Title: Tics and Their Treatment
Author: Meigne, Henry, Feindel, E.
Language: English
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TICS AND THEIR TREATMENT



TICS · AND
THEIR TREATMENT

BY HENRY MEIGE AND E. FEINDEL

With a Preface by
Professor Brissaud

TRANSLATED and EDITED, with a CRITICAL APPENDIX
BY S. A. K. WILSON, M.A., M.B., B.Sc.

_Resident Medical Officer, National Hospital for the Paralysed and Epileptic.
Queen Square, London_

NEW YORK
WILLIAM WOOD AND COMPANY
1907

COPYRIGHTED 1907 BY SIDNEY APPLETON

ALL RIGHTS RESERVED

PRINTED IN GREAT BRITAIN



PREFACE


Nothing could be less scientific than the establishment of a hierarchy
among medical problems based on the relative severity of symptoms.
Prognosis apart, there can be no division of diseases into major and
minor.

Hitherto no great importance has been attached to those reputedly
harmless "movements of the nerves" known as tics: an involuntary
grimace, a peculiar cry, an unexpected gesture, may constitute the whole
morbid entity, and scarcely invite passing attention, much less demand
investigation. Yet it is the outcome of ignorance to relegate any
symptom to a secondary place, for we forget that difficult questions are
often elucidated by apparently trivial data. A fresh proof of the truth
of this remark is to be found in the accompanying volume, to which MM.
Meige and Feindel have devoted several years of observation.

To begin with, they must be congratulated on having done justice to the
word _tic_. No doubt its origin is commonplace and its form
unscientific, but its penetration into medical terminology is none the
less instructive. If popular expression sometimes confounds where
experts distinguish, in revenge it is frequently so apt that it forces
itself into the vocabulary of the scientist. In the case under
consideration Greek and Latin are at fault. The meaning of the word tic
is so precise that a better adaptation of a name to an idea, or of an
idea to a name, is scarcely conceivable, while the fact of its
occurrence in so many languages points to a certain specificity in its
definition.

Yet till within recent years tic had all but disappeared from the
catalogue of diseases. A closer study of reflex acts, however, has led
to the grouping together of various clonic convulsions of face or limbs,
including "spasms" on the one hand, and, on the other, conditions of an
entirely different nature, for which the term "tics" ought to be
reserved. The separation of "tics" from "spasms," properly so called,
has been the object of various experiments and observations made by the
authors and by myself, the practical value of which is evidenced by
their disclosure of efficacious therapeutic measures.

       *       *       *       *       *

Among the confused varieties of spasm, clonus, hyperkinesis, etc., it is
impossible not to recognise the obvious individuality of certain motor
affections--certain movements of defence, of expression, of mimicry,
certain gestures more or less co-ordinated for some imaginary end--all
readily distinguishable from spasms, fibrillary contractions, and
choreiform or athetotic movements. It is only logical to attribute a
somewhat more complex origin to these varying gestures, in which the
influence of the will, however unperceived in the end, is always to be
detected at the beginning.

While some convulsions and spasms are the product of special changes in
muscle fibre, or motor nerve, or spinal cord, in medulla, pons, or
basal nuclei, the synergic and co-ordinated muscular contractions of tic
imply cortical intervention. The will may not play a conscious role
therein, but the cortex alone is capable of initiating such acts. What
part does it take in their genesis?

For an instance, a simple blinking of the eyelids may form a tic.
Considered in itself, it is a movement of defence against dust or light;
but in the absence of irritation it becomes meaningless. How then are we
to explain the abruptness and intensity of contraction of the
orbicularis palpebrarum, and of this muscle alone? If it were due to
stimulation at some point on the reflex facial arc, other facial muscles
ought to be involved; if referable to isolated excitation of the
orbicularis filaments of the facial nerve, why is the contraction
bilateral? It is evident we are dealing here not with a simple reflex of
bulbar origin, but with a movement at once premeditated and purposive,
and it is this purposive element, presupposing, as it does,
co-ordination of contraction, that indicates the cortical nature of the
phenomenon. Such co-ordinated movements, however causeless and
inopportune they may appear, cannot be identified with mere pathological
reflexes or spasms. They are tics.

Such, since the days of Trousseau and Charcot, has been the teaching of
the Paris School of Medicine. Nevertheless, confusion remains, and in
many text-books the unfortunate sacrifice of analytical accuracy to a
premature desire for the schematic classification of disease has not
tended to lessen it.

The authors of this volume have been resolute in their reference of the
pathogeny of tic to a mental process. It is true, recognition of the
psychological aspect of the affection is ready enough where the tic
corresponds or is superadded to other "episodic stigmata of
degeneration"; but the task is infinitely more delicate should the sole
indication of an abnormal psychical state be the tic itself. Even in
these cases examination always reveals insufficiency of inhibition, to
which are due the inception and the persistence of many "bad habits." We
can thus appreciate the rôle of habit in the evolution of tics, and
recognise the analogy they offer to all functional acts. A tic is
frequently nought else than the ill-timed and inapposite execution of
some function. We may even conceive a sort of functional tic centre,
formed by nerve elements corresponding to the functional grouping of the
muscles involved in the tic. In advanced cases we may imagine some sort
of hypertrophy of this functional centre, which may be reduced by
suppression of function--that is to say, by certain methods of
immobilisation.

This is the secret of the treatment of tics, and to ignore it would be
disastrous. As a matter of fact, tic is not merely a neurosis, but a
psycho-neurosis, or, to be more exact, a psychomotor encephalopathy. The
degeneration whose first manifestation in a child is the development of
a tic may reveal itself later by more disquieting signs. This word
"degeneration" is employed either too indefinitely or too explicitly by
those who are ignorant of its true meaning in medicine. To-day the
physician's diagnosis is often anticipated by the parents, who are
willing to own their child "nervous" because of his tic; but they are
not so ready to admit he has a tic because he is nervous, as they would
infer immediately that they have begotten a degenerate. The consolation
of "superior degeneration" does not exclude a certain degree of
humiliation.

No doubt superficial study is content to characterise children thus
afflicted by the simple epithet "nervous," on the ground that their tic
does not constitute a menace to life. But a tic in itself can never be a
negligible quantity. The more it is repeated the more inveterate it
becomes, and the greater the likelihood of its becoming generalised; at
the same time the influence of the neuropathic diathesis is intensified.
An analogy might be drawn between the tics and chorea. Prognosis, even
in a mild case of adult chorea, should always be guarded, inasmuch as
once the ordinary limits of the duration of the disease are
over-stepped, we find ourselves face to face with the dreaded chronic
variety.

The same attitude might be adopted in reference to the distressing
neurosis described by Charcot and Gilles de la Tourette as the "disease
of the tics," which is no more than the superlative expression of a
neuropathic and psychopathic disposition entirely akin to that favouring
the development of the most harmless tic. Its earliest exhibition is a
series of apparently insignificant bizarre convulsions; but its
indefinite prolongation, its gradual involvement of one limb after
another, its association with grave mental symptoms, and its frequent
termination in dementia, are reason enough for eyeing the first little
premonitory tic with mistrust, and combating it with vigour.

From the motor aspect a tic is only a "bad habit," and the checking of
bad habits, especially in the predisposed, must be our goal from the
outset. And, should we succeed, there will be reason for
congratulation, not on the happy issue of appropriate treatment for a
particular tic, but because the result is a step towards _the habit of
correcting bad habits_. Reinforcement of the will is the prime
therapeutic indication, but the physician has no need to resort to
mysterious subterfuges or occult practices; let him borrow the virtues
of the successful teacher. The amelioration consequent on this procedure
is seen not only in the recovery of lost aptitude for work, but also in
the simultaneous restoration of self-confidence and will-power in
patients who had appeared deprived of them for ever. The treatment of
tic is evidence of its nature and curability. Since 1893 MM. Meige and
Feindel have subjected their cases to the educational discipline of
systematised movement and of immobilisation. In contrast to the tendency
of ordinary exercises to render certain useful acts automatic, this
method aims at the suppression of automatic acts that have become
useless. The development of the general principles of the method, as
well as an exposition of recent modifications and their application to
particular cases, will be found in the volume. Suffice it here to say
that the results have been favourable enough to discountenance the
prevalent idea of the incurability of tic, and to prove that persistence
in treatment, as has been demonstrated in many other neuroses, will
assuredly be crowned with success. Common misconception represents
therapeutics as helpless in the presence of nervous disease; but if the
doctor may count on the collaboration of his patient, he has no right to
despair.

I should like, in closing, to be allowed to praise the authors'
production; but I can do so only under great reserve, for after so many
years of co-operation I can no longer distinguish the work of MM. Meige
and Feindel from my own. I think, however, that from many points of view
the book which they have written is a most useful one.

E. BRISSAUD.



AUTHORS' PREFACE


Our object in publishing these studies has been twofold: first, to make
known various facts of clinical observation, which will always possess
at the least an intrinsic value; secondly, to endeavour to assign to the
tics their due place among the numerous motor affections consequent on
nervous or mental disease. With this end in view we sought to free
ourselves of preconceived notions, avoiding at the same time the other
extreme of eclecticism. Independently we have been led to adhere to the
doctrine hallowed by the authority of Charcot, and since advocated by
Professor Brissaud--a doctrine that seems to us to be in harmony with
accepted clinical data.

We have thought it advisable to indicate, by the way, more than one
misconception whose perpetuation is but a stumbling-block in the path of
progress.

Since the eighteenth century the word _tic_ has faced the perils of
definition many a time, and has as often all but succumbed. The limits
of its application have been alternately enlarged and narrowed to an
excessive degree; its original signification has been so obscured that
the inclination to-day is either to hesitate in the use of the word at
all, or to employ it indiscriminately through ignorance of its real
meaning. But if its interpretation be not specified, everything that is
said or written on the subject will remain fatally open to dispute.
Want of precision in words leads inevitably to confusion of ideas and
endless misunderstanding. In this respect the word tic is a great
culprit; its promiscuous use implies looseness in its connotation--a
fruitful source of controversies which, when all is said and done, are
nothing more than regrettable quid pro quos. On fundamental points there
is almost complete unanimity of opinion; any divergence is purely
superficial, and to be ascribed to disagreement in terms.

Hence it has seemed to us essential to adopt a vocabulary, and to employ
any term only after clearly particularising the sense we attribute to
it. Our verbal conventions will not meet with universal acceptance, it
may be, but we shall be the first to abandon them if common consent
assign to the expressions that replace them the exact shade of meaning
we meant to convey.

Our work will not be superfluous if we succeed in allotting to the word
a definite position in medical terminology, or if any information we
have amassed prove of service to future observers. And should we be
enabled to demonstrate how unmerited is the reputation the tics enjoy of
being irremediable, how they may, on the contrary, be mitigated and
sometimes even cured under appropriate treatment, the practical value of
the conclusion will, we hope, justify the importance we have attached to
the subject.



NOTE BY THE TRANSLATOR


Owing to the kind co-operation of M. Meige, it has been possible to
embody in this English version of _Les tics et leur traitement_ his
latest definitions and views, as expressed in his monograph _Les tics_
(July, 1905). The passages thus derived are enclosed in brackets. In the
making of the translation some of the clinical cases have been slightly
abridged, and one or two omitted. The Bibliography has been revised,
largely supplemented, and brought up to date. In a short Appendix
reference is made to various matters in regard to tic on which
discussion has recently centred, subsequent to the publication of Meige
and Feindel's book. Indices of names and of subjects have been added.



CONTENTS


                                   PAGE

PREFACE BY PROFESSOR BRISSAUD      v

AUTHORS' PREFACE      xiii

NOTE BY THE TRANSLATOR      xv


CHAPTER I

THE CONFESSIONS OF A VICTIM TO TIC      1


CHAPTER II

HISTORICAL       25


CHAPTER III

THE PATHOGENY OF TIC      36

  TIC AND SPASM
  TIC AND MOTOR REACTIONS; REFLEX, CO-ORDINATED, FUNCTIONAL,
    AUTOMATIC, AND VOLUNTARY ACTS
  TIC AND CO-ORDINATION
  THE GENESIS OF TIC
  TIC AND WILL
  TIC AND HABIT
  TIC AND IDEA
  TIC AND CONSCIOUSNESS
  TIC AND POLYGON
  TIC AND FUNCTION


CHAPTER IV

THE MENTAL CONDITION OF TIC SUBJECTS       74


CHAPTER V

THE ETIOLOGY OF TICS       96


CHAPTER VI

PATHOLOGICAL ANATOMY       108


CHAPTER VII

STUDY OF THE MOTOR REACTION           118

  THE TYPE OF MOTOR REACTION--CLONIC TIC AND TONIC TIC
  INTENSITY OF THE MOTOR REACTION
  FREQUENCY AND RHYTHM--RHYTHMIC TIC
  ATTACKS
  LOCALISATION OF THE MOTOR REACTION--VARIABLE TICS--FIXED TICS


CHAPTER VIII

ACCESSORY SYMPTOMS       134

  REFLEXES
  ELECTRICAL REACTIONS
  VASOMOTOR AND SECRETORY AFFECTIONS
  AFFECTIONS OF SENSATION


CHAPTER IX

THE DIFFERENT TICS       142

  FACIAL TICS--TICS OF MIMICRY
  TICS OF THE EAR--AUDITORY TICS
  TICS OF THE EYES--NICTITATION AND VISION TICS

    A. EYELID TICS
    B. EYEBALL TICS

  TICS OF THE NOSE--SNIFFING TICS
  TICS OF THE LIPS--SUCKING TICS
  TICS OF THE CHIN
  TICS OF THE TONGUE--LICKING TICS
  TICS OF THE JAWS--BITING TICS--TICS OF MASTICATION
    MENTAL TRISMUS
  TICS OF THE NECK--NODDING AND TOSSING TICS--TICS OF AFFIRMATION,
    NEGATION, AND SALUTATION
  MENTAL TORTICOLLIS
  TICS OF THE TRUNK
  TICS OF THE ARM AND OF THE SHOULDER
  TICS OF THE HANDS--SCRATCHING TICS
  TICS AND WRITING
  TICS OF THE LOWER EXTREMITIES--WALKING AND LEAPING TICS
  SPITTING, SWALLOWING, AND VOMITING TICS--TICS OF ERUCTATION
    AND OF WIND SUCKING
  TICS OF RESPIRATION--SNORING, SNIFFING, BLOWING, WHISTLING,
    COUGHING, SOBBING, AND HICCOUGHING TICS


CHAPTER X

TICS OF SPEECH      206

  ECHOLALIA
  COPROLALIA


CHAPTER XI

THE EVOLUTION OF TICS      221

  DISEASE OF GILLES DE LA TOURETTE
  VARIABLE CHOREA OF BRISSAUD


CHAPTER XII

ANTAGONISTIC GESTURES AND STRATAGEMS      236


CHAPTER XIII

THE COMPLICATIONS OF TICS      242


CHAPTER XIV

THE RELATION OF TICS TO OTHER PATHOLOGICAL
CONDITIONS      245

  TICS AND HYSTERIA
  TICS AND NEURASTHENIA
  TICS AND EPILEPSY
  TICS--INSANITY--IDIOCY
  THE TICS OF IDIOTS


CHAPTER XV

THE DISTINCTIVE FEATURES OF TICS      260


CHAPTER XVI

DIAGNOSIS      264

  TICS AND STEREOTYPED ACTS
  TICS AND SPASMS

    A. TIC OR SPASM OF THE FACE
    B. TIC OR SPASM OF THE NECK--TORTICOLLIS TIC AND TORTICOLLIS SPASM

  TICS AND CHOREAS

    A. SYDENHAM'S CHOREA

    B. HUNTINGTON'S CHOREA

    C. HYSTERICAL CHOREA

    D. ELECTRIC CHOREA, BERGERON'S CHOREA, DUBINI'S CHOREA,
       FIBRILLARY CHOREA OF MORVAN

  TICS AND PARAMYOCLONUS MULTIPLEX--TICS AND MYOCLONUS
  TICS AND ATHETOSIS
  TICS AND TREMORS
  TICS AND PROFESSIONAL CRAMPS


CHAPTER XVII

PROGNOSIS      293


CHAPTER XVIII

THE TREATMENT OF TICS      298

  THE CURABILITY OF TICS
  MEDICINAL TREATMENT
  DIET--HYGIENE--HYDROTHERAPY
  MASSAGE--MECHANOTHERAPY
  ELECTROTHERAPY
  SUGGESTION
  SURGICAL TREATMENT
  ORTHOPÆDIC TREATMENT


CHAPTER XIX

TREATMENT BY RE-EDUCATION      315

  MIRROR DRILL
  REST IN BED
  ISOLATION
  PSYCHOTHERAPY

       *       *       *       *       *

APPENDIX      346

BIBLIOGRAPHY      351

INDEX OF NAMES      380

INDEX OF SUBJECTS      384



TICS AND THEIR TREATMENT



CHAPTER I

THE CONFESSIONS OF A VICTIM TO TIC


At the time when the plan of our book was being sketched we decided to
introduce the subject with several characteristic clinical documents,
since it appeared to us indispensable to preface our definitions with an
illustration of the type of affection and of patient that we had in
view. The choice was rather bewildering at first; but towards the close
of 1901 one of us was put into communication with an individual who is a
perfect compendium of almost all the varieties of tic, and whose story,
remarkable alike for its lucidity and its educative value, forms the
most natural prelude to our study. The history is neither a fable nor an
allegory, but an authenticated and impartial clinical picture, whose
worth is enhanced by no less genuine facts of self-observation.

       *       *       *       *       *

O. may be said to constitute the prototype of the sufferer from tic, for
his grandfather, brother, and daughter have all been affected, and he
himself has not escaped. His grandmother and grandfather were first
cousins, and the latter, in addition to being a stammerer, developed
tics of face and head; his brother stammers too, while both his sister
and his daughter have facial tics, and one of his sons was afflicted
with asthma as a youth. The family history therefore more than confirms
the existence of a grave neuropathic heredity, an unfailing feature in
cases of tic.

O.'s fifty-four years lie lightly on him. His physique and general
health are excellent, and devotion to bodily exercise and outdoor sports
has enabled him to maintain a vigour and an agility above the average;
nor is his intellectual activity any less keen.

His earliest tics--simple facial grimaces and movements of the
head--made their appearance when he was eleven years old;
notwithstanding, his recollection of their mode of onset is very exact.

     I have always been conscious of a predilection for imitation. A
     curious gesture or bizarre attitude affected by any one was the
     immediate signal for an attempt on my part at its reproduction, and
     is still. Similarly with words or phrases, pronunciation or
     intonation, I was quick to mimic any peculiarity.

     When I was thirteen years old I remember seeing a man with a droll
     grimace of eyes and mouth, and from that moment I gave myself no
     respite until I could imitate it accurately. The rehearsals were
     not prolonged, as a matter of fact, and the upshot was that for
     several months I kept repeating the old gentleman's grimace
     involuntarily. I had, in short, begun to tic.

     In my fifteenth year I was at school with two boys whose hair was
     rather long, and who had acquired the habit of tossing it back by
     an abrupt shake of the head. It is true I cannot recollect
     endeavouring to ape this, but in any case it was at the same time
     that I found myself exhibiting an identical gesture, and I have
     little doubt it is the source of one of the tics from which I
     suffer at present.

     I enlisted at the commencement of hostilities in 1870, and had
     already begun my military instruction, when a personal review of
     the company was made by a new colonel. As he passed he came to a
     sudden halt before me, and proceeded to harangue me on my far from
     military bearing; but his invective had no other effect than to
     aggravate my facial contortions, and the affair might have proved
     serious enough for me had not my captain come to the rescue and
     explained the involuntary nature of the spasms. The colonel,
     however, would have none of them and after a fortnight's sojourn in
     hospital I was discharged for "choreic movements of the face."

O.'s tics were at the first confined to the eyes and lips, but others
were not long in appearing. He happened to be out one day for a walk
with his sister during a snowstorm, and a flake entering his nostril
made him sneeze and sniff half a dozen times. Long after the snow had
ceased falling and the tickling sensation had vanished he repeated the
performance, till it passed into a sniffing tic that continued for some
months. His sister thoughtlessly set herself to mimic him, and speedily
evolved an identical tic, which still persists.

In their turn, neck and shoulders were implicated in the affection. The
most inveterate of all his tics is a somewhat complex twist of the head,
whereby the occiput is depressed jerkily, and the chin advanced and
elevated, occasionally to the right, though more commonly to the left.
Such is the clonic form of the tic, at once frequent and obvious; but it
may assume a tonic form, distinguished by an almost permanent
retrocollic displacement of the head, the chin being carried in the air.

If, now, we approach these tics in greater detail, we notice, first of
all, a blinking tic, more marked on the left side. Apart from abrupt and
intermittent contractions of the orbicularis, which close the eye
completely and wrinkle the skin in the neighbourhood, the same muscle
sometimes passes into a state of tonic contraction, whereby the eye
remains only half open, while the rest of the face is in repose, and so
continues for a minute or more. Frontal and eyebrow tics also are
frequently to be remarked.

Of his own accord O. has supplied us with a pathogenic and etiological
analysis of these tics, which for accuracy and insight is truly
astonishing.

     A large number of my head and face movements owe their origin to
     the annoyance caused me by my seeing the tip of my nose or of my
     moustache from time to time. The former organ appears to make a
     sort of screen in front of me, to avoid which I turn or raise my
     head: I can now see the object I am facing, but at the same time,
     naturally, I see my nose again at the side, whence one more tilt of
     the head, and so on. I am well enough aware how nonsensical all
     this is; but it fails to deter me from my desire of playing at
     hide-and-seek with my nose. It is for an identical reason that each
     moment finds me blinking one eye or the other, or both; I wish, and
     yet I do not wish, to see my nose, and so I bring my hand up to
     cover my face. Vain delusion! for if I conceal my nose thus, it is
     my hand I see next, and I escape from Scylla to fall into
     Charybdis!

Here, then, is a tic springing from an ordinary visual impression. Any
one can see the point of his nose if he wishes, but it does not come in
his way should he be looking at something else; whereas our patient
divides his attention between the end of his nose and the object of his
regard, and his volatile will passes lightly from one to the other,
incapable of concentrating itself on either. Force of repetition changes
the voluntary act into an automatic habit, the initial motive for which
is soon lost; and the patient shows the weakness of his character by
making little or no effort at inhibition.

Resort to a pince-nez, in view of advancing age, has contributed
materially to the elaboration of a host of absurd jerky movements, from
which more tics have been recruited.

     No sooner have I put on my pince-nez than I long to alter its
     position in innumerable ways. I must needs push it down or raise it
     up, must set it farther on or farther off; sometimes I tax my
     ingenuity in attempts to displace it by tossing my head. Instead of
     looking tranquilly through the glasses, my eye is continually
     attracted by the rim, some point on which I try to focus or to get
     into a line with the object at which I am gazing. I want to see the
     object and the pince-nez at the same time; as soon as I no longer
     see the former I wish to see it again, and similarly with the
     latter. My tics upset my pince-nez, and I have to invent another
     tic to get it back into place. The absurdity of this vicious circle
     does not escape my observation, and I know I am its author, yet
     that cannot prevent my becoming its victim.

     When the pince-nez is not in use I toy with the spring or with the
     cord, and a day seldom passes without my breaking the one or the
     other. As I wear spectacles at home one might suppose their
     relative stability would check my tricks; but their pressure on my
     temples and ears only serves to provoke fresh movements in a search
     for comfort.

     And so the thing goes on. I was perfectly well aware of it at
     first, and was wont to imagine it was remediable; eventually,
     however, these grimaces of mine took place without any attention on
     my part, and then in spite of it, and I was no longer their master.
     There seem to be two persons in me: the one that tics, the son of
     the one that does not, is an _enfant terrible_, a source of great
     anxiety to his parent, who becomes a slave to his caprices. I am at
     once the actor and the spectator; and the worst of it is, the
     exuberance of the one is not to be thwarted by the just
     recriminations of the other.

In his accidental discovery of a "crack" in his neck originated other
tics. As a matter of fact, these "cracks" do exist, and can be heard at
a little distance; but it always requires a brisk toss of the head to
elicit them. This is O.'s account of their evolution:

     One day as I was moving my head about I felt a "crack" in my neck,
     and forthwith concluded I had dislocated something. It was my
     concern, thereafter, to twist my head in a thousand different ways,
     and with ever-increasing violence, until at length the rediscovery
     of the sensation afforded me a genuine sense of satisfaction,
     speedily clouded by the fear of having done myself some harm. The
     painlessness of the "crack" induced me to go through the same
     performance many and many a time, and on each occasion my feeling
     of contentment was tinged with regret: even to-day, notwithstanding
     that I ought to be persuaded of the harmlessness of the occurrence
     and the inanity of the manœuvre, I cannot withstand the
     allurement or banish the sentiment of unrest.

One could not desire a more lucid exposition of the pathogeny of so many
of these head-tossing tics. The fundamental importance of the psychical
element that precedes the motor reaction, with the secondary psychical
reaction in its turn, the impulse to seek a familiar sensation, and the
illogical interpretation of it under the influence of a tendency to
nosophobia, are all admirably illustrated in O.'s description.

In addition to such "cracks" as are perceptible to others, O. is
conscious of various bizarre subjective sensations that he refers to the
same region--"bruised," "dragging," "crackling" feelings, not at all
dolorous, to which he devotes an inordinate share of his attention.
There is nothing abnormal about these, of course; not only may we notice
them in ourselves, but, with a little effort, we may even reproduce
them. Our indifference to their presence is the exact opposite of the
interest they arouse in the patient's mind; his fickle will is, for no
adequate motive, concentrated on a commonplace event, and on this
slender basis delusions are fostered and tics are shaped.

The insight into the close association between the state of the mind and
the development of tic yielded by a study of the foregoing narrative
will enable us to appreciate the perspicacity of what follows:

     I suppose that we who tic make a great number of voluntary
     movements with the deliberate purpose of withdrawing attention from
     the tics we already exhibit; but step by step they become so
     habitual that they are nothing less than fresh tics appended to the
     old. To dissemble one tic we fashion another.

     Certain objects become for us what might be called _para-tics_.
     Such, for an instance, is my hat. I used to imagine I could mask
     all my oddities by tilting it on my head. I used to carry it in my
     hand, and play with it in every conceivable manner--to the
     advantage of the hatter solely, for it did not last me more than
     six weeks.... We are our own physicians at first: the discomfort of
     a tic is an urgent reason for our seeking to compass its overthrow.

For years it was O.'s custom when out walking to clasp his hands behind
his back, bend his body forward, and hold his chin in the air, and this
habit explains his attitude tic of to-day. The ludicrousness of it was
early impressed on him, but instead of adopting the obvious solution of
the difficulty, he proceeded to devise a whole series of intricate
measures to regain the correct position--measures which he
picturesquely names _para-tics_. At first he used the curved handle of
his cane to pull on the brim of his hat, and so depress his head; a
subsequent modification consisted in putting the cane under his chin and
pressing down on it. Each of these subterfuges attained a degree of
success, and that in spite of the fact that in one case the extensors,
and in the other the flexors, of the head were being resisted: in other
words, each was efficacious so long as O. chose to consider it so.

Eventually their serviceableness dwindled, and O. conceived the plan of
slipping his cane between his jacket and his buttoned overcoat so that
the chin might find support against its knob. In the movements of
walking, however, contact between the two was never maintained--each was
for ever seeking the whereabouts of the other; and while it mattered
little that this incessant groping and jockeying wore out several suits
and the lining of several overcoats, the more serious result was the
acquisition on O.'s part of the habit of making various up-and-down and
side-to-side movements of his head, which continued to assert
themselves, though chin and cane were no more in proximity.

It was not long ere the ceaseless intrusion of his head tics drove him
every moment in search of a support for his chin. To read or write he
was forced to rest it on a finger, or on his fist, or hold it between
two fingers, or with his open hand, or with two hands, although the
distraction provided by a serious occupation sufficed to banish the
impulse and stay the tics.

A day came when application of the hand no longer seemed calculated to
ensure immobility of the head, whereupon he hit on the idea of sitting
astride a chair and propping his chin against it. This idea had its day,
and the next move was to press his nose against one end of the chair
back. Each successive stratagem was of marvellous promise at the outset,
but its inhibitory value rapidly deteriorated and new plans were
concocted.

All schemes for fixation lose their virtue through time, but they may be
abandoned for other reasons, one of the principal of which is the
development of pain. By dint of rubbing or pressing his nose or his chin
on the knob of his cane and the back of his chair, O. has produced
little excoriations and sores on the parts concerned, the pain of which
acts as a deterrent, but his tics and para-tics break out afresh
whenever it has gone. The game has been carried to such an extent that
under the chin and at the root of the nose there have appeared actual
corns--strange stigmata of one's "profession."

The details in the mental process are similar to what has been already
noted:

     It was the craving to keep my head in a correct position that
     induced the habit of leaning my chin on something, and I found it
     essential to feel the contact; familiarity, however, soon ended in
     my failing to perceive it, and a new movement was made that I might
     experience the sensation once more. And so on the ball rolled, till
     augmentation of the force I exerted, under a constant incitement to
     feel something more or something else, resulted in the formation of
     callosities on nose and chin.

In this way factitious wants come into being, which may be described as
a sort of _parasitic function_ of which the patient is alike the creator
and the dupe.

O.'s therapeutic ingenuity, however, could not rest satisfied except
when some fresh contrivance was being put to the test. Needless to say,
at one time he experimented with the stiff collars affected by some
sufferers from mental torticollis.

     At the commencement I used to wear collars of medium height, though
     not wide enough to admit my chin. An attempt to obviate the
     difficulty by unbuttoning my shirt and bending my head down so as
     to keep my chin in the opening proved abortive, owing to the
     weakness of the resistance, so I purchased much higher and suffer
     ones, in which I buried my lower jaw and prevented its moving at
     all. The success of this method was transitory, nevertheless, for
     however stiffly they were starched, the collars invariably yielded
     in the end and presented a lamentable aspect. I next happened on
     the fatuous plan of attaching a string to my brace buttons, and
     passing it up under my waistcoat to connect it with a little ivory
     plate that I held between my teeth, its length being so arranged
     that in order to seize the plate I had to lower my head. Admirable
     idea! I soon was forced to abandon it, however, for my trousers
     were pulled up on the right in a way that was as grotesque as it
     was uncomfortable. I have always had a weakness for the principle
     of the thing, nevertheless, and even to-day as I go down the street
     I sometimes catch hold of the collar of my jacket or vest with my
     teeth and stroll along in this way. At home it is the collar of my
     shirt that acts as my tether.

The retrocollic attitude that O. favours seems to have had the further
effect of making him forget how to look down. There is no impairment of
any of the eye movements, but he has considerable trouble in directing
his gaze downwards, and if with his head in the normal position he holds
a book below the level of the plane of his eyes, reading is more
arduous, and after a little time impossible. Yet there is no indication
whatever of ocular paresis; it is rather a sort of apprehension from
which he suffers. On several occasions we have remarked a synergy of
function, head and eyes moving upward in unison.

       *       *       *       *       *

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!

We need not smile at these explanations, for they are corroborated by
the facts of clinical observation. Fear of silence is nothing else than
a form of phobia, comparable to the fear of open spaces.

O.'s account of the origin of his tics supplies further evidence of the
mental infantilism of those with whom we are at present concerned. It is
the prerogative of "spoilt children" to wish to do exactly what they are
forbidden to do. They seem to be animated by a spirit of contrariness
and of resistance; and if in normal individuals reason and reflection
prevail with the approach of maturity, in these "big babies" many traces
of childhood persist, in spite of the march of years.

In the strict sense of the words there never has been any echolalia or
coprolalia in O.'s case, though it has happened that expressions lacking
in refinement have escaped him; but he never has been consciously yet
irresistibly urged to utter a gross word. The sole vestige of anything
of the kind is a sort of _fruste_ coprolalia that consists in an impulse
to use slang--an impulse which he cannot withstand and which he finds
consolation in obeying.

       *       *       *       *       *

Some additional details may be submitted to illustrate the intimate
analogies between tics and obsessions.

O. is a great cigarette smoker, and with him the call to smoke is
inexorable. It is not so much, however, the effects of the narcotic for
which he seeks as the sum of the sensations derived from the act--the
rustling of the tobacco in the paper, the crackle of the match, the
sight of the cloud of smoke, the fragrance of it, the tickling of nose
and throat, the touch of the cigarette in the fingers, or between the
lips--in a word, a whole series of stimuli, visual, auditory, olfactory,
and tactile, whose habitual repetition gradually introduces into the act
of smoking an automatic element that brings it into line with the tics.
The suppression of this parasitic function commonly produces a feeling
of the utmost discomfort; inability to indulge in it causes the keenest
anguish. More agonising than the actual impossibility of smoking is the
idea of its being impossible. Hence it is that O. lights cigarette after
cigarette, taking a few whiffs at each and throwing them aside scarce
touched, or leaving them here, there, and everywhere. The dose is
immaterial; it is the rehearsal of the act he finds so soothing.

In regard to his taste for liquor a similar description might be given.
The intoxicating effect of any beverage had little attraction for him;
it was the drinker's gesture and the numerous accompanying sensations
that he sought to renew. Any form of drink, therefore, served to gratify
his desire; in other words, his behaviour revealed a phase of dipsomania
rather than a stage of alcoholism. For that matter, the development of
symptoms of alcoholic poisoning proved a blessing in disguise, since
they reinforced the inhibitory power of the will, and enabled it to
abort a sensori-motor habit that had wellnigh become established.

No objective alteration in cutaneous sensibility in any of its forms is
discoverable on examination of O., but he bewails a long array of
subjective sensations, painful or disagreeable as the case may be.
Certain abdominal pains in particular occupy his thoughts: after being
in bed about an hour he begins to suffer from pain in the abdomen and
across the kidneys, so acute that he is forced to rise and walk about
his room, or sit on one chair after another; at length it moderates
enough to allow return to bed and permit of sleep. During these crises
there is no sign of any local pathological condition, no distention or
tenderness or evacuation of the bowel. They usually last for some days
at a time and disappear suddenly, as when, after several nights' and
days' uninterrupted suffering, his pains vanished as by an enchanter's
wand once he set foot on the boat that was to take him to England.

We have had the opportunity of observing our patient in the throes of
one of these attacks, and while we did not doubt the genuineness of his
sufferings, we could not but be struck with the dramatic exuberance of
his gestures. He wriggled on his chair, unbuttoned his clothes, undid
his necktie and his collar, pressed his abdomen with his hands, sobbed
and sighed and pretended to swoon away. Such excessive reaction to pain
is characteristic of a nervous and badly trained child, not of a man of
his years. Notwithstanding his humiliation at these exhibitions of
weakness, he can no more control them than he can his ordinary tics; in
fact, the tics run riot during the crises of pain.

On several occasions the reflexes have been the object of examination.
The pupillary reactions are normal, as are the tendon reflexes of the
upper extremity; but the knee jerks are much diminished, and one day we
failed to elicit them at all, though we noted their return a week later.
A careful search for further signs of possible cerebro-spinal mischief
proved negative, if we except a slight flexion of the knees when walking
and a tendency to a shuffling gait.

Notwithstanding this absence, in O.'s case, of any definite indication
of organic disease, we cannot afford, in our examination of patients,
to overlook any symptom, however fleeting or trivial it may appear,
since it is only by painstaking investigation both on the physical and
the mental side that we can ever hope to determine the characters and
fathom the nature of the affection, apart from the value of such an
investigation as an aid to diagnosis, prognosis, and treatment.

       *       *       *       *       *

With charming spontaneity and frankness, but critically withal, O. has
furnished us with a picture of his mental state. Nothing could be truer
or more instructive than this piece of self-observation, even though his
obvious pleasure in hearing himself talk is a little weakness of which,
to tell the truth, he is the first to accuse himself:

     In childhood and at school my accomplishments were ever on the same
     dead level of mediocrity. I was neither brilliant nor backward; in
     the drawing-room or in the playground, I was good at everything
     without excelling in anything; the astonishing facility with which
     I learned to sing, play, draw, and paint, was linked with inability
     to distinguish myself at these pursuits.

     Each new study, each new game, attract and captivate me at first,
     but I soon tire of them, and once a fresh enterprise has taken
     their place, indifference to them changes to disgust. If I am
     amused with a thing, I do it well; if bored, I throw it aside. I
     suppose it is characteristic of people who tic to be fickle and
     vacillating.

The versatility which is so fundamental an element in O.'s nature has
not been prejudicial to his business career. He has managed and still
manages important commercial undertakings, demanding initiative and
decision, and, so far from sparing himself in any way, he has exhibited
a combination of caution and audacity that has stood him in good stead.
It is more especially in the conduct of urgent operations that his
alertness is displayed. His comprehensive grasp of the situation enables
him to put his machinery at once into action, with eminently
satisfactory results, if we judge by his prosperous and assured
position.

His mobile and impulsive temperament is revealed in his every deed, but
he shows at the same time a curious disposition to alternate between the
pros and the cons of a question. It is the outcome of his extremely
analytical and introspective mind.

     I find myself seeking a knot in every bulrush. I experience a
     sensation of pleasure only to tax my ingenuity in discovering some
     danger or blame therein. If a person produces an agreeable
     impression on me, I cudgel my brains in the attempt to detect
     faults in him. I take it into my head to ascertain how anything
     from which I derive enjoyment might become an aversion instead. The
     absurdity of these inconsistencies is perfectly patent to me, and
     my reflections occasion me pain; but the attainment of my ends is
     accompanied with a feeling of pleasure.

     In regard to my tics, what I find most insupportable is the thought
     that I am making myself ridiculous and that every one is laughing
     at me. I seem to notice in each person I pass in the street a
     curious look of scorn or of pity that is either humiliating or
     irritating. No doubt my statement is a little exaggerated, but my
     fellows and I have an overweening self-conceit. We wish to be
     ignored, and yet we wish to be considered; it is annoying to be the
     object of sympathy, but we cannot bear to become a laughing-stock.
     Accordingly our goal is the dissimulation of our failing by any
     means feasible; yet nine times out of ten our efforts are abortive
     simply because we invent a tic to hide a tic, and so add both to
     the ridicule and the disease.

Alike in speaking and in writing O. betrays an advanced degree of mental
instability. His conversation is a tissue of disconnected thoughts and
uncompleted sentences; he interrupts himself to diverge at a tangent on
a new train of ideas--a method of procedure not without its charm, as it
frequently results in picturesque and amusing associations. No sooner
has he expressed one idea in words than another rises in his mind, a
third, a fourth, each of which must be suitably clothed; but as time
fails for this purpose, the consequence is a series of obscure ellipses
which are often captivating by their very unexpectedness.

His writing presents an analogous characteristic.

     It has often happened that I have commenced a business letter in
     the usual formal way, gradually to lose sight of its object in a
     crowd of superfluous details. Worse still, if the matter in hand be
     delicate or wearisome, my impatience is not slow to assert itself
     by remarks and reproaches so pointed and violent that my only
     course on reperusal of the letter is to tear it up.

By way of precaution, therefore, O. has adopted the plan of having all
his correspondence re-read by his colleague. Strangely enough, to his
actual caligraphy no exception can be taken. The firmness of the
characters, the accuracy of the punctuation and accentuation, the
straightness of the lines, are as good as in any commercial handwriting.

With the aggravation of his head tics writing has become a serious
affair. Every conceivable attitude has been essayed in turn, and at
present the device he favours is to sit across a chair and rest his chin
or his nose on the back; in this fashion he can write all that is
required.

O.'s every act is characterised by extreme impatience. In his hurry he
comes into collision with surrounding objects or breaks what he is
carrying in his hand, not because of defective vision or inco-ordination
of movement, but because of his eagerness to be done.

     In spite of the fact that I know my recklessness to be absurd, that
     I see well enough the obstacles around and the danger of an
     encounter, I am conscious of a paradoxical impulse to do exactly
     what I should not do. In the same instant of time I want what I do
     not want. As I pass through a door I knock against the door-post
     without fail, for the sole reason that I would avoid it.

There is impatience in his speech. His volubility makes him out short
his own phrases or break in upon the conversation of others. If an idea
suggests itself, he must give it expression. Perhaps the word wedded to
the idea is not at once forthcoming, yet he does not hesitate to invent
a neologism, which is often amusing in spite of or because of its
oddness, and if it please him he will enter it in his vocabulary and use
it in preference to the other.

To wait is foreign to his nature. The least delay at table exasperates
him; any order he gives must be executed instanter; no sooner has he set
out than he would be at his journey's end. An obstruction or difficulty
in the way is the signal for a fresh outburst; his irritation soon
exceeds all bounds; his language degenerates into brutality, his
gestures become increasingly violent and menacing.

It is not with any surprise, then, that we learn in O.'s case of
incipient homicidal and suicidal ideas.

     At times when my tics were in full force evil thoughts have often
     surged over me, and on two or three occasions I have picked up a
     revolver, but reason fortunately has come to the rescue.

As a matter of fact, the suicidal tendencies of some sufferers from tic
are seldom full-blown. The will is too unstable to effect their
realisation. Hence the patient's hints at doing away with himself are
nothing more than empty verbiage. Similarly with the inclination to
commit homicide, it vanishes as soon as it arises.

The term "vertigos" is used by O. to designate a long series of little
"manias" or obsessional fears from which he suffers, among which may be
enumerated dread of passing along certain streets and a consequent
impulse to walk through others; dread of breaking any fragile object he
holds in his hands, coupled with the temptation to let it fall; fear of
heights, and at the same time a desire to throw himself into space.

     I have often stood on the edge of the pavement waiting for a
     vehicle to pass, and at the moment of its approach darted across
     just under the horse's nose. On each occasion I have been conscious
     equally of the absurdity and yet of the irresistibility of the
     idea; each time the attempt to withstand it has been labour lost.

O. is a great nosophobe. At one time he was immoderately apprehensive of
contracting hydrophobia, and used to flee from the first dog he saw. To
his sincere regret he had several of his pet dogs killed, because of his
conviction that they would become infected, although he felt such harsh
measures to be quite unjustifiable. At a subsequent stage he turned
syphilophobe for no adequate reason. He was alarmed lest a minute pimple
on his chin should develop into a chancre. Recently his chief misgiving
has been that he may become ataxic or demented.

Among his various afflictions mention must be made of an umbilical
hernia, supposed to have originated in the chafing of his umbilicus by a
belt he was wearing during a long spell in a canoe. As a matter of fact,
the hernia is purely imaginary--at any rate, there is no trace of it
to-day. Yet at the first it bulked very largely in his mind, and he is
still fully persuaded of its reality, though no longer of its gravity.

O. further complains of all sorts of noises in his ears, but these are
simply the ordinary sounds that one can produce in the middle ear by
clenching the jaws together. He will not accept so obvious an
explanation, however, preferring to regard them as indubitable evidence
of the "lesion" with which he is preoccupied. The tinnitus, therefore,
is rather of the nature of an illusion than of a hallucination.

He is distinctly emotional, and lives at the mercy of his emotions, but
from their very bitterness he contrives to derive some pleasure. His
passion for horse-racing is not due to the fascination of the sport,
but to a bitter-sweet sensation which the excitement of the scene calls
into being. He is indifferent to arrest or aggravation of his tics; all
that he seeks is the association of a certain sense of anguish with
certain "tremolos in the limbs," wherewith he is greatly delighted.

In the domain of his affections there does not appear to be any
abnormality. O. is an excellent paterfamilias, adoring his children, but
spoiling them badly at the same time. In this part of our examination we
did not press for details, but as far as we have gathered he is capable
of sympathies keenly felt though rarely sustained.

Thus, whatever be the circumstances, changeableness, versatility, want
of balance, are manifested clearly in all his mental operations; and
when he remarks himself on the youthfulness of his disposition, he is
simply stating a truism as far as those who tic are concerned, for, in
spite of the advance of years, their mental condition is one of
infantilism.

Under our direction O. has devoted several months to the eradication of
his tics, and he has not been slow to appreciate the aim of the method
or to acquire its technique. One of the first results was the
repudiation of various procedures more harmful than otherwise, and the
successful endeavour to maintain absolute immobility for an increasing
space of time. The outcome of it all has been a gradual diminution of
the tics in number, frequency, and violence, and a corresponding
physical and mental amelioration.

We do not intend in this place to enlarge on the details of our
treatment: suffice it to say that it consisted in a combination of
Brissaud's "movements of immobilisation" and "immobilisation of
movements" with Pitres's respiratory exercises and the mirror drill
advocated by one of us. To-day the utility of these measures is an
accepted fact; but at the same time we rely on an inseparable adjunct in
the shape of mental therapeusis, seeking to make the patient understand
the rationale of the discipline imposed.

Our task has been lightened to an unusual degree through O.'s intimate
acquaintance with the beginnings of his tics and his striking faculty of
assimilation. On many occasions he has anticipated our intentions and of
his own accord outlined a programme in harmony with the indications we
were about to give him. Thanks to this happy combination of
circumstances, the improvement effected by our treatment has been
quickly manifested.

     I am conscious of very material gain. I do not tic so often or with
     such force. I know how to keep still. Above all, I have learned the
     secret of inhibition. Absurd gestures that I once thought
     irrepressible have succumbed to the power of application; I have
     dispensed with my para-tic cane; the callosities on my chin and
     nose have vanished; and I can walk without carrying my head in the
     air. This advance has not been made without a struggle, without
     moments of discouragement; but I have emerged victorious, strong in
     my knowledge of the resources of my will.... To tell the truth, at
     my age I can scarcely hope for an absolute cure. Were I only
     fifteen, such would be my ambition; but as I am, so shall I remain.
     I very much doubt whether I shall ever have the necessary
     perseverance to master all my tics, and I am too prone to imagine
     fresh ones; yet the thought no longer alarms me. Experience has
     shown the possibilities of control, and my tics have lost their
     terror. Thus have disappeared half my troubles.

The same sagacity that O. displayed in analysis of his tics has enabled
him to grasp the principles of their subjugation. Notwithstanding that
his guarded prognosis is evidence for his appreciation of the hindrance
his peculiar mental constitution is to a complete cure, he has
impartially put on record his definite progress towards health of body
and mind.

       *       *       *       *       *

Such, then, is the faithfully reported story of our model, such are his
confessions.

During ten years' intercourse with sufferers from tic it has been our
interest to analyse and reconstruct the pathogenic mechanism of their
symptoms, and in the vast majority of cases it has been possible to
determine the origin of the tics and to confirm the association with
them of a peculiar mental state. We have thus been able to supplement
earlier and weighty contributions to the subject by numerous suggestive
instances, prominent among which is the case of O., whose spontaneous
and impartial self-examination forms an invaluable clinical document.
Its importance is enhanced by the fact that its observations are
corroborated by a survey of other examples of the disease.

With commendable good-humour, keenness, and sincerity, O. has of his own
accord plunged into the minutiæ of his malady, and exhibited a rare
appreciation and precision in the scrutiny of his symptoms. The mere
enumeration of them stamps the record as one of outstanding clinical
importance, but it is the study of their pathogeny that is so
fascinating. For a moment the doubt crossed our mind that O.'s
explanations might be merely a reflex of information culled from
scientific journals or of conversations with medical friends, but this
is not so. He has been prevented by his profession both from cultivating
a taste for and from devoting any leisure to psychological and
physiological questions, while he evinces an actual antipathy to medical
literature, fearful as he is of contracting disease. The point we are
desirous of emphasising, therefore, is simply this: that the results of
O.'s voluntary and unprejudiced self-examination are in perfect harmony
with the declarations of our older patients and with the statements of
the majority of those that have made a special study of the tics. For
these reasons we have taken O. as the prototype of the _tiqueur_.



CHAPTER II

HISTORICAL


We have just become acquainted with an individual who may, we believe,
be considered the type of a species, and have described all his tics.
What is a tic, then?

Its etymology has not much information to furnish. The probability is
that the word was originally onomatopœic, and conveyed the idea of
repetition, as in tick-tack. _Zucken_, _ziehen_, _zugen_, _tucken_,
_ticken_, _tick_, in the dialects of German, _tug_, _tick_, in English,
_ticchio_ in Italian, _tico_ in Spanish, are all derivatives of the same
root. It matters little, in fact, since the term is in general use and
acceptable for its shortness and convenience. In popular language every
one knows what is meant by a tic: it is a meaningless movement of face
or limbs, "an habitual and unpleasant gesture," as the Encyclopædias
used to say. But the definition lacks precision.

A glance at the history of the word will reveal through what
vicissitudes it has passed. We need but remind the reader of its
exhaustive treatment in the Dictionaries, and refer him for an elaborate
bibliography to a recent work by R. Cruchet,[1] to which we shall have
occasion to return.

There is no justification for regarding the risus _sardonicus_ of the
ancients as a tic. All that we can say is that the phrase apparently
stood for a complex of facial "nervous movements," whether accompanied
by pains and paralyses or not. Nor can the _rictus caninus_ or the
_tortura oris_ have been other than spasms or oontractures of the face.

Previous to its introduction as a technical term, the word _tique_,
_ticq_, _tic_, was in current use in France, and applied in the first
place to animals. In 1655 Jean Jourdin described the _tique_ of horses.
In eighteenth-century literature tic appears in the sense of a
"recurring, distasteful act"--as expressed by the
_Encyclopædia_--especially in individuals revealing certain
eccentricities of mind or character. This old-time opinion is worth
remembering, particularly in view of latter-day theories.

Once adopted by the eighteenth-century physicians, the application of
the word was extended in various directions. André (1756) was the first
to mention _tic douloureux_ of the face, an affection excluded to-day by
common consent from the category of true tics. Simple, painless
convulsive tic, spreading from face to arms, and to the body as a whole,
was differentiated by Pujol in 1785-7. During the earlier half of the
nineteenth century no solid progress was achieved by the work of Graves,
François (of Louvain), Romberg, Niemeyer, Valleix, or Axenfeld. It is to
the clinical genius of Trousseau that we owe the rediscovery of tic, the
careful observation of its objective manifestations, and the recognition
of accompanying mental peculiarities.

In spite of the fact that he considered it a sort of incomplete chorea,
and classed it[2] nosologically with saltatory and rotatory choreas and
with occupation neuroses, Trousseau's original account remains a model
of clinical accuracy:

     Non-dolorous tic consists of abrupt momentary muscular contractions
     more or less limited as a general rule, involving preferably the
     face, but affecting also neck, trunk, and limbs. Their exhibition
     is a matter of everyday experience. In one case it may be a
     blinking of the eyelids, a spasmodic twitch of cheek, nose, or lip;
     in another, it is a toss of the head, a sudden, transient, yet
     ever-recurring contortion of the neck; in a third, it is a shrug of
     the shoulder, a convulsive movement of diaphragm or abdominal
     muscles,--in fine, the term embodies an infinite variety of bizarre
     actions that defy analysis.

