Tics and Their Treatment

by Henry Meige; E. Feindel

TIC AND FUNCTION

We must now pass on to elaborate our conception of tic as a disordered functional act.

The term function is employed to denote various biological phenomena differing widely in manifestation and design. Vegetative functions such as digestion, circulation, urination, etc., are regulated by a special unstriped muscle system, the mechanism of which cannot be suspended by cortical interposition; hence under no circumstances can its derangement bring a tic into being.

Other functions, subserved by striped muscles, come within the range of voluntary activity. Some—e.g. respiration—are essential to the maintenance of life, and scarcely to be differentiated from those we have called vegetative. Others, such as nictitation, mastication, locomotion, are no whit less important, since their cessation, in the absence of extraneous aid, would speedily have a detrimental effect on the organism. They too are in a sense vital.

Others, again, such as expectoration, are useful, though not indispensable. Some people labour under the disadvantage of being unable to expectorate, but it is not a fatal defect. The function is not universal.

Finally, let us take once more the case of the child.

As he grows up he passes by easy transitions from the voluntary to the automatic stage. He is taught to swim, and swimming soon rivals walking in the unconcern with which the movements are executed; he learns to write, and no less rapidly does the act become one of unconscious familiarity; his games, his exercises, the labour of his hands—be it digging or typewriting—all reach the level of regular automatism; in short, they are functional acts as truly as locomotion or even respiration, with the qualification of being neither essential nor general.

Such examples serve to illustrate the comprehensiveness of the term functional, and embody all the intermediate forms between what is inherently vital and what is purely acquired. When we have to deal in practice with a case of functional disease, discrimination is obligatory from the standpoint of prognosis. We are alarmed at our patient's respiratory embarrassment, not at his impaired caligraphy.

A distinction has also been drawn between functional and professional affections, profession being conceived as a function of the individual in relation to society. But the latter term has the drawback of being too exclusive. As a matter of fact, scriveners' palsy is met with in people who, so far from being professional writers, do not use the pen much at all. Nor is it necessary to be a professional pianist to develop pianists' cramp. It would be more accurate to speak of disturbances in "occupation acts," it being understood that these have by dint of repetition acquired the automatic characters of true functional acts.

Let us consider for a moment the salient features and component elements in our conception of function.

First and foremost is repetition. It is an absolute law, this of the periodicity of function, and strikingly exemplified in the case of the circulation, digestion, urination, etc. Regularity of rhythm is no less obvious in the muscular activity of mastication, locomotion, and respiration, and its degree seems to be in direct proportion to the duration and vital importance of the particular function.

The characters of this rhythm may be influenced by various extraneous causes. A painful stimulus makes us blink or quickens our respiration. The will may intervene, to accelerate or retard. The personal factor accounts for individual differences, but for each individual a certain rhythm and amplitude of movement, suited exactly to the end in view and conforming to the natural law of least effort, may be regarded as normal. It is only in pathological cases that this law admits of exceptions, and these we shall now proceed to investigate.

Disobedience to the law in the shape of exaggeration or redundance of purposive movement indicates functional excess. For instance, the object of the function of nictitation is to moisten the conjunctiva. In its evolution the child's unmethodical reaction gives place to the rhythmical automatism of the adult. Perfection is the fruit of education.

But the person whose impetuous and uninterrupted blinking far exceeds the demand of the eye for lubrication is plainly troubled with excess, with "hypertrophy" of function. Herein may consist a tic, and, in fact, a large number of tics are nothing more than functional derangements of this kind.

The execution of a functional act at an inopportune moment constitutes another variety of functional disorder. A smile with no pleasant thought to correspond; a cry, a word, that betoken no precise idea; a gesture to relieve an irritation that does not exist; a chewing movement when the mouth is empty—all are examples of untimely, inappropriate functional acts, which merit the name of tics if in addition they are anomalous as regards rhythm, amplitude, and intensity.

Again, the performance of function is accompanied by antecedent desire and subsequent satisfaction. Authoritative proof of this law is furnished by the case of micturition and of defæcation, although momentary suspension of the function of nictitation or of respiration is also a sufficiently convincing mode of demonstrating its truth. In the case of locomotion and other motor functions a preliminary feeling of need may not be so imperative, but it is none the less constant.

Now, it has been observed already that these are equally conspicuous features in our conception of tic. In so far, then, as the latter is preceded by irresistible impulsion and followed by inordinate content, it may be considered a functional affection.

We cannot, however, dispose of each and every tic as an anomaly of some normal universal function. We have already had occasion to notice a large number of functional acts that are not of general distribution, so-called professional movements, which of course are liable to derangement. Such functional disturbances may be styled professional cramps, spasms, or neuroses; but are they identical with tics?

To attach the majority of them to the tics is, in our opinion, justifiable. They are the clinical expression of abnormalities supervening in a function that has by repetition acquired the automatism of genuine functional acts: they are germane to the tics. In certain points, however, the analogy is not absolute.

Professional cramps are motor phenomena distinguished by arrest of intended movement. Spasm signifies excess of motor reaction, cramp denotes its inhibition. It cannot, then, be said that they present the characteristic features of spasm as we have defined it: they are akin rather to a form of tonic tic of which we shall give instances later.

With this premise, we can identify the professional cramp as a functional anomaly recognisable by defective amplitude and force on the part of the motor reaction. Its most special character is its appearance exclusively during the exercise of the function of which it forms the anomaly. Writers' cramp manifests itself in the act of writing, dancers' cramp during dancing, and so on. We are ready to admit the close affinity of professional cramp to tic, with which it has an additional element in common in its occurrence among the psychically unstable. But, regarded as a tic, it is unique in its dependence on the casual exhibition of the professional act; as long as the telegraphist has no occasion to transmit messages, his occupation cramp will not incommode him in the least.

The great majority of genuine tics, on the other hand, are roused into activity by anything or nothing, and this distinction is fundamental.

With all due recognition, therefore, of the marked resemblances between the two, we shall be well advised in not confounding them under one designation. For want of a better word, we shall use the phrase professional cramp to specify functional disturbances taking place solely during the discharge of professional acts.

One other class remains to be dealt with, consisting of functional acts not merely superfluous but actually prejudicial to him who is at once their creator and their slave. The idea that induced them and the object they have in view are alike irrational.

An individual as he moves his arm one day becomes aware of a cracking feeling in his shoulder-joint, and from the unwonted nature of the sensation emanates the notion that he must have some form of arthritic lesion. Renewal of the gesture is attended with reproduction of the sound. The thought of a possible injury develops and extends until it is an object of constant preoccupation and becomes a fixed idea. Under its malign influence the movement is repeated a hundredfold and with growing violence until it passes into the field of automatic action. It is typically functional in its repetition, in the association of desire and satisfaction; but it originates in an absurd idea, and is actuated by a meaningless motive: its range is exaggerated, its performance irresistible, and its reiteration pernicious. In fact, it is a tic.

We may thus regard tic as an obsolete, anomalous function—a parasite function—engendered by some abnormal mental phenomenon, but obeying the immutable law of action and reaction between organ and function, and therefore just as prone to establish itself as any motor act of the physiological order.

CHAPTER IV
THE MENTAL CONDITION OF TIC SUBJECTS

THE existence of psychical abnormalities in the subjects of tics is no new observation. Charcot[18] used to say that tic was a psychical disease in a physical guise, the direct offspring of mental imperfection—an aspect of the question which has been emphasised by Brissaud and by ourselves on more than one occasion.[19]

How is the involuntary and irrational repetition of a voluntary and rational act to be explained? Why is inhibition of a confirmed tic so laborious? It is precisely because its victim cannot obviate the results of his own mental insufficiency. Exercise of the will can check the convulsive movement, but it is unfortunately in will power that the patient is lacking. He shows a peculiar turn of mind and a certain eccentricity of behaviour, indicative of a greater or less degree of instability (Brissaud). Noir writes in much the same strain, that careful examination will readily demonstrate the secondary nature of the motor trouble; behind it a mental defect lurks, which may pass for singularity of character merely, or childish caprice, but which none the less may be the earliest manifestation of fixed ideas and of mania.

It is a matter of some difficulty to describe adequately the features of this mental condition; their extreme variability has its counterpart in the diversity of the motor phenomena. In this polymorphism of psychical defect is justification for the numbering of the tic patient with the vast crowd of degenerates, and indeed Magnan[20] is content to consider tic one of the multitudinous signs of mental degeneration. As a matter of fact, one does find numerous physical and mental stigmata in those who tic, just as one finds them in those who do not.

