsion, and even when it was prolonged he contrived by volitional effort to open his eyes sufficiently to pilot himself in avoiding obstacles.