     These tics are not infrequently associated with a highly
     characteristic cry or ejaculation--a sort of laryngeal or
     diaphragmatic chorea--which may of itself constitute the condition;
     or there may be a more elaborate symptom in the form of a curious
     impulse to repeat the same word or the same exclamation. Sometimes
     the patient is driven to utter aloud what he would fain conceal.

The advantage of this description is its applicability to every type of
tic, trifling or serious, local or general, from the simplest ocular tic
to the disease of Gilles de la Tourette. Polymorphism is one of the
tic's distinguishing features.

Apart from his studies in objective localisation, Trousseau, as we have
seen, recognised that the tic subject was mentally abnormal, but the
credit of demonstrating the pathogenic significance of the psychical
factor is Charcot's. Tic, he declared,[3] was physical only in
appearance; under another aspect it was a mental disease, a sort of
hereditary aberration.

Advance along the lines thus laid down has been the work more especially
of Magnan and his pupils, of Gilles de la Tourette, Letulle, and Guinon.
A meritorious contribution to the elucidation of the question is the
thesis of Julien Noir, written under the inspiration of Bourneville and
published in 1893. The still more recent labours of Brissaud, Pitres,
and Grasset in France, and of others elsewhere, have added materially
to our knowledge.

Confining ourselves for the present to the discussion of the latest
interpretations put on the word tic, we may be allowed the remark that
if the influence of Magnan's teaching has been instrumental in making
our idea of tic conform more to the results of observation, nevertheless
his view is not without its dangers.

In the opinion of Magnan and his pupils, Saury and Legrain[4] in
particular, the tics do not form a morbid entity; they are nought else
than episodic syndromes of what Morel called "hereditary insanity," that
is to say, of what is usually designated nowadays "mental degeneration."

Now, if by degeneration be meant a more or less pronounced hereditary
psychopathic or neuropathic tendency which betrays itself by actual
physical or psychical stigmata, then tic patients are unquestionably
degenerates. If degeneration unveils itself in multifarious psychical or
physical anomalies, the subjects of the tic are undoubtedly degenerates.
If a degenerate may suffer from one or other variety of aboulia, or
phobia, or obsession, the man with tic is a degenerate too.

Thus understood, the epithet may be applied to all individuals affected
with tic. In fact, they _must_ be degenerates, if the word is to be
employed in its most comprehensive sense. But the explanation is
insufficient, inasmuch as the converse does not hold good; all
degenerates do not tic.

We may be safe in maintaining, then, that tic is only one of the
manifold expressions of mental degeneration, but we are not much
enlightened thereby. Obsessions and manias similarly are indications of
mental deterioration, yet the fact conveys very scanty information as
to their real nature. Physical anomalies--ectrodactyly, for
instance--betoken physical degeneration, no doubt; but are inquiries to
cease with this categorical assertion? Such certainly was not the idea
of those observers whose is the praise for having demonstrated the
common parentage of the heterogeneous manifestations of degeneration.
Synthesis cannot exclude the work of analysis, and in practice there is
scarcely a case to which this doctrine is not pertinent.

Every physical and every mental anomaly is the fruit of degeneration;
every individual who is a departure from the normal is a degenerate,
superior or inferior as the case may be. As instances of the latter we
may specify the dwarf and the weak-willed; of the former, the giant and
the exuberant. This sane and comprehensive conception of the subject
must command universal acceptance as a synthetic dogma, but it cannot
supplant the description and interpretation of individual facts. However
legitimate be our representation of tic as a sign of degeneration, it is
obviously inadequate if we rest content with styling its subject a
degenerate.

Unfortunately the inclination too often is to be satisfied with the
term, and to imagine that therewith discussion terminates. Still more
unfortunately, in concentrating their attention on the mental aspect of
the disease, some have altogether lost sight of one of its fundamental
elements, viz. the motor reaction, and have conceived the possibility of
its occurrence without any _tic_ at all. Cruchet actually postulates the
existence of an exclusively psychical tic, with no external
manifestation.

To these questions, however, we shall return. The present introductory
sketch is intended merely to demonstrate the ease with which ambiguity
arises, and the desirability of its removal. We are fully conscious of
the value of the work of Magnan and his school in emphasising a phase of
the subject the exposition of which can only result in gain.

       *       *       *       *       *

The investigation of the motor phenomena of tic is no less encircled
with perplexities. Not only are the troubles of motility boundless in
their diversity and correspondingly difficult to classify, but they also
bear so close a resemblance to a whole series of muscular affections
that one is tempted to describe a special symptomatology for each
individual case.

For several years there has been, more especially outside of France, a
manifest tendency to aggregate all convulsions of ill-determined type
into one great class, under the name "myoclonus"; and into this chaotic
farrago, it is to be feared, will tumble a crowd of conditions which
should be studiously differentiated: the tics, electric and fibrillary
choreas, paramyoclonus multiplex, etc., etc.

In the present state of our knowledge, according to Raymond,[5] we must
be guided by the lessons of clinical experience, which teach us, first,
that the varying modalities of myoclonus develop from the parent stock
of hereditary or acquired degeneration; and, secondly, that transitional
forms which do not fall into any of the received categories are of
common occurrence.

From a general point of view, the deductions are entirely reasonable.
There is a suggestive analogy between these conditions and the muscular
dystrophies in the persistence with which their multiplicity seems to
defy the efforts of classification. The analytic stage witnessed the
rapid evolution of such clinical types as the facial, the
facio-scapulo-humeral, the juvenile, the pseudo-hypertrophic, not to
mention others that bear the name of their observer; but it has been
succeeded by the synthetic stage, whose function it is to incorporate
all the former myopathies in the comprehensive group of "muscular
dystrophy."

Yet here, again, peril lurks in too hasty a generalisation. To give the
disease a name is not equivalent to pronouncing a diagnosis. The
denominations "myoclonus," "muscular dystrophy," "degenerate," are alike
inconvenient. Their scope is at once too inclusive and too exclusive.
They may be indispensable; they are assuredly not sufficient.

The possibilities of misapprehension do not end here.

The manifestation of each and every tic--be it a flicker of the eyelid,
a turn of the head, a cry, a cough--is through the medium of a muscular
contraction. On the very nature of this contraction opinion is divided.

To its distinctive features of abruptness and momentariness is due the
epithet "convulsive" habitually assigned it, but the qualification is
not secure. Since the time of Willis the word convulsion has been
employed in a double sense, to signify _clonic_ muscular contractions
(the "convulsion" of popular parlance) and _tonic_ muscular contractions
(a meaning attached to the term only by the scientist).

For our part, we can raise no valid objection to the specification of
tics as convulsive, provided always that the existence of clonic
convulsive tics and of tonic convulsive tics be recognised. As a matter
of fact, clinical observation supplies instances of both sorts.

Nevertheless, attention has been confined by a majority of authors to
the consideration of the former variety only, so much so that a whole
order of facts which in derivation, essence, and external
characteristics ought to be identified with the tics has been passed
over in silence. Even on the assumption that the proposal to recognise
the two classes cannot be entertained, at the least it is advisable to
predetermine the import of the word convulsion, and to speak of _clonic_
convulsive tics. This is the formula of Ferrand and Widal in their
article "Convulsion" in the _Encyclopædic Dictionary of the Medical
Sciences_. Similarly, Troisier[6] says that the convulsive tic properly
so called is characterised by clonic movements, in which opinion Erb and
most German observers concur. Tonic tic appears to have been forgotten,
and we have thought it our duty to resuscitate it.

Cruchet has quite recently approached the subject in a critical fashion:

     To extend the term tic to tonic spasms such as mental torticollis,
     mental trismus, or permanent blepharospasm, is singularly to
     outstep the limits of its significance. We believe Erb, Troisier,
     and Oppenheim are warranted in restricting convulsive tic to clonic
     convulsions, and the consequent simplification and elucidation of
     the question lead us to adopt the same view.

If it be solely a matter of terminology, and if universal consent
reserve tic for convulsions whose expression is clonic, we shall be the
first to withdraw the phrase "tonic tic," making the single proviso that
some other designation be found for a condition which differs from the
clonic tic only in its external features, and not in origin, pathogeny,
or treatment.

What is this other name to be? Are these tonic muscular contractions to
be regarded as synonymous with contractures? If so, do we mean
myotetanic contracture--to utilise the excellent division imagined by
Pitres--as in hysteria, or myotonic contracture, as in Parkinson's
disease? The state of muscular contraction in tonic tic does not
correspond accurately to either, though it is certainly more akin to
the myotonic form; but myotonia is a sort of _caput mortuum_ for the too
facile classification of cases in reality difficult to place, and we are
afraid the term is not calculated to ensure precision of ideas.

Should we be reproached with straining the primary meaning of the word
tic by applying it to a contraction of a certain duration, we find ample
justification ready at hand in the pages of Cruchet himself. "It was
probably in 1656," he says, "that _tique_ appeared in the French
language, in the works of Jean Jourdin." Now, in the quaint description
of the horse's _tique_ given by that writer, the signs of the disease
are said to be cocking of the ears, rolling of the eyes, clenching and
gnashing of the jaws, stiffening of the tail, nibbling at the bit, etc.
What else are these than persistent contractions or tonic tics,
alternating or co-existing with jerking movements or clonic tics?

We have no desire, of course, to over-estimate the argumentative value
of this passage, the interest of which is mainly historical; but we find
ourselves wholly in accord with Cruchet when he remarks of the
scientific distinction formulated by Willis, and again by Michael
Etmüller, between continuous, permanent tonic convulsions, and
intermittent, momentary clonic convulsions, that it is uninvolved,
practical, and of universal applicability.

In 1768 certain tics were classified among the tonic convulsions by
Boissier de Sauvages. Marshal Hall[7] gave an account of various tonic
facial convulsions to which Valleix refers as non-dolorous tics or
idiopathic convulsions of the face. Coming nearer to our own times, we
find the distinction of which we have been speaking again elaborated by
Jaccoud,[8] in 1870, and accepted also by Rosenthal.

Doubtless physiologists and pathologists are not invariably at one as
regards the proper characters of the two, and subdivisions into
continuous tonic contractions as opposed to intermittent tonic
contractions have been deemed necessary; but without burdening the
subject with a plethora of detail, we think it simple, suggestive, and
clinically satisfactory to uphold Willis's generalisations and to enlist
their help in the exposition of the tics. Hence, unless under special
circumstances, we consider recourse to the epithet "convulsive"
superfluous, and we shall employ the word tic by itself, except when
there may be occasion to indicate the form of muscular contraction. The
gain in conciseness is not likely to be neutralised by any loss of
precision.

From our rapid survey of the vicissitudes through which the tic has
passed, we may profitably gather one or two lessons.

In so far as is compatible with its nature, the schematisation of tic is
indispensable. The inevitable variability of the personal factor and the
absence of a real breach of continuity between any two essentially
differing morbid affections ought not to deter us from the attempt to
project a line of demarcation between them. Natural science is pledged
to the labour of differentiation. It is the glory of Charcot's
alternately synthetic and analytic work to have demonstrated the value
of this method in the sphere of neuropathology. At the same time, the
wisdom of attaching only a provisional importance to any scheme and of
welcoming possible modification is of course self-evident. Inexact and
undiscriminating inference may be a stumbling-block in the path of
progress and inimical to the cultivation of the faculty of observation.
Further, inaccuracy of definition not only exaggerates the liability to
misunderstanding, but has sometimes also the disadvantage of promoting
an illusory belief in the possession of the truth.



CHAPTER III

THE PATHOGENY OF TIC


TIC AND SPASM

Our study of tic can be approached only after a preliminary
understanding as to the meaning of two words too frequently confounded
even in scientific literature--_tic_ and _spasm_. Let us explain, then,
once for all, exactly what we intend by the latter.

Etymologically (σπασμὁς, σπἁω I draw) the word signifies a twitch, but
as it is unfortunately considered a synonym for convulsion, the two
expressions are used indifferently in medical parlance, though the
desirability of restricting the application of the former has more than
once been indicated. Littré's definition--"an involuntary contraction of
muscles, more particularly of those not under voluntary control"--may
appear somewhat idle, as the contraction of muscles not under the
influence of the will can scarcely be other than involuntary. His
intention was, no doubt, to reserve spasm for convulsive phenomena in
non-striped muscle fibres; but in this limited sense the term has not
met with acceptance, and it remains equivalent to "involuntary muscular
contraction," whatever that may mean. Thus interpreted, it is applicable
to any and every involuntary muscular movement, physiological and
pathological, to the inco-ordination of tabes, to chorea, athetosis,
tremor, etc.

Rather than imagine a new substantive to characterise certain of these
muscle contractions, we may retain the word in a somewhat wider though
equally precise sense, and follow the distinction drawn by Brissaud[9]
in 1893: "a spasm is the result of sudden transitory irritation of any
point in a reflex arc; ... it is a reflex act of purely spinal or
bulbo-spinal origin."

By definition, then, _a spasm is the motor reaction consequent on
stimulation of some point in a reflex spinal or bulbo-spinal arc_. To
differentiate between the reflex, which is physiological, and the spasm,
which is pathological, we may add as a corollary: _the irritation
provocative of the spasm is itself of pathological origin, and no spasm
can occur without it_. The anatomo-pathological substratum of a spasm
is, then, some focus of irritation on a spinal or bulbo-spinal reflex
arc, which may be situated in peripheral end organ, in centripetal path,
in medullary centre, or in centrifugal fibre. Whatever be its
localisation, it will determine a spasm in our sense of the word.

Cortical or subcortical excitation, however, as well as peripheral
stimuli, may provoke these bulbar and spinal centres to activity.
Irritation of a point on the rolandic cortex, or on the cortico-spinal
centripetal paths, is followed by a motor reaction exactly as with
afferent impulses; the sole change is in the route taken by the
centripetal stimulus; the reflex centre remains bulbo-spinal, and the
efferent limb of the arc is as before.

The application of the word spasm to these motor responses to cortical
or subcortical stimulation is quite justifiable. Developmentally the
grey matter of the cerebral convolutions is ectodermic, as is the skin,
and capable of functioning as a sensory surface; it may be considered
the end organ of an afferent path that conducts to medullary reflex
centres. According to our definition, then, provided the centre of the
reflex arc be bulbo-spinal and the irritation pathological, the
consequent motor phenomenon is a spasm.

A distinction most nevertheless be drawn between the two cases, inasmuch
as in the one the afferent path is peripheral, in the other it is
cortico-spinal, and there is a corresponding difference in the clinical
picture. Jacksonian convulsions, consecutive to cortical stimulation, do
not seem to bear much resemblance to spasmodic movements indicative of
peripheral--_i.e._ sensory nerve--irritation. As a matter of fact, it is
not always easy to differentiate the two, except by the aid of
concomitant phenomena. The characteristic evolution of the Jacksonian
convulsion is of course readily recognisable. We can similarly diagnose
an irritative lesion of the internal capsule not so much from the
objective features of the convulsive movements as from accompanying
indications. In short, there need never be any occasion for confusion.
Convulsive conditions attributable to irritation of cortico-spinal
centripetal paths have long been described and analysed: they constitute
well-recognised morbid entities, among which may be enumerated
Jacksonian epilepsy, hemichorea, hemiathetosis, pre-and post-hemiplegic
hemitremor, etc.

These clinical denominations for the affections under consideration it
is at present desirable to retain. We shall not call them spasms; above
all, we must not call them tics, else we shall end by confounding
conditions absolutely distinct. The case recorded by Lewin,[10] under
the title of "convulsive tic," of a three-year-old infant still unable
to walk, who has daily attacks in which "all the muscles" twitch for
about a minute at a time, is indeed a most singular tic. We were under
the impression that such an attack is usually known as an epileptiform
convulsion. Is the term "convulsive tic" quite a happy synonym?

Again, in the recent thesis of Cruchet the attempt has been made to base
the pathological physiology of tic on researches of von Monakow and
Muratow apropos of the occurrence of choreic, epileptoid, or athetotic
movements after certain lesions of the cerebro-spinal axis, and to find
an analogy in the action of various convulsion-producing substances
(Richet and Langlois). Cruchet's conclusion is that convulsive tic is as
often cortical or subcortical as spinal in origin; that it is, in short,
a mere symptom, common to many cerebro-spinal conditions.

The same regrettable confusion is discernible in various treatises on
neuropathology the work of German and other foreign authors.

As far as we are concerned, the outcome of the whole matter is simply
this: if tic is doomed to be used indifferently for convulsion, its
retention in scientific terminology is unjustifiable. Rather, then, than
widen its application, we prefer to restrict it; we shall employ the
term convulsion in its most general sense of "any anomaly due to excess
of muscular contraction," of whatever variety or origin; and we shall
limit the use of the word spasm to phenomena the result of irritation at
any point on afferent or efferent reflex paths, or in reflex
bulbo-spinal centres.

In thus indicating our position, we find ourselves once more in accord
with generally received opinion since the days of Charcot. These views
have been excellently expressed by Guinon:

     Convulsive movements differ widely in kind. Some consist of
     localised spasms in the domain of a motor or mixed nerve, most
     frequently one of the cranial series--in especial the
     seventh--consecutive to some anatomical lesion, central or
     peripheral. The great majority of observers, French and foreign
     alike, are in the habit of designating such movements "tics." ...
     But they are only partial convulsions limited to the area of some
     one nerve, not true convulsive tics, differing alike in essential
     features and concomitant symptoms. From the anatomo-pathological
     standpoint, moreover, lesions are as constantly present in the one
     as absent in the other.

The opinion of Brissaud on the subject coincides with our own.

       *       *       *       *       *

If we suppose now that the cortex ceases to act as a surface of
peripheral excitation, and becomes itself a reflex centre, we note at
once a complete change. The modification effected by the cortex on
afferent impressions is obvious in altered motor reactions, which appear
with the stamp of cortical intervention, herein differing from
bulbo-spinal phenomena. To this category belong the tics; we shall soon
see why and how.

Conformably, then, to convention sanctioned by usage, and especially by
the teaching of Charcot and Brissaud, we have given a precise definition
to the word spasm, and we can only solicit its general adoption.

To resume briefly the argument we have advanced in the foregoing
paragraphs, we maintain:

If in a given motor phenomenon there is no evidence of actual or
previous cortical intervention, it is not a tic.

If the motor reaction is consecutive to pathological irritation at any
point on a bulbo-spinal reflex arc, it is a spasm.

If the cortex is or has been involved in its production, it is not a
spasm.

Should it present, in addition to the fact of cortical participation,
certain distinctive pathological features, it is a tic.

It is precisely these distinguishing characteristics that we shall now
proceed to examine, preluding our study of them with one or two
physiological considerations.


TIC AND MOTOR REACTIONS; REFLEX, CO-ORDINATED, FUNCTIONAL, AUTOMATIC,
AND VOLUNTARY ACTS

The instantaneous muscular contraction that follows the application of a
drop of sulphuric acid to the limb of a decerebrate frog is an example
of a pure spinal reflex. With the persistence of the irritation
contraction of the other limb and of the whole body ensues; the simple
spinal reflex has become generalised. Observe the frog a little longer.
Soon the sound foot approaches the affected limb and attempts by rubbing
to remove the point of irritation. A movement of attack has succeeded
the simple movement of defence, and indicates a complete change in the
nature of the motor reaction. In the first case the limb is withdrawn
briskly from the painful stimulus; in the second the animal performs a
series of co-ordinated purposive movements. The first reflex is
automatic, and so no doubt is the second, since the frog is decerebrate.
But a co-ordinated movement is not of necessity automatic from the
outset; its automatism may be the sequel to voluntary education.
Co-ordination is often a manifestation of cortical activity.

Take, next, the case of the infant. His earliest muscular movements are
pure spinal reflexes. Pinch his leg, and he withdraws it; continue the
stimulus, and he moves the other leg, his arms, his whole body; he
starts to cry. The original reflex is becoming generalised, yet he makes
no attempt to remove the source of irritation. Should a particle get
into his eye, his lids will blink so long as the pain persists, but he
never rubs them to expel the foreign body. In Virchow's phrase, the
newborn infant is a spinal animal, endowed with spinal reflexes only;
his responses to stimuli are beyond voluntary control.

More complex motor phenomena, however, equally independent of cortical
influence, characterise the early days of the infant's life. The
contact of his lips with the breast at once elicits a reflex in the
shape of sucking movements. These are obviously co-ordinated and adapted
for a particular end; suction is a functional act. Yet the cortex plays
no part therein; the act is automatic from the beginning. Peripheral
excitation from tactile impression of nipple, teat, or finger is
sufficient to provoke this reflex response.

Similarly with the functions of respiration and nictitation--their
establishment follows the stimulation by air of the respiratory or
conjunctival mucosa. The appropriate movements constitute the
spontaneous reaction to afferent impulses; they are simple bulbar
reflexes. Co-ordinated and purposive though they be, they do not come
within the sphere of the will. The newborn child cannot voluntarily
accelerate or retard his respiratory rhythm.

But a day comes when the formation of cortico-bulbar or cortico-spinal
anastomoses renders possible the interaction of higher and lower
centres; respiration may be made quicker or slower; the eyelid may be
closed less rapidly, more often. In a word, cortical modification of
function becomes a reality.

A further step in advance is soon taken.

Under the "law of least effort" the inhibitory power of the will reduces
motor reaction for the attainment of a given object to a minimum. The
infant begins to make more complicated movements, attempting the removal
of a source of annoyance by direct attack, learning to scratch itself,
to spit instead of swallow, etc.

The essential difference between these acts--a thousand other examples
might be chosen--and the reflexes of the first group, is that the
precise and regular execution of the former demands more or less
prolonged education, repetition, and voluntary co-ordination.

It is true these co-ordinated acts are eventually performed with all the
spontaneity of the simplest reflexes; voluntary co-operation is no
longer indispensable; scratching, spitting, walking, can be effected
without any actual intervention of the will. But we must not forget such
muscular automatism entails a preliminary training in the shape of
frequent repetition of purposive movements--a training which varies in
duration with the individual and the nature of the particular movement.
It is only after several years of volitional effort that such acts as
locomotion or the expulsion from the throat of an irritant particle
become really automatic.

The fact that the newly hatched chick is capable of walking has been
advanced as an argument for the existence of congenital automatism. It
is true that the chick's movements are very imperfect--it stumbles and
falls, as does the infant, on the slightest provocation, and even
without any apparent cause; but the rapidity with which certain animals
acquire the faculty is so surprising that the latter almost appears to
have been innate.

In all phenomena characterised as instinctive we cannot deny the
existence of a certain congenital aptitude, the result possibly of
ancestral education, owing to which some individuals learn infinitely
more quickly than others, and in their case a period of preliminary
education may seemingly be awanting. Probably the truth is, however,
that this stage has been a very brief one. In man there is a gradual
transformation of voluntary into automatic acts. Though no teacher be
necessary, teaching is requisite. The infant learning to walk is really
independent of his parents, and might, for that matter, be entirely
self-taught; but the point remains, however automatic his walking
subsequently become, that he begins by voluntarily co-ordinating the
movements of his lower limbs and trunk towards a definite end.

Another advance is still to be made.

With increasing cortical development the individual is able, on
stimulation no longer peripheral but central in origin, spontaneously to
execute movements which frequent repetition has endowed with all the
features of functional acts. Of these ideomotor phenomena physical
exercises, games, manual trades, readily furnish instances. Swimming,
for an instance, requires the rhythmical co-ordination of arm and leg,
to attain which perseverance, retentiveness, and above all repetition
are essential. At length the time arrives when the swimmer is surprised
at the absence of any necessity for voluntary co-ordinating effort on
his part. In fact, to reintroduce volition into this acquired automatism
would be to court disaster. "What I do naturally," said Montaigne, "I
can no longer perform if I attempt it expressly."

From these physiological considerations we are led to make the following
classification of motor reactions:

     1. Simple spinal reflexes, innocent of co-ordination or functional
     systematisation, on whose production or inhibition the will has no
     influence. To this division belong the movements known as spasms.

     2. Functional motor acts. Among these we may distinguish:

     _a._ Essential movements, _e.g._ respiration, suction, etc.,
     appearing at birth, and co-ordinated in view of some definite
     function.

     _b._ Acts such as locomotion, mastication, etc., whose acquisition
     is subsequent to a more or less prolonged period of education.

     _c._ Non-essential ideomotor acts, acquired later in life, which
     soon assume all the characters of functional acts.

The movements belonging to the first group in this latter category may
manifest themselves without any exertion on the part of the will, but
its activity is essential to the perfecting of the second, and the
originating of the third.

In this last division are placed the motor phenomena known as tics.


TIC AND CO-ORDINATION

We have thus come to see that a tic is a co-ordinated, systematised,
purposive act. The majority of observers are satisfied on this point,
although there exist various differences of opinion, more apparent than
real, the inevitable result of disagreement as to the interpretation of
certain expressions. It is imperative to obviate misunderstanding once
and for all.

In his first contribution to the study of the disease which bears his
name, Gilles de la Tourette gave the general description of _motor
inco-ordination_ to the convulsive movements of his patients. It has
been argued by Guinon, on the contrary, that they are really
systematised, and that they reproduce, in an involuntary manner, the
co-ordinated movements of everyday life. That this is sometimes the case
Tourette subsequently admitted, but he still professed their frequent
actual inco-ordination.

This divergence of opinion is entirely attributable to difference of
interpretation. Littré's definition of muscular inco-ordination is, "A
condition occurring in various diseases of the nervous system, in which
the patient cannot co-ordinate the necessary muscular movements for
walking, grasping an object, etc." In this sense the term is applicable
indiscriminately to the gesticulations of choreic, athetotic, or tic
patients; to the ataxia of tabetics and others; to the tremor of
disseminated sclerosis or paralysis agitans, etc. An expression so
general is not merely of no diagnostic value; it leads to positive
confusion.

It is precisely in the type of inco-ordination that the difference lies.
As rigorous a distinction must be drawn between the gestures of chorea
and the gesticulations of the sufferer from tic as between the tremor of
insular sclerosis and of Parkinson's disease.

In assigning an exact meaning to the term muscular inco-ordination, we
cannot do better than quote the remarks of Guinon:

     The tabetic who throws his legs to right and left, who as he sits
     at table cannot carry his spoon to his mouth, furnishes an instance
     of true motor inco-ordination. On the other hand, the subject of
     tic performs his voluntary actions with perfect assurance; though
     his infirmity occasion all sorts of ridiculous involuntary arm
     movements, he never brings his fork against his ear or his cheek,
     nor does he spill a drop from his glass; his walk may be
     interrupted by a sudden halt to bend his knees and kneel, or to
     strike his foot violently on the ground, but he never trips one leg
     over the other and never falls.

In his article in the _Dictionnaire Jaccoud_, Letulle distinguishes two
kinds of tics:

     The _convulsive tic_ consists of a series of partial convulsions,
     while the _co-ordinated tic_ is the expression of some complex act
     by a sequence of muscular contractions for that purpose. In the
     former case the resulting movement is irregular, abnormal, and
     useless; it is a muscular "shock" evolved without reason and
     continued without effect.... The normal individual usually
     possesses _in potentia_ all the elements for the genesis of a
     co-ordinated tic. Some little trick or mannerism, arising perhaps
     from the necessity of gaining time for reflection, or from the
     desire of concealing some innate timidity, or of dissimulating some
     preoccupation, becomes sooner or later involuntary and automatic,
     and though maintaining its regularity and co-ordination, passes
     insensibly into the realm of pathology.

The distinction, however, is far from being absolute. Letulle himself
admits it is a question of degree rather than of kind; the co-ordinated
tic differs from the first variety only in its greater extent,
complexity, and duration. Now, the convulsive tic may be a local,
partial, irregular, abnormal convulsion, yet these characteristics are
not sufficient to differentiate it: biting the lips is classed by
Letulle as a co-ordinated tic, but it is surely a local, partial,
irregular, abnormal muscular act; and the explosive laryngeal "ahem!" he
would similarly place, yet it cannot be said to be a phenomenon
characterised by its extent, complexity, and duration.

According to Guinon, a further distinguishing feature of the convulsive
tic is its frequent though inopportune reproduction of some reflex or
automatic purposive movement of everyday life, whereas we have just seen
that one of the elements in Letulle's co-ordinated tic is its
purposiveness. In a word, these observers apply the same epithet to two
varieties of tic which they are endeavouring to separate.

The explanation of the apparent contradiction is simple. A gesture which
seems meaningless and useless to-day becomes intelligible and logical
to-morrow, when we learn the reason for it. In the course of an attack
of conjunctivitis a patient acquires the habit of winking his eye, and
though the inflammation subsides, the habit persists. If we are ignorant
of its cause, are we to call the tic convulsive since it appears to us
needless? And if we do know its origin; can we say it is co-ordinated
when one muscle only is involved in the contraction?

The distinction drawn by Letulle between the two groups may hold good in
some cases, but certainly not in all, and in our opinion it is
preferable to abstain entirely from the attempt to base a classification
on variation in muscular contraction. Noir remarks very justly that
intermediate forms occur which are difficult to place in one or other
category. In face of the confusion to which an illogical division
inevitably leads, we may safely leave this question aside. In our view,
the motor phenomena of the disease are always systematic, co-ordinated
movements, directed for the attainment of some definite object. We
exclude all simple bulbar or spinal reflexes, and all spasms, since the
cardinal feature in these conditions is the absence of any functional
systematisation.


THE GENESIS OF TIC

We have seen how various purposive, co-ordinated movements may, by dint
of education and voluntary repetition, become automatic and be
automatically repeated should occasion arise. Imagine some such act
recurring involuntarily without any apparent reason and for no apparent
object; what does such an anomaly signify?

Take, for instance, the case of a young girl who inclines her head on
her shoulder to relieve the pain of a dental abscess. The act is called
forth by a real exciting cause; the muscular response is voluntary,
deliberate, undeniably cortical in origin: the patient _wills_ to
appease the pain by pressing and warming her cheek. Should the abscess
persist, the movement will be repeated less and less voluntarily, more
and more automatically; but as the why and the wherefore still remain,
there is nothing pathological about it.

With the healing of the abscess, however, and the consequent relief of
the pain, the girl still inclines her head on her shoulder from time to
time, albeit cause and purpose have ceased to operate. Her primarily
volitional, co-ordinate, systematic, motor reaction is now automatic,
inopportune, and meaningless: it is a tic.

Charcot[11] has given us an excellent description of the process:

     However complex and bizarre may appear the convulsive phenomena
     known as tics, they are not always as irregular, inco-ordinate, and
     contradictory as superficial examination might lead one to
     believe. On the contrary, they are, as a general rule,
     systematised; in a given case they recur always in an identical
     manner, reproducing, and simultaneously exaggerating, complex,
     automatic, purposive movements which are essentially physiological;
     they are in a sense the caricatures of ordinary acts and gestures.
     The tic is not in itself absurd; it appears so only because it
     occurs inappositely, without obvious motive. Source of irritation
     is absent, yet the patient scratches himself; he blinks, but no
     foreign body is to be detected in his eye.

Mere repetition does not, cannot, evolve a tic in every case. Not all
who would may tic; psychical predisposition in the shape of volitional
enfeeblement is a _sine qua non_.

Of the rôle played by mental insufficiency in the genesis of tic we
shall have much to say later. The point we are desirous of emphasising
now is that the first manifestations of tic have their origin in, and
are dependent on, cortical activity, at least in a majority of cases.

Notwithstanding painstaking investigation, determination of the initial
cause may no doubt be difficult in some instances, owing to the
patient's ignorance or forgetfulness; for that matter, the observer may
not know how to set about his task. Prolonged interrogation, however,
and due consideration of the patient's environment, will generally
enable him to reconstruct the pathogeny of the condition.

It has been our practice for some years now to examine with especial
care into the mode of onset, and to scrutinise the reasons for the
particular localisation, of any given tic; and we have been able, in
practically every case, to rediscover the exciting cause, and
consequently to explain the form taken by the tic in its earliest
manifestations as a voluntary response to the stimulus. Time may have
distorted the original movement, but a little patient analysis will
facilitate its recognition even in the caricature made of it by the
tic.

A few concrete instances will help us better to understand the nature of
this psycho-physiological mechanism.

An individual is wearing a collar too small for him, and its frayed edge
chafes his skin; the neck is at once abruptly inclined away from the
irritating point--a simple spinal reflex movement of defence. Now that
he is warned by the sensation of pain, he wishes to avoid it, which he
does by bending his head to the opposite side. The act is similar to the
preceding, but of a totally different nature; it is voluntary, not
involuntary; cortical, not bulbo-spinal.

Next day the collar is replaced by another of ampler proportions. There
is no further irritation of the skin, and accordingly no occasion for
deviation of the head. Memory of the disagreeable sensation may perhaps
incite him to verify the disappearance of the irritation by a few
movements of the head, and in the normal individual the matter ends
there. Even should the idea of repeating the gesture, now become
meaningless, occur to him, he banishes it by an effort of the will.

With the candidate for tic things pass in quite a different fashion.
Uncalled for though it be, he performs the brusque movement of yesterday
perhaps with a view to satisfying himself that the pain is non-existent,
but he is not thus satisfied. He does not limit his experiments to one
or two attempts. He repeats it frequently and complacently. The original
source of irritation is gone; the movement intended at first to relieve
it persists. Soon the whole trouble is forgotten, but the reiterated
gesture becomes habitual and automatic; it may have been rational
yesterday, but to-day it is superfluous, if not actually prejudicial; it
is a tic. In its evolution the cortex has had a part, and the very
untimeliness of this cortical intervention indicates a certain disorder
of psychical function.

Or again: a speck gets under my eyelid, and I wink--a spasmodic act
independent of the cortex. The speck is removed, but the conjunctiva
remains a little tender, and I wink again--still only a spasm. All trace
of irritation vanishes, yet the blinking persists: it is degenerating
into a tic.

Wherein consists the rôle played by the cortex in the production of such
phenomena? It intervenes to order the repetition of the gesture provoked
involuntarily, in the first instance, by peripheral excitation; and
though one may not always be able later to discover evidence of this,
one must at the least recognise the fact that the mere inopportune
persistence of the movement bears witness to psychical imperfection.

It has been remarked by Guinon that patients suffering from tics of
blinking attribute them to the presence of foreign bodies; he declares,
however, that "if they bear a superficial resemblance to simple tic,
they differ widely in essential characters and from the point of view of
prognosis. They are really involuntary movements of reflex origin,
occasioned by abnormal sensations, usually of pain." He cites as a
typical instance the "tic douloureux" of the face.

The description is strictly accurate provided the pain continue; such
acts are not tics, they are spasms. On the other hand, the perpetuation
of the movement in the absence of all exciting cause and pain
constitutes it a tic. In this way a spasm may be the forerunner of a
tic, and in many cases no doubt a purely spasmodic motor reaction may
determine the form and localisation which the latter will adopt; but, as
we have said, its first manifestation is usually a voluntary act of
definite causation, and directed to the accomplishment of a definite
object.

The candidate for tic is mentally unstable. Indifferent perhaps to acute
suffering, he may become entirely preoccupied by some trifling sensation
of pain or by some source of petty annoyance, to rid himself of which he
will resort to all sorts of tricks and assume all sorts of odd
attitudes--tic germs quick to develop in suitable soil.

In many motor reactions of the class we are now considering the main
object is the _avoidance of some abnormal sensation_, suppression of
which, however, brings no relief to the patient's mind. He dreads its
reappearance; he must assure himself of its absence. He taxes his
ingenuity in the attempt to rediscover the sensation, and multiplies his
gestures and attitudes until once again he experiences it. The
satisfaction he felt originally in shunning the pain or the discomfort
is paralleled by the satisfaction he now knows in its rediscovery. In
each instance the motor phenomena are voluntary and co-ordinated, but
their excessive repetition betrays unstable mental equilibrium.

Instructive examples of this pathogenic process are furnished by the
history of O., and by the case of a young patient J., from which we
extract the following:

     In 1896, during the holidays, a tic, secondary to some slight nasal
     ulceration, made its appearance. The child learned the trick of
     wrinkling its nose and of puckering its upper lip, sometimes
     attempting by various facial grimaces to lessen the irritation due
     to the little nasal sore, sometimes, on the contrary, finding
     delight in deliberately seeking the unusual sensation. The sniffing
     soon became involuntary, and for the next two months, long after
     the ulceration was healed, this nasal tic continued.

     Then another cause came into operation, occasioning a new gesture
     and entailing a new tic. Cracking of the labial mucous membrane
     during winter led to incessant licking and nibbling at the
     roughened surface. With the first excoriation the patient proceeded
     to moisten his lips with his tongue, whence fresh cracks, followed
     by the renewal of nibbling and licking movements.

     In March, 1899, after a severe attack of influenza accompanied by
     fever and pains in the joints, he began to complain of stiffness
     and a sort of cracking in the neck, disagreeable rather than
     painful. To avoid this, or to reproduce it--as one sometimes amuses
     oneself by "cracking one's joints"--he quickly learned to make all
     sorts of bizarre head movements, and so a tic of the neck started
     which lasted several months.

Noir has directed attention to a tic of frequent occurrence among
amaurotic idiots, consisting in rapid to-and-fro movements of the finger
before the eyes. The explanation seems to be that their blindness is not
absolute enough to prevent some faint appreciation of light by retinal
stimulation, and the effect of the luminous impression is enhanced by
the alternation of light and shade sensations produced by the waving of
the fingers in front of the eyes. The tic is neither more nor less than
a search after this effect.

Another case in point is reported by Dubois[12]:

     The patient is a young woman twenty years old who has acquired the
     habit of beating her right elbow against her chest fifteen or
     twenty times a minute, until it happens to impinge with rather
     greater violence on a whalebone in her corset; this is accompanied
     by a slight guttural cry. It would appear the sole satisfaction in
     her tic is in the attainment of this object, since it is succeeded
     by temporary cessation of the movements. Their constant repetition
     has caused an insignificant erosion of the skin over a limited area
     on the elbow, and it is only when this particular spot is touched
     that the ejaculation is uttered and the tic arrested. If the elbow
     be at rest, the head is inclined from left to right several times a
     minute.

Evidently, then, in the subjects of tic the _impulse to seek a
sensation_ is of very common occurrence, as is also the _impulse to
repeat to excess a functional act_. It is precisely this exaggerated and
inopportune multiplication of movement that is pathological.

The mother of one of Noir's patients was always tempted to repeat any
simple purposive movement that she had made a moment before, even
though the reason for the act no longer existed.

The imperiousness of these impulses, and the peculiar relief attendant
on submission to them, accentuate the closeness of the resemblance
between tic and obsession, to which reference will be made later; but it
is necessary at this early stage to indicate the bearing of these
psychical phenomena on the pathogeny and diagnosis of tic.

Many of the conditions with which we are dealing are characterised in
addition by an emotional element. Dupré[13] believes an emotional shook
is the exciting cause of tic, as it sometimes is of obsessions.

Apropos of this view, we may quote again from the history of the young
patient J.:

     During his holidays he improved sufficiently to enable him to
     resume his classes, but another attack of influenza in the
     beginning of 1900 was the occasion of a relapse. He began to
     complain of overpowering fatigue; became depressed and morbidly
     anxious about his future; had attacks of hysterical sobbing;
     suffered great mental anguish, accompanied by flushing and profuse
     perspiration; in short, he fell into a veritable state of _mal
     obsédant_.

     At the same time, the slightest pain or annoyance was a pretext for
     his tics to exhibit themselves with redoubled vigour. Even the mere
     idea of his tics, the fear of them, incited him further in the same
     direction. He seems then to have set himself to invent new
     movements, and forgetting forthwith that he himself was their
     creator, became alarmed at them as sure signs of the aggravation of
     his disease.

Analogous details will be found in all cases which have been studied as
well from the mental as from the physical side. For our part, we
consider a tic cannot be a tic unless it be associated with a certain
degree of mental instability and imperfection, indubitable evidence of
which is furnished by a psychical abnormality of constant occurrence in
this malady--viz. anomalies of volition.


TIC AND WILL.

It might be imagined that a tic would cease to exist as such were a
voluntary element to enter into its constitution. The fact, however,
that tic is the sequel to frequent repetition of a primarily voluntary
act, and that it may be arrested, transformed, or aborted, is proof to
the contrary of which there is no gainsaying.

The truth is, once a tic is established, it has all the appearance of an
involuntary movement, but that nevertheless its manifestations may be
either modified or inhibited by an effort of the will is patent from
clinical observation. This is a fact of great importance.

     Spasm knows no control (says Brissaud). Nothing will arrest the
     bolus of food as it passes into the pharynx, unless by the
     inversion of the whole function of deglutition.... As regards tic,
     however, inhibition is possible because the phenomenon is cortical.
     In almost every case, reinforcement of the will can momentarily at
     least check it.

Consensus of opinion admits diminution of will power to be the cardinal
mental symptom of the tic patient. Inhibitory insufficiency, as Blocq
and Onanoff say, allows the persistence of fixed ideas of movement which
reveal themselves by involuntary acts. Noir has admirably supplemented
the researches of Ribot in this direction:

     The infant's activity is purely reflex, and manifested by a
     profusion of movements, to suppress or restrain the majority of
     which is the task of education. It is highly probable that any
     co-ordinated tic whose evolution can be traced at all has its
     origin in the infant's spontaneous muscular play. From this point
     of view the frequency of these movements in idiots is readily
     explicable, since their intellectual development never gets beyond
     the stage of childhood. The more confirmed the idiocy and the more
     rudimentary their mind, the more prone are their tics to be complex
     and inveterate.

These remarks are pertinent to the case not only of idiots, imbeciles,
or backward children, but of all the subjects of tic. In them some
degree of mental infantilism is of invariable occurrence. The tic
patient has the weak and capricious will of the child; young or old, he
does not know how to _will_; if his willing be sometimes excessive, it
is never resolute. Were it otherwise, he might control his meaningless
gestures, but his efforts are both feeble and ephemeral.


TIC AND HABIT

The view which regards tic as a "pathological muscular habit" provides
emphatic illustration of the sinister influence of volitional infirmity.

This aspect of the question is of deep significance. If we define a
habit, in the words of Littré, as a "disposition acquired by the
repetition of the same acts," we can easily conceive how intimate is the
relation between habit and automatism, and how constant rehearsal of the
same movement in the same manner will create a mode of motor reaction
independent of the function of the will. It has been made clear already
that the phenomena of tic, regarded from the motor standpoint, reveal an
identical process at work; but the fundamental difference between the
habits of normal individuals and those of tic subjects is that the
former can be checked or modified by voluntary effort, whereas the
latter gradually acquire the pathological features of tenacity and
irresistibility.

     In a typical case of tic (says Dupré)[14] the establishment of a
     reflex sensorimotor diastaltic arc, viâ the cortex, between
     peripheral stimuli of whatever nature and corresponding muscular
     reaction, is a sign that predisposition has changed the
     physiological to the pathological, and transformed a habit into a
     tic.

Guinon argues, however, that tic ought not to be cited in the catalogue
of diseases, since it is ultimately a deep-rooted "bad habit" only, not
a pathological fact.

We are not prepared to maintain, of course, that all motor "bad habits"
are tics, for a whole host of familiar gestures, tricks, and mannerisms
do not merit the name, superfluous and even detestable though they may
be. It is true they are the product of education, and become, since the
will has less and less to do with their appearing, at the last purely
automatic; they may thus developmentally bear a close resemblance to
tics. As Letulle says:

     The infant who is constantly sucking its thumb, the individual who
     never ceases picking his teeth, or rubbing his eyes, or lips, or
     chin, or ear, who is for ever scratching his head or his beard--all
     have no doubt, originally, been driven to the repetition of the
     trick by some real necessity in the shape of dental caries, or
     ciliary blepharitis, or pityriasis capitis; but removal of the
     cause is not followed by cessation of the gesture. A man will learn
     the habit of perpetually smoothing his hair, and will not desist
     from his favourite trick though he become absolutely bald.

But such automatic habits and mannerisms are not genuine tics so long as
the movement executed conserves in form the characters of a normal
gesture. Be it never so inopportune or absurd, it is not a tic. It comes
rather under the heading of _stereotyped acts_, whose kinship with, and
difference from, the tics, have been well demonstrated by Séglas.

While the stereotyped act has all the appearance of a normal movement,
the tic, on the contrary, is a "corrupt" muscular contraction; its
subject is irresistibly impelled to its performance, and any attempt at
repression is painful, sometimes even agonising. Victory is perhaps not
entirely impossible, but any arrest is, as a rule, only temporary, and
entails suffering which well deserves to be considered pathological.

On the other hand, the thousand illogical and absurd mannerisms of which
we have been speaking betray no irresistible imperiousness in their
execution, and require no agonising struggle for their repression. They
are not tics. The crucial point in the differential diagnosis is the
presence or absence of mental suffering.

The distinction may be further elaborated. Concentration of the
attention may diminish the intensity or even inhibit the occurrence of a
tic; inversely, a simple bad habit is manifested preferably during this
very concentration. In the heat of physical or intellectual labour, we
have all our favourite and characteristic tricks: we curl our moustache,
we twist our beard, we scratch our forehead, we rub our chin, we nod our
head, we fidget with our fingers in reading, speaking, reciting--in any
mental or physical exercise requiring our attention we reveal
innumerable little oddities of movement; but let our thoughts be
directed for an instant to these gestures of distraction, and they
disappear forthwith, to reappear afresh when we are absorbed in our work
again. Charcot used to twist his hair round his index finger so
intricately that to disentangle the finger one day a lock of hair had
actually to be cut off. It was a trick of his, not a tic.

In the case of the latter, leisure of mind and body is the signal for
the apparition of the inopportune movements. Any form of effort
demanding the attention will, as a general rule, lessen their frequency
or abolish them altogether.

Trousseau quotes the case of a young girl afflicted with severe tic who
could play through any piece on the piano without the slightest
interruption. Guinon similarly has known cases, one of whom could juggle
accurately with knives, and another whose infirmity did not prevent her
from taking a successful part in operatic ballet. Young L. is
passionately fond of dancing, but he never tics in the ballroom. O. is
an excellent amateur billiard player and never handicapped by his tic
when playing, or, for that matter, when fishing or fencing; but if his
attention be not thus absorbed, it is only with the utmost difficulty
that he can master his tic.

We all have met the young man who cannot strike a ball at tennis without
protruding his tongue at the same moment; his partner bites his lips at
any difficult stroke. At other times neither betrays the slightest
grimace; neither is conscious of any effort in maintaining repose. The
occurrence of these movements during active concentration of the
attention, and the absence of either difficulty or distress in checking
them, justify their classification as stereotyped acts, in subjects
psychically normal.

Tic is a pathological habit, to use Brissaud's phrase, and its
description as a habit disease is in harmony with the facts. We must
expect, of course, to meet every intermediate variety between the bad
habit and the true tic, but this need not deter us from drawing the
above-noted distinction, the application of which will be found not
without value in the great majority of instances.


TIC AND IDEA

As we have already seen, a peripheral stimulus may originate a cortical
reflex whose expression is a motor reaction, or the reaction may take
place where the stimulus is entirely cortical; in other words, an idea
may be the starting-point of a movement which may in its turn degenerate
into a tic. All that has been already said of these phenomena is
applicable to this movement of ideational origin. It too will be
transformed into a tic when it is repeated without exciting cause and
for no definite end, when its reiteration becomes imperious and
irresistible, its suppression accompanied with malaise and its execution
with relief.

Tics of this sort are numerous enough. "To think an act," as Charcot
used to say, following Herbert Spencer and Bain, "is already to
accomplish it. When we think of the movement, say of extension of the
hand, we have already sketched it in our minds; and, should the idea be
too strong, we execute it."

In this connection Grasset most appropriately cites the fact that the
peoples of mid-France evince a peculiar aptitude for mimicking by
suitable gesture the various ideas which occur in the course of
conversation. "You will always succeed," he says, "with the following
little experiment. In a drawing-room ask ten individuals consecutively
to tell you what a rattle (_crécelle_) is. The answer will in every case
be accompanied by a gesture expressive of an object that turns. To think
an act is already to perform it; the thought and the gesture are
wellnigh inseparable."

The truth of this observation is not a question of geography. Examples
are met with on every hand. It is a law, abundant evidence for which is
furnished by all who tic. But however exuberant be accompanying
movements of explanation, they must present the additional features of
inappositeness and irresistibility to be denominated tics.

A case that has come under our own notice is worth mentioning because of
its peculiarity and instructiveness. The patient was an artistic,
well-educated, and well-travelled man, gifted to a remarkable degree
with the faculty of assimilation. Apart from genuine tics in the shape
of sudden jerks of face, arm, or leg, he had acquired the trick of
accompanying his conversation with a peculiar mimicry of its content.
Not satisfied with providing a gesture for nearly every word, he
divided the words themselves into syllables for each of which he had an
appropriate action, whence arose a series of mimicry puns of most
unexpected effect.

For instance, during the enunciation of the following sentence, "We were
on a paddle steamer, with captain, commissaire, and doctor," he first of
all imitated the movement of paddles; he then put his hand, with three
fingers apart, to his forehead (the captain's cap has three lace bands);
to mimic the word commissaire he shook hands with himself
(_commissaire_--_comme il serre_); to express the word doctor he
pretended to touch imaginary breasts on his body (_médecin_--_mes deux
seins_); and so on throughout all his conversation.

Voluntary execution of these puns had been succeeded by complete
automatism, yet they were not tics, because, however singular the
mimicry, it was appropriate; whereas his facial grimaces, the shrugging
of his shoulders, the tapping of his heels, repeated every minute for no
reason or purpose, were real tics.

If, when asked what a rattle is, we make a turning movement with our
hand, or if when asked to explain the word _brandebourg_ we indicate an
imaginary arrangement of braid on our coat--these two experiments always
succeed--we are attempting to express an idea by mimicry at the actual
moment of its arising in the mind; but the subject of a tic--which may
primarily have been the representation by mimicry of an idea--continues
the gesture long after the idea which provoked it has vanished.

A woman speaking with animation at a telephone will make with face or
hand a thousand useless gestures, useless since her friend cannot see
them, but they are not tics, even though they may be justly described as
functional, automatic, superfluous, and inopportune. If we are normally
constituted, we betray a pleasant idea by a smile, we express our
conviction by an appropriate gesture of affirmation; if we smile or
gesticulate with no motive for doing either, we have begun to tic. It is
not sufficient that the act be untimely at the moment of execution; we
must be persuaded that it no longer stands in any relation to the idea
which called it forth at the first, and that its repetition is
excessive, its inappositeness constant, its performance urgent, and its
inhibition transient, before we can say it is a tic.