It therefore becomes desirable to specify in greater detail the mental peculiarities of patients who, by reason of their motor anomalies, form a distinct clinical group both from the neuropathological and from the psychiatrical point of view. The pathogeny of these motor troubles will thus be elucidated and valuable indications for treatment obtained.

Whatever be our theory of tic, whatever be the shape the individual tic assumes, it is in essence always a perturbation of motility, corresponding to a psychical defect. No doubt appearances are deceptive, and the brilliance of the subject's natural gifts may mask his failings. His intelligence may be high, his imagination fertile, his mind apt, alert, and original, and it may require painstaking investigation to reveal shortcomings none the less real. This practice we have scrupulously observed in all the cases that have come under our notice, and we believe that the information gleaned in this way, coupled with the results of previous workers, warrants the attempt at a systematic description of the mental state common to all who tic.

Charcot[21] had already remarked the presence of certain signs or psychical stigmata indicative of degeneration, or of instability, as he preferred to say, inasmuch as the mental anomalies of these so-called degenerates were not only frequently unobtrusive, but in a great many cases associated with intellectual faculties of the first order. His contention has been amplified by Ballet:[22]

The striking feature of these "superior degenerates" or "unstables" it not the insufficiency, but the inequality, of their mental development. Their aptitude for art, literature, poetry, less often for science, is sometimes remarkable; they may fill a prominent place in society; many are men of talent, some even of genius; yet what surprises is the embryonic condition of one or other of their faculties. Brilliance of memory or of conversational gifts may be counteracted by absolute lack of judgment; solidity of intellect may be neutralised by more or less complete absence of moral sense.

In the category of "superior degenerates"—to use Ballet's terminology—will be found the vast majority of sufferers from tic, of whom O. may serve for the model. A no less instructive example is that of J.:

Of superior intelligence, lively disposition, and ingenious turn of mind, J. is dowered with unusual capabilities for assimilation. Everything comes easy to him. At school he was one of the foremost pupils, and his work elicited only expressions of praise. He is both musical and poetical; his quickness and neatness of hand find outlet in his passion for electricity and photography; for mathematics alone he has little inclination.

In a word, as with physical imperfection, so with mental—it may consist either in absence, arrest, or delay, or in overgrowth, increase, exaggeration, and these contrary processes may co-exist in the same individual. Sufficient stress, however, has not been laid on a practically constant feature in the character of the tiqueur—viz. his mental infantilism, evidenced, as was noted by Itard in 1825, by inconsequence of ideas and fickleness of mind, reminiscent of early youth and unaltered with the attainment of years of discretion. We must remember that imperfection of mental equilibrium is normal in the child, and that perfection comes with adolescence. In the infant cortico-spinal anastomoses are awanting, and volitional power is dependent on their establishment and development. At first, cortical intervention is inharmonious and unequal: the child is vacillating and volatile; he is a creature of sudden desire and transient caprice; he turns lightly from one interest to another, and is incapable of sustained effort; at once timid and rash, artless and obstinate, he laughs or cries on the least provocation; his loves and his hates are alike unbounded.

These traits in the child's character pertain equally to the patient with tic, in whom retarded or arrested development of volition, physical and mental evolution otherwise being normal, is the principal cause of faulty mental balance. That this view is correct may be inferred from a comparison of the individual patient with healthy subjects of his own age. The chief element in mental infantilism is maldevelopment of the will. While in the child deficiency of what one might call mental ballast is usually atoned for by well-conceived discipline and education, it is accentuated by misdirected teaching. Now, it not infrequently happens that the upbringing of the predisposed to tic is not all that might be desired, seeing that mental defect on the part of the parents renders them unsuitable as instructors of youth. Parental indulgence or injustice is the fertile source of ill-bred or spoiled children, in whom, spite of years, persist the mental peculiarities proper to childhood. From the ranks of these spoiled children is recruited the company of those who tic, for tics, generally speaking, are nothing more than bad habits, which, in the absence of all restraining influence, negligence and weakness on the side of the parents have allowed to degenerate into veritable infirmities. These the patients themselves are incapable of inhibiting, for whatever be their age, they remain "big children," badly bred and capricious, and ignorant of any self-control. Hence one of the first indications in their treatment is to submit them to a firm psychical discipline, calculated specially to strengthen their hold over their voluntary acts. Take the following case:

J. is nineteen years old, intelligent, educated, ready to graduate were it not for the interruptions his studies have undergone, and to all appearance arrived at manhood's estate. None the less he presents to-day the mental condition of nine years ago: he is fickle, pusillanimous, naïve, emotional; he laughs at trifles and is provoked to tears at the first harsh word; his nature is restless, his mind inconsequential; he is by turns elated or depressed for the most trivial of reasons. Notwithstanding his seventy-one inches, he must still be fed, dressed, and put to bed by his mother!

An identical mental state obtains in infantilism, properly so called, where to arrest of mental development physical imperfection is superadded. In cases of infantilism the psychical level corresponds more or less intimately to the somatic level, an observation borne out in the case of J.:

From the morphological point of view he shows one or two stigmata of infantilism: his great height need not be held to disprove this, for gigantism and retardation of sexual development are often in association. In spite of his nineteen years, J. has still a eunuch's voice and a minimum of axillary and pubic hair—in fact, one might say that physically he is thirteen years old, and mentally ten.

Or take Mademoiselle R., aged twenty-six:

Her intellectual attainments are those of a child of twelve, her age when her first tics made their appearance. Her artlessness and timidity are simply childish, and at the same time she lacks womanly charm and feminine ways.

Or again:

Young thirteen-year-old M. has been afflicted with tics of face, head, and shoulders for the last three years. Though small, he is well enough built, and has no obvious physical anomaly except an odd admixture of blonde and brown in his hair and eyebrows. His teeth are bad and misplaced, and several of the first dentition persist. There is no sign of pubic or axillary growth. As a general rule he is mild-mannered and docile; sometimes, however, he is irritable, impatient, emotional beyond his years. His degree of intelligence is very fair, but idleness and inconstancy are prominent traits in his character. The ease with which he apprehends is counterbalanced by the readiness with which he forgets, while his reason and judgment are those of a child of seven. The discordance between his actual age and his mental standard is therefore striking enough.

Another of our patients is L.:

Her intellect is quite up to the average, but the exaggerated importance attached by her parents to her "nervous movements" has only served to intensify her whims. Her eighteen years do not prevent her from revealing signs of mental infantilism in every action of her daily life, but, thanks to suitable treatment, she has been astonishing her father by unheard-of audacities—has she not recently ventured to cross the street alone, and alone to go an errand to a neighbouring shop?

X. has a tic of the eyes and has reached the age of forty-eight, yet he told us he was not so much his children's father as their playmate. At the age of fifty-four O. could still remark on his youthfulness of character. The same is true of S., who has attained his thirty-eighth year.

It is as arduous a task to define the term "stability of the will," as it is to explain what is meant by physical or mental health. But as it is not essential to preface descriptions of disease with a disquisition on the signs of good health, so anomalies of voluntary activity may surely be noted without a preliminary excursus on normal volition.

Will power may deviate from the normal in either of two directions—in the direction of excess or of insufficiency. To both of these two forms of volitional disturbance the subjects of tic have become slaves. Weakness of will is seen in irresoluteness of mind, flight of ideas, want of perseverance; exuberance of will in sudden vagary or imperious caprice. The man who tics has both the debility and the impulsiveness of the child; to his impatience his incapacity for sustained effort acts as a set-off; he is impressionable, wavering, thoughtless, even as he is mettlesome and irascible. He does not know how to will; he wills too much or too little, too quickly, too restrictedly.

As a single example of volitional activity, let us take the attention. Diminution of attention on the part of tic patients has been judiciously commented on by Guinon:

It is impossible for them to address themselves to any subject: they skip unceasingly from one idea to another, and apply themselves with zest to some occupation only to forget it immediately. No further proof of this need be sought than the inability of the patient, if he be at all severely affected, to read, a proceeding at once intellectual and mechanical, and absolutely familiar to most. Read the patient cannot, and though the attempt to concentrate the attention diminishes or inhibits the tic at once, there is no sequence in his effort; his eye jumps erratically from one line to another, and his many unavailing trials end in his throwing the book away.

