The patient is a young girl eighteen years old, born of an alcoholic father and an hysterical mother, and brought up amid deplorable surroundings, socially and morally. At the age of seven she contracted diphtheria, and a doctor was called to visit her. The mere sight of him so frightened her that the whole of the right side of her body went into a state of contracture, with mouth and eye deviated to the right, the arm pronated and adducted, the leg stiff and the heel raised off the ground. Some gradual improvement took place after a month, but her mother saw in the incident a means of attracting public sympathy, and encouraged the child to maintain the vicious attitude by sending her into the streets to beg. And so she appears to-day, her right foot trailing, her toes flexed, her forearm bent, her hand extended and fingers curled up. Whenever the patient is unobserved or forgets her professional attitude, at once the arm resumes its normal position and activity.
An examination of sensation reveals a hyperæsthesia of the right half of the body, with points douleureux over the left ovary and the left mamma, as well as over the larynx. There is no contraction of the visual fields; reflectivity is normal; Babinski's sign is absent.
The author considers the case one of "professional mental tic" in a predisposed patient—in other words, the tic is a "mental bad habit" in an individual psychically abnormal.
There is a certain analogy between this condition and mental torticollis in the insignificance of the effort by which the patient corrects the deformity, compared with the great force exerted by any one else to obtain the same result. Yet the symptoms strongly suggest hysteria; their unilaterality, and the combination of motor and sensory alterations, are altogether too special to have been caused by any other morbid process.
Of course everything depends on the exact interpretation to be put on the word hysteria. As far as we are concerned, to consider a symptom of hysterical origin because it seems to be purely functional is sadly to misunderstand the question. The absence of what we call organic signs is a negative feature common to all neuroses, each of which, hysteria included, ought to have definitely fixed limits.
According to Babinski,[159] hysteria is a mental state which renders its subject capable of auto-suggestion. The distinguishing mark of the condition is that its symptoms may be reproduced with mathematical accuracy by suggestion, and may by similar means be made to disappear.
Now, while auto-suggestion may undoubtedly be a factor in the evolution of tic, it is rather too much to maintain that an "evil suggestion" may constitute a tic by itself, and we question whether the influence of persuasion alone will suffice to bring about a cure. Nothing short of re-education, faithfully practised for months and years, will produce any effect, and even this method seldom results in more than a progressive amelioration. Sudden cures are familiar in hysteria, but unknown in tic. Treatment by hypnotism is rarely successful unless the patient is also a full-fledged hysteric, and this is quite the exception.
TICS AND NEURASTHENIA
The relations between tic and neurasthenia need not detain us. Neurasthenic and tiqueur alike may suffer from aboulia, obsessions, and nosophobia, and the same depressive causes may favour the establishment of the two diseases; but this is true of any form of psycho-neurosis. To identify the one with the other is to misinterpret the physical signs of the condition as described by Beard. The term neurasthenia has been so badly abused that its fundamental symptoms have been lost sight of. Yet the polymorphic nature of these symptoms is no reason for failing to recognise the genuineness of the neurasthenic syndrome, characterised as it is by headache, rachialgia, topoalgia, gastro-intestinal atony, neuro-muscular asthenia, insomnia, and mental depression. The occurrence of any one of them in a case of tic is of no special significance; for the diagnosis of neurasthenia rests on their combination, and it is precisely this combination that is so exceptional in tic.
From time to time the co-existence or alternation of tics and headache has been remarked, but the headache bears a much closer resemblance to migraine than to the headache en casque of neurasthenia.