Should the cortex be functioning harmoniously, afferent impulse and
efferent reaction stand in due proportion one to the other; but any
disturbance of psychical equilibrium--_e.g._ the fixity of some idea
combined with inhibitory weakness--will effect a corresponding
disturbance on the motor side. Charcot used to speak of tics of the mind
revealing themselves by tics of the body. Fear may elicit a movement of
defence, to persist as a tic after the exciting cause has vanished.

It is of course quite incorrect to say that each and every motor
reaction to a pathological idea is a tic. The psychasthenic who in his
fear of draughts shakes the door-knob a hundred times a day to make sure
the door is shut, is not a martyr to tic; in spite of the absurdity of
his action, it is logically connected with the idea that originated it,
and it is the idea which is absurd. To make an involuntary movement of
defence against some purely imaginary ill, on the other hand, and to
continue when all fear is past, is to tic.

In practice it may not always be a simple matter to uphold the
distinction, but some such demarcation of the tic's limits is called for
if we are to avoid its being applied to any act performed under the
compulsion of a pathological mental state.

In its mildest form the mental trouble may consist of an ordinary
psychomotor hallucination, but if it be not projected as an objective
phenomenon it does not deserve to be called a tic. One of Séglas's
patients met a choreic woman undergoing electrical treatment in the same
room as herself; on leaving she felt as though her own right arm were
the seat of spasmodic movements similar to those of the choreic patient,
but as they did not betray themselves by any external sign they cannot
be considered tics.

The exteriorisation of the hallucinatory phenomenon suffices at once to
bring it within the scope of our definition. Innumerable tics arise in
this way, provoked, mayhap, by some or other insignificant psychomotor
hallucination. The attitude adopted by certain patients, as remarked by
Séglas, is an index to the nature and seat of their hallucinations. Some
keep their tongue firmly bitten between the teeth; others cram their
mouth with pebbles, or compress their epigastrium tightly, under the
impression that it is the source of their voice. Should such gestures
persist while the hallucination does not, they may give rise to what we
are in the habit of calling "tonic tics," or "tics of attitude," but we
must repeat that the presence of a convulsive element is essential;
however out of place or absurd the contractions are, if otherwise they
are normal we are dealing with what Séglas designates stereotyped acts.
To this question we shall return later.


TIC AND CONSCIOUSNESS

According to Guinon, proof that "convulsive" tic is conscious is
furnished by the accurate description and rational explanation patients
supply of their affliction. Similarly Letulle's "co-ordinated" tic is a
conscious act, at least in its commencement; it is a "bad habit" which
finally passes beyond the limit of consciousness.

Now, while no doubt most subjects show a keen appreciation of their tic
when their attention is directed to it, they are none the less
unconscious of it at the moment of its manifestation. This is the ground
on which Letulle bases his statement that all tics, of whatsoever
variety, are habitually outside the domain of consciousness. To this
fact so much importance has been attached that the attempt has been
made, more especially by Blocq and Onanoff,[15] to differentiate the
conscious from the unconscious tic.

In our opinion, the distinction is ambiguous and tends needlessly to
complicate our ideas on the subject. The patient with "convulsive" tic
is conscious of it in the sense that he is well aware of its existence,
yet how can the gesture be a conscious one if it is synchronous with
mental preoccupation? On the other hand, the patient with "co-ordinated"
tic may bite his lips unconsciously, but he is by no means ignorant of
his little failing.

This divergence of opinion depends entirely on the possibility of
regarding the phenomena at different moments during their production.
The subject is in a position to appreciate his state both before and
after the tic, not during it. In a sense it may be said that tic is
alternately conscious and unconscious, in which respect it is comparable
to the obsession; the close analogy between the two conditions we shall
indicate more fully later. As a matter of fact, the same holds true for
every variety of spasm.

We are not disposed to introduce here a term sacred to the psychologist
and to speak of the tic as subconscious. Pierre Janet does not admit the
absolute unconsciousness of habit; even when the latter has degenerated
into a tic, it is not outwith the realm of consciousness. We prefer not
to venture, however, into the perilous region of the subconscious, in
spite of our appreciation of the happy results attributable to its
careful and discerning exploration by observers such as Janet himself.

According to Cruchet, certain so-called psychical tics are always
subliminal--for instance, the imitation tics common in children and in
idiots.

But if the consciousness of the normal adult be, as it admittedly is, a
most elusive conception to define, how infinitely more precarious is the
task in the case of idiots or infants! Cruchet says it is impossible to
be sure whether at any given moment a tic has been above the threshold
of consciousness or not; and we do not think the question will be
elucidated by the introduction of data so difficult to comprehend as the
consciousness, unconsciousness, or subconsciousness of the tic patient.
In any case, these conceptions are quite inadequate for the
establishment of useful distinctions. All that we can say is that the
participation of consciousness in the phenomena of tic varies in time
and degree. To hazard farther would be to invite disaster.


TIC AND POLYGON

The proposal has been made by Grasset to apply his attractive hypothesis
of the cortical polygon to the interpretation of the pathogenesis of
tic. It is desirable, first of all, to recall briefly the significance
of the word polygon in the sense adopted by that neurologist.[16]

     At the central end of the physiological ladder is the superior or
     cortical system of perception neurons whose cells form the grey
     matter of the convolutions. Physiological and clinical research
     necessitates the subdivision of this system into two groups--the
     neurons of psychical automatism, and the neurons of superior
     (_i.e._ voluntary or free) cerebration. The former function is not
     of the same level as the ordinary reflex arc, since it is in
     relation to co-ordinated, intelligent, and in a sense conscious
     acts; at the same time it is to be distinguished assiduously from
     the latter, in which we include our personality, moral
     consciousness, free will, and responsibility.

     Activity on the part of the inferior psychical neurons is seen:

     1. In normal individuals--during sleep, dreams, and acts of
     distraction.

     2. In the nervous--in nightmares, oniric states, table turning,
     thought reading, the use of the divining rod, automatic writing,
     cumberlandism, spiritualism.

     3. In the diseased--in somnambulism, catalepsy, hysteria, certain
     phenomena of epilepsy, hypnotism, double personality; also in some
     cases of aphasia, and in such conditions as astasia-abasia. Every
     manifestation of this inferior psychism is characterised by
     spontaneity, herein differing from mere reflex acts, but not by
     freedom, which is the _propre_ of superior psychism.

     The various neurons subserving the former or inferior function are
     cortical, and form the cortical polygon. Situated at a higher
     physiological level are those for the latter function, united in
     what I designate the centre O.

Grasset's general conception of tic is accordingly as follows:

     In contradistinction to a pure reflex, a tic is a complex or
     associated act. There is, however, more than one centre for the
     elaboration of these complex or associated acts, notably the
     bulbo-medullary axis, and the cerebral polygon, as we call it. The
     former serves as centre not merely for simple reflexes, but for
     true associated acts also, such as conjugate deviation of the head
     and eyes, walking movements in the decerebrate animal, etc.

     We can conceive, then, a first group of non-mental tics
     corresponding to and reproducing these movements of bulbo-medullary
     origin.[17]

     Let us turn now to our polygon formed by the various centres of
     psychic automatism. Polygonal reactions, such as writing or
     speaking, exceed both simple reflexes and bulbo-medullary
     associated acts in complexity; they are to all appearance
     spontaneous and in a certain measure intellectual, but they are
     neither free nor conscious--attributes that distinguish the
     functions of the centre O, the seat of the personal, conscious,
     voluntary, responsible ego. The polygon consists of receptive
     sensory centres for hearing, vision, and general sensibility, and
     of transmitting motor centres for speaking, writing, and various
     body movements. They all communicate with each other, with O, and
     with the periphery, so rendering possible voluntary modification of
     automatic action. In some cases, on the contrary, there may be a
     sort of dissociation between O. and the polygon, when the activity
     of the latter becomes supreme, as during sleep--we dream with our
     polygon--or in distraction.

     In states intermediate between the physiological and the
     pathological, pure independent polygonal action may reveal itself
     in the remarkable phenomena of nightmare, the divining rod, table
     turning, automatic writing, etc., while certain aphasias and
     agraphias, somnambulism, catalepsy, and various hysterical
     conditions constitute the pathology of the polygon.

     The fact that all mental attributes and functions are situate in O
     definitely negatives, in my opinion, any classification in the
     category of mental diseases of such conditions as hysteria, so many
     of whose manifestations are polygonal alone.

     Our second group of tics--polygonal tics, we may style them--are
     correspondingly associated, co-ordinated, and psychical, but not
     mental; they have nought to do with the superior psychism of O.

     Finally, in direct and strict dependence on an actual idea is a
     third group of tics, the psychical tics properly so called.

We have reproduced Grasset's theory in some detail since it is one of
the two most recent contributions to the study of the tic's
pathogenesis. The other is that of Brissaud.

An apparent lack of harmony between the rival hypotheses is, we shall
see, due rather to a difference in the interpretation of certain terms
than to a real opposition of ideas.

Brissaud's view that the tic is a co-ordinated automatic act and
consequently cortical is objected to by Grasset. Every automatic
co-ordinated act is not of necessity cortical. Conjugate deviation of
the head and eyes may be of bulbar origin; certain spinal movements even
may be no less co-ordinated and automatic. The decerebrate animal's walk
may be perfect in its co-ordination.

Careful analysis shows the divergence of opinion to arise merely from a
differing significance attached to the word origin. Brissaud is
considering the origin of the tic in time, at the moment of its
appearance; Grasset its origin in space, at the seat of its production.
Once the tic is constituted, its repetition each moment is a
manifestation of polygonal activity, but it is none the less true that
the movement which has degenerated into a tic had its source in
cortical, _i.e._ psychical, activity.

Any one who appreciates the import of Grasset's ideas will readily
understand his terminology; it is at the same time expedient that the
possibility of ambiguity in the use of words etymologically synonymous
should be avoided. Now, however judicious be the distinction he draws
between psychical and mental, it is to be feared it is not always
adequately grasped: we do not intend, therefore, to employ either mental
or psychical tic in our vocabulary, still less "psycho-mental" tic
(Cruchet). As for bulbo-medullary tic, it appears to us to be identical
with spasm as we have defined it, unless indeed it is to be taken as
signifying a tic begotten of a spasm, in which interpretation Grasset
and Brissaud both acquiesce.


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."


THE TYPE OF MOTOR REACTION--CLONIC TIC AND TONIC TIC

The motor reaction may be either _clonic_ or _tonic_ in type. Clonic
tics are distinguished by more or less abrupt contractions, separated by
longer or shorter intervals of relaxation or repose. The duration of a
clonic tic convulsion may be exceedingly brief, though perhaps not so
brief as the instantaneous "electric" twitches of a spasm, which have
the extreme rapidity of pure reflex phenomena. Exception ought to be
made for the face, no doubt, seeing that the suddenness of the
movements in facial tic is precisely what complicates the diagnosis
between it and facial spasm, as we shall see. In the limbs, the
variations appear to stand in close relation to the nature of the
primary factor, the mental condition of the patient, and the mode of
reaction peculiar to him. The quickness with which the reaction occurs
increases in proportion to the length of time the tic has existed,
although once it has become habitual, any further change is rather in
the direction of additional complexity.

Sometimes a relative deliberateness of execution raises suspicions as to
the accuracy of the diagnosis. In the case of a child with several tics,
one affecting the mouth in particular, Guinon was struck by the slowness
of the muscular contractions.

     To begin with (he says), the mouth was opened gradually, but as
     soon at the limit of separation of the maxillæ was reached, it was
     immediately closed, without remaining even for a moment in the
     extended position, as one would have expected had there been a
     tonic contraction of the infrahyoid muscles.

Cases of this kind, however, are not really instances of the tonic
variety.

One of us has had the opportunity of observing a young woman afflicted
with a curious combination of motor disorders, akin no less to the
clonic form of tic than to the gesticulations of chorea and the
undulatory movements of athetosis. Their resemblance to the clinical
type described by Brissaud under the name of _variable chorea_ is
noteworthy, a distinguishing feature, however, being the sluggishness of
the muscular contractions, which may well be a reflex of the patient's
mental inertness.

     Mademoiselle R., a young woman twenty-six years old, is a small and
     delicate creature with slender limbs and tapering fingers. She is
     extremely myopic, but her general health is excellent, and there
     is nothing to suggest that she is suffering from organic disease
     of the nervous system. Apart from the fact that her parents are
     rather "nervous," the family history is negative.

     Since the age of twelve she has been subject to various tics of the
     face and head. She wrinkles her forehead and moves her scalp to and
     fro, and sometimes she turns her head slowly and steadily towards
     the left side, raising her eyes up and to the left at the same
     moment. Head and eyes forthwith resume their normal position. The
     deliberateness of the act is altogether exceptional. If, however,
     she happens to be wearing her hat--which is remarkable for its
     size, weight, and unwieldiness--the gesture is repeated in a quick
     and jerky manner. Any diversion, such as reading, knitting,
     listening to a conversation, especially if she feels she is not
     being noticed, will augment the intensity of the movements, which
     the thought of being observed, or the awakening of her interest, or
     rest in bed, or sleep, has the effect of abbreviating or checking.

     Our earliest step was to confiscate the offending hat, and this had
     the instantaneous result of diminishing the violence and frequency
     of the tic, which the subsequent practice of appropriate exercises
     entirely dispelled.

     If now we direct our attention to the psychical aspect of the case,
     we are struck with the goodness, devotion, and disinterestedness of
     our patient. Her one concern is for the welfare of others, and she
     is indifferent to the pleasures of literature, art, games, or even
     work. All that is required of her she performs with docility, but
     never with animation. The extent of her passiveness is seen in her
     childlike acceptance of her parents' wishes. Her temperament is
     neither gay nor sad, but merely dull. Indolence and maladroitness
     predominate in all her actions, and reveal themselves in the
     curious awkwardness and nonchalance that characterise the execution
     of even the simplest movement. She is essentially of a very
     unstable nature, but its torpidity is no less obvious than its
     instability. If there is no abruptness in her acts, it is equally
     true that she is never still. She cannot maintain any given
     attitude; she cannot fix her gaze on any particular object. Her
     restlessness is such that her position is changed from moment to
     moment, however slowly and imperceptibly. Her eyes are only half
     opened; as she speaks, her lips are scarcely seen to move.

     It has been a laborious and protracted task to teach her to sit
     motionless with her hands in front of her, and no less unremitting
     effort has been required to make her open her mouth properly, or
     turn her head naturally from side to side.

     In some ways the endless movements of her hands and fingers--she
     never ceases playing with her dress or her gloves or her
     handkerchief--are vaguely reminiscent of those of athetosis, and on
     the left side especially, if they become a little brisker, there
     is slight hyperextension of the phalanges. She reads aloud in a
     low, colourless, monotonous tone of voice, without punctuation or
     accent, articulating the syllables defectively and slurring the
     ends of the words. At the finish of each paragraph comes a halt, as
     if from fatigue, and on command a fresh start is made with the same
     careless indifference. As for the lower extremities, the tale is
     identical. Mademoiselle R. cannot stand upright. She rests on
     either one leg or the other. Her left foot is never flat on the
     ground, but sometimes on the inner border, sometimes on the outer.
     The faulty attitude is readily enough corrected, though she
     declares she is ignorant of it. It is a sort of half clonic, half
     tonic, tic of the foot, whose slowness is on a par with that of all
     her other acts.

It is because clonic tics are so easily recognised that they are the
most familiar, but we must not ignore another variety--viz. the _tonic
tics_, corresponding to the tonic form of convulsion.

Tonic tic is of common occurrence in cases of mental torticollis. In
that disease rotation of the head may be sustained for a considerable
length of time without interruption, showing the permanent nature of the
muscular contraction. Strictly speaking, we are concerned not with a
sudden gesture, but with an attitude. Abundant evidence is forthcoming
to substantiate its mental origin, and it may therefore be described as
an attitude tic. Among other instances of tonic tics may be specified
the affection of the masseters known as mental trismus (Raymond and
Janet), or that continuous contraction of the orbicularis which keeps
the eye half closed, though it may momentarily disappear under the
influence of the will--a tonic blinking tic. O. and young J. have
already supplied examples of attitude tics, and reference may further be
made to another of our patients[49]:

     Sometimes the mouth is drawn directly and completely to the left,
     more usually to the right; at other times simultaneous contraction
     of the upper and lower lips takes place, constituting a
     sufficiently faithful reproduction of the grimace made by a child
     in the attempt to refrain from crying; at other times still,
     imperfect closure of the lids and upward deviation of the eyes bear
     a resemblance to children's imitation of a blind man. Displacement
     of the mouth to the right is the movement of longest duration, and
     while it persists the patient is capable of stuttering speech,
     without relaxing her lips. The other tics last but a few seconds,
     while all vanish if she laughs or opens her mouth wide to exhibit
     her tongue. They follow each other at irregular intervals, and
     during the moments of rest the face resumes its normal expression.

Cruchet, as has been already remarked, has criticised the use of the
term attitude tic, on the ground that the adoption of an attitude,
however vicious it be, need not be the outcome of a convulsion.
Doubtless; but it is no less true that a tonic convulsion may "take
shape"--_e.g._ the _arc de cercle_ of hysteria, the phenomena of
catatonia and catalepsy, etc. Of course if the word tic is to be
synonymous with _intermittent_ twitching, then it is inapplicable in
this class of case; but if our connotation of the term be accepted, we
must find an expression that will serve to differentiate between tonic
and clonic varieties. We are not aware of any particular advantage in
describing the condition as a permanent contraction, for the obvious
result of a permanent contraction, whether it be clenching of the jaws,
occlusion of the eyelids, or rotation of the head, is the production of
an attitude, a "position in which the body is kept" (Littré). No other
designation could therefore be more appropriate than attitude tic, or
could indeed be imagined, seeing that Cruchet himself ranges mental
torticollis among the tics, and describes it as "an attitude of defence
and of repose."

It may sometimes happen that the manifestations of stereotyped acts
consist in the assumption of attitudes, but in spite of their affinity
to the tics we deem it preferable to reserve the term "stereotyped
attitude" or "akinetic stereotyped act" for cases where the motor
reaction is clothed in the form of a normal movement. As it is
inaccurate to describe as a tic a repeated gesture whose execution is
normal in degree and in rapidity, so the mere immobility of a limb, or
the prolonged contraction of a muscle, ought not to be called an
attitude tic if the muscular effort does not differ from that which a
healthy person would make to preserve the same position. In such
circumstances we say that it is a stereotyped gesture or attitude. For
the diagnosis of tic it is insufficient to establish the existence of a
transient or permanent muscular contraction, and to note the
inopportuneness of the movement; the contraction must be abnormal in
itself, its abruptness unwonted and its intensity excessive--in short,
it must be a convulsion; and finally, its repetition must be continued
and exaggerated.

We have felt that some such explanation as the foregoing is required to
justify our use of the term tonic or attitude tic, to whose close
intimacy and association with the better-known type pathogeny and
clinical observation alike bear witness. In any case such terms as
myotonus or myoclonus are too comprehensive, in view of our present-day
knowledge, to specify the particular motor affection with which we are
concerned.

       *       *       *       *       *

As a general rule it is only one part or segment of the body that is
immobilised by a tonic tic, but in regard to the possibility of a
general involvement, the following instance[50] may be cited, although
we do not think it can be considered decisive:

     A man thirty-two years old, who had recovered from a first attack
     of mental torticollis, underwent a relapse in quite a different
     form. If when walking with his head perfectly straight he were
     asked to go round to the right, he instantly appeared to become
     rooted to the spot and could not turn even his head in the required
     direction; at the same time he felt a compression of his throat as
     if he were being strangled, and for a few seconds he experienced
     acute anguish. A moment later he was all right again, and his
     action unimpeded.

Without going so far as to classify this incident as a tic, and without
venturing to assert the existence of a _tic of immobility_, one cannot
but be struck with its analogy to the attitude tics of which we have
been speaking, and to catatonic conditions met with in the insane, of
which too the pathogeny presents more than one point of similarity with
that of this species of tic.

[In this connection reference may be made to certain conditions
occasionally noted among those who tic--viz. a curious tendency to
maintain abnormal positions of the limbs or trunks, and difficulty in or
impossibility of relaxing various muscles (_catatonic aptitudes_).
Patients are sometimes given to the exaggerated repetition of the
ordinary movements of their members (_echokinesis_), as well as to
imitation of the actions of others (_echomimia_). Such catatonic and
echopraxic phenomena[51] are not confined to sufferers from tic, for
they are encountered among psychopathic subjects generally, and indicate
defect of cortical control--what is called by Brissaud "passive
activity." These catatonic aptitudes may be discovered by resort to
clinical tests, such as letting the arm fall from the horizontal
position.[52]]


INTENSITY OF THE MOTOR REACTION

The muscular contraction varies considerably in intensity, in most cases
exceeding that of the corresponding normal movement, and, especially in
tonic tics, being often so powerful as to necessitate the exertion of
great force to overcome it. Even though one's effort prove unavailing,
however, it is only needful to distract the patient's attention to
perform any and every passive movement with consummate ease.

In the case of S., any attempt to budge the head from its torticollic
position on the left evokes strong muscular resistance; but engage him
in conversation or otherwise divert his mind, and the difficulty soon
vanishes. By similar means, the resistance awakened by sudden change of
the direction of passive rotation will rapidly die down.

Occasionally the muscles brought into play surpass their fellows of the
opposite side in size and power, this secondary hypertrophy being the
natural sequel of repeated exercise. It was noted by Charcot that in
rotatory tics the disused muscles atrophied, whereas the affected
muscles hypertrophied, but they may do so only in appearance. The tonus
of the muscles at the moment of examination may create differences
inappreciable during relaxation. Sometimes one comes across such
expressions as "paresis" or even "paralysis" of antagonistic muscles,
and "contracture" of those in which the tic is localised. To draw a
distinction between slight contracture of the latter and mild paresis of
the former is a problem practically always insoluble. Opinion has been
ever divided on this point; yet some, in their desire to harmonise the
two, take up an eclectic position and do not hesitate to speak[53] of
"paralytic contracture," or "mixed contracture, at once active and
passive," a terminology by no means calculated to simplify the question,
and one the discussion of which we do not care to pursue.

We should like, however, to allude to a matter of clinical observation
that we frequently have had occasion to remark. What simulates muscular
enfeeblement in the subject of tic is often nothing else than a want of
accuracy and _adresse_ in the performance of a given movement. For
instance:

     S. enjoys robust health; his only trouble is a lack of accurate
     control over his limbs. His execution of the most elementary
     movements is incorrect. There is no tremor, no jerkiness, simply a
     loss of the sense of position. He never knows whether he is holding
     himself straight, whether his arms are exactly horizontal or his
     shoulders symmetrical. Often he confuses right and left, and when
     requested to perform some act on one side, he declares he is
     tempted to perform it simultaneously on both. The order to fold his
     arms and rotate the upper part of his body to the right evokes an
     inconceivable display of contortions. In the attempt to bend his
     head and body backward, fear of losing his balance causes him to
     twist and turn about most strangely, and the remark that all this
     he might avoid by merely putting one foot further back seems to
     cause him infinite surprise.

Or again:

     The absence of precision in Mademoiselle R.'s movements, her habit
     of arresting the action before attaining the desired end, are not
     to be ascribed to any feeling of discomfort, but to her ignorance
     of the amplitude of her efforts, and of the position of her limbs.
     Her acts are always feeble, hesitating, and curtailed, a curious
     mixture of muscular languor and vigilance, "as if she were afraid
     of breaking herself." She appears to be constantly seeking some new
     position for herself, and to be as constantly oblivious of her
     actual attitude. With eyes closed, however, she indicates the
     relation of her limbs exactly.

Another example is furnished by the case of L., to which reference is
made on p. 135.

There is no call to multiply instances. Enough has been said to
demonstrate the frequent occurrence, if not of motor inco-ordination, at
least of faulty orientation in space and of defective estimation in
regard to the range and intensity of voluntary movements, among the
subjects of tic. The topic is a very interesting and fruitful one, on
which considerable light may be thrown by the application to it of the
results of Pierre Bonnier's[54] remarkable studies on the sense of
attitudes, a subject that we intend to develop on another occasion.


FREQUENCY AND RHYTHM--RHYTHMIC TIC

The frequency of the muscular contractions in tic is so very variable
that it cannot be regarded as a distinctive feature, nor is there any
evidence to show that it is rhythmical, as some would have us believe.
Contrary to what obtains in tremor, there is no periodicity in the motor
phenomena, even when the tic is based on derangement of a function whose
manifestations are rhythmical, such as the function of respiration.
Conditions described as rhythmic tics, or less well as rhythmic spasms,
seem to form a group by themselves; probably they do not belong to the
same family as the tics, indeed in some cases they are symptomatic of
encephalic lesions, as in the _spasmus nutans_ of infants, or the
rhythmic tics of idiots and imbeciles. In this connection the remarks of
Noir are very pertinent:

     We shall be well advised to refrain from drawing too absolute
     conclusions in questions so difficult, where even the framing of an
     hypothesis demands prolonged observation, but we cannot withstand
     the temptation to note the co-existence of certain of these tics
     with certain definite lesions recognisable post-mortem. This has
     been done before us by our master Bourneville, who has on several
     occasions made the diagnosis of chronic meningo-encephalitis,
     cerebral sclerosis, etc., from this association of rocking,
     rotation, and krouomanic movements with a special symptom-complex,
     and verified it at the autopsy. Nevertheless, there is not always
     an absolute correspondence between them, wherefore Bourneville,
     with an altogether praiseworthy scientific reserve, has hesitated
     to consider these tics as actual symptoms of the affections alluded
     to, and we shall follow his prudent example.

To the combination of various rhythmical acts with hysteria we shall
revert at a later stage. Under the title "rhythmic spasm" an interesting
case has been reported at length by de Buck,[55] concerning a young
woman, free of hysterical stigmata, in whom convulsive movements first
appeared at the age of seven years.

     When she had attained her nineteenth year she commenced to suffer
     from attacks of anguish of some hours' duration, but disappearing
     under the influence of sleep, in which she felt as though her
     breathing were going to stop and she herself were about to die. On
     the termination of these sensations some eighteen months later,
     their place was taken by convulsive movements of the tongue, lips,
     neck, trunk, left arm, diaphragm, pharynx, and muscles of
     respiration. These consisted of clonic rhythmical twitches, each
     preceded by an inspiration and succeeded by an expiratory
     ejaculation, repeated fifty or sixty times a minute. During the
     seizure the tongue was protruded and deviated to the left, the left
     arm was raised, the head and trunk bent down and forward. All day
     long the movements were continued with unflagging regularity. Rest
     in bed was without effect, but they were dispelled by sleep.
     Distraction and occupation exercised an inhibitory influence on
     them, whereas voluntary control was both feeble and fleeting. In
     the condition of the patient there was nothing else abnormal with
     the exception of slow, monotonous, and syllabic speech. Her mental
     development was perhaps a little immature, but signs of hysteria
     were lacking, and all attempts at treatment by suggestion and
     hypnotism failed of their object. Death ensued from pulmonary
     tuberculosis.

De Buck observes that while the action of some of the muscular groups
involved in the rhythmic spasm was, so to speak, purposive, the whole
did not constitute any known, conscious, and logical movement. It may
have been a species of tic, but the rhythmical sequence of the
convulsions imparts to it a quite peculiar character.


ATTACKS

A further mark of the motor reaction is the circumstance that it ceases
for a longer or shorter interval, independently of the tic's
localisation, intensity, or form, the result being an alternating series
of "attacks" and periods of respite. In different patients, and in the
same patient, the number and the length of these attacks are as variable
as are the spaces of rest that separate them. We remember a girl with a
tic consisting in a toss of the head repeated perhaps fifteen times a
minute, three or four occurring together at intervals of one or two
seconds, and being succeeded by a relatively long pause. The effect of
treatment was to modify the sequence entirely, and to reduce the tic to
an isolated jerk reappearing not oftener than once in a quarter of an
hour, and in itself constituting the attack. In another case the
patient's head used to turn to the left, remain so for a moment, then
resume its ordinary place. After a time of repose the tic began again,
and even when the movements followed each other more rapidly, the
intervening period was always appreciable. On the other hand, we have
seen a youth afflicted with multiple tics which continued without
intermission the whole day long; the attack lasted, strictly speaking,
from morning to night, and any break in its continuity was altogether
exceptional. It might then be more exact, perhaps, to use the epithet
paroxysmal in reference to the external manifestations of tics, but it
signifies little what word we employ provided we are familiar with the
clinical facts.

The attacks vary with circumstances and environment. One of our patients
remained quite free from them during a visit to the theatre. Tissié had
a young patient who did not tic at all while on holiday, but the
reopening of his classes was the signal for a fresh outbreak. Similarly,
no rule whatever seems to govern the duration of the times of relief;
they may never be longer than a few seconds, or they may run into
months. In the face of these data we cannot supply further
generalisations; it will be sufficient if we impress on ourselves the
importance of one fundamental element in the constitution of tic--viz.
its repetition.


LOCALISATION OF THE MOTOR REACTION--VARIABLE TICS--FIXED TICS

The localisation of the motor reaction in cases of tic is essentially
physiological. In rare instances its sphere may be limited to a single
muscle, if one muscle only be requisitioned for the performance of a
functional act; but it is very much more usual to find several muscles
contributing, whose synergic contractions fashion the movement of which
the tic is a caricature. If the same effect is yielded by the action of
either of two different muscles or groups of muscles, as in rotation of
the head, and if one be hindered from fulfilling its function, the
incidence of a tic originally located in it will promptly be transferred
to the other. This is the explanation of the persistence of rotatory
tics after exclusion of the sternomastoids by surgical means.

Two symmetrical muscles may be affected, as in tics of blinking and of
affirmation, or a median muscle, such as the orbicularis oris. Much more
frequently the tic is unilateral in its distribution, as, for instance,
when it involves the face; in this respect its figuration as a
functional disturbance is well exemplified, for expressional movements
of the face are normally bilateral. A tic may settle itself on two
mutually antagonistic muscles, and manifest its presence in the
immobilisation of a limb or segment of a limb; or only a portion of a
muscle may contract, as in the case of the deltoid or trapezius, which
are composed of bundles anatomically associated but physiologically
independent, and so capable of being functionally differentiated by
voluntary education. Fibrillary contraction and tic have nothing in
common.

Inasmuch as the muscles concerned are under voluntary control, and their
contractions such as the will can effect, it follows that with adequate
practice the movement of a tic can always be imitated, and in
predisposed soil imitation tics may thus take root; it is not always
feasible, on the other hand, to counterfeit a spasm.

Several functional muscular territories may be simultaneously affected,
and several tics may follow one another in quick succession, the
duration of any one tic on any one site being a more or less varying
quantity.

We have already noted the occurrence of variable tics. They appear one
day to disappear a few days later, and reappear again after another
space. Weeks or months may elapse without any vestige of them, until
they suddenly break forth again unheralded. As a general though not
absolute rule, the younger the patient, the less stable his tics.
Occasionally they are isolated, limited, and stationary, one of the most
frequent of this kind being a tic of blinking, but the intimate alliance
between the motor troubles and the mental level of the subject helps to
explain why these tics of children are so changeable.

     In the case of young J., for instance, it was shortly after
     attaining his tenth year and entering school that first he began to
     tic, and thenceforward, at unequal intervals, trunk, arms,
     shoulders, legs, became in turn the seat of "movements of the
     nerves," while other more definite tics were not slow in
     developing.

     When only six years old B. exhibited a respiratory tic, which
     changed a year later to one of the tongue, and after another year
     to one of the leg; at the age of twelve he used to nod his head in
     affirmation, and this was eventually succeeded by movements of
     negation, etc. He has since started a salaam tic, and finally a
     torticollis with deviation of the eyes.

We may cite an analogous case from Grasset:

     A young girl, who had had eye and mouth tics in childhood,
     commenced at the age of fifteen to advance her right leg
     involuntarily--a sort of tic which lasted several months and gave
     place to paralysis of the same limb; for this affection was next
     substituted a whistling tic, and then for a whole year she used
     from time to time to give vent to a loud "Ah!" When she came under
     observation she was suffering from a tic of salutation, with
     retrocollic jerking of the head and shrugging of the right
     shoulder.

One of our own patients furnished us with the following story:

     The disease made its debut by a blinking tic of both eyes, whose
     origin in the absence of any visual defect remained undetermined;
     grimacing and distortion of the mouth were the next to appear, as
     well as wrinkling of the nose and forehead, twitching of the
     eyebrows and contraction of one platysma, sometimes even of the ear
     muscles and the entire scalp. Then ensued up-and-down tossing of
     the head, or rotation of it from right to left, and, later,
     elevation and advancement of the shoulders, with restless agitation
     of hands and arms. A former trick of his of biting his nails is
     quite in abeyance at present; instead, he catches hold of his under
     lip every moment and abrades its mucous membrane with his nails, so
     much so that the lip is swollen and cracked like those of children
     with nibbling tics. Some months ago he acquired the habit of giving
     utterance to a soft little cry not unlike the sound made by a
     guinea-pig.

     One tic has succeeded another in an unbroken series. The facial
     tics were more of the nature of grimaces, which the child amused
     itself in repeating; no doubt the scratching of the lip was a
     sequel to the desire of experiencing a new sensation, while the
     movements of hands, arms, and shoulders were very variable and
     different enough from the accompanying phenomena. No one of the
     tics was at all of protracted duration; on the contrary, each was
     fugitive and changeable, and therein presented a resemblance to the
     child's mental status. In sleep they completely disappeared; in the
     presence of strangers or if his interest was in any way aroused,
     they quieted down, while they increased on holidays, during games,
     or with physical fatigue.

It is clear that determination of the tic's localisation and mode can
come only with the mental evolution of the patient, and that the
transformation from the psychical inconsistency of childhood to the
stability of the adult is paralleled by the change in the tic's
manifestations as the scale of age is ascended. Any individual, whatever
his years, who is in the stage of mental infantilism, will tic after the
manner of a child, for the characters of a tic are dependent on the
state of mind of its subject.



CHAPTER VIII

ACCESSORY SYMPTOMS


REFLEXES

The question whether in cases of tic there is any alteration in
superficial or deep reflexes can be decisively answered only by an
appeal to statistics, the information afforded by which has hitherto
been too scanty and too incomplete. Judging from our own observations in
about thirty cases, we feel compelled to admit that disorders of this
kind are altogether exceptional. Careful and repeated examination has
convinced us that in patients suffering from tic the knee, ankle, wrist,
elbow, and other jerks, the plantar and fascia lata reflexes, as well as
those of the pharynx, eyes, etc., are all but universally normal, and
any trifling exaggeration or diminution not only varies from day to day,
but also in no wise exceeds the differences met with in health, and is
therefore symptomatologically negligible. In the manifold varieties of
tic represented by R., S., P., N., M., B., etc., whose cases are quoted
here in part, our inquiries have always been negative. Noir's research
on the state of the reflexes in idiocy complicated with tics failed to
expose any abnormality, and even where the knee jerks were increased no
departure from the usual manifestations of the tic was discoverable. It
is of course permissible to suppose that a combination of the latter
with organic disease of the nervous system might explain the
modification of the reflexes. In this connection it may be remembered
that on one occasion we found the customary diminution of O.'s knee
jerks had passed into actual loss, and although on the next day they
were present again, the occurrence was suspicious enough to justify one
in entertaining the idea of incipient tabes. Even if the existence of
other signs had corroborated this diagnosis, the incontestable
genuineness of O.'s tics would have remained, so that the attempt to
correlate the derangement of the reflexes with the existence of tics is
somewhat questionable.

We have enjoyed the co-operation of M. Babinski in the examination of
one of our patients, L., in whom we were able to determine a definite
and symmetrical exaggeration of the patellar reflexes, a slight increase
in the right triceps jerk, and, in making the subject rise from a prone
to a sitting position with the arms folded, a very minor degree of
flexion of the thigh on the trunk.

The first of these symptoms is of no pathognomonic value, and while the
others no doubt are characteristic of organic disease, their development
in this instance is too imperfect to warrant the deduction of pyramidal
involvement. For the last ten years L.'s motor control has been very
defective. The muscular activity of the right half of his body takes the
form of irregular contractions, badly timed and inaccurate in range; in
spite of the absence of pain, the timidity with which they are executed
hinders their ever attaining a normal amplitude; and at the same time
his inability to appreciate the direction and intensity of the motor
reaction, the outcome of excessive muscular vigilance, illustrates a
certain loss of the sense of position of his limbs.

The existence of an actual irritative lesion is therefore problematical,
and it is scarcely conceivable that organic mischief of ten years'
duration could have produced these clinical symptoms without creating
graver disturbance of the reflexes, or effecting changes of a trophic
nature in muscular and other tissues.

From the pathogenic and diagnostic point of view, the detection of
conspicuous and persistent alterations in the reflexes is of deep
significance. It is an important factor in the differentiation between
tic and spasm.

Sometimes the task is unusually arduous, as when the unilateral
distribution of the motor troubles recalls the clinical picture of
lesions of the pyramidal paths. In L., for instance, the hemichorea and
the torticollis were on the right side, and in a case published by
Desterac a similar condition obtained, the writers' cramp, hip spasm,
and head rotation being all confined to the right. Notwithstanding the
fact that this patient had exaggerated knee jerks, ankle clonus, and a
double extensor response, an opportunity for examination given to one of
us made it clear that the untimely movements and bizarre attitudes were
similar to what has been noted in certain cases of tic.

At the Neurological Society of Paris a case was shown by Babinski[56] of
left spasmodic torticollis, with marked spasms of the left arm and left
leg, and a homolateral extensor response, and it was contended that if
one and the same cause underlay these phenomena--nor did there appear
any adequate reason to doubt it--and if the reversal of the plantar
reflex was, conformably to received opinion, to be interpreted as
indicating a derangement in the function of the pyramidal system, then
it was allowable to attribute the muscular spasms to the same
derangement, in which circumstances the natural conclusion was that
spasmodic torticollis itself might sometimes at least be dependent on
pyramidal irritation of an as yet undetermined kind.

More recently still, another patient was exhibited by the same
observer,[57] in whom the association of head rotation and convulsions
of the arm on the left, with increase of the triceps reflex, was
conceivably the outcome of pathological stimulation of the pyramidal
tract. Yet the symptoms in each of these cases were curiously analogous
to what we find in mental torticollis, in which abnormalities of the
reflexes are conspicuous by their absence. We ought not on that account
to reject the hypothesis of concurrent organic disease, inasmuch as a
structural modification may be no longer the cause but the consequence
of inordinate repetition of a motor reaction. Muscular hypertrophy or
atrophy may be the sequel to tics born of ideas that find motor
expression, and circulatory and even cellular changes may ensue on
gesticulatory excess. The objective signs that reveal the existence of a
point of irritation, on the presence of which the diagnosis of spasm
depends, are commonly so trivial as to be wellnigh valueless, and should
they be awanting, the motor disturbance appears to be purely functional,
and may be considered a tic. At the same time we must admit the
possibility of mixed forms, where the functional element is linked with
primary or secondary organic disease, and perhaps their occurrence is
more general than is ordinarily imagined. We repeat, however, that
rigorous and lengthy investigation alike of the psychical and the
somatic phases of the condition, embracing the state of the reflexes,
will usually furnish sufficient information to facilitate the question
of diagnosis and justify a positive statement.


ELECTRICAL REACTIONS

The examination of the electrical reactions of the muscles concerned in
a tic is a clinical method seldom, if ever, resorted to, and we can
scarcely expect it to yield decisive results from the symptomatological
aspect. As with the reflexes, it may happen that we cannot afford to
neglect its diagnostic significance in certain cases. For example, we
have had occasion to test its worth in studying the case of young J.,
whose trouble consisted in a clonic tic of elevation of the left
shoulder, and a tonic attitude tic of the left arm whereby it was firmly
applied against the body. No important alteration in electrical
contractility was discovered, although the response in the upper part of
the left trapezius--which, by the way, was more voluminous than on the
right--was brisker than in its fellow. On the other hand, the right
deltoid, sternomastoid, and pectoral, were more excitable than on the
left.

Here, of course, the evidence supplied by electrical examination only
served to confirm the knowledge gathered from other clinical sources.


VASOMOTOR AND SECRETORY AFFECTIONS

Disorders of the vasomotor system rarely fail to assert themselves in
the subjects of tic, but they do not in any wise differ from such as are
met with in the majority of "nervous" individuals. The average sufferer
from tic is emotional, and apt to betray his emotion by blushing for the
most childish reason. This symptom may be in itself trifling enough, yet
it may afford the earliest indication of mental instability the nature
and extent of which subsequent research will determine. It is even
conceivable that fear of blushing--the _ereutophobia_ of Regis--may be
at the bottom of certain gestures intended to conceal the heightened
colour the apparition of which is so humiliating. The form they assume
is generally a movement of the arm or hand over the face, to mask the
momentary discomfort, and while in most instances they are no more than
stereotyped acts, they may develop into full-blown tics.

In regard to secretory affections, we have frequently observed the
concurrence of hyperidrosis and emotional phenomena in those who tic.
Young J., S., P., are cases in point. The slightest exertion, the least
effort of attention, are followed by an extraordinary secretion of
sweat, entailing constant carrying of a handkerchief in the hand, and
ceaseless mopping of the forehead or temples. This performance becomes
stereotyped, and is gone through even when there is no perspiration at
all. Suppression of the handkerchief sometimes causes actual malaise,
but this injunction must never be forgotten if a cure is to be effected.

[Persons afflicted with tic often develop a sort of visceral instability
which betrays itself in indigestion, dyspepsia, constipation,
diarrhœa, and in every variety of dietetic and alimentary caprice.

It is rare to meet with troubles of micturition, nocturnal enuresis
scarcely deserving mention owing to its frequency among all young
degenerates and to its being so commonly the outcome of neglect.
Oppenheim,[58] however, considers diurnal enuresis worth including in
the symptomatology, and Brissaud[59] has described polyuria and
pollakiuria in association with obsessional preoccupation. These are
really functional disturbances in which increased desire is followed by
increased vesical action, and may be regarded, if one likes, as
micturition or sphincter tics.[60]]


AFFECTIONS OF SENSATION

Generally speaking, objective disturbances of sensibility do not occur,
and while subjective changes are more frequent, they may be entirely
lacking even in long-standing and aggravated cases. What the patients
usually complain of is a more or less persistent, disagreeable,
uncomfortable sensation, rarely described as painful, and often compared
with a feeling of stiffness or fatigue. Or, again, they may be conscious
of a sense of constriction or of dragging in the affected muscles,
either at their insertions or in the muscle belly, or sometimes in the
joints concerned. These subjective sensations are characterised by
extreme variability in time and in degree. Moreover, the accounts given
by patients of their own sufferings ought to be accepted with reserve.
Not merely are they ready to exaggerate and incapable of accurately
depicting and localising their sensations, but they also exhibit a
curious tendency to false interpretation: they attribute an erroneous
pathological significance to their feelings, and proceed to elaborate a
thousand ridiculous variations, thereby inviting in a sense the eruption
of fresh tics. In all this behaviour their mental imperfections are
abundantly manifest.

We may remind ourselves in this connection how O.'s various inventions
had no other effect than that of provoking new tics, and another
illustration is to hand in the case of S., an account of whose mental
torticollis will be found in a previous chapter.

     Any trifling item of passing interest used to make S. forget
     altogether the more or less acute pain he experienced in his neck
     and shoulders, and reacted no less successfully on his torticollis.
     When systematic and methodical exercise of the muscles was ordered,
     nothing was more natural than that their long period of inactivity
     should have the result of causing a vague feeling of stiffness in
     them with the unwonted action. Yet S. never dreamed of such an
     ordinary explanation, but pessimistically exaggerated the
     sensation, and deemed it an infallible sign of the spread of the
     disease. It proved to be a simple enough matter, however, to
     convince him of its harmlessness, for it was sufficient to remind
     him of the corresponding stiffness he had felt after his first
     attempts at riding and fencing, and from that moment he ceased to
     pay any attention to it and therefore to complain.

With spasm, on the other hand, pain is more frequently, though not
always, associated. It may be said, of course, that since a tic may be
evolved from a spasm, the pain of the latter is really the exciting
cause of the former, but in the tic as it is constituted all these
initial disturbances have disappeared, and what the patient does feel is
the consequence of excess of muscular action or of articular
displacement. His dolorous sensations form the sequel, not the prelude;
they are not symptoms, but, so to speak, complications.



CHAPTER IX

THE DIFFERENT TICS


This chapter we shall devote to a review, necessarily incomplete, of the
principal sites in which tics are to be met with. We do not pretend to
have collated every known case observed up to the present, and we
foresee the likelihood, moreover, of new tics coming into being. Their
numbers are as unlimited as is the diversity of functional acts of which
they form the pathological expression. We must content ourselves, then,
with the consideration of the most familiar and most recent examples.

A rational classification would entail discussion of the various modes
of derangement to which functional acts are liable, and this would
demand in its turn a preliminary tabulation of function. How onerous
such a task is, is patent from the uniform imperfection of the attempts
already made, and the equivocal nature of their conclusions.

We have studiously avoided the designation of a tic by the muscle or
muscles that determine it. To specify the precise muscle involved is
sometimes attended with no little difficulty, while if several, as is
customary, are concerned, their association is rarely anatomical;
indeed, this is one of the chief aids to diagnosis between tics and
spasms. Should the convulsion chance to follow an anatomical
distribution, neighbouring muscles are apt to participate as well. Hence
it is advisable to name a tic after its morphological situation, or,
better still, from the functional act of which it is, in Charcot's
phrase, the caricature.

This is the plan we shall pursue in our successive examination of the
different parts of the body disposed to be the seat of tics.


FACIAL TICS--TICS OF MIMICRY

Of all tics, those of the face are the most frequent, and the most easy
to see. No other part is as rich in muscles whose functions are so
diversified--nictitation, mastication, suction, respiration,
articulation, etc. Moreover, the face is the abode of the mimic
expressions, each one of which is the revelation, by muscular play, of
some sentiment, or passion, or emotion. Hence the idea has been
entertained of adopting a physiological classification. In the smiling
tic of Bechterew, for an instance, the muscular contractions are framed
into a smile in the absence of any provocative to mirth; in a similar
fashion, the sniffing tic brings to mind the inhaling performances of
snuff-takers.

Facial tic is frequently unilateral. It is rare to find the whole
muscular distribution of one facial nerve involved, however, this being
a property rather of spasm, as is also the restriction to a particular
branch. A common event is the simultaneous abstention of some facial
muscles and implication of others belonging to a different nerve supply.

If the condition is bilateral, as a general rule only those muscles on
each side co-operate that are wont to act in concert for the
accomplishment of some function. In a case reported as bilateral facial
spasm by Claus and Sano,[61] in which both sides of the face and neck
were affected, the exaggeration of the convulsions by emotion, their
curtailment daring rest and disappearance in sleep, coupled with the
fact of their temporary arrest by recourse to subterfuge, suggest that
the condition is really one of tic.

The contractions of the facial muscles are usually associated to produce
a more or less complex grimace. Movements of forehead, eye, nose, or
mouth, may succeed each other or be superimposed one on the other
without any preconceived order, or the tic may consist in the
synchronous activity of two or more muscles.

Of course any and every facial tic may occur by itself, but careful
investigation will often reveal concomitant reactions of other muscular
groups. The sniff that accompanies puckering of the nose indicates the
engagement of the muscles of inspiration.

Facial tic, moreover, may be tonic as well as clonic, instances in point
being closure of the eyelids, wrinkling of the forehead, twisting of the
nose, distortion of the mouth, etc., of longer or shorter duration.

Any of the facial muscles may be attacked by tics. These commonly
furnish an illustration of functional disturbance of mimicry, as in
Oppenheim's cases of tic limited to the frontales, whereby astonishment
or dismay was expressed, or in contraction of the superciliary muscles,
which conveys a look of pain or of mournfulness. Spread to the scalp
muscles may take place, causing a perpetual to-and-fro movement of the
hair, of which O. and Miss R. supply examples. The platysma is sometimes
the seat of a tic. One of Oppenheim's patients was a child with
alternating twitches of his two platysmas; it is of interest to note he
was able to contract either voluntarily. This condition is generally
associated with similar contractions in other facial muscles, as in a
case of facial and palpebral tic with platysma involvement recorded by
Meirowitz,[62] or as in young M.

A not infrequent accompaniment is a shrug of one or both shoulders, due
to synergic contraction of the trapezius. The resulting complex may be
considered an act of mimicry in so far as it is an expression of
disdain.


TICS OF THE EAR--AUDITORY TICS

The muscles of the external ear come often into play. One of our
patients had a tic of the left ear, consisting in visible elevation of
the pinna. A case of tic of the ear muscles has been described by
Romberg, and another by Bernhardt, in the distribution of the occipital
and posterior auricular nerves. Reference is made by Seeligmüller[63] to
a ten-year-old girl suffering from unceasing involuntary contractions of
the eyelids and of various head and neck muscles, with wrinkling of the
forehead and movements of the ears. His original diagnosis of chorea was
discredited by his subsequently learning that the child, in common with
a younger sister and a brother, had for several years been exercising
herself by making faces, and in particular by attempting to move her
ears.

It is quite conceivable that certain middle-ear phenomena are comparable
to the tics. O. used often to complain of hearing noises in his right
ear, which came and went with his tics of face and neck. Now, it is well
known that the probable explanation of the humming sound attending
forcible closure of the orbiculares palpebrarum is the variation in
labyrinthine tension due to the synergic contraction of the stapedius.
This absolutely normal effect may be exaggerated by predisposed and
preoccupied individuals into a sort of auditory tic.


TICS OF THE EYES--NICTITATION AND VISION TICS

For the sake of precision, tics of the eyes may be subdivided into
eyelid tics and eyeball tics.


A. _Eyelid Tics._--These, perhaps the commonest of all tics, may be
either unilateral or bilateral. They consist simply in a palpitation of
the upper lid, repeated at irregular intervals, and differing from
ordinary blinking only in augmented frequency and abruptness. The form
they usually assume is that of a wink, attributable in the first
instance to contraction of the orbicularis, but supplemented by the
zygomatics and muscles of the nose.