Excess of voluntary activity is disclosed in the whole series of impulsions.

The germ of homicidal or suicidal tendencies, which we have indicated in the case of O., is discoverable also in one of Charcot's patients.[23]

M. Charcot (to the patient)—Tell us what you said the other day about razors.

The Patient—Whenever I see a razor or a knife, I begin to thrill and feel afraid. I imagine I am going to kill some one, or that some one is going to kill me. I have the same sensation when I see a gun, or even if the notion of a gun comes to my mind. The mere thought of it agonises me. The fancy of murdering some one strikes me, and up to a certain point I am envious of fulfilling the desire. Often I am conscious of an irresistible longing to fight somebody, and I am frequently impelled to it by the sight of a cabman. Why a cabman more than any one else, I have not the remotest idea.

We have already touched on the close affinity between an act and the idea of the act, and we have emphasised the absence of any appreciable interval between the idea and its execution, unless the brake of volitional interference be put on at the proper moment. It is in these circumstances that the feeble of will betray their debility; the inadequateness or inopportuneness of their will's activity allows the performance of the act they would fain repress.

A no less characteristic feature of the subject of tic is his impatience.

J. bolts his food without waiting to masticate it, and the instant his plate is empty jumps up from the table to walk about the house. He returns for the next course, which he swallows as precipitately; delay makes him impatient, and all are forced to rush as he does. Meal time for the whole family has become a perfect punishment. Alarmed enough already at his tics, the parents are terror-stricken by the tyrannical caprices of this big baby, who outvies the worst of spoilt children in his behaviour.

Mental instability is not uncommonly associated with a general restlessness and fidgetiness during intervals of respite from the actual tics. The patient experiences a singular difficulty in maintaining repose. Every minute he is moving his finger, his foot, his arm, his head. He passes his hand over his forehead, runs his fingers through his hair, rubs his eyes or his lips, ruffles his clothes, plays with his handkerchief or with anything within reach, crosses and uncrosses his legs, etc. None of these gestures can properly be considered a tic, for, however frequent be its repetition, it is neither inevitable nor invariable. If they are superfluous and out of place, the absence of exaggeration or absurdity negatives their classification as choreic. They are a sign not so much of motor hyperactivity as of volitional inactivity. They are tics in embryo.

The patient's emotions are similarly ill balanced. Any rearrangement in his habits he finds disconcerting; he is upset by an unexpected word, a deed, a look; his timidity and sensitiveness are extreme—fertile soil for the development of tics.

So, too, with his affections, his likes and dislikes, his friendships and enmities—there is commonly a disproportion about them that betokens mental deficiency. At one time it is fear or repulsion that actuates him; at another it is an unnatural tenderness, a sort of philia, if the term may be allowed.

Anomalies such as these, however, are met with in all the mentally unstable, and do not present any special feature when they occur in those who tic.

An acquaintance with the mental state of our patients enables us to understand the mode their tic adopts. As one thinks, so does one tic. To the transiency and mutability of the child's ideas correspond what are known as variable tics, which rarely have a definite localisation, and become fixed only when certain ideas become preponderant. The existence of a solitary tic, however, is not at variance with that disposition we have qualified as infantile, for mental infantilism is the original stock; on it, as a matter of fact, may be grafted further mental disorders in the shape of fixed ideas, phobias, or obsessions.

Should a fixed idea entail a motor reaction, it may give rise to a tic as ineradicable as the idea itself, and a series of fixed ideas may be accompanied by a succession of corresponding tics.

The frequency with which obsessions, or at least a proclivity for them, and tics are associated, cannot be a simple coincidence. Without defining the word obsession, let us be content to recall the excellent classification given by Régis, according to whom they mark a flaw in voluntary power, either of inhibition or of action. On the one hand we have impulsive obsessions, subdivided into obsessions of indecision, such as ordinary folie du doute; of fear, such as agoraphobia; of propensity, such as those of suicide or homicide. On the other we find the aboulic obsessions, such as inability to stand up (ananastasia), or to climb up (ananabasia), or the astasia-abasia of Séglas, or the akathisia of Haskowec. Perhaps we ought also to place here sensory obsessions in the shape of topoalgia, and even hallucinatory affections.

In all these varieties of obsession increase or diminution of volitional activity is undeniable. But this alteration in the function of the will is no less distinctive of tic, and if we compare the psychical stigmata of obsessional patients—the asymmetry of their mental development, their intellectual inequalities and lack of harmony, their alternating excitability and depression, their unconventionalities, eccentricities, and imaginativeness, their timidity, whimsicalness, sensitiveness, and all the other indications of a psychopathic constitution—if these are compared with the mental equipment of the sufferer from tic, we cannot but notice intimate analogies between the two, analogies corroborated by a glance at their symptomatology.

An obsession may be of idiopathic origin, or it may be causally connected with some particular incident, sensation, or emotion. A conflagration may determine fear of fire, or a carriage accident amaxophobia. Further, the obsession is irresistible, as is the tic: opposition endures but for a moment, and is therefore vain. Nor is the inhibitory value of attention or distraction any less ephemeral. This feature of tic was noted as long ago as 1850 by Roth, who held its motor manifestations to be phenomena of "irresistible musculation."

Consciousness is maintained in its integrity both before and after, but not during, an obsessional attack, and this is equally true of tic, as are the preliminary discomfort and subsequent satisfaction that attend the obsession. Noir makes the appropriate remark that idiots affected with krouomania, in whom sensory disturbance is awanting, so far from suffering pain through sundry self-inflicted blows and mutilations, seem, on the contrary, to be thus afforded a certain feeling of relief, if not of actual relish.

Whenever Lam., who exhibits incessant balancing and rotatory movements of the head, is seated in proximity to a wall, he knocks his head sideways against it until a bruise results, and appears to find therein a source of genuine satisfaction.[24]

If, then, an obsession provokes a motor reaction at all, it may originate a tic, and, in the case of tonic tics, this is a very common mode of derivation, as one may well understand how an obsession may occasion an attitude.

Grasset cites the example of a young girl who would never lean backwards in a railway carriage or on any chair or bench, preferring to sit bolt upright on the edge. In this instance the adoption of a stereotyped attitude was directly attributable to an obsession.

Another example of an attitude tic is furnished by the case of young J.:

Standing or seated, he always has his half-flexed left arm firmly pressed against the body in the position assumed by hemiplegics. Its pose and inertia and the awkwardness of its movements unite to suggest some real affection, the existence of which the constant use of the right arm and the elaboration by the patient of intricate devices to obviate disturbing the other tend to substantiate. Nevertheless, the impotence is entirely imaginary. To order he can execute any movement of the left arm with energy and accuracy; his left hand will button or unbutton his clothes, lace his boot, handle a knife, and even hold a pen and write.

It seems that the position of the arm was chosen deliberately to alleviate a supposed pain in the shoulder, and unceasing resort to this subterfuge of his own inventing, which he considered a sovereign remedy, ended in its voluntary adoption being succeeded by its automatic reproduction.

The assumption of this position for his arm was at first attended with satisfactory results, but, as might have been foreseen, its inhibitory value decreased gradually, so he had recourse to other means. It was then that the right hand was made to grip the left and press it more energetically than ever against the epigastrium. In this complex attitude both arms simultaneously participated, but again its efficacy was purely transitory. Evidently dissatisfied with his methods of immobilisation, and convinced that experimentation would end in the discovery of the desired arrangement, J. proceeded to employ the right hand in impressing every variety of passive movement on the left hand, wrist, forearm, and upper arm, and soon there was no checking these gymnastic exercises. He would suddenly grasp the wrist and pull and screw it, while the left shoulder and elbow resisted nobly; or he would bend, or unbend, or twist his fingers, or seize the arm below the axilla and knead it or rub it, forcing it against or away from the thorax; he would pound the muscles and pinch the tendons, sometimes in a brutal fashion; in short, the situation degenerated into nothing more nor less than a pitched battle between the left arm and the right hand, in which the latter endeavoured by a thousand tricks to bring the former into subjection. Victory rested always with the affected arm.

Each time that this absurd combat recommenced, the patient experienced a sensation of relief; resignation to the imperious motor obsession was even followed by a sense of well-being. On the other hand, resistance was accompanied by actual anguish—he would fidget desperately in his chair, cross and uncross his legs, sigh, grimace, rub his eyes, bite his lips and nails, twist his mouth about, pull at his hair or his moustache, he would look anxious or alarmed, would become by turns red or pale, and beads of perspiration would gather on his face. At length he would be compelled to yield, and the bloodless battle of his upper limbs would close more furiously than ever.

