Part 16 (1/2)

TICS OF THE NOSE--SNIFFING TICS

The form these tics commonly take is a puckering of the nostrils to the more or less noisy accompaniment of a nasal inspiration or expiration, a.s.sociated usually with curling of the upper lip. They are princ.i.p.ally the sequel to some coryza, or inflammation, or some little nasal fissure or furuncle, and in their essence const.i.tute a derangement of a complex functional act intended to ensure the dislodgment of any obstruction in the respiratory pa.s.sages of the nose, in which act the muscles of inspiration or of expiration bilaterally co-operate. Where the contraction of the nose muscles is unilateral, it is generally part and parcel of a facial grimace confined to that side, and therefore an anomaly of mimicry.

As for the pathogenic mechanism of the sniffing tic, it is simple enough. Some little pa.s.sing obstacle in the air-ways, some minute, irritating sore, supply the occasion for an expiratory reaction, in the first instance, with wrinkling of the nose and dilatation of the nostrils, the repet.i.tion of which with each fresh sensation of discomfort or of pain speedily becomes automatic, and persists as a tic when mucus or abrasion has disappeared. So far from being obstinate, these tics are eminently amenable to treatment if they are uncomplicated. We have remarked on their occurrence, by the way, in the case of O. and his sister, in young J., in G., in the wife of S., etc.

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 cla.s.s 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 a.s.sociated 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 l.a.b.i.al 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. l.a.b.i.al 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 l.a.b.i.al cracks and dental mischief. More especially in children, towards the end of the first dent.i.tion, 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.

Ma.s.saro[73] 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 ch.o.r.ea, 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 a.s.sociated 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 partic.i.p.ates in suction, mastication, deglut.i.tion, 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 pa.s.sed 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 pa.s.sage of a column of air through an incompletely closed l.a.b.i.al 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 ma.s.seters, 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 Strumpell 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's[74] 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--a.n.a.logous cases are quoted by Strumpell 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 ma.s.seters 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 ch.o.r.eic. 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.