The tonic variety of the same tic is constituted by a contraction of
inordinate length, the outcome of which is the all but permanent
maintenance of the eye in a half-closed position. The suspension of this
tonic tic by volitional effort accentuates its distinction from
contracture. In one of our patients a tic of this nature, which gave a
singularly sleepy cast to the features, was easily relieved by suitable
gymnastic treatment. The converse condition obtained in another case,
where excessive gaping of the palpebral fissure contributed an unwonted
fixity to the expression, which simultaneous contraction of the
corrugator supercilii served to heighten into one of wild anger. These
two tics corresponded to two diametrically opposed traits in their
subject's character--viz. nonchalance and impatience respectively, and
it is interesting to recall in this connection how the varying moods
depend for their physiognomical delineation chiefly on the degree of
curvature of the palpebral arc.

Valleix,[64] who employed the term "idiopathic facial convulsion" to
designate tic, cites a case where even in moments of tranquillity the
left eye seemed slightly smaller than its fellow, by reason of a feeble
contraction of the orbicularis. Persistent grimaces of this kind
resemble tics of attitude and stereotyped acts, and the possibility of
their occurrence must not be overlooked, once the diagnosis of facial
paralysis or spasm has been rigorously excluded.

The terms blepharospasm and blepharoclonus, sometimes applied to tonic
and to clonic involuntary palpebral contractions respectively, ought to
be strictly reserved for spasms and contractures properly so called. For
example, von Graefe's case of blindness consequent on permanent closure
of the eyelids in a child is undoubtedly one of blepharospasm. No tic
could have been attended with such a result, whereas compression of
branches of the trigeminal at their points of exit might determine
reflex tonic contraction of the orbicularis, and so, for that matter,
might a central lesion. Hence in these circumstances it is correct to
use the word spasm.

Palpebral tics are among those that ordinarily begin by a spasmodic
reaction to an extraneous source of irritation, such as that yielded by
a foreign body, a speck of dust, an eyelash, or by any form of
conjunctival inflammation.

     Eyelid tics (says Parinaud[65]) are known to ophthalmologists as
     clonic blepharospasms. Their starting-point is always some
     peripheral stimulus, in particular an everyday variety of
     conjunctivitis characterised by the presence of granulations in the
     lower part of the sac. To discover these granulations it may be
     necessary to explore the internal aspect of the lid. In my opinion,
     they are a prolific cause of tic, especially in young children, and
     their removal effects a cure in the vast majority of cases.

It is only when the blinking abides in spite of the suppression of the
exciting cause that it can be comprised in the category of tics,
otherwise the fact of its being contingent on the continuance of the
irritation shows it is a spasm.

A bright light sometimes suffices to initiate these conditions. During a
course of sittings for her portrait, G., a little girl eleven years of
age, acquired the habit of drooping one eyelid slightly to shield the
eye from the somewhat glaring light of the studio, but the persistence
of this movement in other surroundings was evidence of its degeneration
into a tonic tic.

Noir quotes the case of one of his colleagues who was for a long time
inconvenienced by a most disagreeable blinking, which he held to be a
tic; but a simple explanation was forthcoming in the unusual length of
some of the eyelashes on the outer part of the upper lid having caused
their entanglement with others in the under one, and when they were cut
off the spasm disappeared.

In the following instance, reported by Toby Cohn,[66] the diagnosis
remains undetermined:

     The protracted use of a magnifying glass in the left eye was the
     means, in a watchmaker, of inducing occasional localised twitches
     of the orbicularis, which were not slow, however, in spreading to
     the whole of the left half of the face. They may at first have been
     an involuntary motor response to nipping of palpebral twigs of the
     trigeminal, but at a later period their independence was constant
     and pronounced. With certain associated movements such as
     articulation or deglutition, or during the act of wiping the nose
     or shutting the eyes, the form they assumed was tonic. There were
     neither subjective nor objective sensory phenomena to note.

We have recently had the opportunity of observing a genuine case of
eyelid tic, of obscure origin perhaps, but one whose clinical features
eliminate the hypothesis of spasm.

     Brif., a metal polisher, forty-seven years old, came on March 10,
     1902, to Professor Brissaud's clinic at the Hotel Dieu, complaining
     of involuntary closure of the eyes, especially when out walking. In
     his family and in his personal antecedents there was little or no
     neuropathic or psychopathic tendency. The sole trouble for which he
     sought advice was this spasmodic shutting of his eyes, rare enough
     under most circumstances, but aggravated instantly by a walk of
     even a few paces.

     The onset had been quite insidious eighteen months previously, and
     at the first the average frequency was scarcely more than thrice or
     four times daily. Whenever Brif. passed into direct sunlight the
     movement was particularly liable to occur. As long as he remained
     seated at his work he was free from it, while he had but to rise
     and take a step or two for it to reappear and forthwith commence to
     repeat itself. At home any effort engaging his attention inhibited
     the tic, nor was there any sign of it in the course of our
     interrogation and examination of him.

     Even when he was on his feet, the incidence of the act was not
     always uniform; if promenading with his wife and children, or
     fishing along a river side, or running to catch a tram, he was not
     hampered by his affliction. When he rose in the morning, it made
     its appearance ere he could reach the window to look out. During
     his journeys to and from his place of business, he was generally
     unable to moderate the spasmodic movements, particularly towards
     evening, whereas his professional pursuits in the daytime, and any
     occupation--such as reading the newspaper--when at home again,
     wholly counteracted the inclination to tic.

     The production of this untimely gesture of his Brif. was disposed
     to attribute to the action of sun or wind, though he acknowledged
     the regularity of its occurrence irrespective of either. In its
     actual nature the contraction was tonic in type and of several
     seconds' duration, so that he used to cover some yards with eyes
     shut. From the outset the will had always exercised a marked
     influence on it, so much so that on certain days and for a certain
     space he could check the convulsion, and even when it was prolonged
     he contrived by volitional effort to open his eyes sufficiently to
     pilot himself in avoiding obstacles.

     Careful search by the ordinary tests at the Quinze-Vingts hospital
     failed to reveal any abnormality whatever in his eyes. On our part,
     we satisfied ourselves that there was no restriction of the visual
     fields.

As far as his mental state was concerned, its chief peculiarity was a
somewhat childish turn of mind, a _soupçon_ of that psychic infantilism
so common in the subjects of tic; in addition, he was of an emotional
temperament, and prone to perspire or blush for no valid reason. He was
further a victim to a premature baldness which was hereditary in the
family, and which may be cited as a physical stigma of degeneration.


B. _Eyeball Tics._--The extrinsic muscles of the eye occasionally
participate in the tics we have just discussed. Assiduous observation of
patients suffering from blinking tics will enable the physician now and
then to detect movements of the eyeball behind the lowered upper lid.

In the case of F., for instance, with each tic of the lids the eyeballs
deviated briskly upwards and to the left. Similarly Miss R. turned her
head from right to left at the same time as the eye moved obliquely to
the left and in an upward direction. A patient mentioned by Otto
Lerch[67] used to open and shut his eyes while rotating the eyeballs and
throwing the head back. Occasionally he inclined his trunk to one or
other side, accompanying the act with disagreeable little grunts.

The eruption of these tics may equally be attributed to some foreign
body or minute conjunctival granulation, as was the case with a small
child of ten years under our care, who, in spite of the withdrawal of
the irritating particle, acquired the trick of tickling the inner
surface of his upper lid by rolling his eye about whenever he happened
to blink. The delight he took in this trivial manœuvre led to its
mechanical reiteration, and was the means eventually of its developing
into a tic which required a sufficiently delicate muscle exercise and
drill for its repression.

Defects in the visual apparatus sometimes induce abnormal movements and
attitudes which may become tics if careful examination does not elicit
their explanation.

Tic of the eyeball is generally associated with other tics, ocular or
facial, but it may occur alone and bear a resemblance to nystagmus, a
peculiarity we have noticed in a patient perfectly free from any
cerebro-spinal disease. It is almost always bilateral, but in some cases
of unilateral palpebral tic it is more pronounced on the side of the
latter.

Fixity of the eyes is characteristic of tonic tics of the extrinsic
ocular muscles, and gives a somewhat haggard or maybe merely attentive
expression to the countenance. Very frequently it escapes observation,
and indeed cannot be considered a tic unless there be an incongruity
between it and the ideas at that moment uppermost in the patient's mind.

Reference has already been made to the historic example of an ocular tic
in the person of Peter the Great. A series of interesting discussions
has taken place recently at the Neurological Society of Paris in regard
to the question of a tic of elevation of the eyes.

     The patient, who had come to consult Professor Marie at Bicêtre in
     December, 1899, was presented to the Society in the first instance
     by M. Crouzon.[68] He entered the room with his eyes fixed on the
     floor, but in a few seconds they had resumed their normal position
     in the horizontal plane. At frequent intervals he raised them
     upwards, or inclined his head so as to bring the pupils into
     contact with the upper lids, the natural position of rest of the
     globes being regained by a voluntary effort after each
     displacement. When interrogated, he complained of not being able to
     distinguish objects in an area of his visual fields limited by an
     imaginary line drawn from his eyes to strike the ground at a point
     six feet in front of him; otherwise his sight was excellent. The
     history he gave was to the effect that five months previously, in
     the enjoyment of perfect mental and physical health, he had had a
     sudden stroke, and been unconscious for seventeen hours. No
     sinister results ensued till four days later, when he lost his
     vision, began to articulate very indistinctly, and failed to
     recognise his wife, continuing in that state for the next two
     months. Gradual recovery of speech and sight then commenced, but
     the habit of looking upwards persisted. The absence of injury to
     the visual apparatus, coupled with the presence of admitted
     psychical disorders, decided Crouzon in his consideration of the
     condition as a functional disturbance of the ocular muscles
     analogous to tic.

     In this connection the significant observation was made by Joffroy
     that in the recumbent position the patient's eyes assumed their
     ordinary place, suggesting a comparison with those dolls whose eyes
     open or close according as they are held vertically or
     horizontally. In his opinion, the eye mobility negatived any idea
     of contracture consequent on central lesions.

     A few months later the same patient was submitted a second time to
     the Society, on this occasion by M. Babinski,[69] who declared
     himself in disagreement with the hypothesis of M. Crouzon. In all
     cases of mental torticollis, so called, the contrary movement to
     that the execution of which is impelled by the spasm can from time
     to time be accomplished, whereas in the case under discussion
     downward as opposed to upward deviation was never obtained.
     Further, the acute onset, with loss of consciousness, militates
     strongly against the tic theory, and indicates rather a variety of
     paralysis of the inferior recti, or paralysis of conjugate downward
     movement, secondary to organic disease of the nervous system. The
     difficulty experienced by the patient in inducing his eyes to
     resume the horizontal position after once elevating them is
     explicable on the assumption that the action of the superior recti
     is no longer controlled by their antagonists the inferior recti,
     the former passing into a state of temporary spasm, which is,
     however, strictly consecutive to the paralysis of the latter.

     M. Parinaud expressed himself as being in accord with M. Babinski,
     and recalled certain rare forms of associated ocular palsies
     occurring with paralysis of convergence, a combination manifest in
     the subject in question. Curiously enough, in these cases the
     disturbance of function is always ushered in by a stroke, which
     justifies the belief in the focal nature of the lesion.

     On the other hand, it was noticed by M. Ballet that the range and
     facility of downward deviation varied inversely with the attention
     devoted to the patient by the examiner.

     On yet a third occasion this identical case provided a subject of
     discussion at the Society, after being under the observation of
     Professor Pierre Marie in Bicêtre.

     Professor Marie[70] had failed to satisfy himself of the paralytic
     nature of the phenomenon, and demonstrated the ease with which the
     eyeballs moved downwards if the patient was made to hold his head
     in the position of maximum extension, while in the attempt to look
     at his feet--the head being held normally--they were forthwith
     inclined violently upwards, and were so maintained for thirty or
     forty seconds. The only view tenable was that he was suffering from
     a sort of neurosis whose outward expression was this spasmodic
     elevation of the eyes. Additional confirmation of the accuracy of
     this hypothesis was supplied by a consideration of the
     circumstances attending the commencement of the illness. The sudden
     and unexpected apoplexy, of seventeen hours' duration, had been
     accompanied neither by stertor nor by relaxation of sphincters, and
     had been followed by an equally sudden return to consciousness, the
     faculty of speech and the desire for food reasserting themselves
     unexpectedly. The ensuing three or four weeks the patient had spent
     in a curious delirious state, not unlike the post-seizure stage of
     hysteria, a trace of which remained in the guise of certain
     eccentricities of mind. The difficulty in his speech bore a
     resemblance to hysterical stammering; and, finally, his visual
     fields were concentrically and bilaterally restricted.

     Of the subsequent history of the case some information was
     forthcoming at a later date,[71] corroborating the opinion
     originally propounded by Professor Marie. Simultaneously with the
     diminution in intensity of the ocular spasm there had been grave
     deterioration of the patient's mental level, as evidenced by the
     development of ideas of persecution.

     In the subjects of tic, and especially in cases of mental
     torticollis, we have noted an analogous symptom, consisting in
     inability to look down at the feet, except perhaps by the aid of
     innumerable contortions, in contrast to the consummate ease of
     upward glances. By making the person write at a blackboard, and
     observing his action according as his hand is above or below a
     horizontal plane through his eyes, one can soon convince oneself of
     the reality of the occurrence, yet search will fail to discover any
     sign of ophthalmoplegia.

     Patients of this class evince a remarkable aptitude for elevation
     movements, and the trouble they experience in depressing the
     eyeballs is not of necessity to be construed as denoting paralysis
     of the depressors, but rather indicates the presence of a tic of
     the elevators, as Professor Marie says--a tic born of a habit, and
     nourished perhaps by the dread such persons feel of witnessing an
     exaggeration of their convulsive movements whenever they cast their
     eyes down.

Our object in summarising this discussion has been twofold: at once to
note the existence of tics of extrinsic eye muscles, and to illustrate
the intricacies of their diagnosis.

A case not unlike the preceding, recorded by Noguès and Sirol,[72] was
characterised by inability to look above a certain height without
simultaneous raising of the head. Paralysis of the associated movements
of elevation was excluded by the fact of the gradual onset, without an
ictus, and by the absence of paralysis of convergence and of impairment
of speech and intellect. Basing their conception of the case upon its
post-febrile origin and the knowledge of hysterical antecedents, the
authors were disposed to regard it as a neuropathic manifestation.

It is conceivable that some cases of strabismus in children are nothing
more than vicious habits transformed into tics, since, as a matter of
fact, attentive supervision is frequently sufficient to effect a cure,
although no doubt in other cases some visual abnormality is responsible
for the condition.

Finally, since accommodation is a function subservient to the will, tics
of accommodation are theoretically possible. Our information thereanent
must be sought from the ophthalmologists. We have met with genuine
professional cramps of accommodation in those who use the microscope, as
well as in opticians, watchmakers, etc.


TICS OF THE NOSE--SNIFFING TICS

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

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


TICS OF THE LIPS--SUCKING TICS

The diversity of movement of which the buccal orifice is capable
warrants the statement that the tics of this class are almost too
numerous for detailed description. At times only the orbicularis oris is
involved, unilaterally or bilaterally; at others, concomitant
implication of the elevators and depressors of the lips, or of the chin
muscles and the platysma, furnishes the basis for all sorts of pouting,
biting, and sucking movements, and for every variety of smile and grin.
Here again the clonic form of contraction is the most habitual, although
that rapidity and abruptness which we commonly identify with such
contractions may not always be conspicuous. Guinon says of a young
patient of his, at one time addicted to innumerable tics, that the
relative sluggishness with which she opened and shut her mouth served to
inspire belief in the reality of the tonic tic of certain authors. As a
matter of fact, tonic tics do exist, and are sometimes associated with
another variety known as mental trismus, to the discussion of which we
shall revert ere long.

The action of the muscles of the lips is manifold: whether in the
expression of the emotions, or in the discharge of different functions,
they come into play in miscellaneous modes that may be the forerunners
of a multiplicity of tics. Of these, two types may be distinguished,
according as expansion or occlusion of the labial orifice predominates.
Under the one heading; come the caricatures of ordinary smiling or
laughing, under the second those that exaggerate the pursing or pouting
movements whereby we are wont to indicate chagrin, repugnance, disdain,
etc. Labial tics of this nature may be styled tics of facial mimicry.

In the infant that has long been weaned, and _a fortiori_ in the adult,
the continuance of the act of sucking must of course be considered a
functional anomaly; and while no doubt it is true we use our lips in
imbibing a beverage through a straw, or in extracting the juice from a
fruit, the action is different from that of the infant, and in any case
not to be compared with incessant sucking of tongue or thumb, or of some
object devoid of all nutritive value--merely a bad habit, perhaps, but
frequently indistinguishable from tic.

The most fruitful source of the tics under consideration is to be found
in labial cracks and dental mischief. More especially in children,
towards the end of the first dentition, the torment of loose teeth calls
forth interminable devices for relief, in seeking which tongue and lips
pleasurably co-operate. Once the tooth is out, the lacuna it leaves
provides a new sensation and a new reason for muscular activity.
Irregularity of the permanent teeth may also be referred to as a potent
factor in the causation of tic. It is therefore not superfluous
systematically to examine the teeth of all patients suffering from tics
of the mouth, and to extract any offender.


TICS OF THE CHIN

The muscles of the chin collaborate with other facial muscles in
expressional movement, and are similarly liable to be the seat of tics.

Massaro[73] has observed an interesting series of isolated "geniospasm"
occurring in twenty-six individuals of the same family during five
generations. The characteristic feature of these spasms was an
involuntary intermittent clonic contraction of the transverse muscles of
the chin, suggesting the look of one seized with fear or with cold. The
will did not always effect their inhibition, while emotion appeared to
aggravate and distraction to abate their intensity. With sleep they
vanished entirely.


TICS OF THE TONGUE--LICKING TICS

Tics confined exclusively to the tongue are of rare occurrence.
Moreover, they must be strictly differentiated from the tonic or clonic
contractions of the tongue muscles met with in hysteria, epilepsy, and
Sydenham's chorea, from the varying tremors that accompany organic
disease of cerebral or bulbo-pontine origin, as well as from those
"glosso-spasms" that may or may not be associated with twitches of the
facial musculature.

Functional polymorphism is no less marked in the case of the tongue than
in that of the lips; it participates in suction, mastication,
deglutition, as well as in respiration, phonation, and articulation,
while to "put out the tongue" at any one is equivalent to an expression
of contempt. It is, accordingly, no surprise to find the number of
tongue tics very considerable. Such, for instance, is the licking tic,
where the tongue is constantly being passed over the free border of the
lips, moistening them to excess; or the chewing tic, in which its
perpetual motion inside the mouth in every direction conveys the
impression that the subject is chewing something. Further, its contact
with the palate or the upper lip may yield different clucking,
whistling, or crowing sounds. Letulle remarks that the trick of
producing a little inspiratory whistle by the passage of a column of air
through an incompletely closed labial commissure--a common habit among
people suffering from dental caries--is not slow in developing into an
actual tic.

It has not fallen to our lot to observe the tonic variety of tongue
tics, none the less must we believe in the possibility of their
occurrence. Convulsive lingual movements, consecutive to disease of
mouth or teeth, or to lesions of corresponding nerves, are in all
probability spasms properly so called, to which disturbances of
sensation and of nutrition are often superadded. The tonic contractions
of tongue, lips, and masseters, which have been described in cases of
hypochondriasis and puerperal psychosis, are much more nearly allied to
the tonic type of tic, if, indeed, they are not to be identified with
it. A case has been put on record by Lange of tonic contraction of the
tongue during speaking and eating, each time that it touched the dental
arches. No doubt the condition was a sort of tonic tic. Sometimes
players of wind instruments are afflicted with a "professional cramp" of
the tongue, as Strümpell has reported.

Generally speaking, however, it is particularly in tics of language, and
in the various kinds of stammering, that the tongue muscles are
concerned.


TICS OF THE JAWS--BITING TICS--TICS OF MASTICATION

When the muscles of mastication are the site of tics, a medley of
nibbling and mumbling results, from which convulsive movements of the
same muscles consequent on cerebro-spinal mischief must be scrupulously
separated. A. von Sarbo's[74] case of clonic maxillary spasm secondary
to worry, depression, and an accident to the head, in a woman
thirty-four years old, and otherwise free from stigmata--analogous cases
are quoted by Strümpell and Ranschburg--was referred by him to a "spasm
diathesis," akin to the "diathesis of contracture," but its etiology and
evolution, together with a striking exaggeration of the knee jerks,
negative the hypothesis of tic.

The masseters are chiefly but not exclusively affected. Unilateral
implication of the pterygoids has been noted by Leube in a young girl
who was also an hysteric and a choreic. A patient of ours prefaces every
conversation by rapidly raising or lowering his inferior maxilla four or
five times, and blinking at the same time; the performance has its
variants, moreover, with the occasional addition of several nasal
expirations.

Chattering or grinding of the teeth is a frequent accompaniment of the
tics we are considering, and may have a disastrous issue in the
loosening, cracking, or breaking of these structures, as in the case of
O.

A still more common incident is injury to the buccal mucous membrane, a
significant instance of which is furnished by an episode in the history
of young J.

     One day in June, 1900, J. experienced a feeling of discomfort in
     the articulation of the lower jaw--the sequel, as a matter of fact,
     to a slight alveolo-dental periostitis in the neighbourhood of a
     bad tooth--and, interpreting the sensation as a new and grave
     symptom in the march of his malady, forthwith proceeded to
     investigate its development by playing with his maxilla. Then
     ensued a perfect debauch of masticatory movements, in which
     agreeable repetition of every conceivable grimace was joined to
     protrusion and retraction of the jaw in the search after articular
     cracks. He became so wholly preoccupied with this tic of
     mastication that ere long he had begun to pinch the mucous membrane
     on the inside of the right cheek between the hindmost molars, and
     this fresh object of absorbing attention in its turn led quickly to
     some excoriation of the mucosa on both sides. No halt was called by
     the lower jaw to give the abrasions time for repair, with the
     natural outcome that they suppurated and paved the way for an
     attack of infective stomatitis with pain, fever, and malaise, which
     necessitated the application of the thermo-cautery to the ulcerated
     areas for its relief.

     The explanation given by the patient of the evolution of the
     process was controlled by interrogation of the parents, and no
     doubt was left as to its genuineness. In the attempt to dispel the
     articular discomfort, he had accidentally bitten himself, but the
     consequent pain did not deter him from repeating and continuing the
     act until its execution was irresistible.

In these and similar cases, the infelicitous rehearsal of the movements
of mastication is practically always associated with an imperative
desire to experience a sensation at the place actually bitten.
_Cheilophagic_ children, who bite their lips unceasingly, usually
commence by nibbling at some half-separated fragment of epithelium on
the edge of a labial fissure, with the inevitable result that the
erosion is enlarged and fresh particles of the mucous membrane are
detached. Youthful candidates for tics can scarce escape from the
vicious circle. A juvenile patient of ours, F., was in the habit of
gnawing so vehemently at the most insignificant little irregularity of
the mucosa that his lips were constantly chapped and bleeding, and as
they were no less constantly being moistened by saliva, a succession of
new cracks made their appearance, to be promptly torn apart by the
teeth. Local applications of nauseous substances are not always
sufficient to discourage these young "cheilophagics."

It is still more frequent to meet with _onychophagia_, a condition
rightly held to be a stigma of degeneration, and acknowledging the same
pathogenic mechanism as all biting tics.

So much for the clonic tics of mastication: we pass on to review the
tonic forms, the most curious of which has received the name of _mental
trismus_.


MENTAL TRISMUS

The characteristic feature of this tonic tic is an all but permanent
contraction of the masseters, which may, however, be completely relaxed
by making the subject put out his tongue, show his throat, etc. It may
be maintained during the act of speaking. Its intensity and its
persistence alike stand in rigorous relation to the nature and degree of
the mental affection that provides its occasion. In the insane it may
become so absolute an obstacle to nutrition that recourse must be made
to nasal feeding. Mental trismus resembles mental torticollis in that
any proceeding to which the patient attributes a special inhibitory
virtue is adequate to correct it, as, for instance, the insertion of a
cork between the teeth,[75] or the placing of a finger on the
incisors.[76]

It must of course be clearly understood that the diagnosis of mental
trismus can be arrived at only after previous elimination of every
possible source of confusion, such as tetanus, more rarely tetany,
meningitis, and acute bulbar paralysis, in addition to other
mesencephalic and perhaps also certain cortical lesions. One is inclined
to be less dogmatic where tonic or clonic convulsions of the jaws
succeed violent fright, as in a case of trismus of nine months' duration
recorded by Billot and Francotte. For that matter, trismus is met with
in hysteria, and may be regarded as a manifestation of that disease,
although this cannot always be invoked as its cause. We are not
attracted by Kocher's idea of assigning it to an "idiopathic spastic
neurosis," preferring to ally it to tics of the tonic variety.

Among the crowd of circumstances that reflexly give rise to trismus may
be enumerated abscess, caries, alveolo-dental periostitis, eruption of
the wisdom teeth, disease of the maxilla and the neighbouring soft
parts, and less commonly myositis or injury to the masseters. But so
long as any one of these causes is in operation, and especially if the
affection be attended with pain, we are dealing with a trismus spasm,
not a trismus tic.

S., whose psychical imperfections have already formed the subject of
remark, supplies an example of the combination of mental trismus and
torticollis, the former being the outcome of an inopportunely reiterated
voluntary act, and therefore comparable to the tics.

     S. speaks with clenched teeth. His masseters are generally in a
     state of contraction, yet when he is requested to put out his
     tongue or to open his mouth, and when he is eating or engaged in an
     animated conversation, any and every movement of the inferior
     maxilla is accomplished with the greatest ease. According to his
     story, this tonic tic of the masseters had its origin in the
     forcible efforts he used to make to master his torticollis, in the
     course of which he would close his mouth firmly; by dint of
     continual repetition the habit developed into a tic, and persists
     apart altogether from any endeavour of his to prevail against the
     wryneck.

One of us has had a recent opportunity of examining a young woman whose
obsessions and fixed ideas, and tics of face and neck, indicated an
extreme degree of mental instability, in spite of intellectual power
above the average, in whom trismus of this type was very obvious during
eating and speaking. No effort, however concentrated, to open the mouth
was then of any avail; yet, on the other hand, she could sing to
perfection, and she could yawn, or show her tongue or her throat, in an
entirely easy and normal fashion.

The appearance of this trismus during the performance of certain
functional acts, and of these alone, is unequivocal evidence of its
mental derivation.


TICS OF THE NECK--NODDING AND TOSSING TICS--TICS OF AFFIRMATION,
NEGATION, AND SALUTATION

Regionally considered, the neck is second only to the face in furnishing
the greatest number of tics. Convulsive movements of the neck muscles
produce displacement of the head in all sorts of ways and directions,
giving rise to clonic tics of affirmation, negation, and salutation, and
to nodding tics, as well as to an important group of tonic tics which
find expression in differing forms of torticollis. The latter are so
distinctive in symptomatology and evolution, and have been the centre
round which so much discussion has raged, that a chapter must be set
apart for their special study.

Restricting ourselves for the present to such as are included in the
category of clonic convulsions, we find here abrupt vertical or
horizontal movements, as well as intermediate varieties compounded of
elevation, depression, inclination, or rotation. The most ordinary kind
is a sudden, brief jerk or toss of the head, repeated at irregular
intervals, and followed by instantaneous resumption of the primary
position.

Certain convulsive affections--for instance, the _spasmus nutans_ of
young children, the salaam tic, and what are known as "baboon
movements"--are still rather obscure and in many cases seemingly not
equivalent to tics. Their occasional association with strabismus or
nystagmus constitutes a plea for their possible dependence on some
encephalic lesion. In two cases under Oppenheim's observation the
nodding spasm appeared solely in the hours of the night and during
sleep. From want of more precise knowledge we must confine ourselves to
the remark that conditions analogous to, though not identical with, the
tics, in addition to others more specifically hysterical, have probably
been incorporated with them.

It is a task of peculiar difficulty to determine the share in the final
product to be apportioned to individual muscles, of which the
sternomastoids, as being the most superficial and the most obvious, are
apparently comprised the oftenest, though the trapezius and the muscles
of the underlying strata, such as the splenius, complexus, and other
smaller ones, may also assist.

     According to Guinon, isolated contraction of one sternomastoid,
     whereby the head is rotated and inclined once or twice or several
     times consecutively, to the usual accompaniment of facial
     contortions, is very frequently to be noted. If there occur
     simultaneous contraction of the platysma, its fibres will be seen
     to line the cervical integuments longitudinally from the chin to
     the infraclavicular fossa. Synchronous involvement of the two
     sternomastoids will flex the head and approximate the chin almost
     to the sternum, but more commonly there is only a slight forward
     inclination of the head exactly similar to a gesture of assent.
     Extension and lateral deviation are less generally encountered.

Extreme variability characterises the exciting causes of these tics. It
has been remarked more than once that insecurity of the headgear the
subject happens to be wearing ought to be blamed; instead of
readjustment with the hand, a little toss of the head will make the hat
sit properly, and one need not search further afield for the germ of the
patient's tic. We have been able to trace this mode of inauguration
quite as conspicuously in young men as in young women. Prohibition of
unstable head coverings and resort to exercises of immobilisation
suffice for the tic's correction in early cases.

A not infrequent accessory symptom--viz. elevation of the corresponding
shoulder--may have a similar origin in peripheral excitation connected
with the patient's clothing. To escape the annoyance of a high and
narrow collar, or, on the other hand, to experience an agreeable
sensation by rubbing the skin, it is a very simple and a very easy
matter to lean the head on the shoulder, and to raise the latter at the
same time. The automatic reproduction of this gesture eventually ends in
the formation of a tic which removal of the collar entirely fails to
suppress. The first therapeutic indication, nevertheless, is to
interdict the wearing of the unsuitable collar, and to recommend the
adoption of others softer and more ample. Whatever be the opinion one
holds on the mechanism of tic, the influence of peripheral stimuli is,
according to Pierre Marie,[77] very considerable, and it is his
invariable practice, in the case of youthful subjects, to impress on the
parents the desirability of paying special attention to their
children's clothing, and of discarding any article that is either stiff
or heavy.

     In one of our cases, a girl A., suffering from a nodding and
     rotatory tic of the head, examination of the cervical region
     revealed the existence of a line of cicatrices along the margin of
     the sternomastoid, the vestiges of a previous operation for a
     severe tuberculous adenitis. Some nerve filaments entering the
     sternomastoid and trapezius had no doubt been cut, since these
     muscles presented a minor degree of atrophy, and the irritation
     arising therefrom, as well at that due to dragging on the adhesions
     between the cicatrices and the underlying tissues, had been the
     starting-point of a motor reaction primarily convulsive and
     involuntary, but eventually habitual and automatic, and therefore,
     with the subsidence of the excitation, a tic.

In another case[78] a month's systematic treatment served to curtail to
a noteworthy extent spasmodic head movements resembling those one makes
to get rid of a fly.

From another point of view, some of the tics of this class are merely
the exaggeration of certain functions destined for the expression of the
ideas of affirmation and negation. The nod of the head with which little
G. used to punctuate his "yes's" was logical enough, but he soon began
its repetition irrespective of his topic of conversation, and even when
saying "no"--a veritable tic of affirmation.

Numbers of people are in the habit of emphasising their words with those
to-and-fro movements of the head that we call gestures of approval. Now,
if the gesture be strictly appropriate to the thought present in the
mind, it cannot be identified with the tics. On the other hand, its
execution may be inopportune, in which case, provided the form remain
normal, it is merely a stereotyped act, and must exhibit the additional
features of abruptness and exaggeration ere it rank as a tic.

It is chiefly among the mentally infirm, such as idiots and imbeciles,
that the phenomenon of salutation occurs, and as its rhythm is an
element which is foreign to most ordinary tics, it is not likely to be
confounded with them.

These conditions apart, however, there is one highly specialised
clinical type that merits separate study--viz. mental torticollis.


MENTAL TORTICOLLIS

The medical world has long been familiar with various kinds of permanent
or intermittent torticollis presumably unconnected with muscular,
articular, or osseous lesions of the neck, and been as long divided on
the question of their tabulation.

Instances of this affection, bearing such widely differing names as
"hyperkinesis of the accessory of Willis," "spasmodic torticollis,"
"functional spasm of the neck muscles," "rotatory tic," etc., have
abounded in medical literature ever since the days of Duchenne of
Boulogne, Trousseau, and Charcot. Some twelve years ago now, the term
mental torticollis was applied by Brissaud[79] to a type of convulsion
of the neck musculature whose association with psychical disturbances
justified its description as a tic, and his opinions have been
abundantly confirmed by later observation.

As a matter of fact, mental torticollis is a tic which the patient can
ordinarily curb by some procedure of his own invention. It has its
_raison d'être_ in his mental imperfection. To obviate misunderstanding,
we must premise that the latter term is not synonymous with mental
alienation. It merely signifies that lack of mental balance, to
whatever extent, that is patent in all sufferers from tic.

From the motor aspect the tic under consideration may be characterised
as a functional disorder, consisting in the ill-timed, inapposite,
unceremonious, and exaggerated repetition of the function of head
rotation. Notwithstanding the large number of muscles involved, the
various modifications of movement possible, and the consequent
complexity of clinical types, each individual case is recognisable as a
tic. Let but momentary cessation of the muscular spasm be effected, and
the torticollis disappears without leaving a trace. Instantaneous and
total prevention is in practically every case attainable by resort to
some subterfuge, however vehement be the patient's contortions.

This device, whatever it be, may be called the "efficacious antagonistic
gesture," of which the simple placing of the index finger on the chin
may be cited as an example. Its field of operation is not limited to
mental torticollis, and we shall have opportunities of observing its
working in greater detail in other tics; but in the former affection the
constancy of its occurrence and the facility of its detection combine to
enhance its diagnostic value.

We hasten to remark, however, that conditions other than those we have
just mentioned are capable of producing convulsive movements in the
muscles of this region. In addition to such osseous, articular, and
muscular alterations as may determine a more or less permanent
torticollis, certain nervous lesions are apt to be succeeded by the
development of the spasmodic form, no longer as a tic, but as a true
neck spasm, the due recognition of which may be a matter of no little
perplexity.

Confining our attention for the present to torticollis tic--the mental
torticollis of Brissaud--we notice, in the first place, that it affects
either sex indifferently. The age of our youngest patient was eighteen,
though in a case of Raymond and Janet's the disease made its appearance
four years earlier. A hereditary neuropathic or psychopathic factor is
invariable, but similar heredity is the exception. Paternal alcoholism
has been quoted by Guibert as a possible predisposing cause, also a
rheumatic diathesis (Bompaire), family trembling (Feindel), hereditary
stammering (Noguès and Sirol), nervous and mental disease in the parents
(Feindel and Meige). One of Oppenheim's patients had a peculiarly
sinister family history: the grandparents were related by blood, one
being a diabetic as well, and the other a lunatic; the mother was
nervous, and the sisters either epileptic or psychically abnormal. This
case was characterised by the existence of generalised tics in
childhood, and by the development of torticollis soon after marriage.

Among personal antecedents may be noted hysterical attacks (Sgobbo),
emotional unrest (de Buck[80]), migraine (Brissaud), neuralgia
(Bompaire), irritability, eccentricity, caprice, absentmindedness,
neurasthenia (Brissaud and Meige[81]). Other favouring circumstances are
moral shook, intense and prolonged emotion, remorse, preoccupation
(Bompaire, Sgobbo, Brissaud and Meige, Grasset). Purely extraneous
causes seem sometimes to be the starting-point; for instance, toothache
and dental inflammation (Souques[*]), pain in the neck from carrying
heavy loads (Amussat[*]), chill (Legouest, de Buck, Guibert[*]).

[*] Cited by BOMPAIRE, _Thèse_.

At the Congress of Limoges a case was reported by Lannois where the
onset of torticollis in a young girl was determined by an overpowering
impulse to gaze at a little papilloma on her nose. The extirpation of
the growth was followed by an amelioration of symptoms that amounted
substantially to a cure.

Mental torticollis consecutive to anthrax of the neck has been described
by Briand.

Other conditions that have been invoked as possible causes are the
intoxications and infections, alcoholism, saturnism, mercury poisoning,
typhus, pneumonia, paludism, etc. Oppenheim has signalised the
reappearance, after several months of respite, of a torticollis
secondary to an attack of influenza. Overwork, accident, occupation,
have in their turn been suggested. In some cases, as a matter of fact,
it does seem that the last is of some import, since the incidence of the
torticollis is to a certain extent on those muscles that have been
actively employed in the pursuit of a profession, and they thus acquire
a sort of functional hyperkinesis.

Graff's[82] case of clonic convulsive contractions of the left splenius,
left deep rotators, and right sternomastoid, occurred in an individual
obliged, when carrying heavy loads, to maintain his head in a fixed
position to the left, and unable thereafter to turn it to the right.

In some quarters no little importance is attached from the pathogenic
point of view to the actual state of the muscles, and in particular to
atrophy or hypertrophy of the sternomastoids. Féré holds that sometimes
unilateral atrophy may occasion abnormal contraction of the opposite
muscle, but such muscular changes are, in our opinion, much less likely
to be the cause than the consequence of reiteration of movement or
conservation of attitude. Legenmann's case was one of tonic and clonic
convulsion of the right sternomastoid where there was a cartilaginous
tumour in the left.

The rôle played by ocular affections, by troubles of vision and of
accommodation, in the genesis of wryneck is frequently no insignificant
one, and it is curious how often patients attribute the mischief to the
strain of overwork in bad light. Strabismus (Walton) and ocular palsies
(Nieden) have also been known to lead to lateral deviation of the head
and permanent torticollis. There has been described a variety _ab aure
læsa_.

Albeit these factors have a share in determining the gesture and
attitude adopted by the patient, the resulting torticollis is not of
necessity mental. That which, according to Romberg, is provoked by
compression of supraclavicular nerve filaments is unmistakably a spasm.

To establish the diagnosis of mental torticollis, the existence of those
psychical anomalies that are common to all who tic must first be
substantiated, and then must one essay the reconstruction of its
mechanism. The inquiry may at first prove fruitless, of course, but
continuation of the search can scarcely fail to elicit tokens of mental
infantilism. In pursuance of this quest we shall find ourselves face to
face with the "big baby," the personification of childishness,
obstinacy, and caprice; we shall encounter the peevish, the sulky, the
whining; we shall see how their impotence in presence of their tic turns
their nonchalance to profound despair, how their failure to adapt
themselves to their malady convicts them remorselessly of volitional
imperfection. The utter weakness of their will, according to Déjérine,
justifies their being ranked as neurasthenics; but in the latter class
of case obsessional ideas are both fugitive and fluctuating, whereas
mental torticollis is dependent on a fixed idea of peculiar tenacity.

There can be no doubt that such patients, however undimmed their
intellectual powers may remain, ultimately fail before the everlasting
obsession of their disease, and if in some cases interest in daily life
and work continues unabated, a multitude of others become indifferent
and apathetic, and sink into a state of physical and moral infirmity.

To retrace the steps in the evolution of mental torticollis is a task
not always easy of accomplishment. Very commonly the affection
supervenes as the sequel to the unhindered repetition of a once
voluntary purposive act, a repetition become tyrannical through
volitional debility. One or two extracts from published cases will serve
to illustrate the truth of our contention.

     1. To escape the pain of a dental abscess on the right side, of
     only four or five days' duration, the patient had acquired the
     habit of turning the head to the right and maintaining it so for as
     long as possible at a time. Very shortly after the healing of the
     abscess, the head commenced to move involuntarily towards the same
     shoulder (Souques[83]).

     2. Occipital neuralgia and pain in the neck led the patient to try
     various positions to allay the agony, in the course of which he
     found that rotation to the right brought transient relief. By dint
     of repetition the movement became involuntary (Brissaud and
     Meige[84]).

     3. In this case the subject used to spend the whole evening inert,
     arms folded, without reading or working, tilting his head forwards
     or backwards to rediscover a "cracking" in his neck from which he
     suffered--a proceeding that gradually developed into a tic
     (Brissaud and Meige).

     4. A schoolgirl was dissatisfied with the place allotted to her in
     the schoolroom, and pretended that she felt a draught on her neck
     coming from a window on her left. The initial movement was an
     elevation of the shoulder as if to bring her clothes a little more
     closely round her neck, then she commenced to depress her head and
     indicate her discomfort by facial grimaces, and these eventually
     passed beyond voluntary control (Raymond and Janet[85]).

     5. In order to deceive his friends, the patient assumed a forced
     attitude of gaiety when really sick at heart, by inclining his
     head, raising his shoulders, and arching his back, and at the end
     of a few months a bantering remark revealed the surprising fact
     that he could not correct the position (Raymond and Janet[86]).

     6. A woman used to pass the day sewing or knitting at her window
     and amusing herself from time to time by pensively looking out into
     the street. Not long afterwards she noticed how much more pleasant
     it was to allow her head to turn to the right, and how troublesome
     it was to keep it straight. At length she found this impossible,
     except with the aid of her hands (Sgobbo[87]).

     7. Worried by severe occipital pains, an individual became so
     concerned to find they were being replaced by a feeling of great
     weakness, that he let his head rest by inclining it now and then to
     the left, an act which he is certain was the cause of his
     torticollis (Feindel[88]).

     One further instance may be cited from Séglas,[89] where a
     neurasthenic lady, fifty years old, had been for three years a
     martyr to vague pains which finally settled in her neck, and
     asserted themselves on the slightest exertion. She sought to
     mitigate her sufferings--a veritable topoalgic obsession--by
     leaning her head on her shoulder, and the desire thus to procure
     alleviation gradually became irresistible and the movement
     unconscious.

Multiplication of examples is unnecessary. It is abundantly evident from
the above that the repetition of a deliberate and voluntary functional
act, co-ordinated and systematised, is the first step in the genesis of
mental torticollis.

The mere memory of a frequently repeated movement, especially if the
latter occur in the prosecution of one's avocation, may determine the
type of torticollis, as in Grasset's "post-professional colporteur tic,"
to which reference has already been made.

In the case of one of our patients, N., the prolonged and almost
exclusive use of certain muscles in the course of his business decided
their involvement in the condition of practically permanent torticollis
with which he was afflicted, and which was due to strong contraction of
the right trapezius and sternomastoid. It appeared that for eighteen
years he had been a cutter in a linen draper's, where it had been his
duty, for hours at a stretch, to cut rolls of stuffs with a large and
heavy pair of scissors, and in the execution of this work the right arm
was extended, the hand firmly pressed on the table, the shoulder
elevated, the head rotated and inclined to the left.

We cannot do better in this connection than recall the cases referred to
by Brissaud[90] when directing attention for the first time to this
variety of tics of the neck.

     Here is a patient with energetic contraction of the muscles which
     depress the head on the neck. She holds her head in her hands to
     inhibit the movement, and succeeds. And she is quite convinced that
     the force requisite for rectifying the vicious attitude is not
     simply the power of her will acting on the muscles concerned, but
     the strength of her hands. She has unconsciously doubled her
     physical personality; her hands obey her will, her neck does not.
     At least, this would appear to be the key to the situation, for it
     can be well understood how much easier it would be to readjust the
     position by action of the antagonist cervical muscles than by the
     hands. The contraction, moreover, is entirely painless. It is a
     trivial act of obsessional insanity, provoked by some or other
     insignificant psychomotor hallucination.

     Take this next man, who also must needs keep his head straight by
     means of his hand--obviously no irritation of the spinal accessory
     can be accused of originating the mischief, else would he be unable
     himself to replace his head. It is merely the idea that is urging
     him to its rotation. Try by force to prevent him from twisting his
     head round, or try to twist it against his will, and the difficulty
     of the thing will be at once comprehended. Or try to pull your own
     two hands apart to see which is the stronger, and you will never
     succeed, for the simple reason that abstraction of the will is
     impossible. One hand can prevail over the other only if both
     consent; the left cannot be in ignorance of what the right is
     doing. A "partial" or "local" will is inconceivable; there cannot
     be one for the head and another for the arm.

     Here is a third patient, presenting an identical muscular spasm. He
     is content to apply two fingers to his chin to overcome the
     otherwise irresistible bend of his head to the right. Such has been
     the situation for the last five years. No line of treatment has
     made any impression on this neurosis, to which two factors
     contribute, though one cannot say which predominates--an
     unconscious, imperious, motor impulse, and a conscious though
     ill-informed volition, powerless to arrest the convulsions by
     simple and normal media, and obliged to resort to a puerile
     artifice, to a sickly sort of deceit. The opposition furnished by
     two fingers only cannot be of any avail, yet, however feeble be the
     succour, the patient's imagination is thereby appeased.

     Such (adds Brissaud), fashioned in the same mould, are the
     "mentals" of whom I have been speaking. Recollect the ungovernable
     impulse they feel to execute a convulsive movement that their will
     might thwart; remember, therefore, at the same time, their
     volitional enfeeblement.

Brissaud's earliest observations were followed at no long interval by
various articles, first of all the thesis of his pupil Bompaire,[91]
then others in collaboration with ourselves. The more recent
publications of Lentz,[92] Sgobbo, Noguès and Sirol, Raymond and Janet,
Séglas, Etienne Martin, etc., may be mentioned, as well as a
contribution by Grasset,[93] notable alike for the case it contains and
for the author's interpretations.

The view that considers of prime importance the psychical phenomena of
this affection has received general confirmation. We have seen
protracted cases of "spasm of the accessorius" cured, exactly as with
the tics, by widely differing therapeutic agents. In numerous instances,
according to Oppenheim, torticollis is not consecutive to any peripheral
or central change in the nervous system, but rather indicates
irritability of nerve centres. It is probable that the kinæsthetic
centres in the cortex for the neck muscles are the seat of the lesion,
and that their congenital and hereditary imperfection fixes the form the
convulsion will take.

These and similar facts are well calculated to corroborate the opinion
that mental torticollis is nought else than a form of tic. The subjects
of the disease are satisfied of two things--that no one and no
circumstance can hinder their torticollis from asserting itself, and
that their own antagonistic gesture is the sole efficacious preventative
at their command. The attempt to put the displacement right evokes acute
pain and stimulates opposition on their part. They prefer the display of
considerable resistance to the renunciation of their satisfaction in
their tic, and follow up any momentary restraint by a riot of
inco-ordination, in recompense for the brief sacrifice they have made to
preserve immobility.

The muscular contraction that deviates the head may be either clonic or
tonic, bringing it to one side by a series of convulsions and allowing
it to resume its original position in the intervals, or forcing it to
maintain a vicious attitude for hours. Innumerable variants may occur,
indeed are the rule, even in the same patient. In short, though mental
torticollis may generally be classed as a tic of attitude, it matters
but little whether the adoption of the attitude or the attitude adopted
constitutes the tic. They are simply two successive phases in the same
abnormal muscular act. The most elementary movement is rotation of the
head; it may equally well be inclined on one shoulder, or be both
inclined and rotated to one side, or it may be inclined in one direction
and rotated in the other. There may be accompanying elevation of the
shoulder, or the act may become a much more complex one, involving neck,
shoulder, and arm.

Each and all of the neck muscles may take a share in the torticollic
movement, but some are more commonly affected than others, in
particular the sternomastoid, whose contraction may either be
isolated,[94] or modified by trapezius, splenius, levator anguli
scapulæ, etc., of the same or the contralateral side. It is frequent to
find the head inclined to one side and rotated to the other by the
action of the sternomastoid, or displaced backwards and slightly turned
to the side of the contraction by means of the splenius. If the
sternomastoid and homolateral trapezius are acting together, torsion of
the neck is very pronounced and the skin over that area is deeply
lined.[95] It may happen that the head is rotated and inclined to the
same side, as in Grasset's case, where the curious combination occurred
of clonic convulsion of left trapezius and pectoralis major with right
pectoralis major and sternomastoid. In the same patient the left arm was
pressed against the trunk and the right extended posteriorly.

There are other instances where it would be more accurate to speak of
_retrocollis_, as in a case recorded by Brissaud, or _procollis_, the
two sternomastoids contracting synchronously, as in another case due to
Duchenne of Boulogne. The extreme degree of flexion induced in this way
was neutralised immediately by supporting the head; the adoption by the
patient of a reclining position sufficed to inhibit the tic's
manifestation.

Intensity and frequency of movement, duration and deformity of attitude,
all alike may vary in the same individual at differing times. Solitude,
tranquillity, and repose favour the diminution and even the entire
disappearance of spasmodic movements which fatigue, anxiety, and emotion
are prone to exaggerate. An instructive case in point is one of van
Gehuchten's,[96] the subject being a labourer twenty-five years old, in
whom a tic of the right arm and right sternomastoid of seven years'
continuance disappeared whenever the patient was by himself, to burst
out afresh as soon as he was conscious of being observed.

Distraction is a valuable sedative. A patient of ours used to pass the
day in twisting his head round with ever-increasing violence, while at
night, amid the smiling gaiety of the theatre, hours slipped by without
his betraying the least suspicion of his malady.

Occupation, on the other hand, may provoke the condition. Duchenne has a
reference to a case where rotation of the head to the right commenced
whenever the subject started to read, and ceased only with the laying
down of the book. In one of our cases the head kept turning whenever and
as long as the two hands were simultaneously engaged in some pursuit. If
one hand was disengaged, there was no torticollis.

As a general rule, excitement invites or increases movement, whereas
sleep frustrates it, and after a good night's rest several minutes or
even an hour or two may elapse ere the convulsions reassert themselves.

Acute pain is rarely met with in the disease we are considering, but
sensations of discomfort, of tension, of strain in the muscles, form a
common subject of complaint.

By way of example may be cited the case of one of our patients:

     L. is eighteen years old, and has been suffering from torticollis
     for the last six weeks. The chief movement is abrupt rotation and
     very slight inclination of the head to the right, and the muscles
     principally concerned are the left sternomastoid and the right
     splenius. The head is sunk between the shoulders, of which the
     right one is elevated synchronously with the rotation, and remains
     so as long as the latter persists.

     The displacement is effected by a moderately brisk muscular
     contraction that rotates the head to the right on its vertical
     axis, and succeeding contractions only serve to accentuate the
     deviation or to maintain it when the head is beginning to revert to
     its original position. There are none of those upward or downward
     oscillations, those hesitating, tentative little jerks that some
     patients make before assuming a fixed torticollis attitude. In L.'s
     case the duration of the wryneck is exceedingly variable; sometimes
     the head returns spontaneously to its place, and deviates afresh
     immediately after, but its periodicity changes with the days, and
     even with the minutes.