In this case the typical features of obsession are excellently illustrated—its irresistibility, as well as the concomitant distress and succeeding content.

Conversely, however, a tic may be said to develop into an obsession if the exciting cause of the latter be the motor reaction.

In various psychopathic conditions (says Dupré[25]), especially where the genito-urinary apparatus is concerned, this pathogenic mechanism is encountered. Some source of peripheral irritation in bladder, urethra, prostate, etc., provokes cortical reaction, and a reflex arc is established with centrifugal manifestations in the guise of motor phenomena, which in their turn originate all sorts of fixed ideas, impulsions, and obsessions, forming an integral part of the syndrome.

There is frequently no direct or obvious connection between a patient's obsession or obsessions and his tics. The former may consist, both in children and in adults, in extraordinary scrupulousness, perpetual fear of doing wrong, absolute lack of self-confidence, sometimes simply in excessive timidity, exaggerated daintiness, or interminable hesitation. We have often seen youthful subjects betray in their disposition weak elements such as the above, which at a later stage have proved the starting-point for more definite obsessions. Their intelligence and capacity for work earn the approbation of their teacher, yet they are for ever dissatisfied, haunted by the dread of having overlooked some iota in their task; they dare not affirm that they know their lessons, they stammer over their answers, mistrust their memory, make no promises and take no pledges, and thus bear witness to an absence of confidence in themselves which affects them profoundly, for they are well enough aware of its consequences.

An admirable instance of this is furnished by the case of young F., or by little G., ten years old, who suffers from a facial tic, and constantly hesitates when asked to give a measurement, an hour, a date, a figure, solely by reason of a conscientious fear of not being absolutely accurate in his reply.

In children the emotional excitement of their first Communion often favours the development of religious scruples. By a sort of metastasis, diminution of the convulsive movements goes pari passu with aggravation of the mental phenomena, until such a time as the devotional exercises are done with, when there is a return to the previous state.

Arithmomania betokens an analogous turn of mind. Certain patients are compelled to count up to some number before performing any act. One cannot rise from his seat without counting one, two, three, four, five, seven, leaving out six since it is disagreeable to him. Another must repeat the same movement two, three, ten times, must turn the door-handle ten times ere opening it, must take five steps in a circle before beginning to walk (Guinon). A patient of Charcot's used insanely to count one, two, three, four, used to look under his bed three or four times, and could not lie down until assured that his door was bolted. A further example is reported by Dubois:

A young woman twenty years of age first began to suffer from convulsive tics five years ago. Without any warning she used to bend down as if with the intention of picking up something, but she had to touch the ground with the back of her hand, else the performance was repeated. Twenty or thirty times a day this act was gone through; in the intervals she kept turning her head to the right, looking up at the curtains in a corner of the window, and at the same time making a low clucking sound that attracted the attention of those in the room. For nine or ten years these two tics have prevailed, and have been accompanied with certain obsessions, such as the impulse to count up to three, to regard any person or object three times, etc. With the generalisation of the convulsive movements various phobias have made their appearance—viz. fear of horned animals, of earthworms, of cats, of blight, etc.

Onomatomania is another form of obsession which may be mentioned, exemplified by the dread of uttering some forbidden word, or by the impulse to intercalate some other. The term folie du pourquoi has been applied to the irresistible habit of some to unearth an explanation for the most commonplace of facts: "Why has this coat six buttons?" "Why is so-and-so blonde?" "Why is Paris on the Seine?" etc. This mode of obsession is frequent among those who tic, and is curiously reminiscent of a familiar trait in the character of children, thereby supporting our contention of the mental infantilism of all affected with tics.

Prominent among the mental anomalies of the subjects of tic are found different sorts of phobia: fear of death or of sickness, of water, knives, firearms—topophobia, agoraphobia, claustrophobia, etc.

The following most instructive case has been observed by one of us over a period of several months:

S.'s earliest attack of torticollis, of two or three days' duration merely, occurred when he was fifteen years old, and was attributed by his mother—whose mental peculiarities, in especial her fear of draughts, are no less salient than those of her son—to a chill occasioned by a flake of snow falling on his neck. S. is so blindly submissive that he accepts this pathogeny without reserve. Five years ago a second torticollis supervened, which still persists to-day, and of which his explanation is that he was obliged, when standing at a desk, to turn his head constantly to the left for two hours at a time in order to see the figures that he had to copy, and was forced, after the elapse of some months, to relinquish his work owing to pain in the occipital region and neck. From that moment dates the rotation of his head to the left.

At the present time his head is turned to the left to the maximum extent, the homolateral shoulder is elevated somewhat, and the trunk itself inclines a little in the same direction. The permanent nature of this attitude necessitates his rotating through a quarter of a circle on his own axis if he wishes to look to the right. On the latter side the sternomastoid stands out very prominently, and effectually prevents his bringing the head round; nevertheless he is greatly apprehensive of this happening, and as he walks along a pavement with houses on his right he keeps edging away from them, since he is afraid of knocking himself against them. By a curious inversion, common enough in this class of phobia, he feels himself impelled to approach, with the result that he cannons against the wall on his right as he proceeds.

Contrary to the habit some patients with mental torticollis have of endeavouring to ameliorate the vicious position by the aid of high starched collars, S. has progressively reduced the height of his until he has finished by discarding them altogether. As a matter of fact, it is the "swelling" in the neck caused by the right sternomastoid that is at the root of his nervousness, for he is convinced that it preceded the onset of the torticollis, and he has a mortal dread of aggravating it by compression.

Hence one may perhaps understand what line of erroneous reasoning has led to the establishment of the wryneck. The fear of draughts, instilled in his youthful mind by his mother, had the effect of driving him to half-strangle himself with a tightly drawn neckerchief, to hinder the inlet of air and minimise the risk of catching cold, and when he commenced to turn his head to the left at his work, the pressure of the band round his neck was felt most of all on the contracted right sternomastoid. A glance at a mirror convinced him that the unusual sensation was due to an abnormal muscular "swelling," whereat he was vastly alarmed; he hastened to change his collar, but all to no purpose. By dint of feverish examination and palpation of the muscle, he soon acquired the habit of contracting it in season and out of season, till at length an unmistakable mental torticollis supervened.

It sufficed to explain to S. the role played by the sternomastoid in head rotation, and to demonstrate the absurdity of his interpretation of the so-called "swelling": the gradual relaxation of the muscle and consequent diminution in the "tumour's" size not only satisfied him of its benign nature, but afforded such a sense of relief as was quickly made obvious by a notable improvement in his condition.

A singular tic of genuflexion occurred in a case reported by Oddo, of Marseilles:

The dominant note in the young girl's character is her cowardice; she is afraid of everything. Every evening before the return of her father she repeatedly looks into the corridor to see that no one is there; as soon as her parent arrives, she locks the door behind him hurriedly to prevent any one else appearing; every now and then in her fear of a footstep she listens at the door, and it is this gesture, this attitude of listening, that has degenerated into a tic which no amount of remonstrance or derision seems to affect.

Phobias such as these are associated with an evident tendency to melancholia and hypochondriasis. The majority of our patients are ridiculously preoccupied with the state of their health; the extraordinarily introspective nature of their minds is manifest in their meticulous observation, their laborious analysis of their most trifling sensations, the zeal with which they devise the most complex explanation for their simplest symptom, usually for the sake of making the prognosis seem more grave.

At the other pole from these silly fears and dislikes we meet with various absurd predilections and meaningless attractions: one can sit only on a certain seat, sleep only in a certain bed; another cannot enter a room except by a particular door; a third will make a long detour to pass along a certain street; in this street he will always walk on the same side, and lengthen or shorten his stride to step always on the same flagstones. We are acquainted with the history of a wretched commissionaire who could not go an errand in Paris without starting from the Place Clichy, and the interminable twists and turns on his route can be imagined when his duty took him from Montrouge to the Bastille.

