Tics and Their Treatment

by Henry Meige; E. Feindel

Our patient's category of tics is not yet exhausted, however. He has been afflicted with a shoulder tic, consisting of simultaneous or alternate elevation, sometimes of other movements, and always with some abduction of the arms. Frequent execution of these actions has culminated in the acquisition of the faculty of voluntarily producing a rather loud "crack" in the shoulder articulations, which thus not merely originated in a tic, but supplies an ever-active stimulus for its reproduction; in its occurrence satisfaction and dissatisfaction are blended as before. At the present moment the impulse to this particular tic is in abeyance, and he has ceased to take any interest in the "crack," considering it a trivial society accomplishment of no significance or danger, analogous to voluntary subluxation of the thumb, or to the curious sounds that some people are fond of making by way of diversion.

Again, O. has been a martyr to a leg tic of several months' duration. When he was on his feet, he learned to strike his right heel against his left ankle, wearing his trouser through in no time, and ceasing only with the development of a painful wound over the bone. Once it was healed, however, came the deliberate search for the sensation again, and the pleasurable feeling in its rediscovery.

In O.'s case the inhibitory influence of the will on his tics is abundantly manifest. Should he find himself in the company of one from whom he would fain conceal his tics, he is able to repress them completely for an hour or two, and similarly if he is deep in an interesting or serious conversation. Nevertheless, the desire to let himself go obtrudes itself again, and if he can refrain no longer he will invent any pretext for leaving the room, abandoning himself in his moment of solitude to a veritable debauch of absurd gesticulations, a wild muscular carnival, from which he returns comforted, to resume sedately the thread of the interrupted dialogue.

O. is fond of cycling, and while at first the attention that the necessary co-ordination of hands and feet demanded proved an effective barrier in the way of his tics, now that he can maintain his equilibrium automatically his head assumes its favourite attitude of posterior displacement. His devotion to a game of billiards, or to such exercises as fencing or rowing, is never interfered with by an unruly tic. He is a great fisher, and when he "has a bite," or is expecting one, he will remain motionless indefinitely; his tics do not hinder him from preparing his bait with the minutest care. But let his interest in his prospective catch fade, let the fish be disinclined to "take," and there will be a renewal of the movements.

In his sleep they one and all disappear. The mere assumption of a horizontal position, however, no longer suffices to bridle them, and before dropping off to sleep he passes many a minute in seeking comfort. The rubbing of his head on the pillow, the rustling of the clothes, disturb and exasperate him, and he turns in this direction and that for relief; yet should he hear or feel nothing, he will change about once more in the search for a sensation or a sound. Thus has it come about that to procure slumber he has adopted the extraordinary plan of lying at the very edge of the bed and letting his head hang over.

The series is not yet at an end.

O. exhibits a tic of the inferior maxilla. He protrudes and retracts his jaw alternately in his endeavour to elicit cracking noises from his temporo-maxillary articulations. At one time his hands used to join in the fray, the goal being to overcome the masseters and effect a sort of dislocation. A biting tic ensued. One day O. was alarmed to discover two dark patches on the internal aspect of the cheeks, but was reassured on learning from his sister—whose proclivities lay in a similar direction—that she had noticed the same in her own case, and that it was the result of constant nibbling at the buccal mucous membrane.

Nor was this the solitary biting tic. Formerly a pencil or a pen-holder used to be unrecognisable at the end of twenty-four hours, and the handles of canes and umbrellas suffered as well. To obviate the nuisance he entertained the unfortunate idea of using metal pen-holders and carrying silver-mounted walking-sticks; but his teeth failed to make any impression on the objects, and began to break in consequence. The irritation produced by a small dental abscess proved an additional source of mischief, for he developed the habit of trying, with finger, cane, or pen-holder, to shake the teeth in their sockets, and was finally compelled to have the incisors, canines, and first molars drawn. Then he ordered a set of false teeth—a move that afforded a new excuse for a tic. Every moment the set was in imminent risk of being swallowed, so vigorously did his tongue and lips assail it. Fortunately such an accident has never occurred, although he has already broken several sets. Sometimes he would be seized with an insane impulse to take his teeth out, and would invent the flimsiest pretext for retiring; the set would then be extracted and immediately reinserted, to his complete satisfaction and peace of mind.

An infinite variety of scratching tics must be added to the number. He has also a tic of phonation dating back to his fifteenth year. His custom was, when learning his lessons at school, to punctuate his recital of them with little soft expiratory noises that may still be distinguished to-day among a host of other tics. The following is his proffered explanation of the pathogeny of this "clucking" tic:

We who tic are consumed with a desire for the forbidden fruit. It is when we are required to keep quiet that we are tempted to restlessness; it is when silence is compulsory that we feel we must talk. Now, when one is learning his lessons, conversation is prohibited, the natural consequence being that he seeks to evade the galling interdict by giving vent to some inarticulate sound. In this fashion did my "cluck" come into being. Moreover, we abhor a vacuum, and fill it as we may. Various are the artifices we might employ—such, for instance, as speaking aloud; but that is much too obvious, and does not satisfy: to make a little grunt or cluck, on the other hand—what a comfort in a tic like that!