     The torticollis is accompanied by a rather disagreeable sensation,
     a feeling of fatigue in the muscles concerned, of "dragging" in
     their bellies as well as at their insertions. The site of this
     sensation is over the left sternomastoid, on the right half of the
     posterior aspect of the neck, and deep in the right shoulder,
     whereas the upper parts of the trapezii, the left half of the neck
     and its anterior surface, and the right sternomastoid, are areas
     that are free from pain.

     Here, further, as in all cases of the same nature, the subjective
     sensations differ from day to day, and moment to moment. It is just
     as perplexing to localise these pains exactly as to fix the
     topoalgia of a neurasthenic. The lack of precision of the answers
     is no doubt explicable by the variability of the muscular
     contractions.

     Emotion, apprehension, the presence of strangers, tend to intensify
     the spasm, which tranquillity and rest will attenuate. On the other
     hand, the most trivial incident--a sudden noise, an unexpected
     question, the act of swallowing saliva, of putting out the tongue,
     etc.--will reawaken the latent torticollis; any surprise, any
     movement, or even the idea of a movement, suffices for its
     ebullition.

     Under the influence of the will, particularly after a time of rest,
     the head may sometimes reoccupy the mid position spontaneously, a
     result unfailingly obtained by distraction also, as when the
     patient is hearkening thoughtfully to her father's conversation. On
     her "bad days," however, the use of even considerable force fails
     alike to hinder the head's turning and to effect its replacement.
     That is to say, the resistance offered by the torticollis to
     reduction may at one moment be nil, at another, feeble, or
     forcible, or even insuperable.

Some patients affected with mental torticollis seem to have lost the
sense of position of their head, others evince a want of precision and
assurance in the execution of different limb movements. Speaking
generally, it may be said that downward movements of the arms are less
good than upward ones, and that their synchronous and symmetrical
action is accomplished with greater ease than is the operation of one
only.

The debut of mental torticollis is usually insidious. Whether head or
shoulder be implicated first, the incipient motor reaction is
infrequent, inconsiderable, and transitory. Little by little its
frequency increases and its duration lengthens, till the end of a few
months sees the torticollis established.

It may happen that the onset is so stealthy that it eludes the subject's
own notice, and attention is called to his peculiar attitude by the
members of his circle. Not seldom the earliest localisation of the
condition in a particular muscle is abandoned in favour of some other,
and resumed at a subsequent stage. Occasionally the torticollis passes
from right to left, or vice versâ; occasionally, too, the clonic variety
may give way to the tonic after a few weeks or months.

It has been already remarked that at the outset the tic is infrequent,
and may depend for its manifestation on certain predetermined
circumstances, as, for instance, the exercise of the faculty of writing.
Such was the case with S., with P., and with N.

     N. was a patient forty-eight years old, with a left torticollis
     dating back twenty months. His account of its origin was to the
     following effect: for some years he had been employed in a
     commercial office, where from seven in the morning to eight at
     night he was occupied in writing, head and body being turned to the
     left. At the beginning of 1900, consequent on a succession of
     troubles, he noticed that his head was twisting round to the left
     in an exaggerated fashion while he was writing, and the rotation
     gradually began to assert itself at other times, when he was
     reading, or eating, or buttoning his boots. Even apart from any
     other act, the rotatory movement soon became incessant, continuing
     while he was on his feet, but vanishing completely if he lay down
     or if the head was supported. At present he has the greatest
     difficulty in writing, for his head at once deviates violently to
     the right.

The spasmodic movements sometimes spread to the shoulder, arm, and
trunk, and, in one of our cases, to the leg. Should the condition be
advanced, it is frequently complicated by choreiform or athetotic
movements in the limbs, or by irregular and arhythmical tremors.

A case of this nature was shown at the Neurological Society of Paris by
Marie and Guillain[97]:

     The patient, forty-nine years of age, was suffering from muscular
     spasms that kept turning his head first to one side and then to the
     other. Fixation of the head between the hands assured a few
     moments' respite, but the convulsions were quick to reappear. The
     left hand was constantly being brought up to the face in the
     endeavour to procure immobility, while the arms were the seat of
     abrupt jerking movements intermediate between tremor and chorea.

     The various reflexes were normal; stimulation of the sole of the
     foot evoked a flexor response on either side, and no symptom of
     hysteria was forthcoming. The disease had made its appearance in
     1879, when, without discoverable motive, the head had commenced to
     tremble and to work round to the left. Section of the tendon of the
     sternomastoid did not impede the development of the affection,
     which two years ago increased in intensity, when the
     above-mentioned movements in the arms were superadded. The
     likelihood seemed to be that they were of the same nature and
     origin as the torticollis itself.

In reference to this communication, the following remarks were offered
by Professor Brissaud:

     It is true of all forms of functional hyperkinesis, that the
     indefinitely prolonged repetition of the same act leads finally not
     merely to muscular hypertrophy, but to a ceaseless over-activity of
     contraction in all the muscles affected. That this hypertrophy and
     hyperexcitability depend on some organic central lesion is not the
     necessary sequel. A purely functional exasperation may entail
     visible augmentation of movement, the cause of which is not
     central, but lies in the external manifestation of muscular
     over-activity.

The antagonistic gesture is, in some instances, contemporaneous with the
wryneck, although more usually it is not in evidence until months or
years after the distortion has become inveterate.

Mental torticollis is characterised by remarkable chronicity. We have
seen cases of ten or fifteen years' duration and more. Temporary
remissions have been known, however, and alternations with other tics or
with psychical affections. At the Congress of Limoges, the following
case was reported by Briand:

     As the result of a bicycle accident, a young man developed a
     torticollis which ordinary treatment was sufficient to cure, and it
     remained in abeyance until he entered a government school, when its
     place was taken by a tic of the shoulder, with twitching of the
     mouth and eye. At the approach of the annual vacation the tic
     disappeared, and the torticollis, for some simple reason or other,
     became obvious again. The latter had once more been got under
     control by the time the holidays were over, but on the patient's
     re-entering school the shoulder tic again manifested itself, and
     this sequence recurred several times. A permanent cure was
     eventually effected, but he continued as psychasthenic as ever.

In another of Briand's cases torticollis alternated with astasia-abasia,
a sort of "mental paraplegia." The patient could not walk at all without
crutches, or without a little _minerve_, which he used either to steady
his gait or to keep his head straight.

No doubt facts such as these just given are rather uncommon, but there
is abundant reason for considering mental torticollis one of the most
tenacious and intractable of all tics.


TICS OF THE TRUNK

The rarity of isolated involvement of the thoracic muscles, and the
frequency of their inclusion in tics of the neck and limbs, arise from
the fact of their insertion into the bones of the extremities, and
consequently conditions affecting them will be dealt with in another
place. Omitting for the present all reference to the muscles of
respiration, we have to consider only the vertebral and abdominal
groups. These pass into activity in the rhythmical salutation and
balancing movements so common among idiots, movements bearing the most
intimate analogies to the tics, though their peculiarity of rhythm
justifies their separate classification.

Tonic contractions that find expression in attitude tics of the body are
generally associated with tonic tics of the neck and limbs, and in some
cases of mental torticollis the deformation they produce is extensive.

The material part played by the abdominal muscles in the function of
respiration explains their implication in respiratory tics. A curious
case of this kind has been published by Pierre Janet[98]:

     A woman thirty-two years old had been afflicted for three years
     with a respiratory tic that consisted in imitating with the lips
     the neighing of a horse, and with a still more extraordinary tic of
     the abdominal parietes. She appeared to "swallow her stomach"; in
     other words, her abdomen, prominent enough in its ordinary state,
     was flattened and retracted, and the skin so stretched and dragged
     upwards that the umbilicus approached the costal margin. Just as it
     seemed to be disappearing, to be "swallowed," relaxation of the
     abdomen slowly took place, and this procedure was repeated ten or
     twelve times a minute. Pressure on the epigastrium inhibited the
     abdominal movement, but was accompanied by immediate renewal of the
     neighing, whereas with the relief of the pressure the sequence of
     events was inverted.


TICS OF THE ARM AND OF THE SHOULDER

In the upper extremity tics may affect the various muscles of the
shoulder, arm, or forearm. Shoulder tics are of frequent occurrence, and
often owe their origin to the discomfort of a tight sleeve or of a badly
fitting collar. They are generally a concomitant of neck tics, in
particular of mental torticollis.

In this connection we may recall the case of O., and supplement it by a
description of another--viz. young J.

     This boy J. had always been "nervous," and affected with "nervous
     movements" of face or limbs. At the age of thirteen years, when
     playing in the house one day, he knocked himself against an open
     door and bruised the shoulder near the outer end of the left
     clavicle. Three or four days later all pain and discolouration had
     vanished, and the child's movements were perfectly unimpeded again.
     His tics continued as before.

     Two months after this little accident was over and forgotten, it
     was remarked that at the seat of the contusion there was a slight
     swelling, quite painless and scarcely even uncomfortable, but
     disquieting enough to the parents and thought to require
     applications of neapolitan ointment and the actual cautery. This
     line of treatment effected no alteration in the local condition,
     but it had other far-reaching consequences, for the boy noticed the
     anxious interest aroused by the singular exostosis, and began to
     devote attention to it himself. From the moment that his parents
     manifested their apprehension by words of pity and by solicitous
     examination, his tics developed a preference for the left shoulder,
     though continuing to exhibit themselves in the face and the right
     arm. He would unexpectedly elevate or depress his shoulder, would
     shrug it forwards or brace it back, accompanying the performance
     with inclination of the head or abduction of the upper extremity.
     He was very positive as to the painless nature of his affection;
     his sole complaint was of a certain stiffness in the joint, and at
     the thought of it came an impulse to move the shoulder which there
     was no resisting. The twitching would disappear for a time for no
     fathomable reason, and reappear again. By the exercise of a little
     circumspection he could temporarily overcome it, and during sleep
     it subsided entirely.

     The facts--duly controlled and confirmed by the parents--that
     involuntary shoulder movements preceded not merely the application
     of the counter-irritants, but the accident itself, and that the
     unique difference lay in the similarity of his shoulder tic to all
     his other tics before the trauma, and in its marked preponderance
     in degree and frequency after, especially subsequent to the
     treatment, are of weighty diagnostic significance. Plainly the
     injury and its sequelæ did not exert any causative influence on the
     tic, and while it is conceivable that the clavicle may have been
     cracked and an exostosis ensued, we must repeat that the
     pre-existence of the movements in question negatives the
     possibility of their being attributable to nerve irritation from a
     periosteal overgrowth. The only effect which the accident and its
     consequences had was to intensify the patient's preoccupation and
     to determine the incidence of the tic.

     By the month of October, 1900, the latter was at its height, and
     had reached a state where differentiation of the movements and of
     their muscular counterparts was attended with no little difficulty.
     They could be resolved into four principal groups, whereby the
     shoulder was raised, lowered, advanced, or drawn back,
     respectively. The first of these presented no unusual feature
     except that with it the head was commonly inclined to the same
     side; but the act of depression was rather peculiar, inasmuch as it
     was achieved by a sudden contraction of the inferior muscles of
     the scapula, together with the pectoralis, which drew the humeral
     head downwards, elongated the capsule, and stretched the deltoid
     fasciculi over it. The space thus left between the separated
     articular surfaces was partly filled in by the neighbouring
     ligamentous and muscular structures. Anterior or posterior
     projection of the shoulder took place at the expense of an actual
     subluxation, the head of the humerus bulging under the pectoral or
     the scapular muscles. Each and every movement was accompanied by
     articular cracking, sometimes so insignificant as scarcely to be
     pathological, to which, nevertheless, the boy attached extravagant
     importance and devoted methodical investigation.

     Ordinary arm movements were, without exception, unimpaired, nor was
     any bony malformation discoverable. The two shoulders were
     practically symmetrical, though the upper border of the trapezius
     on the left side was, if anything, thickened and more prominent
     than its fellow, and the same applied to the left scapular muscles.
     Horizontal extension of the left arm revealed a slight
     tremulousness, quite distinguishable from pathological tremor and
     from fibrillary twitching, and wholly comparable to what is seen
     when, by reason of a fracture or otherwise, a limb is for a certain
     length of time prevented from executing movements of extension.

[Beating or striking tics (the patient using his own fist against
himself) arise from the attempt to alleviate some insignificant pain or
irritation; but tics of this kind are in their turn the exciting cause
of local discomfort, and so of fresh tics. In spite of the obviousness
of this, it is often difficult to convince the patient that his
movements are prior, not consecutive, to the unpleasant sensations.[99]]

Finally, tonic tics of the upper extremity find expression in attitudes
that vary with the localisation of the contraction. We have already had
occasion to observe this, which is an almost constant phenomenon in
mental torticollis, in the case of young J., in Madame T., and in N.,
where, it will be remembered, the all but permanent elevation of the
right shoulder seemed traceable to the habit of cutting stuffs with a
pair of large scissors.


TICS OF THE HANDS--SCRATCHING TICS

Scratching movements are infinite in their variety, and since the
co-operating muscles vary in each case, the question of muscular
localisation is of secondary interest.

The object in view in the act of scratching is relief from some such
source of cutaneous irritation as a pimple, an abrasion, a burn, the
bite of an insect, etc., and so long as the cause persists, the function
is being rationally exercised; but to persevere mechanically,
involuntarily, immoderately, in the absence of pruritus or of other
paræsthesiæ, is a sign that the functional act is growing into a tic.
Innumerable tics are thus developed, and they are intimately associated
with biting tics.

S. passes his hand every instant over his forehead, O. over his eyes, T.
over her lips, P. over his moustache, young J. over his budding
whiskers, etc., etc. These elementary tics are scarcely more than
stereotyped acts, and may maintain the semblance indefinitely, though
there is also the likelihood of their becoming immeasurably more
pronounced.

M. scratches his lips with his nails till they are bleeding; E. suffers
from a facial tic, and scrapes at his forehead and temples to such an
extent that his complexion is perpetually blooming with a crop of little
bleeding excoriations; in some places, as a result of ceaseless rubbing
and tapping, the skin is thickened and discoloured--a condition that
might be known as "scratchers' corns." Madame W. used to tear at her toe
nails with her fingers whenever she had retired for the night; and at
the present time, as a result of incessantly passing a fine gold chain
between the pulp of her fingers and the nails, she has succeeded in half
detaching the latter from their bed.

A case reported by Raymond and Janet[100] is one of unusual severity.

     A little girl ten years old was covered from head to foot with
     scabs and sores, some of which on the body were several centimetres
     in diameter and looked very ugly. These she had contrived to
     inflict on herself, in spite of every precaution and admonition. It
     appeared that successive attacks of measles and of whooping-cough
     at the age of five had entailed long rest in bed, and had been
     followed by a tardy convalescence, in the course of which the
     development of a few pimples on the forehead was the signal for her
     to commence scratching them and any other part of her body where
     there was the least discomfort, or where the skin was at all
     roughened. This merciless self-mutilation ended in the production
     of large and painful excoriated areas; nevertheless a tic had
     sprung from the habit, and it remained inveterate.

Another analogous case is quoted by the same observers[101]:

     In this instance, apart from the obvious existence of a confirmed
     tic, the patient had a curious look about the eyes which a nearer
     glance showed was caused by complete absence of the eyelashes. He
     had a trick when speaking or talking of lifting his right hand and
     running his finger carefully along the margin of the lids, and if
     it encountered an eyelash projecting beyond the skin, he promptly
     plucked it out. The endless repetition of this toilette rendered
     the eyelids barren of lashes.


TICS AND WRITING

Are writing tics to be recognised?

Tricks and turns of writing, however ridiculous, involuntary, and
ingrained they be, scarcely deserve to be called tics. Those flourishes
and ornaments that some people take delight in adding to their letters
can no more be considered the expression of a pathological state than
the superabundant gestures, the redundant words, the exuberant mimicry,
of which others are so prodigal. They are simply modes of
exteriorisation peculiar to the individual, and if in their superfluity
and excess they go beyond the strict requirements of the case, still,
they are only mannerisms of writing or of speech. Their manifestation is
rigorously dependent on the performance of some function, and is not
preceded by an imperious need of execution.

More akin to the tics is stereotypy of written language, so common an
appanage of mental disease. The term is intended to include such habits
as repetition of a particular formula, underlining of words, constant
use of hyphens in the same way, writing of certain pages in a hand
differing from the rest of the manuscript. Séglas[102] has done
excellent work in the analysis and interpretation of these troubles. One
of his patients used every week to write letters bearing the same
complicated address, and signed invariably with the following rigmarole:

     De Senez de Mesange, great Prince Napoleon, great Prince of the
     Blood Royal and Imperial of the Universe, great Admiral, great
     Marshal of my armies, ... great Procurator of the Republic, Royal
     and Imperial, great President of the Republic, Royal and Imperial,
     great Pope, great Duke, great King, great Emperor--Jupiter, Louis
     XIV. and Louis XV.

Another would write after almost every sentence:

     _Dieu et son droit_, let him be cursed in all that is most cursed
     _qui mal y pense_.

This was a sort of exorcism, a cabalistic formula enabling the
persecuted unfortunate to defend herself against the wiles of the evil
spirit.

A tic of writing, however, is of a totally different nature. He who,
without pen or pencil, is constrained by irrepressible impulse to go
through the movements of writing with his fingers, convulsively,
impetuously; and he who, without rhyme or reason, feverishly traces
characters utterly at variance with the ideas he would express, are
alike subjects of a writing tic. Of the former, we know no
characteristic example, while in the latter case the study of the
phenomenon would lead us too far into the realm of automatic writing and
graphic impulsions. We must content ourselves with recalling its
occurrence in an undeveloped form in the case of O.

Among those who are affected with tics, disorders of writing are very
infrequent, even where the tic's exhibition is displayed in the upper
extremities. One of the distinctive features of tics, in fact, is the
brevity of the interruption they cause in the performance of any
voluntary act on the part of the patient. Tics of arm or hand effect but
little modification of his writing. He is rarely taken aback by his
tic's convulsive demonstration. He can permit the co-existence, on a
perfect understanding, of two automatic acts, normal and abnormal,
writing and tic.

     One of Guinon's patients was wont to proceed in the following way:
     if asked to write, he would lean on the table, pick up his pen, and
     just ai it was about to touch the paper, make several little
     movements of circumduction with his right hand, as a child does.
     Thereafter, he would sometimes pass on at once to trace the
     letters; at other times he would have to grind his teeth, contort
     the right half of his face, put out his tongue, pucker his nose, or
     dip his pen spasmodically into the ink ten consecutive
     times--ejaculating ahem! ahem! the while--before being able to
     commence. He would often cease altogether, to make one or two
     grimaces, or to wave his hand about. As far as the actual writing
     was concerned, its distinctness and evenness were no less
     praiseworthy than its style and content, and though a glance at his
     gesticulations led one to expect blots and irregularities in his
     manuscript, he conducted his task with assurance and correctness.

Of course, if the tic, whatever it be, exceed a certain limit of
frequency and violence, accurate writing may amount almost to a physical
impossibility, in which case the patient usually discontinues, although
if called on to exercise his will he can always pen a few words and
even a few lines. However this may be, the spots and scrawls and zigzags
and shaky cramped characters we associate with such organic affections
as tabes, Friedreich's disease, paralysis agitans, etc., are wholly
exceptional in the case of tic.

While, then, disturbances of the function of writing are seldom
ascertainable in those who tic, we have convinced ourselves on more than
one occasion of the truth of the converse, that the exercise of the
faculty is sometimes intimately combined with the evolution of tics of
neck and shoulder.

S. dated his mental torticollis from the time when he used to copy
figures for several hours a day. As a matter of fact, he wrote an
excellent hand, and experienced no difficulty in performing the
necessary movements, but continued writing increased the rotation. N.'s
torticollis was the sequel to long spells of office work, during which
he never laid down his pen. In the case of L., the wryneck and the
convulsions of the right arm were preceded by a sort of writers' cramp
of the right hand, and subsequently of the left.

In the accompanying instance, the development of which one of us has had
the opportunity of observing, the appearance of the torticollis was at
first confined to occasions of writing, but gradually it came into
evidence with other arm actions, and eventually established itself in a
permanent fashion.

     P., fifty years old, occupies a responsible position in a big
     railway company, is director in a large office, and performs his
     duties with peculiar conscientiousness and zeal. Naturally an
     emotional man, he was much distressed by an unusually sad family
     bereavement about the middle of 1900, which coincided with a period
     of great overwork. As he was obliged every day to arrange
     innumerable papers and affix his signature to them, he began to
     notice that each time he wrote his name his head turned to the
     right involuntarily, and he felt a sensation of discomfort in the
     neck and right shoulder. He tried to remedy the faulty position by
     holding his chin with his left hand; nevertheless, in the course
     of the next few months the movement began to assert itself not
     merely as he wrote his signature, but also when he cut his food at
     table, or sharpened a pencil, or trimmed his finger nails.

     _October 14, 1901._--Whenever P. proceeds to write, his head is
     immediately rotated to the right and maintained in that attitude by
     successive contractions. Simultaneously, the right side of the face
     is distorted by a grimace, the right eye blinks, and the right
     corner of the mouth is drawn down by a strong effort of the
     platysma. The state of affairs is unaltered so long as he is
     handling a pen, though, curiously enough, his caligraphy itself is
     flawless. The more firmly he grasps his pen, the more violent the
     spasms; the substitution of a pencil abates them somewhat, as does
     writing on the floor with a cane, while if he traces letters in the
     air in front of him with his finger, they do not occur at all. When
     both hands are occupied in writing, the head still turns to the
     right.

     He was advised to incline his head on his right shoulder as he
     wrote, and to force his right sternomastoid to contract, in
     carrying out which instructions he managed to form several hooks
     and rods correctly without any torticollic movement, and was both
     elated at the success of the experiment and dejected by the thought
     of his infirmity. Accordingly all writing was prohibited, all
     signature making reduced to a minimum, and he was recommended a
     simple pencil exercise, to be performed with slowness and
     deliberation while the head was kept in the position just
     mentioned. Identical rules were to be observed when eating, etc,
     and a tepid bath was prescribed night and morning.

     _October 21._--Some improvement has taken place. The patient is
     less uneasy and less discouraged. Dissociation of the movements of
     writing into their component parts and isolated execution of each
     are accomplished admirably at the first trial, less well the
     second, and at the third, rotation recommences. Fatigue rapidly
     increases, and P. sinks again into impatience, enervation, and
     despair. Occasionally his anguish is so extreme he is covered with
     perspiration even after the most elementary pencil drill, and is
     forced to mop his brows.

     _November 21._--Improvement is maintained. He can now write various
     letters and short words at his ease, though he still feels
     uncomfortable in anything requiring a more sustained effort.
     Otherwise, he is conscious of greater control over his head.

     _December 15._--The amelioration has not persisted. While he was
     paying a visit to the barber's, and having his hair cut, rotation
     to the right began again, and when lifting his hat in the street to
     salute a friend, he repeated the movement. At table, too, he
     noticed it as he was in the act of bringing his glass to his mouth.
     P. is consequently upset, and often plunged into tears.

     _December 24._--The patient's condition is more than ever
     deplorable. On the slightest provocation--indeed, on no provocation
     at all--furious torsion movements force the head backwards and to
     the right, while the right shoulder rises.

     Complete rest in bed was ordered, yet after two or three days of
     this repose the torticollis manifested itself even in the recumbent
     position. As a result, he was quite unnerved and talked of suicide.
     Another physician called in consultation agreed with what had been
     done, confirmed the integrity of all the reflexes, including the
     plantars, and recommended a course of electricity.

     _January 20, 1902._--There has been no further change. P. stays
     abed all morning, inventing endless arrangements of pillows and
     dictionaries to prop his head. When he goes out for a walk, he
     turns up the collar of his coat and leans his head on the point of
     it.

     _January 27._--The electrical treatment has been relinquished. He
     has also taken one douche at a hydrotherapeutic establishment, but
     expressed his dissatisfaction and vowed never to return. He then
     departed to undergo a "water cure" in the country, since when he
     has vanished entirely from observation.

More than once we have had occasion to notice that the degree and extent
of such neck and arm convulsions as are provoked or exaggerated by the
act of writing vary with the level at which the patient has to write.
With elevation of the arm the movements are weak and easily mastered;
conversely, lowering of the arm augments them in a marked manner. We
repeat, however, that in all these cases the handwriting itself is not
interfered with.

It is quite otherwise with writers' cramp, the so-called "graphospasm"
or "mogigraphia." This condition is purely and exclusively a disorder of
the function of writing, depending for its exhibition on the exercise of
this function, else is its existence concealed. For this reason it ought
to be differentiated from the tics, although, by its development in
obvious neuropathic or psychopathic subjects, it is closely linked to
them.

One of Oppenheim's cases was a lady whose husband suffered from
paralysis agitans; in her case, fear of becoming affected with the same
disease led to the development of writers' cramp. Sometimes it occurs in
families, and it may be a concomitant of genuine tics. In spite of the
affinity between these two sorts of functional disturbance, we do not
feel it incumbent on us to enter on a detailed study of scriveners'
palsy in this place.


TICS OF THE LOWER EXTREMITIES--WALKING AND LEAPING TICS

Tics of the lower limbs are infrequent, and seldom isolated. One of the
most habitual of these is the "kicking tic." Sometimes one leg knocks
against the other, as in O.'s case, or it is kicked out in front, or to
the side, or even backwards, after the manner of a horse. Tonic
convulsions of the leg muscles have been observed to give rise to
phenomena analogous to tonic tics. Tonic contractions restricted to a
particular muscle, or group of muscles, and accompanied by relaxation of
the antagonists, have been christened by Ehret[103] "habit contractures"
and "habit paralyses." Their characteristic feature is the fact of the
contracture being voluntary in origin. For instance, an individual
wounds the inner margin of his foot, and learns to escape the pain by
throwing his weight on the outer side. Voluntary contraction of the
adductors of the foot passes gradually into an involuntary stage, giving
place to spasmodic contraction, and the simultaneous inactivity of the
antagonists--in this case the peronei--leads ultimately to their
atrophy.

In Ehret's view the fact of loss of volitional control argues the
psychical nature of the affection, and a similar opinion is held by
Thiem, Jacoby, and Wolff, who attribute the analogous cases they report
to a sort of traumatic neurosis in which the psychical element is
preponderant. Needless to remark, the patients in question were not
suffering from hysteria.

In this connection ought to be recalled the cases described by Raymond
and Janet[104] under the title of "tics of the foot."

     The first was a woman thirty-seven years old, who as she walked
     used slightly to invert her left foot, forcibly dorsiflex the great
     toe, and separate the remaining toes widely one from the other.
     Notwithstanding its painful nature, the condition had persisted for
     seven years, and had originated in a very interesting way. She
     happened to be undergoing a course of mercurial inunction at the
     same time as she was troubled with a corn. The idea struck her that
     perhaps the application of the ointment to the corn might prove
     efficacious, but while trimming the latter some days later, she had
     the misfortune to cut herself. Dread of the possible evil effects
     of the injury was followed on the morrow by an accession of cramps
     in the foot, the continuance of which led to the deformity that
     ever since had made walking a misery.

     The other patient was a young man twenty years of age, whose gait
     used to be arrested, after a walk of ten minutes, by sudden and
     vigorous plantar flexion of his right toes. Momentary repose
     sufficed to make the spasm disappear, but it constantly recurred.

Re-education and psychotherapy effected a cure in each instance, so that
their psychical nature cannot be called in question, nevertheless the
painful character of the affections must not be forgotten, and since the
occasions of their manifestation were confined to the act of walking,
they correspond rather to "functional" or "professional cramps." In any
case, they cannot be confounded with the painful cramps of the calf
muscles that characterise certain toxæmias and infections (alcoholism,
cholera, etc.).

On the other hand, there can be no doubt of the existence of definite
tics of walking--widely varying functional derangements of tonic or
clonic type, distinguished by the unexpected interruption of ambulatory
rhythm.

     We have met with a patient (says Guinon) who would abruptly halt
     and bend his knees at though he had just received a violent blow on
     the hock for which he was unprepared. To see him, one would have
     thought he was about to sink to the ground.

Such tics of genuflexion are not particularly uncommon. Oddo[105] has
recently recorded a very instructive example, whose pathogeny he has
been at pains to elucidate.

     A little girl, Th., ten years of age, takes four or five perfectly
     normal paces when she starts to walk, then bends down quickly to
     the right, flexing her knee to an acute angle and inclining her
     trunk forward with the deflection of her pelvis, just as a child
     whose genuflexion in front of an altar has become mechanical by
     repetition. The performance is sometimes so altogether sudden that
     Th. actually falls on to her right side. One striking feature of
     the case is that if she makes a tour of the room in order to be
     observed at leisure, the inclination never fails to occur at
     exactly the same point in the circuit--namely, when she is opposite
     the observer. It is useless formally to interdict her from this
     routine, for before one has time to notice any irregularity in the
     gait her knee suddenly flexes at the bidding of an invincible
     impulse, and a moment later, without any deviation from her path,
     she has resumed her rhythmical step round the apartment.

     This movement is not her only one, however. While she lies in bed
     she can, by flexing her thigh on her pelvis, crack her joints loud
     enough to be heard, and when she has been up a little while the
     same action is exhibited. The absence of these cracking sounds
     during ordinary walking, and their occurrence in the act of
     genuflexion, very properly explain, as Oddo thinks, the origin of
     the tic. It seems that the articulations at hip and knee on the
     right side were affected as the result of successive attacks of
     scarlatina and diphtheria two years ago, which necessitated a
     prolonged sojourn in bed, and were accompanied with severe pain. It
     is interesting to note that the tic made its appearance only after
     the latter had considerably subsided.

     Raymond and Janet[106] have reported the case of a young woman who
     fell on her knees every few paces, rising again with facility and
     taking a few more steps, to come down on her knees once more with a
     loud noise. She never did herself any harm, however, and for that
     matter the accident never occurred on a staircase or in a
     unsuitable or dangerous spot.

Leaping tics are met with also.

     Sometimes when walking, but more usually when standing quietly,
     according to Guinon, the patients make little jumps or leaps in
     their place, looking rather as if they were dancing than really
     springing into the air. Some actually bound along, others run for a
     yard or two.

Still more bizarre and complex tics have been described, in particular
by Gilles de la Tourette. One patient used to commence to run, then
kneel suddenly, then rise with equal abruptness. Another was in the
habit of stooping down, as if to pick something off the ground, and
smartly rising again.

The kinship of these and other similar conditions to the tics is
undeniable, and such seems to be the case with the yet more
extraordinary phenomena of _jumping_ in Maine (Beard), _latah_ among the
Malays (O'Brien), _myriachit_ in Siberia (Hammond). All these affections
show, among others, this peculiarity--that unexpected contact produces a
spring (Guinon).

In a recent thesis Ramisiray has depicted the dancing mania
(_ramaneniana_) of Madagascar, a condition allied to the latah of the
Dutch Indies, but more intimately connected with hysteria, perhaps, and
with the saltatory choreas, the saltatory cramps of Bamberger, St.
John's and St. Guy's dance, tarentism, etc. The exact nature of these
convulsive disorders is still _sub judice_, but in any case they present
more than a mere resemblance to the tics.


SPITTING, SWALLOWING, AND VOMITING TICS--TICS OF ERUCTATION AND OF WIND
SUCKING

In some tics the palatal muscles are found to contract, but this
contraction must not be confused with the spasmodic twitches of the same
muscles associated with facial spasm and due to central or peripheral
irritation of the seventh nerve. One of us has had occasion to observe
an excellent case in point in a young man afflicted with spasm of the
orbicularis and zygomatics on the right side, in whom synchronous
displacement of the uvula occurred with each twitch. The extreme
abruptness and rapidity of the muscular discharges, the inadequacy of
voluntary effort to check them, the absolute uselessness of prolonged
and systematic treatment, left no doubt as to the accuracy of the
diagnosis.

The occurrence of palatal spasm in intracranial lesions has, of course,
been recognised--in cerebellar tumour (Oppenheim), in epidemic
cerebro-spinal meningitis, in aneurism of the vertebral artery
(Siemerling and Oppenheim). It is occasionally associated with the
emission of clucking sounds, and with convulsive action of hyoid and
tongue muscles. In such cases the distinction between a tic and a spasm
is not always easy to establish. We may, however, readily recognise that
we are dealing with the former if the contractions of tongue, palate,
and larynx are contemporaneous with the execution of a functional act,
such as expectoration.

Among those who labour under obsessions, tics of expectoration are well
known. One of Guinon's patients, while making forced expirations, used
to bring his hand up over his mouth convulsively as though he were
afraid of spitting on some one in his neighbourhood.

     A case of Séglas', from whom stigmata of hysteria were absent, was
     possessed, among other things, with the fear of having swallowed
     certain objects, such as pins, knives, etc. The obsession
     eventually became so vivid and so intense at certain moments, that
     it began to be accompanied with a sensation as of a foreign body
     arrested in the œsophagus, and the anguish thus created revealed
     itself by various reactions, one of which consisted in excessive
     salivation and ceaseless expectoration, entailing the carrying
     about and use of numbers of handkerchiefs.

It is scarcely possible for the mechanism of deglutition, the orderly
succession of muscular contractions, to be interfered with by the will,
but increased frequency of these movements may constitute an
abnormality. Hartenberg's[107] case of deglutition tic was characterised
by a continual desire of swallowing saliva; the patient, it is true, was
an hysteric.

Rossolimo[108] has called attention to what he distinguishes as
amyotaxic troubles of deglutition, a dysphagia of which three types,
motor, sensory, and psychic, may be specified. Cases of the last form
had already been described by Bechterew.[109] The patient either suffers
from a genuine obsession, or is ever at the mercy of an involuntary or
even an unconscious dread of choking as he eats, a dread with which he
is powerless to cope, though in the case of others the phobia and the
dysphagia may alike be intermittent. In the majority of instances there
are grave hereditary or personal neuropathic antecedents.

Some people are afflicted with eructations so continual that they amount
to tics. One of us is acquainted with a family several of whose members
present this peculiarity in different degrees, yet none of them suffers
from hysteria.

Otto Lerch[110] has published a case of multiple tics, among which may
be enumerated opening and closing the eyes, rolling of the ocular
globes, tilting back of the head, with instantaneous recovery of
position, inclination of the whole trunk to right or left--each and all
of which movements are frequently attended, especially at night and in
the morning, by profound eructations.

Of course, the prominent place occupied by these signs in hysteria is
well recognised: the demonologues of old regarded them as an index of
the departure of the devils that dwelt in the possessed. In a case of
hysteria that came under the notice of Raymond and Janet,[111] a general
tremulousness of the whole body was replaced by a chorea of the right
arm, which in its turn was succeeded by the perpetual emission of
sonorous eructations. In another instance[112] inspiratory hiccoughs and
expiratory eructations co-existed. A similar example is cited by Cruchet
in his thesis.

In the same category of facts are included those to which the name of
_aerophagic tic_ has been applied. Various cases have been narrated by
Pitres and by Séglas,[113] the latter of whom, in a remarkably complete
analysis of the condition, has demonstrated its identity with the tics,
and written very instructive commentaries on his observations.

     I was consulted (says Séglas) by a man thirty-four years of age,
     who was sent to me as a hypochondriacal neurasthenic. No sooner had
     he entered my consulting-room than I was astonished to find he was
     giving vent to repeated sonorous eructations at very brief
     intervals. His story was to the effect that several weeks
     previously he had been suddenly seized in the middle of a meal by a
     sort of vertigo, and had lost consciousness. A consideration of
     subsequent events made it more than probable that he had had an
     ictus; the patient, however, was for no apparent reason persuaded
     that he had been poisoned by badly cooked food, and from that
     moment became despondently preoccupied with the state of his
     stomach. A few days later the eructations made their appearance.

     A closer examination very soon dispelled the idea of their gastric
     origin, seeing that the digestive functions were in every respect
     normal, whereas the symptom in question occurred at any moment,
     independently of the stage of digestion, and the gases evolved
     were absolutely inodorous. On the other hand, one could easily
     satisfy oneself that the eructations were preceded by an
     inspiratory effort and by two or three very obvious movements of
     deglutition, accompanied by a low, rumbling, pharyngeal noise, and
     followed almost immediately by the expulsion of gas. Their
     reproduction several times a minute was spasmodic in character and
     irregular in rhythm, and continued, it might be, for hours.

     Of this series of phenomena the patient had conscious knowledge
     only of the last--viz. the eructations--and affirmed their
     involuntary nature and his desire to be rid of them.

     The influence exerted on them by various circumstances is worthy of
     notice. Any emotion, or any reference on the part of the patient to
     the condition of his stomach, tended to exaggerate them, while,
     inversely, it was remarked by his wife that the distraction of
     conversation, or of a promenade, or of musical séances--to which he
     was passionately devoted--served to banish them instantaneously and
     for as long as the distraction endured. Sleep suspended their
     activity, but at any interruption of it they scarcely ever failed
     to reassert themselves.

     These considerations determined my view of his trouble as a
     peculiar form of tic, which consisted in "muscular spasms
     systematically harmonised to produce the alternating deglutition
     and expulsion of a certain quantity of atmospheric air" (Pitres),
     which therefore might be denominated an _aerophagic tic_.

Different varieties of this tic exist, according as the air swallowed is
derived from the exterior or from the lung, and depending on its
penetration into the stomach or simply into the pharyngo-œsophageal
canal; and further, the physiological mechanism of the condition varies
with them.

     Let us suppose that the swallowed air comes from the lung. In this
     case, a certain quantity of air is imprisoned at the beginning of
     expiration in the pharyngo-œsophageal cavity, whose orifices are
     firmly closed by simultaneous contraction of the muscles of the
     palate, glottis, and base of the tongue. At this moment a brisk
     contraction of the constrictors of the pharynx drives the
     accumulated air out by the mouth, setting the membranes surrounding
     the supero-anterior opening of the cavity into vibration in so
     doing, whereby the air escapes as a more or less noisy eructation.

     Should the mouth not open at this juncture, however, the air is
     compressed and crowded back into the lower part of the
     œsophagus, whence it passes through the easily dilatable cardiac
     ring into the stomach, to be expelled again by the mouth in the
     same noisy way once it has accumulated in sufficient quantity.

     The deglutition of external air is preceded by an aspiratory
     thoracic effort; closure of the glottis forces the œsophagus to
     open under the stress of increased negative intrathoracic pressure,
     and to suck air down. When aspiration ceases, this air is either
     driven out forthwith, or gathered in the stomach, as we have just
     seen.

     One may sometimes notice that the act of suction is succeeded by
     movements of swallowing, in which case the probability is that at
     the moment of aspiration the closure both of glottis and of pharynx
     prevents the penetration of atmospheric air into either the trachea
     or the gullet, in spite of the differences of pressure, and that
     these movements allow its passage through the œsophagus.

Aerophagia is by no means, therefore, a simple involuntary movement, but
a combination of systematised muscular actions. In fact, it is a tic,
and as such has both a physical and a psychical side.

     From the material point of view (to quote Séglas again), the
     predominant symptom is the eructation, and the object in
     determining the accessory symptoms is to distinguish it from
     gastric eructations properly so called, the consequence of improper
     fermentation. In our case the appetite is good, and the digestion
     normal--tympanites, splashing, and abdominal pain are all absent.
     The gases evolved are inodorous, and their analysis in different
     cases (Ponagen, Hoppe-Seyler, Pitres, Sabrazès and Rivière) has
     shown that so far from containing any abnormal constituent, they
     have almost the same composition as atmospheric air. Application of
     the ear to the vertebral column at the level of the stomach enables
     one to detect a noise that appears to correspond to the passage of
     air into that viscus, and less than a second later comes the
     eructation.

     Facts of another kind indicate the participation of a psychical
     element. The activity of the tic increases under the influence of
     the emotions and decreases or disappears momentarily at the bidding
     of the will. Distraction, concentration of the attention on some
     particular thing, speaking, reading aloud, are also calculated to
     suspend its manifestations. In some cases, especially where there
     is an association with hysteria, support is given to the theory of
     its psychical origin by the observation that prolonged opening of
     the mouth, and the administration of mica panis pills or of
     distilled water tinted with methylene blue, have had a definite
     effect in controlling the spasm (Pitres). Moreover, the
     co-existence or pre-existence of intellectual troubles or mental
     peculiarities is often incontrovertibly proved by a painstaking
     psychological examination.

     In reality this aerophagic tic is a symptom-complex encountered in
     very different pathological conditions. No doubt its frequency is
     greatest and its development highest in hysteria, but we are in
     error if we suppose that it is the exclusive appurtenance of that
     disease: its occurrence in our case of general paralysis is
     evidence to the contrary. I have noted it where there was not the
     slightest suspicion of hysterical antecedents. Nevertheless its
     relation to pathological mental states of some form or another is
     invariable.

It is often found in cases of insanity of the obsessional or of some
other type.

     I have had an opportunity (says Séglas) of observing an instance of
     aerophagia in a woman of fifty-four years, who for the last fifteen
     years has been suffering from hypochondriasis in a delusional form.
     She believes she has a hole in her head, and that her brain is
     gangrenous; she is no longer conscious of her body, nor of her food
     as it passes through. "It is like a cupboard empty of everything
     but air." Grafted on this delusion is an aerophagic tic, upon which
     the patient relies in support of her contentions. So little is she
     able to withstand its ceaseless repetition that the sequence of
     muscular actions continues though the tongue be held outside the
     mouth or fixed with a spoon.

     I have seen the same phenomenon in another woman, forty-six years
     of age, afflicted with fixed and systematised delusions of
     persecution. She imagined that she was being pursued by sorcerers,
     who had cast a spell on her and were about to poison her, torture
     her, break her on the wheel, etc. In addition to very distinct and
     frequent verbal hallucinations and disorders of general
     sensibility, she exhibited several tics, one of which consisted in
     spasmodically closing her eyes, brandishing her right arm, and
     uttering a string of incomprehensible words; the other was this
     aerophagic tic, characterised by a jumble of quick swallowing
     movements, pharyngeal grunts, and long-drawn-out, sonorous
     eructations. All this performance was rehearsed two or three times
     a minute as a sort of convulsive discharge, which she alleged the
     sorcerers forced her to emit in spite of herself, exactly as they
     coerced her into uttering a jargon she did not understand, and
     wagged her tongue at their own sweet will.

To quote Séglas again in conclusion:

     The air-swallowing tic is merely a syndrome common to various
     pathological conditions differing widely enough, but all alike in
     being associated with some degree of mental impairment, in which
     perhaps may be discovered the actual cause of the condition. It
     cannot therefore be looked upon as a simple spasm, based
     anatomically on a reflex arc, but must be regarded as a reaction
     whose substratum is a cortico-spinal anastomosis--that is to say,
     it is a tic.

Tics of vomiting may be produced if the diaphragm be affected. Noguès
and Sirol[114] have reported the case of a woman with a
pharyngo-laryngeal derangement resembling vomiting, except as far as the
actual ejection of alimentary matters was concerned. She used to become
conscious of a sensation of constriction, and to feel the tickling of a
foreign body in the gullet; at this point the slightest pressure on the
neck provoked a convulsive attack, in which all the pantomime of
vomiting was gone through without the actual emesis taking place.

It is possible, as Noguès and Sirol think, that the trouble may have
originated in a reflex spasm, and that with the disappearance of the
primary irritation a new psychical factor operated to effect its
repetition and prolongation.

The designation of all these functional disorders as tics is not always
justifiable, and their separation from the corresponding normal act is
frequently a task of delicate diagnosis, but patient search for the
exciting cause and study of the concomitant mental anomalies will supply
the necessary indications.


TICS OF RESPIRATION--SNORING, SNIFFING, BLOWING, WHISTLING, COUGHING,
SOBBING, AND HICCOUGHING TICS

Respiratory tics are exceedingly numerous. They concern the diaphragm
and the muscles of inspiration or expiration, and are accompanied by
synergic movements of the muscles of the nose, lips, tongue, palate,
pharynx, as well as by laryngeal noises or by tics of the face and
limbs. They embody disturbances of various functional acts, and may be
subdivided into inspiratory and expiratory tics.

It is only as regards their frequency that such reflex mechanisms as
yawning and sneezing are liable to be modified by the intervention of
the will. Saenger[115] records the case of a woman twenty-nine years
old, not affected with hysteria, who used to suffer from attacks of
yawning and of stiffness in the arms, followed by rapid contractions of
the tongue lasting for about a minute. He describes the condition as one
of "idiopathic spasm"--probably a species of tic. It is in hysteria,
however, that functional variations in sneezing and yawning are most
commonly found, and the latter, moreover, may constitute the aura of an
epileptic fit. Yawning occurs in a most intractable form in meningeal
affections, and in cerebral and cerebellar tumours.

"Rhincho-spasm," a snoring tic, has been observed by Oppenheim in a case
of neurofibromatosis. In certain tics of this nature, and in sniffing
tics, the onset is sometimes attributable to the presence of adenoids.

Among various expiratory tics may be enumerated the habit of blowing
through one's nose or mouth. Schapiro has reported a case of expiratory
"spasm" due to contraction of the buccinators. Whistling ought to be
considered a stereotyped act, rather than a tic, as Letulle maintains.

Spasmodic troubles of respiration, defined indifferently as "spasmodic
dyspnœa," "spasmodic asthma," "spasmodic cough," "asphyxial spasm,"
"nervous cough," etc., ought not to be classified as tics; in many cases
they are genuine spasms, arising from some irritation in sensory paths.
At the instant of any contact, or under the influence of a sudden noise
or a bright light, a patient of Edel's used to become distressingly
dyspnœic. Evidently the condition was one of spasm.

Coughing tics also are of remarkably common occurrence. Many
individuals ceaselessly interrupt the thread of their conversation to
make more or less audible explosive expirations, for which there is
neither reason nor necessity, since the respiratory paths are free from
all irritation or obstruction. These useless little coughs do not always
deserve the appellation of tics; in many instances they are mannerisms
comparable to the gestures of conversation or reflection, although in
some people their insistence, abruptness, and irresistibility might
justify their incorporation in the other category. Their co-existence
with tics of face and limbs has been noted, as in a case published by
Tissié[116] of an eight-year-old child, with ocular and facial tic and
spasmodic cough.

Clonic contraction of the diaphragm gives rise to conditions imitated or
caricatured by the tics, in particular sobbing and hiccoughing. It must
not, of course, be forgotten that these are apt to occur in hysteria, as
well as in organic disease of the nervous system, and in grave
infectious states. Careful and searching inquiry must therefore precede
any expression of diagnosis.

Tonic diaphragmatic contraction is of very much greater rarity. In such
cases abdominal respiration comes to a momentary standstill, whereas
thoracic respiration is accelerated. The patient is in imminent danger
of being asphyxiated, and the insertions of the diaphragm sometimes
become painful. What is known as acute pulmonary eructation is
occasionally the sequel to this convulsive affection. Tonic contraction
of the diaphragm is nearly always of an hysterical nature, and is
doubtless akin to the aerophagic type.



CHAPTER X

TICS OF SPEECH


In movements of inspiration or of expiration the passage of air through
a more or less contracted glottis gives rise to all sorts of sounds,
some of which, under certain conditions, must be included in the
category of tics.

     The most elementary of these, and at the same time the most common
     (says Guinon), is the involuntary exclamation. In the midst of his
     tics and grimaces, a cry--ah!--escapes the patient's lips at
     intervals, a shrill, sudden, and momentary cry which interrupts his
     talk, or breaks in on a period of silence, and which he repeats
     only once or perhaps several times in succession. The thread of his
     conversation, nevertheless, is seldom if ever discontinuous, and
     his audience is witness of its rationality and accuracy of
     expression. Rather more complicated is the ejaculation "ouah!"
     Sometimes one meets with noises that are faithful reproductions of
     the sounds emitted by various animals.

Guinon is disposed to exclude such simple involuntary explosions as
"ahem! ahem!" from the tics, though he admits the analogy to them. He
says the sound exactly resembles the trifling little clearance of the
throat which is repeated a thousand times a day by people suffering from
chronic angina. We, however, are inclined to look upon it as an ordinary
spasmodic reaction evoked by some laryngeal or pharyngeal irritation,
which in spite of the removal of the latter continues to take place, and
because of its meaningless repetition is fairly to be classed as a tic.
All that we have said of blinking, for instance, is applicable in this
connection.

Of course the embellishment of one's discourse with more or less
audible expirations is of frequent occurrence: the hesitating eh ... eh
... to which children give vent in the recitation of their lessons is
not confined to them alone. It can scarcely be maintained that these
laryngeal noises are tics, since their production is coincident with the
exercise of the faculty of speech; hence they are not unlike "functional
cramps." On the other hand, the unexpected bark or gurgle that breaks
the silence is a pure tic of phonation.[117] Those who suffer in this
way reveal characteristic stigmata in the immediateness of the
compelling idea and the exaggerated nature of the subsequent
satisfaction. To unravel the intricacies of the origin of these tics is
a matter of considerable difficulty, though probably imitation is not
without influence in their genesis. Reference will be made later to a
tic of this kind attributed by Charcot to imitation.

Among the insane similar cries are often the outcome of delusions. At
the Congress of Limoges a case was reported by Briand of an old man who
imagined himself transformed into a clock and swung his arms with
pendulum-like regularity, indicating the hours by uttering raucous
sounds at the proper intervals. However curious these sounds were, the
fact of their being appropriate is decisive against their classification
as tics.

Unmistakable tics of speech, however, do occur.

Speech is a complex of different muscular acts, and, being so, is liable
to be disarranged in various ways, by defect in respiration, phonation,
articulation, even in ideation. Organic affections aside, it is
inadmissible to describe as tics each and all of the functional
disturbances of speech that are not based on any discoverable material
lesion of nerve centres. One must in fact distinguish between troubles
of speech confined to occasions when the faculty is in operation and
those that consist in not merely useless but inopportune utterance.
However arduous it may occasionally be to draw this distinction, however
common the occurrence of transitional forms, it has the advantage of
limiting the scope of the term "tic of language." To the latter category
only can the description be applied.

For this reason we think it preferable to exclude stammering,
stuttering, and all defects of phonation or articulation whose existence
is revealed only in the act of speaking. At the same time reference must
be made to facts linking these functional anomalies to the tics, and to
instances of the latter existing with or succeeding the former.

Such is the case with stammering.