Akin to the conditions we have been enumerating is an exaggerated love of order, somewhat unexpected in those whose mental disarray is often extreme. Some cannot sleep without previously arranging their clothes in an unvarying plan. One of Guinon's patients contrived to have one half of the objects in front of him to his right, and the other half to his left. In the case of a little nine-year-old hydrocephalic child with tics and echolalia, Noir[26] makes the following remarks:

The fundamental element in the child's character is an overweening vanity coupled with an excessive orderliness. Her desire of personal ornament is such that at one time she is lost in admiration of a new dress, at another, she is decking herself out with old pieces of tarletan. When going to bed she folds her clothes in the same exact order each evening. Her self-conceit makes her furiously jealous of the attention paid to any other patient in her presence.

A similar mental state has been observed by Noir in other hydrocephalics.

The same tendency is revealed in an inane search after precision in the most petty details, the natural result in the case of conversation, for instance, being that its thread is quickly lost in endless digressions and parentheses within parentheses.

A score of other mental peculiarities, commonly described as "manias" by the lay mind, are nothing else than fixed or obsessional ideas in miniature, as Grasset says, and he narrates how for a time he himself used to be irresistibly forced, on entering a railway carriage, to divide the figure representing the number of the carriage by the number of the compartment. He further cites the case of an otherwise normal individual, who whenever one foot strikes on a stone raised a little above the level of the ground, is obliged to seek an analogous sensation for the other, and who cannot let one hand touch anything cold without giving its fellow the opportunity of receiving an identical impression. A common impulse is to count the windows in the house one is passing, or the bars of the railings. Sometimes it is a "mania" for setting things straight, or for rubbing out marks in a book; but while these and similar psychical accidents are singularly prone to develop in the subjects of tic, they are not to be considered in any way special to them.

Hallucinations, too, and sometimes actual delusions, may form a basis from which springs a motor reaction that passes into a tic.

If even the most sane among us (says Letulle) are conscious of a wellnigh invincible propensity to repeat a particular movement or expression or sequence of thought, we can understand how the temptation falls with overwhelming force on such as suffer from persistent hallucinations or fixed ideas. Take, for instance, this woman who utters a shrill cry and waves her hand before her face; the regularity of her action is a sequel to the delusion that possesses her, for in her imagination she is chasing away the birds that would pluck out her eyes. And when at a later stage these visual hallucinations are lost in a progressive dementia, the gesture becomes an incurable tic.

Here is another patient: his habits of continually washing his hands, of expectorating as he passes any one, have their explanation in his dread of being poisoned by imaginary foes, and, though subsequent mental disintegration precludes the possibility of the delusion continuing, the trick remains to the end of life.

A case has been put on record by Wille,[27] under the name of "disease of impulsive tics," concerning a young man twenty-two years of age, who, in addition to the grave taint of a psychopathic heredity, exhibited early indications of irritability and a tendency to obsessions. Systematised movements of face, shoulders, and arms, accompanied with coprolalia, were not long in appearing. It was noticed that the psychical symptoms were periodic, and that their nocturnal exacerbation coincided with the advent of hallucinations. Two attacks of mania came on, but a cure followed after four years' time.

It may be questioned whether we are not dealing here with a case of dementia præcox, rather than with the true Gilles de la Tourette's disease; at any rate, tic may be a concomitant of grievous mental affections.

Another case of still more advanced mental deterioration may be quoted from Bresler:[28]

In this patient contractions of facial and limb musculature at the age of nine were succeeded by some years of epileptic outbreaks; and outrageous conduct towards his mother and sister, coupled with acts of wanton brutality and destruction, at length necessitated his removal to an asylum. He suffers from convulsive tic of face and shoulders, while his speech is drawling and syllabic, and interrupted by guttural ejaculations corresponding to the manifestations of his tic.

It is superfluous to dilate further on this part of our subject, and we shall take another opportunity of dealing with the question of tics in idiots and the mentally backward. For the present, the statements of the chapter may be summarised in a few words:

In the mental condition of the subject of tic there may be differentiated two elements: the one is fundamental, and is sufficiently described in the phrase mental infantilism; the other is superadded, and consists of a multiplicity of psychical imperfections which reveal, at the same time as they exaggerate, the inherent defects constituting the former, in particular volitional infirmity. By this means a useful clinical distinction may be drawn between various tics, according as they take their rise in one or other form of mental affection, and at the same time the practical gain is considerable, for treatment must be directed both to the physical and the psychical aspect of the malady, and its success in the former sphere is greatly dependent on intelligent recognition of and acquaintance with the nature of the latter.

Manias, obsessions, phobias, and other accompaniments of the disease known as tic (says Grasset)—those abnormal phenomena that testify to the affection as the stigmata of hysteria confirm that neurosis—are nothing more than psychical tics; that is to say, special types of the disease. If their occurrence is frequent and indeed habitual, their absence in no way invalidates the diagnosis. They resemble coprolalia, salutations, etc., in being accidental and not essential symptoms.

We are entirely at one with Grasset on this last point; but if they do occur, are they to be denominated tics? We must beg to be excused for dwelling with such insistence on a question of words, but we are assured that the rigorous limitation of the word tic to conditions in which it is possible to recognise two inseparable and indispensable elements, one motor and the other mental, cannot fail to simplify matters. Otherwise, of course, we are merely adding to the meaning of a term already interpreted in far too liberal a fashion.

Abuse of language such as this leads to inevitable confusion. Noir, for an instance, in whose excellent thesis there is abundant evidence of painstaking observation and judicious discernment, is constrained to write:

Tics of idea are exemplified by fixed and obsessional ideas, such as folie du doute, misophobia, arithmomania, etc., and are allied to motor tics in that they consist of isolated or complex psychomotor reactions, which may, however, assume a purely psychical form. They are mental affections clothed, in the case of convulsive tic, in a motor garb.

In our opinion, all such formulas as "tic of idea," "psychical tic," "mental tic," "motor tic," etc., ought to be abolished. An obsession ought to be called an obsession, and there ought to be a similar understanding in the case of phobias and fixed ideas, for each and all may exist independently of any motor reaction whatever, and therefore can never be classed with tic. It is only when the obsession or the fixed idea entails the automatic repetition of some motor phenomenon that a syndrome can be constituted to which the name of tic may be applied. As a matter of fact, a tic can no more be exclusively mental than exclusively muscular. A mental condition that does not find expression in a motor reaction is not a tic, and to speak of purely mental or purely motor tics is a contradiction in terms. Cruchet's proposed category of psycho-mental tics serves only to aggravate the misunderstanding, so long as everyday usage emphasises the identity of the two words "psychical" and "mental."

[Tics are not the private property of the human species. The word appears to have been first employed in reference to horses, and while little attention has hitherto been paid to the subject in veterinary annals, its methodical study has recently been undertaken by Rudler and Chomel.[29] It is remarkable how intimate are the analogies established by these observers not merely between the tics of animals and of mankind, but also between their respective mental conditions. Physical and psychical stigmata of degeneration are as obvious in the horse that tics as in the man who tics, and it is not without interest to note that the tics of such animals as have the most rudimentary psychical development present a close resemblance to those that occur among the least advanced of the human race, among idiots and imbeciles.]

CHAPTER V
THE ETIOLOGY OF TICS

THE circumstances favouring development of a tic in soil already prepared by psychical predisposition are manifold. Our studies in the pathogenesis of tic have illustrated the significance of exciting causes, so-called. We have seen how the motor part of the tic was originally directed to some definite object, and therefore provoked by some definite cause, and how the eventual disappearance of this cause does not justify the conclusion that it has never existed.

We shall be able to quote numerous instances in point when dealing with the different localisations assumed by the tics; what we wish to remark here is that the initial cause is by no means always easy to ascertain. The subjects of whom we are treating exhibit a vexatious tendency to invent a more or less fantastic etiology for themselves, and their statements cannot be accepted without rigorous investigation. Of any actual exciting cause they may be really ignorant, or more likely oblivious.

In this connection an important case is reported by Pierre Janet[30]:

A young man twenty-five years old was affected with a facial tic in the shape of constant grimaces, accompanied by violent expirations through one nostril. Six years of the condition had neither enabled him to determine its origin nor brought him any relief. He presented, in addition, the phenomena of automatic writing and was the subject of somnambulism, and when in the latter state explained that the tic arose from the effort to expel an irritating nasal obstruction due to an epistaxis six years ago.

Needless to say (adds Janet), there never had been any obstruction in the nose; the truth was that in the somnambulistic state he was reminded of a subconscious fixed idea of which he was ordinarily unaware.

Recognition of the causal factor, then, is not without value, as otherwise the tic's situation and form may rest inexplicable.