According to Letulle,[118] stammering is a tic of speech whose beginning
is a functional disturbance of nervous centres, as is that of tics in
general. Holding as we do, however, that one of the features of tic is
its appearance in season and out of season, we cannot class stammering
as a tic, since its exhibition is restricted to the exercise of a
certain function, viz. speech. It is therefore comparable to a
"professional cramp," and we may briefly note the analogies it offers to
the tics.

Stammering,[119] which in more than fifty per cent. of cases is
hereditary, and associated with a neuropathic diathesis, usually betrays
itself in childhood and becomes aggravated at puberty. The old idea
which credited stammerers with exceptional intellectual powers, in whom,
however, rapidity of thought surpassed rapidity of action on the part of
the muscles of articulation, is exploded, and to-day those thus
afflicted are assigned their true place among the volitionally infirm.
In a few rare cases stammering has been due to organic disease of the
centres for articulate speech, or of bulbo-pontine nuclei; it has been
supposed also to result from genuine spasm on a reflex arc, and this is
a possible explanation; as a general rule, however, the pathogeny of
stammering is identical with that of tic. Its dependence on such
affections of nose, larynx, and pharynx as hypertrophic rhinitis and
adenoids has been emphasised by Biaggi[120]; and Derevoge,[121] in
directing attention to the association of volitional enfeeblement with
respiratory troubles, remarks that stammerers sometimes have a phobia
for certain words. Many observers have been convinced of the psychical
nature of the affection from the fact of its disappearance during
singing, as well as from the effect anger, elation, and other stimuli
have in momentarily inhibiting it. The same is of course true of the
tics.

Further, little attempt is made either by the _tiqueur_ or the stammerer
to correct his failing, so that prognosis improves with the adoption of
systematic treatment. Stammering is a functional anomaly; it is a
derangement of respiration, phonation, and articulation. However normal
be the movements of lips and throat in the execution of certain acts,
they are far from being normal in the exercise of speech. As a
preliminary to speaking the stammerer clenches his teeth and
approximates his lips, thus effectually preventing the inrush of air
except by the nares; simultaneously he contracts his tongue and
obstructs the isthmus of the pharynx, while the glottis also may close
spasmodically. Then he abruptly expands his thorax and inhales a
considerable quantity of air, yet is he ever on the verge of
breathlessness, for he cannot voluntarily arrest himself, or make a
break between two respirations. He seeks to continue speaking though his
lungs are empty of air; he cannot control expiration by antagonistic
contraction of inspiratory muscles; often he finds himself unable to
commence speaking at all.

The glottis is either open, allowing the silent escape of air, or it is
completely occluded. In the midst of syllables or words the voice is
frequently "cut" by a sudden halt indicative of spasmodic closure of the
glottis. A contrast to the ease with which vowels are pronounced is
provided by the difficulty experienced in the enunciation of various
consonants. Convulsive movements of the lips frustrate the endeavour to
form the series of successive positions which the consonants demand.

An association of stammering with convulsive phenomena of a different
nature has often been remarked. Instances of this have been given by
Janke.[122] One patient takes a few paces backward, limping with his
left leg till he finds something to give him support, and knocking his
shoulder several times against wall or furniture, as soon as he
encounters it; if he is seated he rises slowly from the chair, holding
it with his hands the while, and forthwith falls back into his seat in
order to begin. Another taps his fingers on his thigh whenever the word
he is about to utter commences with "g" or "k."

In Brissaud's clinique we have met with a couple of instructive cases:

     The first concerned a showman who used to exhibit a series of
     dissolving objects by means of mirrors, and who found one day that
     he could not speak without scanning his syllables and explosively
     ejaculating his words; at the same time his conversation was
     punctuated by sudden and exaggerated shutting of the eyes and by
     facial contortions. After a pause the inauguration of a phrase was
     ushered by still more energetic and widespread spasms of the head
     and even of all the body.

     The other was an eighteen-year-old Jewish boy, who before beginning
     to speak gave vent to a hard sound like "kh" four or five times in
     succession, each being accompanied by a violent rotation of the
     head to the right, wrinkling of the face, and a little jump. The
     patient then addressed himself to speak with the utmost assurance,
     there being no sign of tic or stammer unless he stopped for a
     moment and endeavoured to recommence. On the other hand, he could
     sing to perfection.

There may also be troubles of speech of a tonic kind, whereby a more or
less complete and sustained mutism is produced, an excellent example of
which has recently come under our notice:

     A young girl, various members of whose family are stammerers,
     occasionally suffers from an extraordinary sensation of anguish in
     the course of conversation; she flushes and then becomes suddenly
     immobile, finding it impossible to articulate or even to utter a
     sound. Her glottis contracts forcibly; her efforts at expiration
     are ineffectual, or else the air escapes in little explosive puffs,
     and at the same time her lips twitch and her eyelids flicker. The
     whole seizure is over in a few seconds, whereupon the patient
     launches into conversation with volubility, until pulled up by a
     fresh attack. She shows remarkable acumen, moreover, in an analysis
     of her symptoms. "What happens is that I am suddenly overwhelmed
     with the fear of being unable to pronounce a given word, and at the
     thought my lips are sealed, I cannot make a sound, my throat is
     compressed, my tongue refuses to obey me, and my condition becomes
     one of abject misery." Curiously enough her phobia is not related
     to a particular word, and moreover her articulation is accurate and
     not embarrassed in presence of certain of the consonants. Phonation
     and respiration are implicated as well as articulation. The origin
     of this "cramp of speech" in psychical abnormalities is manifest.

To a similar affection characterised by total inability to speak in a
high or a low voice, whispering only being practicable, the term
"spastic aphonia" has been applied. It is at the moment when the patient
wishes to speak that the spasm occurs, as in a case reported by
Hasslauer,[123] which resisted all treatment and was considered by him
to have features in common with hysteria and occupation neuroses.

There can be little doubt that the arrest of movement in these cases is
comparable to what obtains in writers' cramp, and therefore, rigorously
speaking, a tonic tic.

A case has been recorded by F. Pick[124] of a man of thirty-eight years
of age afflicted with convulsive movements of the face and troubles of
speech.

     Whenever the patient tried to speak oral contortions and deviation
     of the tongue ensued, and hands and feet began to beat the air
     without his being able to utter a single word. The agitation was
     increased by emotion and diminished with volitional movement.

Another instance is referred to by Aimé[125] under the name of tic of
elocution, where the combination of convulsive movements of neck,
shoulder, and arm with spasm of articulation of eight years' standing
disappeared under the influence of methodical re-education.

Kopczynski cites the case of a man with facial and other tics who used
often to utter a long string of words or even a whole sentence in an
extremely monotonous voice, resuming his natural tone thereafter;
occasionally, too, he used to pause in the middle of a remark for as
long as forty seconds.

Mention must be made here of true spasms of phonation or laryngospasms,
the result of local irritation, which disappear with its removal.
Central lesions, of course, might conceivably produce the same effect.

     Uchermann[126] has reported a case of recurrent attacks of mutism
     at intervals of five or ten minutes in a man of sixty-eight,
     examination of whose larynx during the seizure showed the glottis
     to be in spasm. Synchronously with these rhythmical clonic
     alternations of adduction and abduction occurred tonic
     contractions of the masseters and clonic contractions of the
     palate, tongue, and forearm. The phenomena had lasted for about a
     month when a right hemiplegia was superadded, and was followed by a
     fatal issue three weeks later. Unfortunately no autopsy was
     obtained to verify the observer's opinion of a lesion in the
     neighbourhood of the left precentral sulcus, involving the centres
     for mastication and phonation, for the tongue and for opening of
     the glottis.

If now we direct our attention to the content of speech, we shall see
how it too may reveal anomalies not unlike tics.

Letulle quotes the case of a man who could not utter four consecutive
words without sandwiching a "sir" between them. Similarly, the "don't
you know," "do you see," "you know," of so many people are repeated _ad
infinitum_. One of us has an acquaintance who interlards his talk with
"you understand," and this formula is reiterated without modification
though he may be addressing his friend in the second person singular.

There used to be a poor creature driven by destitution to sell papers in
the streets, or to figure as a negro in the corridors of the Hippodrome,
who was wont to garnish his speech with a "Well, my boy! all right, by
Jove!" repeated at intervals, whoever it was he happened to be speaking
to, and even though it was their first time of meeting.

In Ibsen's play of _Hedda Gabler_ is a character George Tesman, a weak
being who begins every sentence with "I say, Hedda," and ends with a no
less invariable "eh!"[127]

These habitual words and phrases--and many more instances may be
cited--are analogous to the mannerisms exhibited during concentration of
the attention on the performance of certain acts. They cannot be
considered tics unless reproduced at other times as well. Moreover,
while the use of such terms may be overdone, it can hardly be said to be
unreasonable. However irritating their effect, they indicate simply an
exuberance of style and a degree of inattention, not a grave mental
shortcoming.

Of a less trivial nature is a curious anomaly that consists in the
complication of speech by the introduction of meaningless expressions
uncontrolled by the will. This is a functional defect very much akin to
the tics.

A distinguished medical colleague was in the habit of muttering the word
_cousisi_ as he talked.[128] Séglas described similar occurrences as
"stereotyped acts of speech." One of the Salpêtrière patients used to
close every sentence with the phrase "in all and for all." Another's
opening remark was always "Araken-Doken-Zoken." It is permissible to
regard many of the neologisms imagined by the insane as examples of
stereotyped speech. A patient, for instance, who suffered from delusions
of persecution, said he was being pursued by the Evil Eye
("_reluquets_"--_reluquer_, to leer at). With the eventual disappearance
of the association linking the original idea to the neologism, the
patient may no longer be capable of explaining the meaning of the
phraseology he has invented, but in the case of those whose mental level
is more nearly normal the coining of new words need not be more than a
sort of eccentricity, which is generally accompanied, however, by other
indications of instability. We may remind ourselves of O., with his
"vertigos" and "para-tics."

But if, finally, words or phrases escape the subject's lips at moments
of silence, with whose imperious and unexpected emission he is powerless
to cope, then we are dealing with true tics of speech. Their
investigation has been conducted by Guinon with great analytical skill.

     At the upper end of the ladder among exclamations we meet words
     involuntarily and senselessly repeated, in a loud tone of voice, to
     the accompaniment of tics and grimaces. These expressions fall
     naturally into two groups that require to be rigorously
     differentiated.

     In the first of these the words uttered may be simply anything;
     each patient may have his own, and so their number is absolutely
     limitless. Occasionally one is in a position to discover in the
     antecedents of the case the reason for the choice of a particular
     word in preference to another, as in the instance of the man whose
     involuntary ejaculation, "Maria!" was the echo of a passion he had
     conceived years before for a young girl of that name.

Such troubles are unmistakable tics. The mechanism of their production
is identical, be the actual localisation brachial, facial, or laryngeal,
and this applies in particular to the motor verbal hallucinations so
excellently studied by Séglas. As a matter of fact, tics of speech are
often nothing more than the mode of exteriorisation of these
hallucinations. The same is the case with verbal impulsions.

In this rubric of tics of speech we may class various cases recorded
under differing titles, among which an interesting one due to Pitres may
be quoted:

     Subsequently to his retirement from active business pursuits, the
     patient, a man fifty-nine years old, became depressed, morose, and
     irritable, till insomnia at length drove him in desperation to
     attempt suicide. By the merest chance he failed of his purpose. The
     development of involuntary sounds a few weeks later was followed at
     the end of a month by the equally involuntary ejaculation of his
     wife's and children's names--"Numa! Helen! Camille! Maria!" This
     habit persisted for as long as fourteen months, after which during
     three years he enjoyed excellent health. Owing to financial
     worries, however, a relapse occurred. Every few minutes he uttered
     various articulate cries in a loud, clear, and well-modulated
     voice, sometimes repeating the four names with great rapidity, at
     others calling out the same name with increasing violence. Severe
     convulsive twitches of arm and trunk musculature synchronised with
     his exclamations. The patient was incapable of either restraining
     or even modifying the cries; he was equally unable to replace one
     by another, to say Henry instead of Numa, or Jean instead of Helen.

     For hours at a stretch he would repeat the names of friends who had
     come to visit him; on the day before a consultation on his case his
     one cry was the name of the new physician who was going to examine
     him.

     A gradual improvement took place, and eighteen months after the
     onset of the condition the cure was complete.

In the same connection Pitres refers to a case reported by Calvert
Holland.

     A miner who had gone through the experience of incipient
     suffocation found himself two months later irresistibly impelled to
     exuberant speech. The rapidity and indistinctness of his
     enunciation of words were very much in evidence, as well as a
     tendency to stammering and to tautology. A further symptom
     consisted in rotatory spasms of the head; but after five months a
     satisfactory cure resulted.

We may cite a last instance from Ball:

     A young girl was in the habit of kneeling down, making the sign of
     the cross, and repeating "Jesus, Mary, Joseph." The performance was
     limited to this order of events, but its practice in drawing-rooms
     and still more in thoroughfares led to her being certified as
     insane.


ECHOLALIA

In his description of the disease which bears his name, Gilles de la
Tourette used the expression echolalia to denote a certain phenomenon of
occasional occurrence among those who tic.

     The patient (says Guinon) repeats echo-like the sounds he hears
     around him, and like the echo his reproduction of them is more or
     less lengthy. In its mildest form the symptom may consist in the
     repetition of a simple involuntary "ah!" which some one near by has
     ejaculated, or the last word or two of some one's talk is mimicked,
     or in a more advanced stage the whole of a phrase is reproduced.

     As a general rule the "echo" is rather obtrusive, but its
     commencement at least may be very different, the patient being
     astonished to find himself repeating in a subdued tone of voice
     what he hears others saying; and, struggling in fear to rid himself
     of the habit, he ends by sinking into a state of actual anguish. It
     is at this moment that he fails to inhibit his impulses and gives
     vent to the word he has been endeavouring to check, which he may
     repeat loudly and violently in a sort of fury. The fidelity and
     clearness with which the utterances of others are imitated are
     remarkable.

     Sometimes by an effort of the will the patient is able to suppress,
     it may be imperfectly, the impulse to echo, so that while his
     tongue is under his control, his will gives rein to his other tics,
     and a regular muscular debauch takes place. In the mildest cases he
     can replace a word by a movement, by a little cough or an
     insignificant "ahem!" but not beyond a certain point, for he will
     thus restrain himself only when he is forewarned; a sudden and
     unexpected ejaculation in his neighbourhood will catch him off his
     guard.

In spite of their frequency among those who are addicted to tic,
echolalia and echokinesis cannot be enumerated with the tics, seeing
that their exhibition is dependent on the actions of others, whereas
once a tic is established it requires no stimulus from without for its
manifestation. Of course their affinity to the tics is very close: they
spring from the same soil; they represent in the adult the persistence
and amplification of the child's propensity for imitation, and therefore
in their own way postulate a degree of mental infantilism.

Echolalia in the blind has been made the subject of an interesting study
by Noir.

     The echolalic repeats abruptly and rapidly what is said by others
     in his presence. That he does not stop to reflect is attested by
     his mimicry of bizarre words, technical terms, even of idioms in a
     foreign language.

     It is an interesting fact that of twelve cases of echolalia that
     have come under our observation, fifty per cent. occurred among the
     blind. The coincidence is a rational one; blindness and echolalia
     are united as cause and effect. In the case of the person born
     blind the auditory memory is in such an advanced state of
     development that, if he be not very intelligent, he will seek to
     fix the sound of an auditory impression in his defectively
     organised mind as soon as he hears it, and being unable to whisper
     it mentally, he stimulates his auditory centres by a less delicate
     process, and forthwith repeats aloud the word he has just heard.
     This is why we meet with instances of the echolalic blind repeating
     a sentence before replying to it. It is instructive to note in
     this connection that the choicest example of echokinesis we have
     seen was in a deaf mute, in whom no doubt the visual phenomena were
     analogous to the auditory phenomena of the echolalic.

Noir is inclined to apply this mechanism to the case of echolalics who
are not actually blind. He quotes instances which go to show that their
visual memory is awanting, that as far as it is concerned they are
"blind."

The hypothesis is attractive. It may be further remarked that the
echolalia is a "motor," in the same way as the patient afflicted with
hallucinations of sight or hearing is an "auditory" or a "visual."

Echolalia is amenable to treatment, and is even capable of cure. Noir
gives an interesting example of the evolution of the process.

     If I say to an echolalic, "Are you hungry?" he will instantly
     answer, "Are you hungry?" Under the influence of re-education the
     reply will eventually change to "Are you hungry? are you ...? Yes,
     sir, I'm hungry," then to "Yes, sir, I'm hungry," and finally to
     "Yes, sir."

Echolalia, however, is not an exclusive appurtenance of those who tic.
We can remember a case of general paralysis in the clinique of Brissaud
at the Hôtel Dieu, who had the regular habit of repeating the question
that was addressed to him; if it were a little long, only the last ten
or fifteen words were echoed. A case is quoted by Cantilena of a woman
with right hemiplegia and partial epilepsy who invariably reiterated the
closing phrase of anything said to her. Several cerebral tumours were
discovered at the autopsy.

It is conceivable of course that an actual lesion, as well as a
congenital developmental defect, may interfere with the will's
inhibitory powers, in which case auditory or visual stimuli are
transmitted to motor centres unmodified, the result being the production
of sounds or of other movements.


COPROLALIA

Coprolalia, the _manie blasphématoire_ of Verga, is, according to Gilles
de la Tourette, one of the most frequent affections of speech in the
disease of convulsive tics.

There is no necessary connection, as a matter of fact, between tic and
coprolalia, though of course they may co-exist, sometimes in association
with other syndromes; they are in reality only episodic syndromes of
hereditary insanity.

A distinction ought to be drawn between coprolalia and the use of
trivial or inconvenient terms, words with which even some well-educated
persons are wont to garnish their conversation. Guinon had a case of a
man who in the presence of his mother resorted to language of a kind
absolutely disallowed in polite society. In the etymological sense of
the word, no doubt, he was a coprolalic, but it cannot be said that he
was suffering from tic.

On the other hand, the abrupt and impetuous utterance of oaths or
obscene expressions, to the ejaculation of which an irresistible impulse
seems to drive the patient independently of time and place, amounts to a
coprolalic tic of speech, and reveals a deplorable volitional debility
on his part; for he is incapable of checking an act to the impropriety
of which he is fully alive.

     The victims of this disease (says Guinon) have an extraordinary
     propensity for choosing the foulest and most indecent words,
     however elevated their position and correct their breeding.
     Reference may be made to the classic instance of the Marquise de
     Dampierre, who all her long life was in the habit of repeating
     certain immodest sayings even on the most solemn occasions.

According to Guinon the reason of this bizarre preference for obscene
remarks is absolutely unknown, although Charcot's view[129] that
coprolalia is frequently nothing more than echolalia is one of some
plausibility. He refers to one of his patients who alternated her
coprolalic utterances with a sort of barking noise that was an exact
imitation of her favourite dog.

We ourselves have had for a long time under observation a youth in the
service of Professor Brissaud whom some instinct seemed to prompt to
repeat any lewd expression he happened to hear, or indeed any which
might be so interpreted. It might then be said of him that his
coprolalia varied with his surroundings and with his own ideas; it was
accompanied by inconstant and irregular convulsive movements of the
limbs.

After all, there is not so very much to choose between the coprolalic
and the individual whom impatience or anger forces to blaspheme or at
any rate to utter words that do not form part of his ordinary
vocabulary. And though the ejaculation be not audible, the first degree
of coprolalia consists in the mental presentation of the objectionable
phrase. Among those who suffer from obsessions mental coprolalia is far
from uncommon. A patient with _folie du doute_, mentioned by
Séglas,[130] was afraid to pronounce indelicate words because he felt
himself articulating them mentally, and sometimes he used to ask whether
they had not really escaped him. One step more, and these verbal
hallucinations assume the characters of a genuine tic.



CHAPTER XI

THE EVOLUTION OF TIC


Tic is, from its nature, highly variable in its evolution; each tic has
a development peculiar to itself. Mental differences among individuals
have their counterpart in physical differences, in health as well as in
disease, and a comprehensive sketch of the evolution of tic is therefore
impracticable. We shall restrict ourselves accordingly to a few general
remarks.

In the great proportion of cases of tic the onset is an insidious one.
We have already made a sufficiently detailed examination into the
pathogenic mechanism to obviate any repetition in this place, but we may
note how unsettled the earliest manifestations are, how a tic may pass
from one muscle or group of muscles to another, and even when its
exciting cause is patent an apprentice stage always precedes its final
establishment. Of the truth of this the history of J. provides an
excellent instance. Another one is from Pitres:

     A nine-year-old boy received a severe shock one day through being
     pounced on by some companions who were in hiding behind a wood
     pile, and though the emotion was of short duration, he commenced a
     few days later to exhibit involuntary muscular twitches of the
     upper part of his body, and to utter suppressed cries. The
     phenomena increased in violence and in frequency, and, in spite of
     treatment, a year later he was not freed of them entirely. For an
     unknown reason the tics renewed their activity when he was
     seventeen and continued so for the next three years, until a spell
     of Pitres' respiratory exercises effected a complete cure.

An evolution such as the above may be considered more or less typical of
the great majority of tics.

We have seen that the tic may be localised indefinitely in one and the
same muscle or muscular group, but its site may also vary from day to
day. Two tics may co-exist and coincide, or a third may appear with the
disappearance of the others. Unexpected resurrections may succeed
periods of complete repose.

Tic always shows a tendency to invade; regarded as a functional act, it
moves in the direction of greater complexity.

     After involving the orbicularis, for instance, a tic will spread to
     neighbouring groups, in particular to those muscles whose synergic
     contractions form a special expression of countenance. That is why
     tics of the eyelids are associated with movements of the
     pyramidales, frontales, and corrugators. Tics of the lips or of the
     alae nasi very commonly extend to the corresponding elevators. It
     is not surprising that muscular groups accustomed to act in
     physiological unison should also be affected together (Noir).

Moreover, the fecund imagination of the victim to tic is calculated to
facilitate the invention of all sorts of modifications, complications,
parodies, and caricatures of the functional acts on which his tics are
grafted.

Tics are constantly varying in amplitude, degree, and frequency; as O.
remarked spontaneously, "We have our good days, and we have our _mauvais
quarts d'heure_." The sedative effect of rest, solitude, silence, and
obscurity may be contrasted with the detrimental results of fatigue,
noise, fear of ridicule, etc.

     However incapable S. is of rotating his head to the right when
     requested to do so, the movement is executed with the utmost
     readiness should his attention be drawn in that direction. But if
     he hesitates, even momentarily, before looking round, he cannot
     then do so without the preliminary performance of all sorts of
     contortions, ending in a twist of his body through a half circle to
     the right. Sometimes he actually turns round two or three times,
     after the fashion of a dog chasing its tail. Let him have a
     pleasant visit, on the other hand, let him engage in a discussion,
     or be engrossed in a play, let him administer a rebuke to some one,
     and immediately his trouble is forgotten, his speech is accompanied
     with animated gestures, the vicious position of his head
     vanishes--in short, he becomes normal.

An intercurrent affection may act either as a deterrent or as a
stimulus; with convalescence, however, there is usually a
re-establishment of the mischief. The most potent influence over the
phenomena of tic is wielded by a sense of well-being, to employ Janet's
discriminating expression. Well-being is a panacea for the _tiqueur_ no
less than for the hysteric. The tic of the worried financier disappears,
as we have had occasion to note, under the magic of a rise in stocks or
a knowledge of solvency. The child's happiness is bound up in his
freedom, which explains the cessation, in Tissié's little patient, of
all convulsive movements during the holidays.

Much evidence is forthcoming to support these points, but we must admit
that the why and wherefore of a tic's amelioration or aggravation often
escape us, nor must we forget that both in the child and the adult
spontaneous cure is not unknown.

As has been remarked, the evolution of tic does not lend itself to
systematic description, but there are cases that form an exception,
their course being regularly progressive. Strictly speaking, they are
instances of Gilles de la Tourette's disease.


GILLES DE LA TOURETTE'S DISEASE

Under the title, "Study of a nervous affection characterised by motor
inco-ordination, and accompanied with echolalia and coprolalia,"
Tourette[131] grouped together, in 1885, a certain number of cases
presenting features in common and so enabling him to describe a morbid
entity, specially remarkable for its progressive evolution. He was
followed in the same line by Guinon, who supplied an account in
nosographical form, and since then the disease has figured in all the
text-books.

To obtain a schematic picture of the condition we shall borrow from
Tourette's[132] last communication on the subject:

     About the age of seven or eight a little boy or girl--for the sexes
     are affected equally--commonly with a wretched family history,
     begins to exhibit a series of tics. The attention of the parents is
     soon drawn to the fact, but they seldom give much heed at first,
     since the twitches are limited preferably to the facial
     musculature. At this stage, too, expiratory laryngeal noises are
     occasionally superadded.

     The movements may be confined for a long time to the face, but
     under the influence of causes very difficult to determine they
     gradually invade the shoulders and the arms. First one shoulder is
     shrugged and then the other, then the trunk is inclined _en masse_
     to right or left; then the patient waves his hands or his arms, or
     bends backwards and forwards, or jumps up and down, flexing the
     knees alternately and tapping with his feet. The muscles of the
     larynx sometimes participate in the abnormal functioning, whence it
     is that many sufferers from tic give vent to quick expiratory
     "hems" and "ahs," which coincide often with the twitches of trunk
     and limbs.

     The disease may be limited to this stage, but it is not uncommon to
     find, a few months or years after the beginning of the facial
     movements, that the inarticulate laryngeal sound becomes organised
     and develops in a particular direction, thus, in a sense, showing a
     pathognomonic value. Under the influence of causes whose action we
     are, in the majority of cases, powerless to appreciate, the patient
     gives vent one day to a word or short phrase of a quite special
     character, inasmuch as its meaning is always obscene. These words
     and phrases are exclaimed in a loud voice, without any attempt at
     restraint. There must be a complete absence of the moral sense
     where there is coprolalia such as this; at the moment of the
     ejaculation some irresistible psychical impulse must drive the
     patient to utter filthy words unreservedly and with no
     consideration for other people.

     Another psychical stigma--echolalia--is occasionally, though less
     frequently, observed in these cases.

Such, then, is Gilles de la Tourette's disease, a clinical type of which
many examples have been recorded. We do not think, however, that all
tics can be brought under the same category; we lose sight of its
distinguishing features if we make the attempt. Of course _fruste_ and
atypical cases are encountered, but even in them it is rare not to find
a certain degree of mental instability in dependence on which echolalia
and coprolalia rest, so completing the morbid syndrome, and it is
important to recognise the successive development of these various
constituents.

It is, indeed, this evolution of symptoms which is so characteristic of
Gilles de la Tourette's disease. A careful scrutiny of recorded cases of
tic, however, makes it abundantly clear that they do not all belong to
the disease of convulsive tics; their localisation, form, and progress
are so different that the effort to assimilate them to Tourette's
disease would abolish the nosographical value of the latter. One patient
may have an ocular tic all his life, and nothing else; the affection of
another may be limited to a tic of the shoulder and arm; a third blinks
and makes a facial grimace; a fourth is a coprolalic who has never
suffered from tic. Are they all to be considered incomplete cases of the
disease of convulsive tics? To answer in the affirmative is equivalent
to a failure to appreciate the distinctive characters of a judiciously
isolated syndrome, and a refusal to describe tics as they are met with
in everyday life. One questions, in fact, whether some of the cases
allotted to Tourette's disease really conform to it. Take an instance
from Chabbert[133]:

     A woman, aged forty-two, had had an injury to the left side of her
     face at the age of nine, as a result of which appeared a
     convulsive facial tic, accompanied at times by hysterical attacks
     which continued for eight years. The tic itself, an abrupt
     contraction of the inferior portion of the left orbicularis
     palpebrarum, underwent no subsequent change, in degree or extent.
     At a later stage a fairly definite tendency to coprolalia became
     manifest.

An unvarying post-traumatic palpebral tic in an hysterical subject
cannot be said to constitute the syndrome of Gilles de la Tourette, in
spite of the coprolalia.

In another of his cases the diagnosis is no less open to doubt:

     The son of the previous patient was a youth of nineteen, with a bad
     heredity on the father's side. In boyhood he had been a
     somnambulist. Some months previously to his coming under
     observation he developed a convulsive tic limited to the frontalis.
     Stigmata of hysteria were present in dyschromatopsia, restriction
     of the visual fields, and left hemihyperæsthesia.

A third case reported by the same author does probably belong to the
disease of convulsive tics:

     A woman aged forty-four, of a strumous diathesis, exhibited tics of
     face and limbs, occurring in the form of attacks sufficiently
     violent to cause bruises, attacks which were invariably associated
     with coprolalia. In addition, she suffered from echolalia,
     echokinesis, and _folie du doute_.

We can only repeat, of course, that each type of tic passes by
insensible gradations into others that precede it or succeed it in the
hierarchy of tics; but we must, provisionally at least, neglect the
links that unite neighbouring groups if we are to avoid losing sight of
admittedly distinctive characters in too comprehensive summaries. It is
desirable to retain the term "disease of convulsive tics" for those
cases whose progressive evolution ends in the generalisation of the
convulsive movements, to the accompaniment of coprolalia and sometimes
of echolalia. This clinical form represents the most advanced degree
attained by the disease; it might be called the tic's apogee. From its
psychical aspect, moreover, the development it undergoes may culminate
in actual insanity.

       *       *       *       *       *

According to the teaching of Magnan, the disease of convulsive tics does
not constitute an entity, since each and all of its symptoms may occur
separately as episodic syndromes of degeneration. The general
considerations with which we introduced our study are applicable in this
connection, and we shall be content to say with Noir:

     We cannot deny the validity of the objections raised by Magnan and
     his school; but the fact that these various symptoms may and do
     most frequently occur singly is no reason for expunging the disease
     of Gilles de la Tourette from the text-books. The combination of
     these symptoms constitutes a clinical entity which has a specific
     evolution, and while its subjects are degenerates in the sense of
     Magnan and of Charcot, they may be ranged by themselves in a very
     definite group.

In some cases which apparently come under this category, psychical
disturbance has not been a prominent feature.

Sciamanna[134] is the reporter of a case where a young man with
neuropathic antecedents was afflicted with tics involving various
muscular groups; his intellect, however, was normal, and the only
psychical change was an insignificant disorder of affectivity.

In such a case it would be instructive to know the mental condition
after the lapse of some years.

Two typical examples of Tourette's disease have been described by
Köster[135] as "disease of impulsive tics"; a third case--in which
widespread muscular twitches, the muscles of respiration and the
cremasters included, were coupled with sometimes a monotonous
intonation and sometimes a jerky speech, though psychical functions were
unimpaired--is considered by Kopczynski[136] to be a case of convulsive
tic, which he distinguishes from the "disease of convulsive tics."

A last instance, published by Innfeld[137] as a case of "chronic
progressive muscular spasm," is an unmistakable example of tic, in spite
of the author's declaration that it does not correspond to any known
morbid type and his attempt to liken it to chronic chorea. A boy of
fifteen exhibited convulsive movements which had begun in the facial
musculature and thence spread to the head, shoulders, and hands, and
were accompanied with respiratory noises and involuntary exclamations.
There was no alteration in sensation or in reflectivity, or in
electrical excitability. Sleep banished while emotion aggravated the
movements.


VARIABLE CHOREA OF BRISSAUD

If the disease of Gilles de la Tourette, by reason of the uniformity of
its symptomatology and the regularity of its evolution, justifies its
differentiation as a separate entity among the tics, a comparison of it
with another type, of polymorphic manifestation, irregular evolution,
and uncertain duration, may prove instructive. We refer to the affection
described by Brissaud as variable chorea.

The form of the motor reactions in this condition warrants the
application to it of the term chorea, but the analogies the disease
presents to tic are very close, nevertheless, and sometimes the two
occur in the same individual. Patients suffering from variable chorea
reveal the same mental abnormalities as are found among those who tic,
while the troubles of motility are sometimes so similar to what we meet
with in the latter that Gilles de la Tourette regarded the condition
simply as one form of convulsive tic, the more so that it is
occasionally accompanied by explosive utterance and even coprolalia.

This view, however, is calculated to obliterate the distinctive
characters of the two affections, and ought not to be entertained. We
cannot do better than repeat Brissaud's original description:

     The use of the word chorea need occasion no ambiguity: the chorea
     consists in the appearance of meaningless and apparently idiopathic
     involuntary movements, whose repetition during rest and action
     alike is proof of their irrationality and incongruity; the duration
     of the symptoms may be limited as in chorea minor or Sydenham's
     chorea, or unlimited as in chorea major or Huntington's chorea.
     "Variable" is the epithet we apply to the chorea because of the
     lack of uniformity in its exteriorisation, the irregularity of its
     development, and the inconstancy of its duration. It comes and
     goes, waxes and wanes, vanishes abruptly to reappear unexpectedly;
     it is a neurosis without a characteristic march.

     Notwithstanding the fact that we are dealing with a chorea--that is
     to say, with a disease which is almost as readily recognisable by
     the public as by any professional--the difficulty of fixing its
     onset is paralleled by the difficulty of knowing when it has
     ceased. This uncertainty is explained by the facile and changeable
     nature of the patient; until the condition is revealed by
     unmistakable signs it passes for an insignificant muscular caprice
     of no pathological importance, while its disappearance is not
     associated with any particular modification of the patient's ways.

     There is a natural tendency to identify all "nervous movements"
     with myoclonus, but the conception is a remarkably nebulous one,
     and means nothing more than "muscular twitch." On the other hand,
     it is well understood that "nervous movements" are more or less
     sudden movements of limbs, shoulders, face, always involuntary and
     generally increasing in force and frequency with the nervous state
     of the patient.

     Parents say, for instance, that their child has become more
     restless and irascible, and at the same time that he has had "more
     movements of the nerves." The coincidence is unfailing. Is the
     expression "nervous movement" lacking in precision? Yet it
     signifies what it is intended to signify. We are concerned neither
     with tonic convulsions nor with clonic spasms, nor yet with tics of
     habit; what the term stands for is a complex contraction, brisk but
     not violent, closely allied to the simplest of automatic acts, such
     as a step in advance, a shrug of the shoulders, a frown, a sigh, a
     moan, a crack of the fingers, an exclamation--in any case usually a
     gesture of impatience. The whole thing, however, is so variable and
     fugitive, that it cannot be said to constitute a definite
     convulsive phenomenon. The contractions, further, in spite of their
     complexity, escape the notice of their originator, who is quite
     surprised at being asked the meaning of the movement he has just
     made, as he is almost entirely ignorant of it.

     Briefly, the "nervous movements" of which we have been speaking do
     not belong either to myoclonus or to tic, but owe their
     distinctiveness to their multiplicity and inconstancy. At the same
     time they are always grafted on a certain neuropathic diathesis
     akin to that of chorea; in fact, they are nought else than a form
     of chorea themselves.

The psychical peculiarities of the patient with variable chorea may be
summed up in instability of thought and action, combined with mental
infantilism. Hence the terms "polymorphous chorea" and "chorea of
degenerates" are used synonymously for variable chorea.[138] Sometimes
the disorders of the mind include hallucinations, and various forms of
phobia or mania.

One or two examples may be given:

     A microcephalic youth of sixteen, a monorchid, developed what
     appeared at first to be an ordinary chorea subsequently to an
     orchidopexy. The movements, however, varied from day to day and
     from hour to hour. Sometimes they disappeared for days at a time,
     to reappear suddenly just when the neurosis seemed cured. The
     influence exerted on them by the will was both mild and transient.
     They constituted, in short, a particular kind of chorea, changing
     and changeable, and differing from intermittent chorea in that
     neither remissions nor relapses were ever wholly complete. Further,
     the condition was implanted on a basis of mental and physical
     degeneration, and seemed likely to become established as a
     permanent functional stigma.

     In another case a peculiar chorea gradually supervened, for no
     obvious reason, in an adult female of tardy and imperfect physical
     and intellectual development. It was difficult to decide whether
     the psychical or the somatic phenomena were preponderant; but to
     the material, tangible, and visible signs of constitutional
     inferiority was superadded a choreiform instability of the whole
     voluntary muscular system, consisting in agitation, gesticulation,
     and incorrigible motor restlessness, coupled with a conspicuous
     incapacity for rational action.

     The steps in the evolution of this functional defect were very
     slow, and coincided with final confirmation of the intellectual
     insufficiency. As for the chorea, its localisation and its
     intensity, its increase and its decrease, its extension and its
     limitation, seemed to vary, in a way that could not be foreseen, at
     the call of certain undetermined circumstances.

In a third instance we meet with many of the symptoms already noted
among those who tic:

     X. is a well-developed boy of fifteen, but there is something
     peculiar about his physiognomy which defies analysis. If his
     mother's statements can be trusted, he is intelligent, quick,
     witty, sound in judgment, and blessed with an excellent memory.
     From the very first he has been eccentric, timid, and
     hypersensitive, and is to-day as tender-hearted and affectionate to
     his people as ever. He has various little "manias" of his own; he
     must have a knife, fork, and spoon for himself, and cannot take his
     food in comfort if they have been set before some one else. Each
     morning he dresses himself with extreme deliberation, then comes
     down to breakfast, of which, however, he will not partake unless he
     has touched all the door handles on his way. This little matter has
     developed into an obsession. His loathing of cold water is so
     pronounced that his morning toilet is rather a stormy proceeding,
     and as he is too old to be washed by his mother, the inevitable
     result is that his face and hands are never clean. At school he is
     both attentive and docile, finding pleasure in his study of the
     classics, but evincing a perfect passion for German. Anything
     German is a source of ineffable joy, so much so that he hugs his
     dictionary with childish exuberance. He listens deferentially to
     his teachers, but takes no note of what he hears. In German, Greek,
     and Latin he is at the head of his class, whereas in history and
     mathematics he is at the foot.

     The "nervous movements" for which he has been brought to the
     consulting-room consist of a series of gesticulations akin both to
     tic and to chorea. Some are much more frequent than others,
     meaningless gestures executed spontaneously, one might almost say
     unconsciously. As he walks to school with his books under his left
     arm, his right hand roams over his person; and in the class-room
     the movements are repeated. At table he rubs his back against the
     chair, and alternately flexes and extends his right leg. Apart from
     these "habit tics," he exhibits actual twitches of his muscles
     generally, and evidence of the consequent disturbance of his
     movements is furnished by a glance at his untidy bedroom, his
     disarranged books, his blotted papers, his slovenly clothes. When
     he goes out with his parents, he is never at their side, but
     lounges along in his own way, then suddenly hurries to regain his
     place by them, falling back again and occupying himself by crossing
     his legs, knocking his ankles together, shrugging his shoulders,
     grimacing, etc. All the movements can be arrested for a time by an
     effort of the will. At any one's behest he can maintain
     tranquillity for a minute, but the strain is too severe, and the
     muscular dance recommences sooner or later.

     The movements are highly variable in type and degree, nor can the
     mother specify the date of their appearance. It is only during the
     last three years that her attention has been more particularly
     drawn to them, and their increasing gravity occasions her some
     anxiety. The boy has become the laughing-stock of his companions at
     school, hence he limits his stay there to the actual hours of his
     classes.

     Three years later the choreic symptoms vanished. X. is to-day a
     stalwart youth, though still timid and eccentric. It is evident
     that in his case the variable chorea has been but an episode in
     adolescence, to be added to the numerous stigmata of degeneration
     enumerated above.

     Notwithstanding its slow evolution (says Brissaud), the neurosis,
     in so far as it was a disorder of motility, seems to have
     completely disappeared. The importance of this for prognosis is
     fundamental, but from the point of view of diagnosis it is no less
     significant, seeing that the nature and form of the movements
     suggested chronic or Huntington's chorea.

A case described by Gilles de la Tourette[139] as disease of the tics
seems really to have been one of variable chorea.

     A woman of twenty-two, who had never been very strong, had an
     attack, at eight years, of involuntary movements of face and arms
     which prevented her feeding herself, and at the hospital a
     diagnosis of chorea was made. Two months later cessation of the
     movements allowed of her return to school, but a second attack
     followed after two years, and a third a year later. At the time of
     observation she was in the throes of her sixth relapse. Every one
     who had seen her considered the condition as chorea.

Tourette, however, was dissatisfied with the diagnosis. There was no
suggestion of its being Sydenham's chorea, or hysterical chorea, still
less of its belonging to Huntington's variety. According to the author,
the muscular twitches were amorphous and indefinite, and characterised
by extreme variability in form, expression, and intensity.

In our opinion the clinical picture is that of variable chorea, and we
are confirmed in our opinion by a consideration of the patient's mental
condition.

     She comes of a pronounced neuropathic stock. One of her two sisters
     is nervous and impressionable, and probably a neurasthenic, while
     the other is subject to hysterical attacks. She herself is of a
     profoundly nervous temperament; she cannot go to bed without
     assuring herself several times that no one is concealed beneath it;
     she suffers from fears and dreads and obsessions of all sorts; she
     is, in fact, an "unstable," a degenerate.

In one of our patients the symptoms were unilateral, constituting a
variable hemichorea.

     It is a matter of some difficulty to furnish an adequate
     description of the movements of the right arm. We note, first of
     all, that their activity depends on whether the arm is free or held
     in a fixed position. Voluntary movements are carried out stiffly,
     but are interrupted by sudden deviations, sometimes of rather a
     wide range, and highly irregular in distribution. Notwithstanding
     these breaks, the end to which the movement is directed is always
     attained with precision.

     While L. was an apprentice dressmaker, she occasionally used to
     make various contortions with her arm, though if her attention was
     diverted they did not occur, and as a matter of fact she did her
     work well enough. Once she became familiar with the mechanical act
     of sewing, the involuntary performances ceased. Before her disease
     asserted itself, she had commenced to learn the piano, and she
     continued to make unimpeded progress, as her teacher discovered a
     method of holding her elbow which checked all convulsive twitches.

     The involuntary movements of the right leg were so insignificant as
     to be almost negligible; they united to produce a sort of irregular
     tremor which became appreciable only when the patient was very
     tired or very annoyed. Sometimes a long walk was followed by a
     certain hesitation in putting the right foot to the ground, and by
     defective inhibition of the antagonists of the desired movement.
     Sometimes one foot was knocked against the other, and sometimes the
     right appeared to assume an equinovarus position. On the other
     hand, we have seen L. walking in the street with her father, when
     no anomaly could be detected in her gait. The distraction of any
     occupation such as dancing or playing a game has the effect, for
     the time being, of banishing the greater part, if not all, of the
     spasmodic phenomena.

This is undoubtedly a case of Brissaud's variable chorea of a unilateral
type, and a consideration of the symptoms confirms the intimate
relationship between it and tic.

Various intermediate forms have been noted. In one of Brissaud's cases,
variable chorea and multiple tics co-existed. Féré[140] reports a case
of variable chorea preceded by tic, and Bernard another in which
starting, trembling, facial tic, variable chorea, etc., were associated.

Tics of phonation are often superadded to the gesticulations of variable
chorea. Brissaud refers to the case of a girl of sixteen in whom
involuntary movements resembling those of this type of chorea were
coincident with a sort of hiccough, and a more or less inarticulate cry;
at a later stage the movements became very infrequent, the hiccough was
more constant, and the cry developed into a coprolalic ejaculation.

Variable chorea and variable tic are obviously very closely allied. The
movements of the latter, however, are distinguished by their greater
abruptness and smaller variety. They are tics by reason of their
systematisation and co-ordination; they are variable because they pass
from one region of the body to another. There is no necessary relation
between them; each has an individuality of its own and is independent of
the rest. In variable chorea, on the other hand, one movement passes
insensibly into another, and the variants of any particular one are
legion.

However easy it is, then, to separate the two clinically, it is none the
less true that they spring from the same soil of mental defect. Variable
chorea differs in nature from other choreas, though its form is the
same; it may be distinguished from tic by the type of movement, but in
essence it is identical.



CHAPTER XII

ANTAGONISTIC GESTURES AND STRATAGEMS


However harmless and insignificant a tic may be, it is a source of
annoyance to its subject of which he constantly seeks to disembarrass
himself. But the feebleness of his will militates against any sustained
effort, and if for a brief space he can conserve his immobility, victory
eludes his grasp, for his tics resume the offensive and increase in
violence. More than ever convinced of his helplessness, he resorts to
measures that serve but to accentuate the mischief. Thus it comes to
pass that he desists from his attempts at repression and admits himself
vanquished.

Some there are, nevertheless, whose inventive faculty leads them to
adopt singular attitudes, to execute curious gestures, to utilise
elaborate apparatus--proceedings always more or less childish, whose
employment is usually followed by success, but only for a time. The
history of O. acquaints us with a whole series of these subterfuges, for
which the expressive name of para-tics was invented by him, tricks
intended to mask or to modify existing tics, but they soon themselves
became as involuntary and as inevitable.

Not all who tic are imaginative enough to conceive such plans, and many
have no thought of showing fight at all, but it is worth while dwelling
on this point for a little, especially in view of the frequency with
which certain tics are accompanied by methods of correction evolved by
the patient.

To begin with, we may quote the case of mental torticollis. The
sufferer's head is irresistibly driven to the right, say, yet he
replaces it immediately by the mere application of his right forefinger
to his chin, and the correct attitude is maintained so long as the
finger is applied. Of the variants of this efficacious antagonistic
gesture the most common is the grasping of the head in the hands, or its
support in the palm, or the simple contact of the fingers with chin, or
cheek, or temple. In some cases the mere threat of this gesture suffices
for the purpose. S. approximates his hand to his left ear, but before he
has actually touched it his head turns spontaneously to the right. It
would be difficult to find more conclusive evidence of the purely
psychical value of such corrective acts.

Sometimes the resources at the patient's disposal are confined to one
measure, though more frequently he avails himself of several, as in a
case recorded by Sgobbo.[141] The antagonistic gesture may fail of its
object if some one other than the patient put it to the test. Even with
the expenditure of considerable force he may make no impression on the
tonic contraction; this rule, however, is by no means general.

One of our patients, whose head used to be strongly tilted on to his
elevated right shoulder, while his right arm was flexed, his left
shoulder depressed, and his whole trunk deviated to the former side, was
able instantaneously to resume his normal attitude by merely placing his
thumbs one on either side of his head. If any one else sought to correct
his vicious position he could do so by applying his fingers to two
well-defined spots on the occiput, towards the base of the mastoid
processes.[142]

Occasionally the antagonistic gesture is of the nature of a paradox. We
may cite an example from Raymond and Janet.[143]

     If we ask the patient whether she cannot sometimes prevent her head
     from rotating, she declares she can, and demonstrates how it is
     done by lightly touching her forehead with her finger tips. Now, in
     view of the fact that her head is deviated to the left and
     backwards, it will be seen that no pressure exerted in front could
     obviate this. What really happens is that at the moment of contact
     not only does she inhibit the movement by the aid of her will, but
     she also makes a slight forward inclination of her head to rest it
     on the point of support. No performance of this description could
     have any efficacy in the case of a genuine spasm due to irritation
     on a reflex arc.

At length the day arrives when the hand is unequal to the task, and the
patient endeavours to utilise more resistant bodies, such as the back of
a chair or the wall of the room, as in a case of retrocollis reported by
Brissaud. These devices in their turn prove insufficient, and relief is
obtained only in the recumbent position. Fournier[144] has seen a case
of convulsive twitching of the right sternomastoid and trapezius
arrested when the head was reclining on a pillow.

Even in bed, however, there is usually something to complain of: the
pillow is too high, or too low, or too soft; the rustle of the packing
is disagreeable, the sheets are too rough, etc., etc. It is then that
all sorts of unlikely arrangements are adopted, and the patient puts his
head under the bolster, or lets it hang over the edge of the bed, or
piles up additional cushions and mattresses calculated to retain it in
the desired situation.

Frequently the stratagems are highly ingenious and complicated.

     Madame K.,[145] forty-three years of age, suffers from clonic
     movements of the head which disappear with the adoption of a
     torticollic attitude, the face looking to the left. Nothing is
     easier than voluntarily to correct this attitude, but the clonic
     movements at once reassert themselves, although they may
     momentarily be kept in abeyance by placing the hand on the chin.

     Numerous and ingenious have been the devices framed by this lady,
     but in no instance has their success been other than transient. Her
     latest invention is a stiff high collar fashioned of several
     thicknesses of a heavy material. At the risk of strangling herself
     she has so compressed her neck that no movement is possible, but
     the right arm has now become the seat of action.

A patient of Grasset[146] used to promenade in the grounds of the
hospital holding a cane in his teeth and maintaining his head in
position by keeping one finger on the end of the stick.

     Another patient, under the care of Noguès and Sirol,[147] whose
     head was fixed in irresistible anteroflexion and rotation to the
     left, had invented a most elaborate piece of apparatus, the
     adoption of which was followed by perfectly satisfactory results.
     On the frame of a pair of pince-nez deprived of the glasses he
     fixed a piece of iron wire ten centimetres long in such a way that
     it stood out from the spring at right angles to the plane of the
     pince-nez. It was sufficient to wear this thing on his nose to
     inhibit the spasm, and to be able to talk, walk, do anything
     unhampered by his torticollis; it was not even necessary to
     concentrate his gaze on the extremity of the rod.

In the case of one of our patients, N., whose head we had on several
occasions succeeded in keeping straight while he was writing by
directing a pin towards his left cheek, the idea was entertained of
utilising this procedure out of doors, and accordingly a long pin was
fixed in the collar of his overcoat. There never was the slightest prick
on his cheek, but we strongly dissuaded him from the continuation of
this objectionable practice.

Antagonistic stratagems of this kind are met with in other tics.

A curious case of mental trismus is reported by Raymond and Janet,[148]
where the patient always spoke through his clenched teeth, but opened
his mouth widely enough when showing his tongue or when eating. To
overcome the tonic contraction of his masseters he used to insert a
minute piece of cork between his jaws, though he could also open them to
articulate properly by holding his chin with his hand.

Chatin's patient[149] nullified the permanent contraction of his
masticatory muscles by insinuating his little finger between the dental
arches.

In this connection reference may again be made to the fixation attitude
adopted by young J.[150] for his left arm, a subterfuge of his own
invention which he considered a sovereign remedy. In essence it was
nothing else than an efficacious antagonistic gesture, inspired by a tic
and become its indispensable complement. Of other ingenious ideas of his
brief mention may be made.

     Convinced of the necessity and possibility of checking the
     movements of his shoulder, he sought the aid of his "immobilising
     mattress," an ordinary mattress spread in a corner of the
     dining-room, on which he flung himself and reclined from morning to
     night, making the wretched thing his companion, solace, and
     confidant, who alone understood and could alleviate his tics. In
     his anxiety to find some point of resistance for his left arm to
     work against, he had a second and much narrower mattress put under
     the first, so that prodigious efforts were required on his part to
     maintain equilibrium on the cylindrical surface. This was exactly
     what he desired, and for a time he ceased to tic.

An equally curious case is that of one of Raymond and Janet's patients
afflicted with multiple tics.[151]

     He was a man thirty years old, who denied having had tics for more
     than four years; he had always been eccentric, however, and came of
     a family some of whose members were dullards and others hysterics.
     His career at school and college was brilliant, but his vain and
     erratic disposition had prevented him from realising his boundless
     ambitions, and carrying into effect many ingenious schemes. For
     that matter, a prominent trait in his character was a curious
     scrupulousness that led him to seek an impossible perfection for
     all his actions. Anything he put his hands to he thought might be
     better accomplished if he had a system for the purpose; he had, for
     instance, all sorts of plans for improving his caligraphy, for
     holding the pen, interminable "tips" for correct punctuation, for
     learning, for reciting. To such an extent was he embarrassed by
     these procedures that he could not write two letters consecutively.
     Purposeless voyages to Africa ended in his contracting
     conjunctivitis, malaria, and dysentery, and he returned to France
     worn out and more eccentric than ever. Thereafter the state of his
     health, and above all his functions of respiration and digestion,
     became matters of absorbing attention. A system had to be thought
     out for breathing better and for avoiding possible suffocation. He
     next devoted himself to the question of alimentation, and conceived
     the idea of moistening each mouthful of food with water, soon
     finding it desirable to wet his lips, apart from meal time, in
     order to breathe better. One day during a journey by train he
     suffered agonies from want of his drop of water.

Examples such as these serve to illustrate how the misplaced ingenuity
of the sufferer from tic complicates his misfortunes instead of
banishing them, and indicate to what extremes his eagerness to obtain
respite may lead him.

All these gestures and stratagems may be considered as manifestations of
ideas of defence, comparable to what obtains among those afflicted with
obsessions and delusions of persecution.



CHAPTER XIII

THE COMPLICATIONS OF TIC


Following in the train of the tics may come a number of complications,
insignificant enough as a general rule, the dread of which may in some
cases actually be instrumental in stimulating the will's activity to rid
the patient of his tic.

Dislocations have in violent cases been known to occur. Incessant
repetition of a tic may lead alike to hypertrophy of certain muscles and
atrophy of their antagonists, conditions which in aggravated instances
may produce permanent malformation.

It is of course in cases of spasm and other convulsive phenomena
dependent on structural disease of nerve centres or conductors that such
trophic disturbances are most liable to occur. Gaupp[152] has described
a case of partial congenital myotonia localised in the muscles of the
forearm and hand, and associated with atrophy, in a patient presenting
certain stigmata of infantilism; but the condition can scarcely be
classed with the tics.

As for actual paralysis supervening on a tic, the case recorded by
Grasset[153] of a young girl in whom a tic of the right leg was
succeeded by a trailing movement of the same limb in walking can hardly
be considered conclusive, inasmuch as such incidents usually indicate
hysteria or functional disturbances akin to tonic tics.

Biting tics are more apt to be accompanied by various sequelæ, such as
mutilations, excoriations, ulcerations of all sorts. By constant
nibbling at his lip J. produced an erosion of the mucous membrane, which
became infected and developed into an ulcerative stomatitis. The
accident, however, had a salutary effect on his tic.

We may quote another illustration from the history of the same patient
to show how complications may sometimes be of curative value.

     In January, 1901, in consequence of excessive cudgelling of one
     fist by the other, the back of the left wrist became inflamed and
     painful, but the bruise soon disappeared. In April of the same
     year, however, a large reddish ecchymosis made its appearance in
     the neighbourhood of the left elbow, with a painful swelling of the
     whole arm on the proximal side, and a few days later the discovery
     of a hard, cordlike mass along the border of the biceps made it
     clear that phlebitis had set in. With proper treatment the symptoms
     gradually diminished in intensity, but there can be no doubt of
     their origin in the reiterated violence of J.'s onslaught on his
     left arm.

     The immediate outcome of the event was to put a brake on his
     exuberant gestures, and although the impulse was still sometimes
     urgent enough to tempt him to recommence, the thought of his
     phlebitis and fear of the dangers of a relapse were sufficient to
     recall him to his senses.

Apropos of complications the case of O. occurs to the mind, his biting
tics ending in the premature loss of all his teeth, while his habit of
rubbing his nose and his chin against the back of a chair led to the
development of callosities. Tonic tics of the neck may in cases of long
duration result in permanent deformities.

Apart from such complications, the vast majority of the accidents that
accompany tics are attributable to various concurrent affections. A case
reported by Féré[154] of rotatory movements of the head passing some
years later into the initial symptom of epileptiform convulsions ought
not, in all probability, to be placed among the tics.

As for the grave mental affections that sometimes are superadded to
long-standing tics, it is unjustifiable to class them as complications;
they are rather manifestations of psychical instability that have found
a suitable medium for their evolution; in many instances they occur
quite independently of the tics.

It may, however, be remarked that the persistence of a tic entails
ceaseless preoccupation on the part of the subject, and may thus pave
the way for obsessions or hypochondriacal ideas. The motor disturbance
reacts adversely on the mental state of which it is the outcome. Hence
an obsession may give rise to a motor display that has all the
appearance of a tic, while the motor act in its turn may become an
actual obsession.



CHAPTER XIV

THE RELATION OF TICS TO OTHER PATHOLOGICAL CONDITIONS


A vast number of disturbances of motility, distinguished as spasm,
chorea, cramp, myoclonus, myotonia, etc., may be derived from the same
pathological substratum as tic, and an equally vast number of psychical
anomalies may spring from that psychopathic diathesis of which tic is
merely the motor expression.

The frequency of these associations is confirmed by innumerable clinical
observations, many instances of which have been given already.

That the relations between tic and other diseases of the nervous system
are very intimate is patent from every-day experience; such and such a
tic may be succeeded, in the same individual, by a much graver condition
in the shape of mental disease, general paralysis, tabes dorsalis, etc.
Inversely, some cases of chorea seem to terminate by leaving no trace of
their occurrence beyond some little convulsive movement or tic. The
position tic occupies is, then, a peculiarly interesting one, for it may
be the starting-point of another affection, it may be an intercurrent
phenomenon, or it may persist as the reminder of some previous disease.
For this reason it well merits attentive study.

In this chapter we shall examine the connections of tic with hysteria,
neurasthenia, epilepsy, mental disease, and idiocy respectively.


TICS AND HYSTERIA

Our response to the question whether tics are hysterical in origin is a
direct negative. Without attaching pathognomonic significance to
stigmata, we may remark how seldom they are encountered among those who
suffer from tic, and how rarely the latter exhibit any of the paroxysmal
manifestations of hysteria.

Modifications of general sensibility such as anæsthesia or hyperæsthesia
are unknown; the special senses are intact; in particular, contraction
of the visual fields is never met with. Though these signs are negative,
their importance from the point of view of diagnosis is none the less
real.

The mental condition of patients with tic is no doubt analogous to that
of hysterical cases, but it is no less common in many others that
present no sign of that neurosis. There is little or nothing in tic
characteristic of hysteria, and one sometimes questions whether the
_soi-disant_ hysteria of certain subjects of tic is the real disease.

In the same way as all who are predisposed, the sufferer from hysteria
may develop a tic or tics, and although tic was held by Briquet,
Axenfeld, Bouchut, and others, to be merely an accessory symptom of
hysteria and _nervosism_, these doctrines were propounded prior to the
analytic researches of Charcot.

Pitres,[155] whose opinion is so weighty in matters neurological,
considered a predisposition to tic as a sign of hysteria, for which
neurosis the subjects of tic were candidates, and supported his
contention by various clinical examples:

     A resin-gatherer of Landes carried all day from tree to tree a
     notched stake of wood by which to climb up the pine-trunks. The
     weight of it on his left shoulder began to cause a slight but
     persistent aching, which was followed by involuntary deviation of
     the chin to that side. The movements took place at the rate of ten
     to thirty a minute, but diminished materially in frequency and
     degree whenever the patient lay on his left side, or when he
     inclined his head voluntarily on either shoulder, and disappeared
     entirely if he was asleep, or if he sang, or whistled, or recited
     in a loud voice.

     Examination of his visual fields revealed a marked restriction, and
     every effort to cure the condition proved ineffectual.

Pitres' conclusion is that the condition is one of tic, probably caused
by the habit of carrying the stake, and probably also of hysterical
origin. It is true the hysteria is reduced to its most simple elementary
symptomatic expression, but it is difficult not to recognise its
activity in the concentric contraction of the fields of vision.

Nothing is more likely, we think, than that we are dealing in this
instance with a tic occasioned by a professional act, but we doubt
whether alterations in the visual field are sufficient to justify a
diagnosis of hysteria.

In another case of the same author, where a facial tic made its
appearance in a hystero-neurasthenic after a series of worries, the
association of the two is of course undeniable, but it does not follow
that tic is in essence hysterical.

Take another example from Chabbert:

     A little girl of twelve years, with a bad family history, began to
     exhibit involuntary movements as the result of a succession of
     frights, which led at the same time to the production of certain
     hysterical phenomena. The stigmata were unmistakable, and in
     addition the girl was an echolalic.

Here there seems to have been a combination of hysteria with the disease
of convulsive tics. Charcot,[156] however, drew a sharp line of
distinction between them, although they may co-exist in the same
individual.

Apropos of this subject Raymond and Janet[157] call attention to the
fact that in the somnambulistic state the memory may be much more
extensive than in the waking state, and may recall events that have not
passed the threshold of consciousness, which nevertheless have been the
determining cause of various phenomena of the conscious life. In this
way may be explained the genesis of certain tics, although it is not a
necessary sequel that they themselves are stigmata of hysteria.

Sometimes, however, that disease does appear to play an indispensable
part in originating convulsive movements. An interesting case in point
has been published by Scherb[158] as "beggar's tic."

     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.

Whatever be the variety of tic, the remarks we have made, based as they
are on clinical observation, are applicable to it. In particular, they
have a direct bearing on Cruchet's psycho-mental tic. To quote that
author again:

     Hysteria and neurasthenia are two diseases which we meet at every
     turn in our study; and if we remember that, according to Raymond,
     fibrillary chorea of Morvan, paramyoclonus multiplex of Friedreich,
     electric chorea of Hénoch-Bergeron, painless facial tic of
     Trousseau, and disease of Gilles de la Tourette-Charcot, are all
     mere varieties of myoclonus, which is itself a product of
     neurasthenia and hysteria, we are forced to admit that it is these
     conditions which dominate our conception of psycho-mental
     convulsive tic.

Thus it comes to pass that tic is lost in a crowd of widely differing
convulsive phenomena, and is threatened with the permanent loss of its
distinctive characters, while hysteria itself is like to become a
perfect Proteus once more. Neurasthenia too is again to sink to the
level of a receptacle for all manner of ill differentiated conditions.

We, on the contrary, feel it more than ever incumbent on us to resist
the tendency to class in the same section facts which clinical
observation distinguishes, otherwise hysteria and neurasthenia will soon
signify nothing at all. If tic is to be considered one of the
polymorphic manifestations of these diseases, we shall be transported
back fifty years, to the time of the famous "chaos of neuroses," out of
which, in some ways at least, Charcot finally produced order.


TIC AND EPILEPSY

The co-existence of epilepsy and tic has been noted sufficiently often
to open the question of their possible relationship. Of course the
mental state of epileptics is such as to favour the development of tics.
Usually, however, the convulsive phenomena supposed to be of the nature
of tic merit some other description.

In the first place, they may be Jacksonian in type, and under these
circumstances confusion is scarcely possible. It is not without interest
to compare the gestures and stratagems of defence which sufferers from
tic devise, with the procedures adopted by some Jacksonian patients,
such as compression of the arm or wrist by the fingers, or by string or
more elaborate apparatus. There might conceivably be some hesitation in
making a diagnosis if it depended on these arrangements, but the mere
observation of one actual attack will dispel all difficulties.

We may mention the convulsive seizures of idiopathic epilepsy only to
dismiss them. Loss of consciousness is an unfailing criterion.

It is more especially the association of epilepsy with the ill-defined
group of myoclonus that we propose to discuss.

According to Maurice Dide,[160] myoclonus, which he calls motor petit
mal, occurs in five per cent. of cases of epilepsy. Attention has also
been directed to this question by Mannini[161]:

     After an attack of epilepsy the convulsive twitches are at a
     minimum, but during the next few days the myoclonus, or rather the
     polyclonus, becomes increasingly intense and varied, until it
     reaches a maximum, which is crowned by a second epileptic fit. The
     spasmodic contractions begin in the face and invade the rest of the
     musculature; they recur in the form of seizures at diminishing
     intervals, leading to the epileptic attack, when the muscles pass
     into permanent contraction.

     Sometimes the myoclonus takes the shape of fibrillary spasm,
     sometimes the whole of a muscle is involved; the twitches may be
     rhythmical and symmetrical, or arhythmical and asymmetrical, so
     much so that at a given moment the patient may present the clinical
     picture of convulsive facial tic, or paramyoclonus multiplex, of
     Gilles de la Tourette's disease, or electric chorea.

Mannini's view is that the varying convulsions known as myoclonus or
polyclonus are akin to epilepsy, and are the outcome of the same
cortical lesion, the nature of which has not as yet been fathomed--a
lesion whose expression is hyperexcitability of the cells of the
rolandic area. Analogous conclusions may be drawn from a case of
epilepsy and myoclonus, with autopsy, reported by Rossi and
Gonzales,[162] where a general ischæmic degeneration of the central
nervous system was found, the greatest changes being discovered in the
rolandic zones of each side, as well as in the extremities of the three
frontal convolutions. Schupfer[163] has recorded cases of family
myoclonus with epileptiform attacks.

We are content to note the facts. Any conclusion applicable to the tics
is premature.

Various observers have drawn attention to the development of tics in
persons formerly subject to epilepsy. Malm[164] has described a case of
rotatory tic in a man who has been a known epileptic for ten years.
According to Féré,[165] epilepsy may supervene in patients who at one
time suffered from tic. As an example, he quotes a case of tic localised
in the left ear and dating from infancy; the patient had reached his
thirty-fifth year when the recrudescence of the tic ushered in the first
attack of epilepsy, which consisted of elevatory movements of the left
ear and convulsions of the left half of the face, passing thence to the
right arm and the left leg, and becoming generalised. The fact that the
twitches of the left ear could not be imitated voluntarily suggested
that the original "tic" may have been the result of some minute cortical
irritation, the increase of which became eventually the determining
cause of a Jacksonian attack.

Another case due to the same author concerns a woman of fifty-four
years, subject from her youth to fixed ideas.

     For the last four years she has had seizures which may be
     attributed to her idea that she must see the whole of the objects
     on her left. Under the impulse of this idea, she turns her eyes
     upwards and to the left, rotates her head in the same direction,
     and her body too, if she happens to be on her feet. The performance
     is gone through fifteen or twenty times a day.

     In addition, she suffers from epileptiform attacks, which commence
     by this deviation of head and eyes to the left, and spread to the
     arms and to the left leg, leading to loss of consciousness as they
     become generalised. The patient finally succumbed to an apoplectic
     stroke followed by left hemiplegia.

In this instance the connection between the fixed idea and the patient's
gesture favours the diagnosis of tic, but the subsequent history of the
case makes one consider it with reserve. All such cases ought to be
followed up carefully, and we may modify Féré's conclusions somewhat to
declare that the appearance of a convulsive movement in an adult, or the
aggravation of a similar movement of ancient date, should lead one to
suspect epilepsy and to look for signs of it: "The patient runs more
chance than risk in being treated as an epileptic."

We have had the opportunity of observing, in one of our mental
torticollis cases, a condition not unlike what is known as _absence
épileptique_. The term "incantation" was applied by the parent to his
daughter's habit.

     On two occasions we noticed the patient's eyes turn upward and
     remain fixed for a moment or two, while her expression changed to
     one of tranquillity and unconcern--a sign of distraction, not of
     ecstasy. She merely appeared to be thinking of something other than
     the immediate topic of conversation, and after two or three seconds
     resumed her ordinary ways.

     These brief "absences" are trifling enough, of course, but their
     painstaking study is of inestimable aid in the matter of diagnosis.
     They began at the age of seven or eight, and at first occurred as
     often as sixty times in a day. What the patient did was to raise
     her head, and turn up the whites of her eyes; in a second or two
     her countenance had resumed its ordinary expression. From their
     onset, the "incantations"--to use her father's term--gradually
     increased in frequency and length, and attained a sort of maximum
     when she was eleven years old, slowly diminishing thereafter till
     at present they have become rather exceptional. They proved to be a
     source of great tribulation to L., seeing that she was exposed to
     the practical jokes of her companions, who used to seize the
     occasion to relieve her of any books or toys she had in her hand.

     During the "absence" there is no change of colour, nor has there
     ever been any vertigo or sense of rotation. She has never actually
     fallen, though she has allowed things to drop out of her hands.
     Once it is over, she is aware of it, but her memory of what has
     just taken place is very vague, though she usually can tell what
     preceded it. She can be aroused from the "incantation," to sink
     back into it an instant later, as though she had not dreamed
     enough. Sometimes a series of "incantations" occurs, one following
     on the heels of another. Occasionally she utters such words as
     "yes, yes!" or "no, no!" in an impatient tone of voice, and plucks
     at her hair or clothes, or toys with the handkerchief which is
     never out of her hands.

Call these phenomena "epileptic absences" if you like, but after the
reverie is over, L. knows quite well that she has had it; besides,
prolonged bromide treatment has been totally inefficacious.

One of us has come across a somewhat similar condition in a ten-year-old
girl:

     Fifty times a day she interrupts her work or her play to retract
     her head and roll her eyes upward. The duration of the attack is
     not longer than ten seconds, and there is no cyanosis or distress
     of any kind. The application of tactile or painful stimuli at these
     times makes her shut her eyes and withdraw her head or her limbs,
     and she can tell afterwards what was done. She knows that she has
     had a "sensation," and remembers any noise that occurred while she
     was in that state.

     Otherwise, there is little to note. For one month she presented
     very mild convulsive movements in the left arm and leg, but no
     trace remains of them to-day. Treatment with bromides has failed to
     effect any modification.

Examples of the same nature, but said to be of hysterical origin, have
been recently published by Luzenberger:[166]

     A young girl, twelve years of age, has brief attacks in which she
     loses consciousness, and turns her head to the right, while the
     angle of the mouth is drawn to the left. This sort of attack recurs
     forty or fifty times a day, and has been going on for three or four
     years.

The reporter thinks the case a difficult one to diagnose, though the
trifling nature of the symptoms, and their evolution, do not suggest
epilepsy. One may question, however, whether they indicate hysteria.

Our sole object in referring to these cases has been to note the
co-existence of these "absences" with motor phenomena closely allied to
the tics, if not with tics themselves. We cannot be satisfied with
finding a common bond for all such conditions in mental degeneration,
but it is perhaps premature to seek to interpret the facts.


TICS--INSANITY--IDIOCY

Insanity in any of its forms may be accompanied by clonic or tonic
convulsive movements--movements that may be of the nature of tics or
spasms or stereotyped acts, or that may belong to conditions which we
distinguish by the names of myoclonus, polyclonus, myotonia, catatonia,
etc. It is highly probable that many instances have been described as
spasms which, according to our nomenclature, must be considered tics.
Brodie, to take an example, quotes a case where a "spasm" of the spinal
accessory was replaced by a mental affection. Alternation of
hallucinatory mental confusion with "spasm" of the neck muscles has been
observed by Oppenheim, as well as a case where the "spasm" originated
in the course of an attack of alcoholic mania. In another, due to
Gowers, "spasm" of the muscles of the neck was preceded, at a ten years'
interval, by an attack of melancholia.

Most of the cases of this nature would be held to-day to be instances of
mental torticollis.

That tics and mental disease accompany each other is notorious, but a
discussion of the question would carry us beyond our limits. We must say
a word, however, on the tics of idiots.

The study of tic as it occurs in idiots, imbeciles, and _arriérés_, has
engrossed the attention of alienists since the days of Pinel and
Esquirol. Cruchet says the mental state of the idiot and the imbecile is
so characteristic that the diagnosis of convulsive tic in such cases is
never attended with any difficulty. Yet the task is sometimes
sufficiently delicate, for we maintain that upon our insight into the
subject's mental condition depends our ability to analyse his tics.

Considerable light has been thrown on the question by the important
information amassed by Bourneville, as well as by the fine psychological
studies of Sollier and the meritorious thesis of Noir, from which we
shall borrow largely in this place.

In the first instance, we meet with tics in every way comparable to
those we have already described, and we may give one or two examples.

     R. accidentally wounded his left eye at the age of eleven, and
     contracted a tic which consists in spasmodic blinking of the
     eyelids, though no sign of ocular lesion is left. A diminution in
     its intensity has been taking place, which has culminated recently
     in its spontaneous disappearance.

     N. had an attack of ciliary blepharitis and keratitis which left an
     opaque patch on the upper and inner part of his left cornea, and he
     has blinked ever since. Yet there is no local irritation to justify
     the continuance of the movements.

The tics are occasionally as numerous and violent as in Gilles de la
Tourette's disease, and are accompanied with cries and with coprolalia.

     L. is afflicted with abrupt blinking of the eyelids, retraction of
     the head, and elevation of the lip. Once the tic is established, it
     persists on an average for from eight days to a month, and during
     this time no effort on his part will check it. Sometimes he makes
     peculiar growling noises; sometimes he cannot prevent himself from
     stooping down as if to pick up stones; sometimes he is unable to
     restrain himself from touching everything within reach.

     From the age of five, C. exhibited frequent blinking movements, and
     gestures which seemed to indicate that his clothes were
     uncomfortable. No attempt at modification was attended with
     success. The tics steadily increased, till he found himself
     uttering cries and letting obscene words escape his lips. For a
     long time they remained in abeyance, then reappeared in his face
     and trunk, in the form of salutation movements. His propensity for
     clastomania, pyromania, and kleptomania necessitates his being kept
     under strict supervision, and though he is intelligent and has a
     good memory, he is also lazy and inattentive.

Other tics of still greater complexity and peculiarity are met with
among those whose psychical imperfections are very pronounced. Some
"co-ordinated tics" are remarkable for their intricacy; they consist of
a series of movements which mimic some act of everyday life. In this
group may be specified various rhythmical movements, such as those of
balancing, head rotation, and striking or beating oneself--the
krouomania of Roubinowitch; they may be compared to the mother's rocking
of her infant, inasmuch as they have a soothing effect on their subject,
however brutal the movement itself sometimes may be.

     In most cases the patient is seated and rocks himself to and fro in
     an antero-posterior direction. Or it may be the head only that is
     rhythmically moved from side to side, and the performance may go on
     indefinitely. A mere touch or a word, on the other hand, is
     commonly sufficient to interrupt its sequence.

There remains a final class of co-ordinated tics, which Noir
distinguishes by the epithet "large," tics which are confined to idiots
of good physical development. They consist of a movement or series of
movements of considerable amplitude, and constitute the predominant
clinical feature of the patient's idiocy. Here we find subjects who
jump, or climb, or turn round and round; in other cases they are reduced
to the level of mere automata, and go through a long series of actions
in a mechanical way.

     Their memory for recent occurrences is very poor, but in their
     minds are stowed away vague souvenirs of events long past, which
     they translate into action, and which they are incapable of
     modifying, even as they are unable to add to their mental store or
     to alter their mental routine.

A classic instance of this variety of tic is Ros., long known at Bicêtre
as "the waltzer."



CHAPTER XV

THE DISTINCTIVE FEATURES OF TIC


We are scarcely inclined to believe in the possibility of condensing
into an adequately concise and adequately precise formula our conception
of tic, or at least all the notions which contribute to it. Because most
authors feel it incumbent on them to fall in with this nosographical
custom, definitions have been proposed whose brevity only serves to
confuse the issue. Opinion on the interpretation of certain words which
concern our subject is far from being unanimous, and, as we remarked at
the outset, accuracy in our terminology is urgently called for. This has
been our reason for preceding our definitions by the results of clinical
observation and pathogenic analysis.

Our idea of tic, however, may be couched in the following terms:

_A tic is a co-ordinated purposive act, provoked in the first instance
by some external cause or by an idea; repetition leads to its becoming
habitual, and finally to its involuntary reproduction without cause and
for no purpose, at the same time as its form, intensity, and frequency
are exaggerated; it thus assumes the characters of a convulsive
movement, inopportune and excessive; its execution is often preceded by
an irresistible impulse, its suppression associated with malaise. The
effect of distraction or of volitional effort is to diminish its
activity; in sleep it disappears. It occurs in predisposed individuals,
who usually show other indications of mental instability._[167]

We are in a position, now, to elaborate the details of this definition.
Tic is a psychomotor affection, and there are two inseparable elements
in its constitution, a mental defect and a motor defect.

The prevailing mental defect is impairment of volition, which takes the
form either of debility or of versatility of the will. This being
characteristic of the mind of the child, its continuance in spite of
years argues a partial arrest of psychical development. Hence the
epithet infantile may be employed to qualify the patient's mental state.

Other psychical troubles, which similarly are anomalies of volition, may
be superadded, in particular impulsions and obsessions.

Speaking generally, a certain degree of mental instability is a
distinguishing feature of the patient with tic.

The defect of motility consists at first in the provocation of a motor
reaction by some external cause, or by an idea.

In the former case, the reaction is the cortical response to a
peripheral stimulus, and its logical execution becomes by dint of
repetition habitual and automatic. With the disappearance of the
stimulus it continues to manifest itself, without cause and for no
purpose, in which circumstances the feebleness of the inhibitory power
of the will is revealed.

In the latter case, the motor reaction is called into being under the
influence of an idea, normal or pathological, which eventually ceases to
operate, and by virtue of the same pathogenic mechanism the act remains,
inopportune and exaggerated.

The objective manifestation of tic is a clonic or tonic convulsive
movement, an anomaly by excess of muscular contraction.

In the clonic variety there are undue rapidity and increased frequency
of the movements.

In the tonic variety, the duration of the contraction is prolonged.

The intensity of the movements, likewise, is abnormal in degree.

In spite of these disfigurations, so to speak, of the original movement,
it is practically always possible to detect in them co-ordination and
purpose, the cause and the significance of which ought to become the
object of our search.

The motor disorder can never be reduced to mere fibrillation, nor indeed
to fascicular contraction unless in some one muscle different bundles
have different physiological attributes. It is usual for several muscles
to be concerned, and their anatomical nerve supply may be from separate
sources.

Like ordinary functional motor acts, tics are distinguished by
co-ordination of muscular contraction and repetition; they are preceded
by a desire for their execution, and succeeded by a feeling of
satisfaction.

These features, however, are carried to excess.

In addition, the functional act is inapposite, sometimes even harmful;
it may be described as a parasite function.

The muscular contractions follow each other at irregular intervals; they
come in attacks, which, it is true, are highly variable in frequency,
duration, and degree.

Volition and attention exercise a restraining influence on the motor
phenomena, but repression is accompanied by malaise, sometimes by actual
anguish.

Distraction suspends the activity of tic; physical fatigue and emotion
are calculated to arouse it.

Tics always disappear in sleep.

They are unaccompanied by any alteration in sensation, in the reflexes,
or in the trophic functions.

They are not associated with pain.

       *       *       *       *       *

In this general way we have indicated the distinctive features of tic,
and we may take the opportunity to remind ourselves of their extreme
variability.

In discussing the question of diagnosis, we shall have occasion to
emphasise the importance of _fruste_, atypical, and transitional cases,
not because we think they can be systematised as yet, but because they
may be capable of new pathogenic interpretations which we cannot afford
_a priori_ to set aside.

We venture to believe that tic has a clinical individuality of its own
which we have tried to portray, and we go so far as to say that an
appreciation of the points we have touched on will prove of service in
matters of diagnosis.



CHAPTER XVI

DIAGNOSIS


TICS AND STEREOTYPED ACTS

We have already, on more than one occasion, drawn attention to the
phenomena known as stereotyped acts, demonstrating their intimate
kinship with the tics and the frequent difficulty of establishing a
differential diagnosis. To ensure precision of ideas and of terminology,
we must restrict the expression to motor disturbances in which the
characters of the muscular contraction are identical with those of
normal acts. On this view many motor reactions are really classifiable
as stereotyped acts, and among them are those denominated by Letulle
"habit tics."

Stereotyped acts occur in normal individuals, and it may fairly be said
there is no one but has his habitual gesture, his movement of
predilection. As a matter of fact, a certain number of what Letulle
calls co-ordinated tics belong to the group under consideration; others,
no doubt, are genuine tics, and between the two may be found innumerable
intermediate varieties.

From the diagnostic standpoint the stereotyped acts that occur in the
course of mental disease, of which a conscientious study has recently
been made by Cahen,[168] are highly instructive. He defines them as
non-convulsive, co-ordinated attitudes or movements, resembling
intentional or professional acts, repeated at frequent intervals and
always in the same fashion, till their conscious and voluntary
performance is replaced by a degree of subconscious automatism. In the
case of the insane they are secondary to some delusion, and persist
though the latter may disappear. Hence the patient may be incapable of
explaining his movements and attitudes, however much he may persevere in
their automatic execution--an evolutionary process akin to that of the
tics.

A typical instance may be quoted from Séglas:

     B. passed under observation in 1891, suffering from delusions of
     persecution, and not long afterwards it was noticed that from time
     to time he used to come to a halt in the courtyard, gaze at the
     sun, and rotate his hands round an imaginary axis. The reply he
     vouchsafed to interrogation on this point was that he was effecting
     the sun's revolution. At present, however, he has sunk into a state
     of dementia, and while the gesture continues he is unable to
     furnish any explanation of it.

Of course it is inadmissible to apply the term to co-ordinated acts that
are neither conscious nor voluntary, such as the teeth grinding of the
general paralytic, or the body oscillation of the idiot. Similarly one
must differentiate them from impulsive seizures, abrupt irresistible
motor explosions neither frequent nor prolonged.

A distinction has been drawn between _akinetic_ (attitude) stereotyped
acts and _parakinetic_ (movement) stereotyped acts. As instances of the
former we may give the following:

     A woman reclines continuously in bed because she believes she has
     an infernal machine in her abdomen.

     Another patient sits on the ground all day long, buttoning and
     unbuttoning his clothes.

     An old gymnast maintains while he stands a professional attitude
     in which his head is raised, his right fist closed on his hip, his
     right leg crossed in front of the left, and his right foot elevated
     vertically.

Conditions such as these present the most intimate analogies to our
attitude tics, though in the case of the latter there is always a more
or less pronounced exaggeration of muscular contraction, a certain
degree of tonic convulsion.

Parakinetic stereotyped acts are of common occurrence, and embrace every
variety of movement or gesture.

     A former acrobat leaps staircases, climbs railings, exercises his
     arms rhythmically and regularly, etc.

     A patient promenades untiringly in the same corner and at the same
     pace.

     An old engraver, now a dement, passes the day in reproducing in a
     more or less modified form certain actions associated with his
     former profession.

Alike in tics and in stereotyped acts, a time comes when the motor habit
establishes itself, for no apparent reason or purpose; hence the
co-existence of the two classes in chronic delusional insanity, in
dementia precox, in catatonic states, in systematised mental disease of
other forms, and in general paralysis.

Stereotyped acts may be the embodiment of ideas of persecution and of
grandeur, or the outcome of mystical, hypochondriacal, and other states.
A patient with delusions of persecution writhes because he is being
"electrified." A hypochondriac rests motionless because he believes
himself made of glass. A mystic maintains an attitude of genuflexion for
hours at a time.

Obsessions also play a part in the genesis of the acts we have under
consideration, but of all delusional ideas those of defence are the most
fertile in this respect.

A patient under the care of A. Marie used to carry a fragment of glass
between his teeth and other pieces beneath the soles of his feet, the
idea being that they formed insulating cushions whereby to protect
himself from the electricity of his enemies.

The suggestion was thrown out by Bresler that the movements of tic are
often of a defensive character--that the disease, in fact, is a sort of
"defence neurosis" linked to hyperexcitability of psychomotor centres.
This theory is not unlike the view of hysteria taken by Brener and
Freud, and as the movements themselves are usually of the nature of
mimicry, Bresler has proposed the term _mimische Krampfneurose_.

In some cases of mental torticollis, the attitude assumed may be
considered as a stereotyped act. Martin has recorded an example of
torticollis in relation to melancholia. Another of his patients suffered
from rotation of the head to the left, a position which could easily be
rectified by asking the man to make the sign of the cross. The moment he
put his finger on his forehead the displacement of the head was
corrected. If, however, he were requested to look straight in front of
him, he remained incapable of altering the vicious attitude, the reason
he advanced being that he could no longer see the sun.

One cannot but be struck with the remarkable analogies to the cases
given by Cohen. And it is worth remembering further, that sometimes
mental torticollis degenerates into actual dementia.


TICS AND SPASMS

Nothing is more arduous, at first sight, than the differentiation of a
tic from a spasm, the similarity of their external forms being a fertile
source of confusion. Yet the establishment of a correct diagnosis is of
prime importance, since in their case prognosis and treatment alike are
diametrically opposed.

Tic is a psychical affection capable of being cured, if one can will to
cure it: at the worst we may fail, but there is no idea that it is
indicative of a grave organic lesion prejudicial to life. A spasm, on
the contrary, though it appear in almost identical garb, is excited by a
material lesion on which depends the degree of its gravity. The focus of
disease may disappear, no doubt, but it is only too likely to persist
and to occasion other disorders. Hence the desirability of making sure
of one's diagnosis--a proceeding not necessarily of insuperable
difficulty. If we apply the principles of diagnosis enunciated by
Brissaud, to which our attention has already been directed, we shall not
find the task beyond our powers.

Let us take a concrete instance.

     Here is a cabman, forty-nine years of age, the left half of whose
     face is the seat of convulsive twitches. These commenced eighteen
     months ago by brief insignificant contractions of the left
     orbicularis palpebrarum, which have gradually spread to the whole
     of the muscular domain supplied by the left facial nerve. Their
     momentariness and rapidity, their apparent independence of
     extraneous stimuli, their indifference to treatment and resemblance
     to the twitches produced by electrical excitation, their occurrence
     in sleep, the fact of voluntary effort, of attention or
     distraction, serving so little to modify their range and
     intensity--all make clear the spasmodic nature of the condition.

     The motor manifestation is the consequence of irritation at some
     point on a bulbo-spinal reflex arc; its abruptness and
     instantaneousness negative the possibility of recognising in it any
     sign of functional systematisation. It is not a co-ordinated act of
     a purposive nature, but a simple, unvarying, constant motor
     reaction to a particular stimulus. That its intensity should be in
     direct proportion to the intensity of the latter, changing from
     feeble contractions to a state of transient tetanus, is further
     proof of its spasmodic origin. When the excitation is at its
     maximum, there is sometimes involvement of the opposite side of the
     face, by virtue of the law of the generalisation of reflexes.

     It is true there is no association of pain with his attacks, as in
     so-called tic douloureux, but the spasm is heralded by a tingling
     sensation below and to the inner side of the outer corner of the
     eye. This sensation, "like an electric battery," persists during
     the spasm and disappears in the intervals. Its occurrence suggests
     that the ascending branch of the infraorbital nerve, springing
     from the trigeminal, is affected, and indeed pressure over its
     point of emergence evokes a certain amount of pain. Moreover, there
     is occasionally a flow of tears when the spasm is at its height. It
     may be difficult to decide whether this is the result of mechanical
     compression of the lachrymal gland or an exaggerated secretion of
     tears under the influence of stimulation of the lachrymo-palpebral
     twig of the orbital nerve. In any case the pathogeny of this facial
     spasm is entirely comparable to that of tic douloureux of the face,
     and it is quite within the bounds of possibility that a minute
     hæmorrhage--for the patient is of a very florid type--somewhere on
     the centrifugal path of the trigemino-facial reflex arc, may be
     giving rise to the phenomena.

     What we wish to insist on, however, is the dissimilarity between
     this facial spasm and tic. In the movements we have been describing
     we fail to distinguish any purposive element, any co-ordination for
     the fulfilment of a particular function: they are not imitative in
     character, nor do they express any sentiment; no impulse precedes
     their execution, no satisfaction follows.

     The patient's mental state presents no peculiarities, as far as we
     have been able to discover. There is no volitional debility or
     instability; if he cannot control the convulsions, it is to be
     remarked that he cannot control them even for a moment, whereas all
     sufferers from tic are capable of inhibiting it for a longer or
     shorter period by an effort of the will, by concentrating their
     attention on it.[169]

The following remarks on this case are due to Professor Joffroy:

     If the patient be asked to open his mouth, the spasm of the left
     cheek remains in abeyance at long as it is open, but the platysma
     of the same side then begins to twitch spasmodically. Or if he be
     requested to shut his eyes, so long as they continue closed the
     cheek is quiescent; but, on the other hand, both orbiculares
     palpebrarum, as well as the pyramidal muscles and the adjacent
     fibres of the frontalis, are seen to contract irregularly. There is
     a sort of transference of spasm, and this is of peculiar interest,
     inasmuch at it affords evidence that the lesion is not so
     restricted as one might suppose.

     The explanation no doubt is to be sought in the law of the
     diffusion of reflexes, confirming the diagnosis of an irritative
     lesion at some point on the trigemino-facial reflex arc.

In the differential diagnosis of spasm assistance may be obtained by a
consideration of the following points:

The extreme abruptness of the movement recalls the contractions produced
by electrical stimulation.

There is no purposive or co-ordinated feature in the spasm, which is
confined to some nerve area anatomically limited.

Volition, attention, distraction, emotion, all fail to effect any
modification of the phenomena.

No irresistible impulse precedes their manifestation, nor is it
succeeded by a feeling of satisfaction. Sometimes the spasm is
accompanied by severe pain.

As a general rule the patient's mental state does not present the
anomalies met with so frequently among those who tic.

Important information may be gleaned from a scrutiny of the condition
during sleep. Should the convulsive movement persist, it may be said
with confidence to be a spasm; whereas if it completely disappear, it is
probably a tic. Whether a spasm may vanish in sleep, however, is another
question, which clinical observation has not yet satisfactorily
answered, and if no other indication of organic disease be forthcoming,
the problem must in the present state of our knowledge be left unsolved.


A. Tic or Spasm of the Face

In cases where the face is the seat of the convulsive movements this
problem of diagnosis becomes one of the utmost nicety. That a
distinction may be drawn, however, is universally admitted.
Hallion,[170] for instance, specifically separates clonic spasms due to
structural changes from the "nervous movements" of neuroses such as
chorea or tic. Facial spasm is rigorously limited to the distribution of
the nerve, and is commonly the result of some alteration in it effected
by causes similar to those that occasion facial paralysis.

Clonic spasms of the face are occasionally a sequel to local
traumatism--that is to say, they are the result not of direct but of
reflex excitation of the facial nerve. Tic douloureux belongs to this
class. Tic non-douloureux also is sometimes merely a simple reflex
spasm.

One of the most pregnant of Brissaud's lessons is devoted to the
elucidation of this part of our subject, and we have already made
several quotations from it. In many cases he is forced to say, "I
decline to hazard a diagnosis when etiology is silent." We too have been
face to face with this diagnostic difficulty on several occasions, and
it may be instructive to give the details of one or two cases where no
definite conclusion could be arrived at.

     A man thirty-seven years of age had been suddenly seized with
     facial paralysis on the left side thirteen years before,
     accompanied after an interval of eight days by bilateral
     fronto-temporal cephalalgia, nausea, vomiting, and disturbances of
     vision. These attacks recurred irregularly during the next four
     years, since when they have ceased, although the palsy persists.
     Recently the patient woke up abruptly in the middle of the night to
     find that the left side of the face was in a state of spasmodic
     contraction, a condition which has continued absolutely without
     intermission. There is no pain in relation to the spasm, merely a
     peculiar sensation at the site of the muscular twitches. Of what
     nature are they?

     If we analyse the muscular play somewhat more closely, we observe
     that with the exception of the frontalis all the muscles of the
     left face, including the platysma, contribute. On a background of
     more or less permanent contraction are outlined short, incomplete,
     greatly varying twitches, affecting one muscle after another, and
     sometimes only a few fibres, in a highly erratic way. The march of
     the movements obeys no law, either of space or time, nor is there
     any co-ordination in their activity. That the condition is one of
     tic, therefore, is scarcely conceivable. No purposive element is
     discoverable in the phenomena, no systematisation, no expression
     of emotional excess. All is disorder, confusion, contradiction.

     We should, accordingly, be content to make a diagnosis of spasm,
     but an examination of the patient's mental condition must not be
     neglected, and in this particular case it is very instructive.

     It appears that his imagination has always been singularly fertile,
     amounting indeed to eccentricity. The picturesque description he
     furnished of the unusual sensations in face and neck lent support
     to the view that his muscular activity was intended, consciously or
     unconsciously, to free himself from their insistence, so that his
     grimacing may have been but a gesture of defence.

     But however much his lack of psychical equilibrium may favour the
     relegation of his affection to the category of tic, certain
     considerations make one question the validity of the hypothesis.

     In the first place, it is rather an uncommon functional adaptation
     of the facial muscles to utilise them in an attempt to disembarrass
     oneself of disagreeable sensations; and in the second it is no less
     uncommon for the sufferer from tic to be unable to restrain his
     muscles even momentarily, as our patient appears to be. The actual
     time of onset of the movements is significant enough, but of
     supreme importance is the fact of their supervention in an area
     previously the seat of paralysis. To our mind this is more than a
     coincidence; from the history supplied by the patient it is plain
     that the paralysis was peripheral and that the lesion involved the
     facial trunk somewhere in its intracranial course after its
     emergence from the side of the pons. Thirteen years later,
     convulsive movements appear in the same domain. Taking all the
     circumstances into consideration, we think the hypothesis tenable
     that the trigeminal is implicated in the pathogeny of the spasm,
     although the condition is not strictly comparable to the classic
     tic douloureux.

     The exact nature of the lesion is more difficult to determine. A
     review of the details of the facial palsy suggests its vascular
     origin, to which theory the headache, nausea, and photophobia of
     succeeding days and months--indicating, as they do, a circulatory
     disturbance in the basilar region--lend support. With the gradual
     restoration of vascular equilibrium the migrainous attacks lessened
     in frequency and severity, though the facial trunk remained
     compressed, till the spasm appeared, no less suddenly than had the
     paralysis. It is feasible that the former, too, is the derivative
     of a minute hæmorrhage irritating either the centrifugal or the
     centripetal arm of the facial reflex arc, probably the latter,
     which would explain the paræsthesiæ.

     The possibility of this explanation being accurate is confirmed by
     a case reported by Schültz, where facial spasm of ten years'
     duration was shown at the autopsy to have been caused by an
     aneurism of the left vertebral artery impinging on the facial nerve
     in the neighbourhood of the basilar trunk.

     The arguments, therefore, which plead in favour of the spasmodic
     nature of the condition seem to us so cogent that the hypothesis of
     tic must be rejected. We ought not to forget, on the other hand,
     that a spasm, of whatsoever origin, may be transformed into a tic
     by the perpetuation of a morbid habit.

Let us take a second case, no less instructive than the preceding.

     Madame L. was sent to one of us by Professor Pierre Marie. She had
     always been nervous, impressionable, and high-spirited, but had
     never suffered from fits. At the age of eight years, during
     convalescence from one of the exanthemata, she got a chill, and the
     very next day developed an acutely painful torticollis, the head
     resting on the right shoulder and the chin touching the left
     clavicle. A complete cure ensued, but from that time a certain
     degree of facial asymmetry was remarked. At the age of eight and a
     half menstruation commenced, and it still continues, at the age of
     fifty-nine.

     From youth she had at intervals been stricken with pains in the
     limbs, and with recurrent bilious attacks. Two years ago the death
     of her husband was the occasion of great mental strain and
     distress. Sixteen months ago she noticed a curious sensation in the
     right eye, not painful, accompanied from time to time by blinking
     of the lids. Very gradually the convulsive movements spread over
     the whole of the right face, and for the last month their frequency
     and intensity have been such that rest is an impossibility.

     When she came under observation what impressed the mind first was
     the remarkable asymmetry of her figure: the right side of the face
     was smaller than the left, the right eye appeared to be at a lower
     level than the other, while the mouth was strongly deviated to the
     right and the chin twisted in the same direction. For a minute or
     two the facial contortion held sway, disappearing only to reappear
     quickly.

     Not solely to the old torticollis was the facial asymmetry
     attributable, but also to the convulsive movements of the right
     half of the face. The effect of these was to close the right eye,
     deflect the nose to the same side, drag the mouth in a similar
     fashion, and wrinkle the skin of the chin and neck. Hence was
     evolved a unilateral grimace quite unlike any ordinary expression,
     resembling rather the facies in contracture secondary to facial
     paralysis.

     During the next few months there was a gradual change from this
     tonic to a clonic stage, in which the movements were of less
     frequent occurrence, but more rapid. In repose there was no further
     indication of the old facial palsy than the flattening of the
     facial lines on the right. Under the influence of any emotion, or
     any passing contrariety, or in the course of an animated
     conversation, or if circumstances call for their repression, the
     spasms increase in number and degree, whereas solitude and
     tranquillity favour their subsidence.

     A recent development has been the discovery of a means of checking
     the spasm--viz. by compressing the larynx with the fingers of the
     two hands. Madame L. admits the illogical nature of the
     manœuvre, but extols its efficacy. As a matter of fact, it
     sometimes fails of its object.

     How, then, is this localised convulsive movement to be designated?
     Is it a tic or is it a spasm?

     The march of the disease, its painlessness, the absence of any
     reaction in sleep, the success of the little laryngeal trick, the
     inhibitory effect of the will, the definite influence of attention,
     distraction, in short of the psychical condition of the moment--all
     plead in favour of its classification in the former category. On
     the other hand, we cannot shut our eyes to the fact of the
     pre-existence of specific organic disease, and, moreover, the spasm
     is strictly confined to the anatomical distribution of the facial
     nerve. Even in periods of repose there is a certain amount of
     fibrillation on that side. On these counts are we to hazard the
     diagnosis of facial trophoneurosis?

     A subsequent opportunity of examining the same patient served to
     confirm the diagnosis of spasm secondary to facial dystrophy, and
     treatment failed to make any impression on the condition.

Our object in giving these cases has been to point out the difficulties
in the way of diagnosis, especially where spasm is superadded to a
mental state that itself predisposes to tic. The wisest plan in many
instances is to confine oneself to a description of the symptoms and to
tabulate the arguments for and against a particular view, without
perpetrating the error of committing oneself.

Many cases labelled convulsive tic might be quoted where the expression
of so definite an opinion ought to have been reserved, as in one
reported by Mayer[171] under the title of convulsive tic consecutive to
infraorbital neuralgia:

     A man, thirty-two years of age, had suffered from a severe
     infraorbital neuralgia of some weeks' duration, apparently
     attributable to a chill. The pains recurred at intervals till their
     substitution five years later for slight spasmodic twitches of the
     left eyelid, which gradually developed into violent convulsions of
     the whole of the left half of the face. These spasms were preceded
     by a sensation of numbness in the left ear, while during repose no
     modification of facial expression was to be remarked.

     Further, there was a history of exactly similar neuralgia and spasm
     in the mother of the patient, although in her case the latter had
     been the first to appear, and had been replaced after a six years'
     interval by left facial neuralgia, which resection of the nerve
     failed to relieve.

In these cases the condition is undoubtedly one of painful facial spasm,
inaccurately and unfortunately styled "tic douloureux."

Bruandet[172] has recorded a typical example of right facial hemispasm
consequent on facial neuralgia, in which, however, no certain
macroscopical or microscopical lesion was detected, in either cortex or
bulb. But the mere fact that no structural alteration was discovered
post-mortem cannot invalidate the diagnosis; the imperfection of our
methods of investigation suffices to explain the negative results of
such researches.


B. Tic or Spasm of the Neck--Torticollis Tic and Torticollis Spasm

To make a diagnosis of torticollis, it is essential to satisfy oneself
of the integrity of the bones, muscles, and articulations of the
cervico-scapular region, previous to directing attention to the
psychical state of the patient. In regard to the latter point, the
question of heredity must not be neglected. If personal and hereditary
defects are prominent, the presumption is in favour of mental
torticollis; and if the convulsive movements present the characters of
tic, the diagnosis is practically certain.

In three cases under the observation of Fornaca,[173] for instance,
there is no room for doubt. Not merely was there no sign of irritation
from peripheral sources, but also no one of the three was psychically
normal.

Nevertheless we frequently find ourselves confronted by the question: is
the movement a tic, or is it a spasm? For, strictly speaking, there are
both a torticollis tic and a torticollis spasm, and their separation one
from the other is often a matter of the greatest perplexity.

We must refer the reader to the chapter devoted to mental torticollis
for a consideration of the features of that condition, and we need not
dwell on those cases of spasmodic torticollis that are obviously
occasioned by irritative lesions of nervous centres or conductors. In
this latter category may be placed the case put on record by Oppenheim,
where torticollic spasms were produced by pressure of a cerebellar
tumour on the cranial nerves.

But in the affection known as hyperkinesis of the accessory of Willis we
have little doubt both tics and spasms have been included. Apart from
the cases of spasmodic torticollis, so called, which Babinski has
published and to which reference has already been made, we may be
allowed to cite one or two more, in order to exemplify the differences
of interpretation to which they are liable.

At the Congress of Toulouse two patients were shown by Desterac,[174]
both of whom had suffered since the age of eight from a disease akin
either to Friedreich's disease or to hereditary cerebellar ataxia.

     They presented the spastic gait of the former with the involuntary
     movements of the latter, in addition to spasm of the hand in
     writing, spasmodic movements of the trunk, and spasmodic
     torticollis. Both had club foot and scoliosis, and one was
     afflicted with spasm of the face and left arm. In his case,
     further, there was nystagmus, together with loss of reflexes and
     difficulty in articulation, while fibrillary contractions were to
     be observed in his muscles. The other patient's reflexes were
     exaggerated, and he showed a double extensor response.

In Desterac's opinion their spasmodic torticollis was dependent on this
congenital constitutional affection, which might be regarded as a
_fruste_ form of one of the diseases above mentioned.

Through the kindness of M. Desterac the opportunity has been granted one
of us of examining the two patients, and we should like to point out why
we think his interpretation of their symptoms must be considered with
reserve.