These exciting causes we shall discuss more closely at a subsequent stage, confining our attention for the present to one or two general considerations.

Age.—Tics may occur at any period, except in infancy. "Nervous movements" appearing previous to the age of three or four cannot be tics, as has been made plain in the chapter on pathogeny. It is only with the development of psychical function—about the age of seven or eight—that revelation of its imperfection, if such exist, becomes possible.

Initiation or exacerbation of a tic is very frequent about the time of puberty, when both physical and mental evolution is peculiarly apt to suffer interruption.

Sex.—Sex is without influence on the disease.

Race.—In spite of the absence of precise statistics on the subject, the opinion that the tendency to tic increases with the advance of civilisation is not, we think, premature.

We have had the curiosity to interrogate several travellers familiar with different savage tribes of Central Africa, who, although notified beforehand to be on the look-out, declare they have practically never met with tic in negroes. These observations require to be confirmed.

It may be questioned if the level of mental attainment of such primitive peoples is sufficiently high to allow of the establishment of tics. Their occurrence in the lower animals has been recorded, it is true; but with our ignorance of what constitutes an animal tic, and until further information is forthcoming, it is prudent not to speculate on these matters. We must be content with the remark that savages and animals are less exposed than the civilised to circumstances facilitating the development of mental instability.

Trauma and infectious disease may provide the occasion for either the appearance or the disappearance of a tic, but of themselves they are incapable of originating the affection.

One of Noir's patients had a brother similarly afflicted, and a sister in whom an attack of bronchitis at the age of five was accompanied by tics of arm and head, which recurred subsequently in an exaggerated form during smallpox. On each of two occasions on which J. suffered from influenza his tics increased in violence and extent; while in the case of G. aggravation heralded the approach of measles.

Young M., on the other hand, remained free of all his face and head movements during the immobilisation of a fractured leg, with the cure of which his tics returned.

To disturbance of the reproductive organs, in particular to uterine disorders and even pregnancy (Gowers, Bernhardt), has been ascribed the onset of tic.

Of the possible influence of climate, season, and atmospheric change in general, precise information is lacking. Stormy weather or a falling barometer frequently exercises a depressing effect on the subjects of tic, but this is habitual in all neuropathic individuals. Oppenheim declares he has seen severe cases of convulsive tic follow an earthquake.

Heredity.—To this Charcot used to attach the greatest importance. In every case of tic, he maintained,[31] however trivial, especially if attended with phenomena such as coprolalia, a hereditary element is discernible.

Similar heredity is of common occurrence. In Gintrac's cases, two brothers had the same facial tic. Blache's patients were three children in the same family. Delasiauve observed identical tics in brother and sister, and Piedagnel in mother and daughter. A father and two sons of whom Letulle has given an account all suffered from a tic of blinking. The same author has seen two brothers with a complex tic of face, scalp, arms, and diaphragm. More recently Tissié has recorded a series where a mother was affected with ocular tic, while the eldest son also had an ocular tic, which eventually spread to the face and was associated with a spasmodic cough; a younger son was likewise the subject of ocular tic.

A case has come under our notice of a young girl with a head-tossing tic which had been preceded by a variety of others now imitated by her youngest sister, such as sniffing, screwing of the face, shaking of the shoulders, abrupt pulling up of the garters, etc.

These and similar instances undoubtedly serve to show the effect of hereditary predisposition; but the element of imitation enters no less into the question, and the elimination of its influence, owing to family promiscuousness, is peculiarly arduous. To this point we shall revert immediately.

Dissimilar heredity, in any of its forms, neuropathic or psychopathic, is no less frequently met with, and emphasises the kinship of tic with almost all the psychoses and neuroses.

It is a matter of common observation for a tiqueur's father to be a neuropath, his mother a hysteric, his brother an epileptic, or his grandfather a general paralytic or a maniac, while neurasthenia, hypochondriasis, psychasthenia, etc., or organic disease of the nervous system, may occur among the collaterals. A case has been under our care of a boy M., who has two brothers and one sister, all in good health. The sister bites her nails. The mother is normal, but excessively weak where her children are concerned. The father is neurasthenic, and the grandfather has trigeminal neuralgia.

Occasionally a family history of syphilis or alcoholism is forthcoming. Sometimes tic and psychical troubles alternate. Flatau[32] quotes a case of a mother with impulsions and a son with tics, and another of a mother and sister who tic, with a son possessed of fixed ideas.

In the subjects of tic and in their families, mental instability and intellectual superiority have repeatedly been conjoined. To refer again to the case of young J., no particular deviation from the normal was traceable on the part of any ancestor or relative on the paternal side, except that the father himself was unusually emotional and a prey to scruples; but the mother's whole family were either brilliantly clever or prematurely broken down, succumbing to "strokes" and paralyses of various kinds.

Many figures celebrated in history had their tic.

At the time of his early appearances Molière was held even in the provinces to be a comedian of a very inferior order, owing perhaps to a hiccough or throat tic of his leaving a disagreeable impression of his acting on those who were not aware of its existence.[33]

Brissaud recalls the curious picture of Peter the Great handed down to us by Saint-Simon[34]:

If he gave thought thereto, his mien became majestic and gracious, else was it forbidding, and almost savage, his eyes and his face occasionally distorted by a momentary tic that rendered his expression wild and terrible.

Similarly with the Emperor Napoleon[35]:

His moments, or rather his long hours, of work and meditation were characterised by the exhibition of a tic consisting in frequent and rapid elevation of the right shoulder, which those who did not know him sometimes interpreted as a sign of dissatisfaction and disapproval, seeking uneasily wherein they could have failed to please him.

Cases of tic in the descendants of great men are far from rare; we have met with several instances.

Among etiological factors of a general description, the rôle played by imitation is all-important, especially in the young. Mimicry is strong in the child's nature, and bad habits are quickly contracted. Should he be tainted with nervous weakness in addition, he is apt to tic on the slenderest pretext, in which case to encounter, or still more to be associated with, the subject of a tic would be the direst of misfortunes.

That such a contingency should arise is not essential. A novel gesture on the part of any one catches the child's attention, and he forthwith attempts its reproduction, finding therein a source of complacent satisfaction. On the morrow the movement is repeated, and again, till it oversteps the bounds of habit and enters the realm of tic.

Cruchet concedes this to be a possible though by no means invariable mode of tic production, for the reason that the unconscious, or, more correctly, subconscious—polygonal, if you will—nature of imitation is undeniable, indeed self-evident.

Without entering into too great detail, it may not be amiss to examine this contention.

To imitate, in Littré's definition, is "to seek to reproduce what another is doing." How such an act is to be accomplished without the co-operation of the will we cannot conceive. Its duration being so brief, our recollection of the conscious stage may be very imperfect, but that is no ground for denying its reality. Involuntary execution of a gesture to-day does not exclude the possibility of its voluntary execution yesterday. If we find accurate reconstitution of the steps in our own habitual mental processes impracticable, a fortiori ought we to question the likelihood of our gaining full insight into the mechanism of the processes of others.

It is no doubt this perplexity which has induced Cruchet to regard the simple convulsive tic as the sole manifestation of the disease. On his own admission, nevertheless, this simple convulsive tic is of exceptional occurrence, apart from children, in whom mental trouble is conspicuous by its absence.

But the psychical disorders of infancy, however embryonic they be, are none the less real. Their insignificance may hinder their recognition, yet they are often the prelude to graver and more definite anomalies in later life. And if their detection demands painstaking study and repeated interrogation, fruitless results may very well mean that the investigation was not sufficiently thorough.

Moreover, the view that regards imitation as a prolific element in the genesis of tics has met with widespread acceptance.

The onset of the disease (says Guinon) is sometimes the consequence of the patient's partiality for mimicry. Contact with an affected person supplies the occasion. His first experience is a sort of constant preoccupation; the other's grimace is ever before his eyes, inviting imitation; at length he suddenly yields to the obsession, and his tic is in the making.

Reference has already been made to a case of Tissié's,[36] where an eight-year-old child acquired from its mother an ocular tic, which a second child imitated in its turn. The cure of the latter was followed with the cure of the two others, by imitation.

The word "echokinesia" was imagined by Charcot to specify the inclination some people show to copy what they see others doing. It has also received the names of "mimicism" and "imitation neurosis." To quote Guinon again:

The movements most closely and most infallibly mimicked are facial. These the patient either is driven actually to reproduce, or feels impelled to reproduce, without allowing the impulse to pass into action. Simple and circumscribed gestures involving the limbs are similarly, if less frequently, the object of imitation. Such tricks as rubbing the nose or cheek or some other part, or stooping as if to pick up something on the ground, may be counterfeited in their entirety, though at other times the movement is only initiated.

Echokinesia may be considered a motor disturbance analogous and akin to tic, but distinguished by the fact that it occurs exclusively during the performance, and as the reproduction, of some movement executed by another. It is true, of course, a genuine tic may be a reminiscence of some gesticulation, but it is quite independent of time and place.

A similar difference exists between echolalia—the habit of repeating another's sounds or words at the moment of their ejaculation—and tics of phonation or of language; the latter are always ill-timed and inappropriate, though they may have had their origin in acts of imitation.

It has become classical to draw a comparison between these echokinesic phenomena and the observations of O'Brien apropos of latah among the Malays.

A sailor on board a boat will pick up a piece of wood and proceed to rock it as if it were a child, whereupon a latah standing alongside commences to rock the infant he holds in his arms. The sailor then throws the piece of wood on to the deck, and the latah promptly follows suit with the baby (Guinon).

This is echokinesia carried to an extreme, revealing a complete absence of inhibition from the higher psychical functions.

Prominent among influences calculated to facilitate the evolution of tics is the patient's environment, more particularly where children are concerned.

The parents are often disposed to be deplorably "fond." Their ignorance or their thoughtlessness permits the installation of obnoxious habits and fosters their growth into tics. Any endeavour after suppression usually serves to expose the inadequacy of the family authority to exercise control and compel obedience. For the watchful discipline that should curb all such childish tricks and caprices is unfortunately substituted a disastrous indulgence that only stimulates the development of these embryonic tics. It should not be forgotten, moreover, that the mental instability of the fathers is visited upon the children in the guise of a certain aptitude for psychical anomalies.

The accompanying case supplies conclusive evidence of the mischief wrought by weakminded parents, and of the calamitous results of hereditary predisposition and bad example combined.

S.'s mother is a lady of over fifty, who spends her leisure hours in writing novels, and who suffers from different varieties of phobia. In the first place, she has an absurd fear of cats and dogs. When she goes out, a maid follows at several yards' distance to prevent the approach of any dog from the rear; and if she is driving, the same precautions are observed.

Her dread of chest complaints is equally extravagant. A cold is her bugbear, a draught her bête noire. In the intervals of her literary labour she occupies herself with seeing that all doors and windows are properly shut. The room temperature is maintained at 68° F. at least.

Since her husband's death her devotion to her son's education has been fatal to his best interests. Her unfailing solicitude for his health, her constant terror of accident and illness, have reduced volitional effort in him to a minimum, and under this régime of tyrannical affection he has been as delicately nurtured as a young girl. Even at the age of thirty he must be indoors at night by ten o'clock, and a few minutes' delay will bring his mother to a state bordering on frenzy, and end in the dispatch of some one to seek him; whence all sorts of domestic discussions, and quarrels, and "scenes," with tears and mutual recrimination.

Little wonder then, with such an example, that, in spite of his own robust health, S. evinces the same senseless fear of chills and colds and currents of air, and tries the doors and windows so incessantly and so violently withal that they have to be repaired almost every month. In his own room they have been doubled and padded. His anxiety to avoid catching cold actually leads him to weigh the samples of cloth submitted to him, to ensure that his next suit of clothes will be of the same weight as his last.

With all this excess of tenderness, S.'s mother does not always err on the side of leniency. On the contrary, punishment is apportioned for the most trivial fault, although it is only necessary on S.'s part to simulate illness for his mother at once to yield to his most ridiculous caprice.

S. suffers from a rotatory tic of the head, which he attributes to a blow on the neck once administered by his mother by way of chastisement; but it may very well be questioned whether the torticollis was not rather a clever imposition intended to soften the mother's heart and bring about her repudiation of corporal punishment.

The case of J. is no less instructive, since he came of a family of veritable syphilophobes whose extraordinary frailties and sentimentalities contributed not a little to the progress of his disease.

A glimpse into the domestic life of L. is equally illuminating.

L. is an only child, who from infancy has usurped her parents' attention. Their uneasiness lest her "nervous movements" should prove detrimental to her general health is the explanation of her highly irregular attendance at school and of repeated holidaying. She may not go out alone, as her "incantations" are liable to arrest her in the middle of the street; at the same time lack of control over her legs may endanger her safety, and erratic arm gestures render the aid of a stick or umbrella useless.

To add to her misfortunes, her head has now begun to rotate to the right. She used four times a day to cross the narrow and little frequented road that separated her father's house from her place of employment; but since her last accident she has remained strictly within doors, trifling away the time in a chair, and finding in the petty life of a side-street all that she wants to attract her gaze or arouse her interest.

In this microcosm her father has been reduced to the position of a slave. He anticipates her slightest want and indulges her most fanciful whim; his commiseration for her woes is only equalled by his unselfishness in foregoing his own pleasure and his ingenuity in vindicating her weaknesses. In short, his ready acceptance of his daughter's instability argues a lack of mental balance on his own part.

Brain fatigue is another element in the formation of tics whose influence ought not to be underestimated. In the case of young D., nineteen years old, a clucking tic supervened during the period of preparation for an examination, to disappear at its close.

No less fruitful are anguish, anxiety, worry, disappointment, as will freely be conceded. Any prolonged concentration of the attention on a particular act or a particular idea presupposes a concomitant weakening of inhibitory power over other acts and ideas, which then become corrupt and inopportune, are incapable of further repression, and blossom into tics.

Indolence, too—the mother of all the vices, according to the adage—favours the outbreak of tics, and accelerates their growth. The idle patient's thoughts are all for his tic; its perfecting taxes his inventiveness.

Mention may be made in passing of the effect of "professional movements" in predisposing to the subsequent apparition of a tic in the muscles concerned. We have already alluded to the relation between tics and certain cramps or occupation neuroses, and we shall refer to the topic again at a later stage.

It would appear that even the memory of a familiar gesture sometimes suffices to initiate the condition: witness Grasset's case of post-professional colporteur tic, where the subject reproduced the movement of swinging a bag over his shoulder, a souvenir of his former avocation.[37]

A final example, none the less instructive though it occur in lay literature, may be cited from Alfred de Vigny[38]:

With a child's delight the worthy battalion commander gravely made ready to speak. He readjusted his polished shako on his head, and gave that twitch of the shoulder appreciated only by such as have served in the infantry—that twitch which is meant to raise the knapsack and momentarily to lighten its load; it is a trick of the soldier's which with his elevation to officer's rank becomes a tic. Another sip of wine followed this convulsive gesture, a kick of encouragement in the little donkey's stomach, and he began....

The description could not have been more accurate. The passage from the voluntary to the involuntary—the kick too may have been a tic—and the obvious infantile traits in the old gentleman's character, make the picture remarkably complete.

Apart, however, from the causes we have just enumerated, and others to be noticed below, we must emphasise the fact once again that mental predisposition is a sine qua non for the development of tic.

CHAPTER VI
PATHOLOGICAL ANATOMY

OUR ignorance of the pathological anatomy of tic is profound. Hitherto all the cases labelled tic in which a post-mortem examination has been made have in reality been spasmodic affections differing essentially from the tics as we understand them, according to the ideas of Trousseau, Charcot, and Brissaud. As far as we are aware, not a single sectio of a genuine case of tic is on record where a lesion, of whatever nature or whatever site it be, has been discovered to which the tic might be attributed. Either an autopsy is not obtained, or if it is, no special abnormality is remarked, or else the diagnosis has been erroneous and the changes described have not been those of tic.

It would be premature, of course, to conclude that tic is a disease sine materia. The affirmation is quite unwarranted. As is the case with numbers of neuroses and psychoses, we must for the present rest satisfied to observe symptoms; the mystery of their morbid anatomy will remain unsolved until our methods of investigation attain perfection. Magnan[39] says of "superior degenerates" that clinical observation reveals functional disorders so distinct and so invariable that it is impossible they should not be the outcome of some pathological modification of the organism. It is true he declares in another place[40] that the mentally unstable have all a family likeness, consisting not in identity of well-defined anatomical lesions, but in similarity of functional derangements. As it is, from the motor point of view tic is a functional act, and the governing centre is a functional centre that has become hypertrophied, so to speak, by being educated to excess. This physiological centre must not be confused with the "centre" of current anatomical terminology; it does not exercise an exclusive control over a particular territory—several such may co-exist in a single anatomical area.

Our lack of knowledge concerning the precise localisation of these functional centres is paralleled by our ignorance as to the manner of their involvement.

Noir has prudently observed that the manifestation of co-ordinated tics in cases of widespread cerebral disease, and the frequent occurrence of the most extensive and complex varieties in patients who have suffered from meningeal affections, suggest their cerebral origin. On these points, however, anatomo-pathological information is to seek, and for that matter the direct dependence of such an habitual movement as a co-ordinated tic upon one lesion is scarcely within the bounds of probability. Tic pertains to a psychical rather than to a motor sphere, and is to be regarded as a disease of the will.

With this statement, and with the expression of our hope that subsequent work will aid in the elucidation of the question, we shall close the chapter of the tic's pathological anatomy. It may not prove superfluous, however, to indicate why and how the facts gleaned from pathology and supposed to be in harmony with the clinical picture of tic should be allocated to other morbid entities.

In several cases considered to be tics of the face, cortical lesions have been discovered at the posterior end of the second frontal convolution, in the centre for voluntary and co-ordinated movements of the contra-lateral facial muscles. It has become classical to cite an example described as long ago as 1864 by Debrou[41] under the title "painless facial tic," but a glance at the observation suffices at once to negative its classification as a tic, and to justify the diagnosis of a spasm of a quite peculiar sort.

On February 26, 1862, a porter, aged forty-nine, was suddenly seized with an "attack of the nerves," and at its close lost his speech. When examined at the hospital two days later, he was found to have full use of his limbs, understood perfectly all that was said to him, and evinced great impatience at being unable to respond except in writing or by gesture. He made signs to indicate that his head was paining him, and that he had difficulty in swallowing. In addition, abrupt, forcible, and rapid movements of the facial muscles on the right side were taking place; the angle of the mouth and the outer angle of the palpebral aperture were being dragged on; the external ear was elevated, or moving to and fro; the platysma was twitching visibly and the hyoid bone so acted on as to pull up the larynx spasmodically. The exhibition was an exact replica of the effect produced in animals by intracranial galvanisation of the facial nerve. Moments of absolute repose alternated with periods of spasm of a few seconds' duration, which addressing or handling the patient seemed to aggravate. There was synchronous spasm in the masseter muscles, resulting in elevation of the inferior maxilla. No other region of the body was affected.

On the night of March 2 the attacks of spasm and of pain increased in intensity and frequency, without any other change in their nature. The patient's mind remained unclouded, and as he was still deprived of the faculty of speech, he again indicated in writing the severity of his sufferings. About eleven o'clock at night the situation became more distressing; he began to be profoundly agitated, then passed into a more or less maniacal state, in which his limbs were involved in powerful muscular spasms, his eyes rolled in their sockets, and his respiration commenced to be stertorous, while the violence of his struggles necessitated the intervention of two assistants to control him. An hour or two later, during one of these attacks the end came.

At the autopsy, under the arachnoid and spreading over the left hemisphere at the junction of its anterior and middle thirds, was a large blood-clot, dark, coagulated, and free in the cerebral substance, which it had penetrated for a depth of about one centimetre. It appeared to be of about four or six days' formation, and probably dated from the incipient "attack of the nerves." Painstaking scrutiny of the cerebellum and cranial nerves failed to reveal any further pathological condition.

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.

Féré[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 pass 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 rôle played by the bulbar centres in the production of convulsive movements, which are in such circumstances, 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 homolateral facial contraction, is wholly comparable to the so-called "tic douloureux."

No less positive is our refusal to accept as tics spasmodic contractions in association with or subsequent to facial palsy or contracture of peripheral or central origin. They are spasms, not tics. Cruchet, for instance, describes indifferently as labial tic or intermittent labial 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-choreic 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 hæmorrhage 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, analogous 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, otitis 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 Duchenne 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, associated 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 passage 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 pronounced 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. Some hours previous to the child's death the tic disappeared, only occasional slight convulsive twitches of the right arm remaining. Consciousness was maintained to the last minute.

At the autopsy the characteristic appearances of tuberculous meningitis were found: the base of the brain at the anterior perforated spot and origin of the sylvian artery was covered with gelatinous purulent patches, the colour of prune juice, which extended backwards to the pons; one in particular had enveloped the basilar trunk and sent out a prolongation on the right side, which surrounded the sixth, seventh, and eighth nerves at their point of emergence.

For our part, we cannot apply the word tic to the convulsive phenomena of tuberculous meningitis. If localised spasms occurring in the course of a grave illness, associated with fever, headache, and delirium, with contractures and generalised convulsions, and if the spasmodic manifestations of rapidly fatal pyrexias, are all to be denominated tics, then the term has no longer any significance, and it would be wiser to give it at once its quietus.

We are well enough aware that Cruchet believes there is a "convulsive tic symptom"; in other words, certain symptoms in such and such a disease appear in the guise of convulsive tic, "a movement or combination of movements representing in a clonic fashion a physiological act." Nevertheless, we are not convinced that the convulsive movements of Cruchet's patients exhibit the sequence of "regulated physiological acts."

He further draws an analogy between the foregoing case and the partial convulsions of toxæmias, cerebral tumours, etc., "transient convulsions supervening in the course of acute or chronic affections, and readily recognisable." In exceptional circumstances they may "assume the form of convulsive tic." In strict truth the form may be the same, but examination of the patient will soon demonstrate that the two are alike merely in appearance, and compel the reconsideration of an immature diagnosis.

Our position is that tic is more than a symptom—it is a symptom-complex. Cruchet's definition of convulsive tic just quoted is by itself insufficient; the additional and indispensable factor is the characteristic mental defect, of which so illuminating an exposition was given by Charcot.

Finally, the knowledge derived from the pathological investigation of myoclonus and polyclonus does not of necessity throw light on the morbid anatomy of tic.

In the case of an epileptic who suffered from myoclonus in his last years, ischæmic degenerations were found by Rossi and Gonzales disseminated throughout the brain, especially in the rolandic area, but any inference to hold good for the tics would be premature.

The term polyclonus has been employed by Murri to designate a succession of clonic contractions of the limbs, due to the existence of punctiform hæmorrhages or areas of softening scattered throughout the rolandic cortex. The character of the motor reaction in these cases, however, bears no resemblance either to tic or to chorea, although the fact of the relation between diffuse cortical lesions and convulsive movements is calculated to enhance the difficulties of diagnosis.

Vincenzo Patella[48] has recently called attention to a case of polyclonus in which the disappearance of the symptoms during sleep suggested their purely functional origin, but histological examination of the rolandic grey matter at a subsequent period revealed the presence of numerous foci of degeneration. We are as yet, however, far from grasping the real meaning of such symptoms, which, moreover, from the clinical standpoint, cannot always be assimilated to those of the tics. Conclusive anatomical information is therefore still being awaited.

The functional nature of the movements we have had under discussion is unfortunately an obstacle in the way of our early knowledge of their pathology. As long as we remain ignorant of the actual cause of the neuroses and psychoses, so long will the pathological anatomy of tic continue a sealed book. All that has been written on this topic hitherto really concerns spasm and other convulsive affections secondary to irritation of nerve centres or conductors. If we may venture to express an opinion, it is that we should not be surprised if post-mortem examination rest constantly negative. As a matter of fact, we do not favour the view that the phenomena depend on an acquired lesion; rather are we inclined to believe that they represent some congenital anomaly, some arrest or defect in the development of cortical association paths or subcortical anastomoses, minute teratological malformations that our medical knowledge is still unhappily powerless to appreciate.

CHAPTER VII
STUDY OF THE MOTOR REACTION

THE general characters of the motor reaction constituting the objective manifestation of tic form the subject of previous analysis in the chapter on pathological physiology. It is our present intention to approach them from the semiological point of view.

To give a description of the motor disturbance of universal applicability is evidently to attempt the impossible. The modifications of functional acts are legion, and in the case of tic anomalies of muscular contraction vary not merely with the individual, but in the individual. Each tics after his own fashion; and no two tics are ever exactly interchangeable. As Trousseau was wont to say, "the disease in a sense forms part of the constitution of the person affected."