Speaking generally, we thought the cases closely resembled those in
which a long-standing mental torticollis is accompanied with convulsive
movements of the limbs. The scoliosis was not permanent, the deformation
of the foot could be overcome, and at the same time we failed to
convince ourselves of the presence of nystagmus and the absence of the
knee-jerks. Moreover, we happened to observe one of the patients in the
street unawares, and remarked how between two phases of bizarre
contortions his vicious attitudes and convulsive gestures almost
entirely vanished. In fact, the clinical picture seemed to us to be
quite other than that associated with organic disease such as
Friedreich's disease or hereditary cerebellar ataxia.

Another case recently brought before the Neurological Society of Paris
by Marie and Guillain[175] serves even better to illustrate the
intricacies of diagnosis.

     The patient was a man of fifty-eight, who for years had exhibited
     certain movements apparently of an athetoid nature. His head was
     extended and rotated to the right synchronously with elevation and
     eversion of the left shoulder, then it passed into flexion. Except
     for a few odd movements of the tongue, the face conserved
     immobility. In the arms the localisation of the contractions was
     mostly proximal, though there were alternating flexion and
     extension movements of the fingers which suggested athetosis.
     Flexion, inversion, and adduction of the thighs also occurred. The
     recti abdominis were similarly involved.

     Under the influence of emotion the movements were increased, but
     they could not be inhibited by an effort of attention. Their rate
     was too slow for chorea. Ordinary voluntary movements were
     performed without apparent trouble; the patient was able to dress
     himself, and to drink without spilling the liquid. Diminution of
     the knee-jerks was noticed, with what seemed to be an extensor
     response. Slight scoliosis of the vertebral column and a misshapen
     right foot recalled Friedreich's ataxia. There was nothing to
     justify a diagnosis of hysteria.

     This curious condition dated from the year 1874, when the patient
     had a febrile attack, in the course of which pain and tingling
     appeared in the toes of the right foot, followed by involuntary
     movements of the same member. Analogous symptoms were not long in
     appearing in the left arm. Two months later the condition had
     become general, but from that time no special modification took
     place.

In the subsequent discussion it was remarked by Souques that the case
resembled one recorded by Chauffard[176] as Friedreich's disease with
athetotic attitudes, where the patient was a child with club foot,
diminution of the knee-jerks, and generalised athetotic movements.

Notwithstanding our inability to assign a definite nosographical
position to examples of this kind, we think it desirable to make some
reference to them, in the hope that further observations will aid in
their diagnosis. They at least remind us that convulsions occurring in
the course of organic disease may be simulated by the manifestations of
certain motor neuroses.


TICS AND CHOREAS


A. Sydenham's Chorea

It would be difficult to find a better description of chorea minor than
that given originally by Sydenham himself:

     The dance of Saint Guy, chorea Sancti Viti in Latin, is a sort of
     convulsion whose incidence is greatest, in both sexes, between the
     age of ten and puberty. Its onset is characterised by weakness of
     one limb, which the patient drags behind him, and soon the arm of
     the same side is affected in the same way. He finds it impossible
     to maintain the same position of the arm for two consecutive
     moments, however great be his efforts to attain this object. Before
     he can bring a full glass to his lips he makes innumerable gestures
     and antics, as the convulsive moments of the limb deviate it from
     one side to the other, until at length he has piloted the glass
     opposite his mouth, when he empties it at a gulp.

If we were to confine ourselves to this description by Sydenham, which
so far as typical cases of the disease are concerned is perfectly
accurate, differentiation between tic and chorea would not be a matter
of any complexity. Unfortunately, however, the varieties of this form of
chorea are legion, and in practice one constantly meets with conditions
suggesting alike the gesticulations of chorea and the convulsive
reactions of tic. Moreover, it has been pointed out by Oddo[177] that
the fact of the habitual exaggeration of tic during the very years when
chorea is liable to appear is calculated to confuse the issue.

He has attempted, however, to specify certain factors in the
differential diagnosis. In the first instance, the form of the movements
is of significance: there is no co-ordination in the muscular play of
the choreic; it is amorphous, indefinable, and erratic, whereas the
gestures of tic are purposive, and may be said to have a shape. One
never sees in chorea a succession of similar movements, but though a
patient be suffering from several tics, each of them is reproduced
always in the same fashion. Unilaterality of distribution is more common
in chorea than in tic; in other words, chorea, more or less, follows
anatomical lines in the regions it affects, whereas the incidence of tic
is physiological.

Both are arhythmic in their manifestation; nevertheless the repetition
of tic is noteworthy for its regularity as compared with the changing
mode and rate of the other. Noir emphasises the diagnostic value of its
frequency, abruptness, and reiteration of identical movements. In a
majority of cases the interference of the will is futile as far as
chorea is concerned, while the victim to tic is usually capable of
restraining his muscular activity at least for a space. The choreic
exhibits his movements in public, but the _tiqueur_ seeks the seclusion
of his own room. The association of tic with obsessional ideas is
frequently encountered, but there is no similar connection between
obsessions and chorea. In addition, the myasthenia, pains, and
alterations in the reflexes that often characterise chorea are awanting
in the other affection.

It cannot be gainsaid, however, that the frequency with which atypical
varieties of chorea occur is inimical to a ready diagnosis, and the
onerous nature of the task is not lessened by the circumstance that many
choreics are the offspring of neuropathic parents and reveal psychical
anomalies comparable to those of the subjects of tic.

In a disease such as variable chorea, which has features in common both
with tic and with chorea properly so called, the problem of diagnosis is
still more complicated, though excellent hints for its solution have
been furnished by Brissaud.[178]

     However frequently and warmly the theory of the origin of chorea in
     a neuropathic predisposition was advocated by Charcot, the fact of
     its usual evolution consecutive to some toxic or infective process
     is no less certain. Its incidence is greatest in children and the
     adolescent; it runs a regular course of increase and decrease; and
     the circumstances which cause the symptoms to vary during this
     cycle are never sufficiently potent to bring about even transitory
     suppression of them.

     It is true that changes in the intensity of the symptoms seem to
     confer a remittent character on the affection, but there is nothing
     at all comparable to the sudden and unexpected waxing and waning of
     the form of chorea at present under consideration. None of the
     pathological attributes just mentioned concerns variable chorea,
     which, in addition, differs from Sydenham's chorea in two
     points--the multiplicity of the types of movement, and the fact
     that the patient can voluntarily check his involuntary actions. For
     these reasons, assimilation of the two clinical varieties is
     impossible, and the confusion of the two in practice need never
     occur.

A form of chorea entitled "habit spasm" by Gowers, and "habit chorea" by
Weir Mitchell, has been the subject of further study by Sinkler,[179]
but in all probability the cases of this description reported are
instances of the variable chorea of Brissaud.


B. Huntington's Chorea

In spite of the preponderating etiological significance of heredity and
the constancy of psychical imperfections in the chronic chorea of
Huntington, its confusion with tic is not at all likely to occur.
Difficulties might arise in distinguishing chorea major from variable
chorea, however, and here we have the views of Brissaud to help us.

     True chronic chorea is an incurable neurosis, of life-long
     duration. We have no trouble in pronouncing a diagnosis of chronic
     chorea if the symptoms date back five, ten, or twenty years, but
     they must have had a commencement, and the whole problem is to
     foretell the course of a chorea as yet only a few weeks or months
     old.

     The involuntary movements of chronic chorea, like those of
     Sydenham's chorea, are illogical, but they are combined in a
     co-ordinate manner--that is to say, certain functionally associated
     muscular groups act simultaneously as for a particular end: the
     patient shrugs his shoulders, closes his fists, cracks his fingers,
     utters cries, he swallows, sniffs, sucks in his breath, makes the
     sound of kissing, etc, in all of which actions orderly
     participation of the musculature in a foreordained way is evident.
     Slight twitching of individual muscles and parts of muscles also
     occurs.

     There is no limitation of the movements to a special division of
     the body; on the contrary, they spread from one muscle to another,
     and from one segment to another, rapidly and arhythmically. The
     gait is by turns skipping, dancing, or stumbling, interrupted by
     falls or by abrupt jerks of the loins. Speech is uncertain or
     monotonous; writing is incorrect and badly formed, sometimes
     illegible. A fact of the utmost importance is that all these
     involuntary movements may be modified, abated, relieved, so to
     speak, by voluntary movements in an inverse direction. In some
     cases the power of willing is still sufficiently developed to
     permit of the patient's following his occupation.

The steadily progressing increase in the seriousness of the motor
trouble, paralleled by progressing mental deterioration, is one of the
most significant factors in the differential diagnosis. It is precisely
the variability of the symptoms that distinguishes variable chorea.


C. Hysterical Chorea

The conditions to which the name of hysterical chorea is applied may
assume two forms, the commoner being known as rhythmical chorea, the
other as arhythmical chorea. In the former case the convulsive movements
are usually unilateral, being confined sometimes to a single limb, and
reproducing, for instance, the actions of dancing (saltatory chorea), or
of swimming (natatory chorea), or such professional movements as those
of the blacksmith (_chorée malléatoire_). Occasionally there is a more
or less faithful reproduction of deliberate and purposive acts in the
form of attacks of varying duration, recurring, moreover--and this is
their cardinal feature--at equal intervals.

Under the title of disease of the tics two cases have been published by
Nonne,[180] the first consisting of rhythmical twitches in a man of
forty years, secondary to a head injury, the other presenting similar
appearances, but concerning a young girl of eighteen years who had
sustained a shock. In neither was there any sign of hysteria. The
reporter animadverts on the designation "rhythmical chorea," and
protests that the systematisation and co-ordination of the movements are
very different from the clinical picture of Sydenham's chorea, while
their rhythmical nature does not allow of their being classified as tic.

Sometimes hysterical chorea is arhythmical--that is to say, the
movements are irregular and contradictory, as in ordinary chorea. True
chorea in cases of hysteria comes under this heading, as well as those
cases where hysterical patients imitate the movements of chorea. The
presence of the distinctive characters of hysteria makes a diagnosis of
tic improbable.

The separation of hysterical from variable chorea may be peculiarly
perplexing, as in one of Brissaud's cases, where the patient's
extraordinary mental instability was such as is encountered only in
advanced hysteria, while her disorders of motility were highly
characteristic of what is known as variable chorea.

The condition described as chorea gravidarum may be placed at one time
in the category of hysterical chorea, at another in that of ordinary
chorea. In it there is intense motor restlessness, and accompanying
mental symptoms are not awanting in a majority of instances.


D. Electric Chorea, Bergeron's Chorea, Dubini's Chorea, Fibrillary
Chorea of Morvan

To render the study complete, we may remind ourselves of those still
imperfectly differentiated forms known as electric chorea
(Hénoch-Bergeron) and Dubini's chorea.

Bergeron's chorea affects children chiefly, and is characterised by the
suddenness of its onset and the rapidity with which it attains its
maximum. The movements are abrupt and brief, as though produced by an
electric discharge at regular intervals, but their intensity does not
hinder the execution of voluntary acts. They are sometimes confined to
the head and limbs, most commonly they are generalised, and during sleep
they disappear.

In the opinion of many, Bergeron's chorea is secondary to gastric
disturbance. A cure may be regarded as certain, and indeed frequently
follows the administration of an emetic. Sometimes the effect of the
latter seems to be purely psychical.

Pitres thinks that this condition, as well as the electrolepsy of
Tordeus, is simply a manifestation of infantile hysteria. According to
Noir, there is an affinity between tic and electric chorea, and Ricklin
is inclined to consider the two identical, but further study of the
question is desirable.

Dubini's chorea is ushered in by pains and aches in the region of the
head, neck, and sometimes the loins, and these are succeeded by
electric-like twitches in the segment of a limb, which quickly become
general. Severe convulsive attacks also occur, without loss of
consciousness, entailing actual paresis of the limbs. The duration of
the disease may be days or months, and 90 per cent. of the cases have a
fatal issue. Confusion with tic is impossible.

We need not concern ourselves with so-called paralytic chorea, or with
the fibrillary chorea of Morvan, which is a disease of adolescence,
characterised by fibrillary contractions in the calves and thighs,
passing thence to the trunk muscles and even to the arms; the face and
neck, however, are spared, and during voluntary movement the
fibrillation vanishes. Probably it is merely a variety of the
paramyoclonus of Friedreich.


TIC AND PARAMYOCLONUS MULTIPLEX--TIC AND MYOCLONUS

It is not our intention here to seek to provide a differential diagnosis
between tic and the various conditions usually classed as myoclonus, and
that for two reasons: in the first place, we cannot admit that the
latter form a distinct clinical or nosographical entity, since the term
myoclonus seems simply to be an abbreviation for clonic muscular
convulsion, and is a symptom rather than a clinical syndrome; secondly,
the fact that the tics themselves have been incorporated with myoclonus
involves the investigation of all the published cases with a view to
their critical sifting. This task we have pursued for our own
edification, but to enter on it here would serve no useful purpose, and
we shall rest content with examining succinctly several recent cases
described as myoclonus, in the hope that the prosecution of further
research will introduce order into what is at present chaos.

       *       *       *       *       *

Among the various forms of myoclonus there is one which presents a
certain individuality, and which was described originally by Friedreich
under the name of paramyoclonus multiplex.

This disturbance of motility supervenes, in patients with a neuropathic
heredity, after some psychical accident such as a sudden fright or
emotion, and consists in clonic muscular convulsions affecting the body
generally, with the exception of the face. The contractions appear
without obvious cause in one or in several muscles, are instantaneous,
involuntary, and usually bilateral, but their most important feature is
their inequality and irregularity. They may or may not effect
displacement of the limbs; in any case they compose neither gesture nor
gesticulation. Volition occasionally seems to have some transient
inhibitory influence over them; they are exaggerated by cold and by
emotion, and usually disappear in sleep.

It is obvious that this account of a typical case precludes the
possibility of any confusion with tic, but the published cases are not
always in conformity with it.

In 1892 Lemoine[181] reported a case where the movements of
paramyoclonus multiplex were accompanied with echolalia and psychical
changes. Raymond quotes an instance of the disease being preceded by
facial tic, and another associated with tremor and choreic movements.

D'Allocco[182] has recorded twenty-four cases of differing forms of
myoclonus, of which nineteen occurred as a family disease, in
conjunction with stigmata of degeneration, epilepsy, and hysteria.

In a patient, aged twenty-six, suffering from general paralysis,
Hermann[183] noted the presence of abrupt, irregular, myoclonic twitches
in the sternomastoids, recti abdominis, adductors, and in some of the
toes and fingers, first on one side and then on the other, also in both
legs, and subsequently in both arms, the face being unaffected.

Jancowicz considers diagnosis possible only in typical cases, and
expresses the opinion that paramyoclonus is a syndrome common to many
affections. Further, Schupfer makes the perfectly justifiable remark
that under this denomination have been included cases of chorea, tic,
hysteria, and rhythmic spasm; others have been secondary to organic
disease of the cerebro-spinal axis, such as rolandic lesions, spinal
muscular atrophy, chronic poliomyelitis, syringomyelia. Others, again,
depend on one or other of the psychoses, others on infective conditions
such as malaria, diphtheria, typhoid, or on intoxications such as
uræmia, mercurialism, or lead poisoning. Only a few recorded cases
cannot be attributed to any of the conditions enumerated above, hence
Schupfer's objection to the promiscuous classification of them all as
paramyoclonus multiplex is quite warranted, in the absence of a uniform
etiology and symptomatology.

Schultze[184] has suggested the term monoclonus for the tics, and he
distinguishes monoclonus, polyclonus, and paraclonus. Embraced in the
last of these is the paramyoclonus of Friedreich, which, according to
Schultze, is usually unilateral, voluntary action diminishing the
intensity of the involuntary movements, whereas the converse is the case
in tic or monoclonus. Mixed forms are met with, however, and Schultze
himself mentions one in which the movements were bilateral and increased
with voluntary activity.

Heldenberg[185] applies the term intermittent functional myoclonus to
twitches occurring from time to time in antagonistic muscles during
voluntary movement, twitches exaggerated by excitement and diminished
with rest. They occur in combination with well-marked vasomotor
phenomena.

The myokymia of Kny and Schultze is characterised by fibrillation, pain,
hyperidrosis, and changes in electrical excitability.

A case which seemed to be a combination of paramyoclonus with Thomsen's
disease has been reported by Hajos[186] under the title myospasmia
spinalis.

There cannot possibly be any hesitation in arriving at a diagnosis
between tonic tic and Thomsen's disease, a condition consisting in
slowness of relaxation of a strongly contracted muscle, and conceivably
due to defective metabolism or organic change in muscular tissue.[187]

Examples such as the above, culled at random from an abundant medical
literature, and variously entitled, will serve to demonstrate the
protean nature of what the medical world is content to call myoclonus,
and if from this collection of motor disorders we may hope to extricate
the tics, there will remain still no inconsiderable labour of
differentiation for the student.


TIC AND ATHETOSIS

The athetotic movements that may accompany hemiplegia are scarcely
likely to be confused with those of tic, but difficulties may arise
where the athetosis is double.

It has been universally remarked that athetotic movements of the face
reproduce the expression of emotions, such as admiration, astonishment,
sorrow, gaiety, etc. Of course the same may be said of the grimaces of
chorea; the latter, however, are usually more abrupt and pass less
readily one into the other. The gesticulations of athetosis are
undulatory, so to speak, and their excess leads to deformities
principally in the direction of forced extension. The musculature is
often rigid, and the reflexes are increased in activity. Sometimes there
is a considerable degree of mental disturbance.

Now, it is precisely in cases where mental deterioration is a prominent
feature that "nervous movements" have been described resembling those of
athetosis, for which the term pseudo-athetosis has been coined. Two
examples may be quoted from Noir.

     E. is a girl of eleven years. Her expression is grimacing; her
     tongue is often protruded, but never bitten; her head is regularly
     flexed or extended, or rotated rhythmically to left or right. The
     arms are moved spasmodically at shoulder and elbow, while the hands
     are the seat of athetotic movements. She walks curiously, throwing
     her feet out in advance without bending her knees. She has a silly
     smile, and her mouth almost invariably hangs open. On request she
     can keep her hands quite steady, but one observes at once the
     effort this entails in the sudden seriousness of her expression.
     The ordinary acts of every-day life are performed satisfactorily
     enough: she can dress and undress, use a knife and fork, thread a
     needle, sew, etc.

     J. is eleven years old also. She puckers her lips, contracts her
     eyebrows, elevates her alæ nasi; at the same time she exhibits
     pseudo-athetotic movements of her fingers which are entirely under
     voluntary control.

The question may indeed be asked whether pseudo-athetosis and variable
chorea are not really identical. Further, all sorts of combinations of
athetosis and myotonia have been noted,[188] but more light must be
shed on the subject before any further classification can be attempted.

The following case has recently been published by Marina[189]:

     A blacksmith, aged seventeen years, already treated three times for
     recurrent chorea, suffered from slow contractions of the shoulder
     muscles, involving the elevators and internal and external rotators
     successively, and accompanied by movements of the head and arm, and
     by twitches of the quadriceps. Nothing seemed to have any influence
     over these movements except sleep. The faradic excitability of the
     shoulder muscles was augmented, the galvanic excitability
     diminished. Application of the constant current to the head and
     back sufficed to effect a cure in three weeks.

Marina proposes the term athetotic myospasm for these incessant slow
alternating contractions, impulsive myospasm being employed to signify
convulsive movements of more than one muscular group, purposive yet
irresistible, as in tic and chorea major. Simple myospasm consists of
single twitches in individual muscles, recalling those produced by
electrical excitation. If several muscles are implicated, the condition
is one of multiple myospasm or myoclonus.


TICS AND TREMORS

All tremors, whether they occur during muscular repose or muscular
activity, are distinguished by the relative restriction of their range
and the regularity of their time. The tremors of paralysis agitans,
disseminated sclerosis, senility, toxæmia, hysteria, ex-ophthalmic
goitre, etc., are not liable to be mistaken for tic.

It is true, of course, that tremor is sometimes combined with choreiform
or athetotic movements in patients with psychical stigmata.[190] A
proposal, too, has been made to unite hereditary and functional tremor
and to describe them as a tremor neurosis.[191]

However simple be the diagnosis between tremor and tic, it is worth
while to note in passing the etiology they may have in common. In a case
recorded by van Gehuchten an intention tremor of the right arm
co-existed with a tic of the right sternomastoid.

A sudden twitch of the whole body Letulle particularises as a "tic of
starting," and Noir too thinks that a start of this nature may
constitute a tic, but we are inclined to consider it a generalised
reflex.


TICS AND PROFESSIONAL CRAMPS

We have already had occasion to enlarge on the distinguishing features
of professional or occupation cramps, spasms, or neuroses. Writers,
pianists, violinists, flutists, dressmakers, telegraphists, watchmakers,
milkers, knackers, blacksmiths, shoemakers, tailors, dancers,
embroiderers, barbers, etc., etc., are all liable to suffer from
occupation cramps. In every case the condition is one of inability to
perform the professional movement, and that alone.

Grasset proposes to separate intra-professional from post-professional
spasm, the former consisting in the impossibility of making the
necessary professional movements, the latter in the involuntary
over-reproduction of the familiar act. Properly speaking, the
post-professional spasm is a tic.

We need not do more than remind the reader of the close affinities we
have already seen to exist between tics and professional cramps, and of
the mental instability which both classes of patient present.

L. supplies an instance of variable hemichorea followed by writers'
cramp and later by mental torticollis.

     When L. was eight years old choreiform movements of the right arm
     began to appear, and soon rendered writing an impossibility. The
     disease continued for so long a time that one might not
     unreasonably expect to find considerable actual impairment of her
     caligraphy. As a matter of fact, it is scarcely affected: the
     patient can make her letters correctly, but after each letter she
     lifts her pen to allow her fingers to perform an abrupt movement,
     then she proceeds.

     It cannot therefore be considered a true writers' cramp, but when
     she had learnt to write with the other hand it was not long ere
     that became the seat of a genuine cramp. The moment she attempted
     to make the pen move over the paper her grasp of it tightened and
     her fingers stiffened; her wrist would no longer answer her. To
     obviate the trouble she used a pencil, at first with complete
     success; but the cramp occurred afresh, and she gave up writing
     altogether. Prolonged holidaying, however, and respite from the
     exercise, had a salutary effect, and to-day there is no trace of
     former mischief.



CHAPTER XVII

PROGNOSIS


The prognosis in a case of tic depends solely on the mental state of the
patient. After what has been said of the rôle played by psychical
disorders in the genesis of tic, we can readily comprehend the reason
for this. The intensity and tenacity of any tic are determined by the
degree of volitional imperfection to which its subject has sunk. He who
can will can effect a cure; be it a simple tic, or be it a case of
Gilles de la Tourette's disease, if he can struggle long and
energetically, the tic's doom is sealed. Permanent cures have
undoubtedly been obtained, but they are the exception. Left to himself,
the victim to tic can seldom escape from it.

As far as life is concerned, tics are harmless, yet, according to Gilles
de la Tourette, the prognosis is by no means always unchanging.

     The establishment of a tic is never followed by its ultimate
     disappearance; it may be modified in all sorts of ways, yet the
     expert observer will not fail to mark its presence. A complete cure
     is not to be expected, for however much paroxysms may be alleviated
     and their frequency reduced, the morbid condition has become a sort
     of function, a product of the patient's mental constitution.

The statement may be taken to imply that no tic abandoned to itself ever
vanishes completely, but the generalisation is inaccurate. Systematic
treatment may lead not only to amelioration, but also to cure. Certain
tics of children are by nature ephemeral, and disappear spontaneously,
never to return. It is easy to understand how that may be. Psychical
evolution and physical evolution alike are liable to singular
variations. Hence the development of a tic in early life is no reason
for despair, seeing that we are not justified in the assumption that the
volitional debility which it proclaims is to persist. We must believe
that volition may be reinforced, and we must further the attainment of
this end by every means at our disposal. Negligence on our part is
highly culpable.

Tics of childhood are curable: we draw attention to the fact afresh.
Their spontaneous dissolution is not unknown, but parents must not
consider the question merely one of time. They must impress on their
children the sobering effect of good behaviour and decorum. Discipline
of this kind may be a long and delicate task, but to condone indulgence
in untimely movements, on the pretext that they are merely quaint, is a
mistake fraught with the gravest consequences.

When a child holds its knife or fork incorrectly, or puts its elbows on
the table, or its finger in its nose, we feel that the habit is
displeasing; but how much more serious the outlook if the trick consists
in biting the lips, or tossing the head, or blinking the eyes! The
former is an offence against good taste; the latter is a tic in embryo.

It may be said, as a general rule, that the chances of spontaneous cure
are in inverse proportion to the age of the patient and the duration of
his tic.

Tics of adult life may also be cured, less often, it is true, than in
the case of children. Oppenheim gives the history of a woman with a
rebellious facial tic of twelve years' duration, which ceased on the
occasion of a certain happy event in the family life. Of course one
wants to know whether it ever returned, for many so-called cures are
simply remissions.

T. had suffered from torticollis for a whole year, but on the eve of her
son's marriage it stopped entirely for three days, and she deemed the
cure permanent; it was not long, unfortunately, ere she underwent a
relapse.

Brissaud[192] quotes an instructive case of temporary cessation of tic.
A patient afflicted with mental torticollis of three years' standing
learned that his son had been injured and had been removed to hospital
to undergo an operation. In an instant his torticollis disappeared, but
a reassuring report from the surgeon a few days later was followed by a
recrudescence of the condition.

It is true a hardened _tiqueur_ may be relieved of his tic, but the
potentiality remains. He is still at the mercy of the impulse to tic,
should it arise. Cruchet gives the history of a young man who suffered
in succession from convulsive movements of negation, facial tic,
blinking of the eyes, abrupt yawning, and twitches of the shoulder--all
in the space of two years. Each disappeared in its turn, independently
of treatment, without leaving any trace behind. In cases of this
description a new tic is ever imminent. The facility with which one tic
replaces another is a matter of common observation. We have often had
occasion to observe relapses, or partial relapses, in which an
altogether new tic suddenly makes its appearance on the top of one which
has either been improving or has actually been checked.

Apart, however, from obdurate forms of long standing, especially such as
are accompanied by signs of grave mental defect, we maintain that the
subjection of patients to appropriate treatment for an adequate period
has a favourable influence on prognosis. The curability of tic was
denied by Oddo, but he has recently seen fit to change his opinion, and
to confine his pessimistic views to Gilles de la Tourette's disease.

The prognosis of the mental state of victims to tic is outwith our
province: it is a topic long since handled by psychiatrists. We may ask,
however, whether any particular prognostic import is to be attached to
the tics themselves.

In cases of Gilles de la Tourette's disease the progressive unfolding of
motor disorders suggests a corresponding evolution of psychical
derangements which may end in dementia. Brissaud warns us that in cases
of mental torticollis we must be on our guard against the apparition of
some much more redoubtable affection than the torticollis, for that,
sometimes, is an incident in the prodromal stage of general paralysis of
the insane. Séglas has had a case of ærophagic tic which eventually
became one of general paralysis, and a similar instance occurred in the
practice of one of us.

Not long ago Dufour[193] advanced the opinion that the occurrence of a
motor syndrome consisting of the automatic movements of tic, in a case
of delusional insanity, heightens the gravity of the prognosis as
regards chronicity. It had been already remarked by Morel that such of
the insane as contract tics usually degenerate into dements. Most of the
contributors to the study of idiocy have noted the relation between the
degree of intellectual debility and the extent of the automatic and
rhythmical movements.

In this connection Joffroy has made some interesting statements.

     Sometimes there is not merely co-existence, but an actual
     parallelism between the motor and the psychical disturbance. I have
     under observation at present a young woman suffering from attacks
     of agitation, with delusions and hallucinations, who has developed
     a facial tic in the course of her psychosis, and increase in the
     violence of the tic is associated with abrupt utterance of
     imperfectly formed syllables. During the last two months she has
     been having attacks in the evening, when the psychical troubles
     have become more intense, and simultaneously there has been
     aggravation of the tic and incessant emission of laryngeal sounds
     and syllables. Here then is a parallelism between the two groups of
     symptoms.

     I am disposed, however, to believe that the usual prognosis given
     where motor and mental defects co-exist is too guarded. I have seen
     the catatonia of dementia præcox disappear spontaneously, in spite
     of its intensity and the unfavourable outlook prophesied by all who
     had seen the case.

In distinction, then, from the value of a knowledge of the patient's
mental condition, we consider the motor reactions of tic of little
prognostic significance.



CHAPTER XVIII

THE TREATMENT OF TICS


THE CURABILITY OF TICS

Tics are commonly held to be trivial affections of but passing medical
interest, while in addition they have gained the notoriety of being
peculiarly rebellious to treatment. Such undeserved criticism is at once
too superficial and too severe. As far as life is concerned, the
prognosis is favourable, but they often contrive, quite as forcibly as
many graver diseases, to render existence intolerable. To neglect them
or to consider them _a priori_ incurable is entirely unwarranted. Some
degree of amelioration is practically always attainable, and even
complete cures may be effected.

It is an old doctrine this of the incurability of tic, but the sufferers
have not always been left to their fate. Forecasts of methods of
treatment likely to ensure success were made long ago. In the
"Dictionary in Sixty Volumes" of the year 1821 will be found a
definition of tic, a little out of date perhaps, but affording a glimpse
of therapeutic possibilities: "The word tic is ordinarily employed to
designate certain unnatural habits, bizarre attitudes, peculiar
gestures, etc., whose correction demands a painstaking perseverance that
is not always sufficient to procure the desired result."

Trousseau later introduced an element of precision into current
therapeutic measures by the application of a sort of gymnastic exercise
to the muscles involved. He declared his opinion, however, that the
arrest of one tic would soon be followed by the development of a second,
which would in turn give place to a third, and so on; for the disease
was essentially chronic, and in a sense formed part of the constitution
of its subject. Subsequent observation has frequently borne witness to
the truth of this remark, though the expression is too absolute.

For the majority of the older writers, nevertheless, the incurability of
tic was axiomatic.

Pujol held non-dolorous facial tic to be most intractable. In the hands
of Duchenne of Boulogne faradisation of the muscles was followed by only
transient improvement. Axenfeld considered idiopathic facial convulsions
hopeless from the point of view of treatment.

It has been remarked already that many of the earlier observers failed
to discriminate between tic and spasm. In the article "Face" in the
Encyclopædic Dictionary, for instance, Troisier includes every sort of
facial movement under the term "convulsive tic," among them reflex
spasms from dental caries or buccal ulceration, and muscular
contractions occasioned by peripheral or nuclear irritation. His
opinions as to the curability or otherwise of these movements are
sufficiently dogmatic: "Convulsive tic is not a serious condition, yet
it is in a majority of cases incurable and as a consequence most
distressing. One can hope for success only if the tic is of reflex
origin, where extraction of a tooth, or local treatment of an ulcer, or
resection of part of the trigeminal nerve may be indicated."

Here the confusion is obvious.

Gilles de la Tourette's description of the disease known as convulsive
tic accompanied with echolalia and coprolalia is couched in equally
pessimistic terms.

"It is no menace to existence, and the patient may well attain a ripe
old age, but in revenge he stands very little chance of escaping from
it. A radical cure is yet to be found. Isolation, hydrotherapeutics,
electricity, and constitutional treatment cannot do much more than
retard its evolution."

In Guinon's article on convulsive tic in the Encyclopædic Dictionary of
the Medical Sciences of 1887 thirty pages were devoted to description
and the following few lines to treatment:

     "This chapter will of necessity be brief.... In presence of this
     affection the physician is unfortunately helpless. During
     exacerbations any nerve sedative may be tried. In severe cases or
     if the symptoms become aggravated, the sole treatment likely to be
     accompanied by improvement, scarcely by success, is a combination
     of hydrotherapeutics with isolation."

Nor is Charcot much more encouraging[194]:

     We cannot say that cure is certain, but we may count on longer or
     shorter intervals of arrest, either spontaneous or as a sequel to
     the employment of serviceable measures such as hydrotherapy or
     rational gymnastics.

It should be said that the cases which Charcot, Tourette, and Guinon had
more especially in mind were of a graver nature, such as the disease of
generalised convulsive tics with echolalia and coprolalia, and
peculiarly resistant to treatment. Patients suffering from these forms
of tic present in the most advanced degree psychical instability and
volitional fickleness, and betray an irresistible tendency to impulsion
and obsession, calculated to render the institution of any methodical
treatment futile. In their case patience and perseverance may be
rewarded, but they never consent to undergo for a sufficiently long
period the discipline indispensable for their cure.

Fortunately, these severer varieties are exceptional. The vast majority
of cases are certainly more amenable to modern therapeutic measures, and
the results obtained so far place the disease in a much more favourable
light. Letulle had already remarked, in 1883, that the most tenacious of
co-ordinated tics might be amended, mitigated, and even wholly
inhibited.


MEDICINAL TREATMENT

All the ordinary medicinal agents in vogue in nervous and mental
diseases have at one time or other been applied to the cure of tics; all
have proved equally inefficacious.

Sedatives and hypnotics, such as the bromides, chloral, or the
preparations of opium, sometimes effect a transient improvement, but
they cannot permanently modify the psychasthenia which is the key to the
situation. According to Grasset and Rauzier, the injection of morphia,
atropine, curare, and the inhalation of chloroform or ether have been of
some avail, as has the employment of zinc valerianate, and of gelsemium
in large doses. Quinine, cannabis indica, and arsenic have also been
tried.

Unexpected success has followed the administration of the bromides in
some instances, and for the treatment of various neuroses, convulsive
tics in particular, Flechsig's opium and bromide cure for epilepsy has
been adopted by Dornbluth, with encouraging results. It is true some of
the symptoms of epilepsy may be manifested in the guise of tics, while,
on the other hand, the association of tic and epilepsy is not unknown;
but however that may be, there is sufficient and reliable evidence to
justify at least the empirical use of bromide as a last resource.

Every conceivable sedative and derivative have had their advocates,
while local and counter-irritant medication has not been without
support. Grasset and Rauzier obtained transitory improvement by means of
strong mustard plasters; Busch applied the actual cautery to the
vertebral column.

Cold, hot, and tepid douches, warm fomentations, simple, medicinal, and
vapour baths, have all been prescribed. Resort has been made to rhythmic
traction of the tongue, to thoracic compression, to phrenic
electrisation, in all of which procedures, as Oppenheim observes, the
principal effect must be a psychical one.

The predisposition of the subjects of tic to mental disturbance renders
the administration of ether, morphia, or cocaine in their case
inadvisable. For a similar reason it is better to avoid antipyrine,
sulphonal, hypnotics generally, and above all opium in the form of
laudanum or thebaic extract.

If a sedative be really indicated, we prefer the preparations of
valerian, as their disagreeable odour is scarcely likely to encourage
abuse of the drug. Stimulants such as kola, coca, caffeine, etc., are
rather to be avoided. Hartemberg recommends the preliminary use of
lecithin to improve the patient's general condition.

The inconstancy of the therapeutic results hitherto obtained must not be
allowed to act as a deterrent. Success achieved by medicinal means may
not always be attributable merely to suggestion.


DIET--HYGIENE--HYDROTHERAPY

The details of the patient's diet are not to be neglected; he may be the
victim of some caprice which is injuring his general health. In the case
of children supervision is desirable, to obviate their eating either too
much or too quickly.

General hygiene must be made the subject of special attention. We have
often been convinced of the salutary effects of alteration in a
patient's mode of life, or of modification of his environment, such as
is ensured by holidaying, or by sea voyages, or by "cures" at
watering-places and seaside resorts.

Hydrotherapy in one or other of its forms may also be utilised. Except
in cases of hysteria, the tepid douche is preferable to the cold one. A
morning and evening tub, followed by energetic friction of the skin, is
a favourite prescription.


MASSAGE--MECHANOTHERAPY

In every case of tic the physician ought to assure himself of the
integrity of the muscles involved by examining for developmental
anomalies, atrophies, hypertrophies, etc., the presence of which might
lead him to reconsider his diagnosis. He may then order massage, of
special value in tonic tics as a prelude to passive movements, or
counsel the employment of some form of instrument or apparatus to
correct muscular insufficiency or to gauge the extent and rapidity of
motor reaction.

As a general rule we deprecate these devices. They are open to the same
objections that have been raised to all the mechanical arrangements ever
invented to counteract stammering, from the pebbles of Demosthenes to
the fork of Itard, or Colombat's interdental plate, or Wutzer's
glossonachon, or Morin's marbles: the patient is relieved of his
infirmity only to become the slave of his instrument.


ELECTROTHERAPY

Electricity in all forms has been requisitioned, but it does not appear
to have justified its trial. In our opinion, moreover, it is
contraindicated in convulsive affections.

In cases of functional spasm of the neck, Charcot[195] was wont to extol
the combined use of electricity and massage, citing instances of a very
protracted and aggravated nature where relief or even cure followed the
application of the induced current to the muscles not involved in the
spasm.

     A case in point was a man who entered the Salpêtrière in 1888 with
     clonic spasm of the sternomastoid and trapezius, originating in
     depression caused by financial losses. The symptoms were not unlike
     what has been described more recently as mental torticollis. The
     condition had resisted all treatment during nine months, but
     vanished with singular rapidity after a few applications of the
     battery, during which the unaffected sternomastoid was faradised
     for fifteen minutes so as to produce the inverse of the
     pathological attitude.

Equally satisfactory results are frequently obtained in mental
torticollis from the maintenance of the antagonistic position by the
hand or campimeter, or simply by order given. It ought not to be
forgotten, however, that Charcot himself was astonished at these
unlooked-for successes, since he closes his lesson with the sceptical
injunction not to hail the victory complete nor ignore in such histories
the chapter of relapses.

Several of our own patients, similarly affected, have found
electrotherapy an egregious failure. Most sufferers from tic have
essayed it at one time or another, and if they do not accuse it of
having intensified their symptoms, the memory they retain of it is
usually anything but pleasant. All that is permissible in suitable cases
is to employ electricity "in psychotherapeutic doses." Let the patient
see the coil, or hear the interrupter, or feel the damp electrodes, and
even though the current be infinitesimal, in the sequel the suggestion
may prove efficacious. Generally speaking, however, such subterfuges
ought to be avoided.


SUGGESTION

Hypnotic suggestion has sometimes given tangible results, but it is
strictly applicable only to hysteria, which is, as we have seen, a
comparatively rare accompaniment of tic.

Reference may be made to some cases of Raymond and Janet, where the
method was successful in curing a constant giggle of four months'
duration; hiccough also, and spasms of the limbs, were combated by these
means.

One of the cases recorded by Welterstrand[196] was a child of ten years
who had stammered ever since he could speak at all, and who in addition
had for some time suffered from facial contortions--elevation of the
eyelids and eyebrows, and twitching of the lips. Six séances sufficed to
banish the symptoms, which at the end of several months had not
recurred. Another of his patients was a young woman, twenty years old,
with incessant spasmodic movements of mouth and eyebrows. The
disfiguring grimaces of years disappeared completely by the tenth
sitting.

Van Renterghem[197] has recorded a case of rotatory tic also cured by
hypnotism. Feron[198] and Vlavianos[199] report similar successes, but
one may legitimately ask whether the phenomena were not really
hysterical manifestations, and if the results attained any degree of
permanence. Treatment by suggestion is, as a general rule, ineffectual.
In Maréchal's[200] case of mental torticollis with symptoms of two
years' duration, recourse was made to this measure but without avail,
and our experience has been identical.

Raymond and Janet[201] have noted favourable results by the adoption of
suggestion during waking hours, without going the length of hypnotic
sleep; in one case of tic simulating chorea, a cure followed the threat
of surgical intervention.

The same objection may be raised to ordinary as to hypnotic suggestion,
that it is not of universal applicability. Besides, it is very difficult
to know exactly what meaning the term is intended to convey. To
encourage the patient and assure him of progress, to reproach or
reprimand him on occasion, is to employ an integral and invaluable
factor in all re-educational treatment of tics; but is this truly
suggestion?


SURGICAL TREATMENT

Surgical procedures are and can be applicable only to a small minority
of tics, principally those of the neck, and in particular mental
torticollis.

Now, while we question the necessity of emphasising afresh the
uselessness of surgical interference, we believe it incumbent on us to
indicate more precisely the extreme, inefficacious, and sometimes
perilous nature of the measures to which patients are exposed in the
vain hope of putting an end to their _mal obsédant_.

In the vast majority of cases the upshot of operative intervention is
the creation of transient or permanent muscular paralyses and pareses.
Of two infirmities patients voluntarily choose the one whose evils have
not yet been brought home to them. To enlighten them, to warn them
against their own rashness, to impress on them repeatedly the truth of
the fact that so-called radical operations do not exclude the
possibility of recurrence--this we conceive to be our bounden duty.

Spasmodic torticollis more particularly has tested the surgeon's
sagacity and talent. Yet in the ever-increasing number of recorded cases
there is usually a curious indefiniteness of statement on a point of
primary importance: was surgical aid sought for the treatment of a tic,
or of a spasm?

Torticollis tic--mental torticollis--is a psychical disease pure and
simple, which does not enter the province of surgery, while torticollis
spasm--spasmodic wryneck--may come within the scope of the surgeon's
knife, though only on condition that the irritative lesion be sharply
localised. Now, not only is this information generally missing, but even
more frequently perhaps a hard and fast line between the two cannot be
drawn. The wisest course would be to delay the adoption of a plan of
treatment whose results are so problematical, but these considerations
have unfortunately been outweighed by the operator's laudable desire and
expectation of ensuring respite from a most painful affliction.

It is purposely to demonstrate how invalid this plea must henceforth
remain that we shall now pass rapidly in review the various surgical
devices imagined for the relief of torticollis tics and spasms.

The first methods to be practised were elongation, ligature (Collier),
section (Gardner and Giles), or resection, of the spinal accessory. The
last of these was performed for the first time by Campbell in 1866, then
by Southam, Mayor, Collier, Pearce Gould, Edmond Oxen, Appleyard,
Atkins, etc. Eliot[202] was convinced of the value of this measure, and
made a special study of the technique. Coudray[203] recognised the
insufficiency of section or resection of the accessory, yet decided in
its favour.

     In the present state of our knowledge (he says), the treatment to
     be preferred for spasmodic torticollis is resection of the external
     branch of the accessory. Its superiority over the multiple and
     successive divisions of the neck muscles vaunted by Kocher--apart
     from the absence of proof that the latter is more efficacious than
     the simpler operation--is based on the view that, as the dependence
     of the condition on cerebral lesions and its occurrence in nervous
     individuals render uncertain the accomplishment of a complete cure
     in every instance, with such a class of patient it is essential to
     have recourse to an operative minimum. In nearly every case,
     nevertheless, marked amelioration ensues on this procedure, the
     benefit derived from it forming its thorough justification.

If the advantages of such an operation are not more appreciable, we must
take up a position of much greater reserve regarding its suitability,
particularly in view of the fact that the prosecution of a line of
treatment absolutely devoid of risk may assure equally, if not more,
satisfactory results.

The next step was to devote attention to the cervical nerves.

The co-existence of goitre and functional spasm of the neck suggested to
Pauly[204] that pressure on the recurrent laryngeal nerve might occasion
a reflex spasm via the muscular branch of the spinal accessory. By
analogy, in some cases of spasmodic torticollis a point of irritation on
one of the sensory nerves of the cervical plexus might generate a
reflex motor reaction in the area of the accessory, with possible
diffusion to neighbouring trunks.[205] It might then be a good plan to
divide the branches of the superficial cervical plexus, just as the
trigeminal is divided for tic douloureux of the face.

It soon became obvious that resection of the spinal accessory was
insufficient. Risien Russell[206] adduced physiological evidence to show
that some of the muscular groups involved in the condition are not
innervated by the spinal accessory, but by the second, third, and fourth
cervical roots, section of which is imperative to obtain positive
results.

The surgeon had not been behindhand, however. Gardner in 1888 was
convinced of the necessity of dealing with the posterior branches of the
second and third cervical pairs, a method practised a few months later
by Smith and by Keen. One or two cases recorded by Ballance, according
to whom division of the posterior roots was performed as far back as
1882 or 1883, are highly instructive:

     A woman, thirty-two years old, had suffered for seventeen months
     from convulsive movements inclining the head to the right shoulder
     and turning the face to the left, the muscles affected being the
     sternomastoids, right trapezius, and complexus. On May 30, 1887,
     half an inch of the left spinal accessory was resected before its
     entry into the muscle, whereupon the spasm diminished in intensity
     and the sternomastoids ceased to contract. On June 6 two-thirds of
     an inch of the right accessory was removed, the patient being able
     four days later to keep her head straight by the application of her
     hand to the right side; but on July 4 violent spasms of the
     trapezius recommenced, demanding section of the posterior branch of
     the second pair. By the 21st there was a little stiffness of the
     neck on the right which speedily disappeared, and in March, 1891,
     recovery was still complete.

     The second case concerned a woman, aged twenty-nine, with
     convulsive movements of the trapezii dating back seven years.
     Resection of both spinal accessory nerves at the posterior border
     of the sternomastoid was practised on November 21, 1892;
     consecutive double trapezius paralysis revealed the fact that the
     deep rotators of the head on either side were similarly in a state
     of spasm; on December 13, 1892, the posterior branches of the
     first, second, and third left cervical roots were divided by Keen's
     method, the contractions being now confined to the deep rotators of
     the right side, which were to be treated in their turn in the same
     manner.

Comment is needless.

In a case of spasm of the left sternomastoid and certain muscles of the
neck reported by Chipault,[207] bilateral removal of the superior
cervical sympathetic ganglion was followed by instantaneous relief,
succeeded by a relapse and a second cure; a degree of retrocollic spasm
persisted.

Kocher's plan of cutting successively all the muscles affected has given
varying results, according to de Quervain. This procedure has been
adopted by others, notably by Nové-Josserand[208] in a case where
treatment by suggestion had proved of no avail. For some days after the
operation the spasm was exaggerated, although it eventually disappeared.

It is permissible, however, to doubt the definite and radical nature of
these cures if we look at the long catalogue of admitted operative
failures.

Linz's two cases[209] of resection were unsatisfactory. In Popoff's
experience[210] tonic muscular spasm returned in spite of repeated
neurectomies, in contradistinction to the notable improvement he
accomplished by simple re-education. Tichoff[211] found the torticollis
reappear four days after division of the spinal accessory, and though,
in his opinion, relapse supervenes after this operation in more than
fifty per cent. of cases, he expresses himself in favour of further
operative interference.

Two of Dalwig's patients developed a functional torticollis to avoid the
diplopia caused by a superior strabismus. Ocular tenotomy, as might have
been foreseen, was quite ineffectual in checking the tic; indeed, the
author himself seems to have been well aware of the necessity, in curing
such vicious habits, of influencing the attention. He proceeds to
emphasise the hopefulness of orthopædic, as opposed to surgical,
treatment, and recommends the use of a cardboard collar, though any
benefit thus derived is, in our experience, purely ephemeral.

A case of Oppenheim's underwent first tenotomy, then elongation, and
finally resection of the spinal accessory, with the result that, in
spite of complete atrophy of the sternomastoid and partial atrophy of
the trapezius, spasm settled with renewed intensity on the splenius,
omohyoid, and remaining fibres of the trapezius. Application of a seton
was equally negative, but the patient soon after made astonishing
improvement by a mineral water "cure"!

In face of such facts, it is truly surprising to see the increasing
support given to surgical intervention. Walton,[212] for an instance,
admits the central origin and progressive nature of the disease, and
recognises the futility of surgical procedures, yet constitutes himself
their advocate. Would it not be more in accordance with the dictates of
reason and wisdom to refrain?

We must not omit to mention the extraordinary method devised by
Corning[213] of injecting into the muscles a warm mixture of tallow and
oil which will solidify at 37° C., to which proceeding he proposes to
give the fantastic name of _elœomyenchisis_. The idea is to fix
previously relaxed muscles. He does not seem to have had many imitators.

       *       *       *       *       *

Torticollis apart, few tics invite treatment at the hands of the
surgeon, with the exception of facial tics or spasms.

Here, too, the results have usually been anything but encouraging.
Stewens[214] reports three cases of facial tic cured by the correction
of errors of refraction, while elongation of the facial nerve failed of
its object. Resection of a branch of the trigeminal is valueless; facial
elongation only causes a corresponding paralysis, and should this latter
accident be transient, as in a case of Bernhardt's, so is the relief
from the tic.

To obviate the much more frequent inconvenience of a permanent facial
paralysis, J. L. Faure[215] suggests spino-facial anastomosis. In a
woman suffering from contracture and spasmodic twitchings in the region
of the facial, Kennedy, of Glasgow, divided the nerve and immediately
anastomosed the cut end laterally with the spinal accessory. At the end
of fifteen months the spasm had vanished and the paralysed facial nerve
had recovered its functions.[216]

Strictly speaking, then, in certain cases of genuine facial spasm the
possibility of some such treatment may be entertained if all other means
have failed, but persistence of the facial palsy and the grave
consequences it may entail are always to be dreaded. In facial tics,
however, under no pretext whatever is the surgeon justified in
attempting to interfere.

In the case of spasms properly so called, efforts directed to the
removal of the exciting cause--should it be known--are often crowned
with success. Conjunctivitis, rhinitis, odontalgia, may occasion
grimaces and contortions which cease with the disappearance of the
irritation. In 1884 Fraenkel showed to the Medical Society of Berlin a
woman, forty-five years old, with mimic convulsions of four years'
duration, attributable to a rhinitis. Every time the mucous membrane of
the left nasal fossa was touched a violent spasm ensued; but a few
applications of the galvano-cautery brought the phenomena to an end.

Oppenheim has seen facial and masseter spasm checked by the extraction
of a carious tooth, and in another case by an operation on the ear.

Emphasis must once more be laid on the fact that any success achieved
has been in reference to spasms; as much cannot be said of tics and
analogous affections. The surgical treatment of stammering has long
since received its quietus.

       *       *       *       *       *

We may bring this discussion to a close by applying to tics in general
certain considerations of Brissaud[217] anent mental torticollis:

"Instead of proceeding to operate at once and being content thereafter
to enjoin on the patient, whenever the wound is healed, a course of
exercises to be persevered with over long months or even years, better
give the same good advice long months or even years before inflicting
him with the operation."


ORTHOPÆDIC TREATMENT

The use which has in some instances been made of various forms of
apparatus for temporary fixation or for gymnastic purposes is, as a
rule, rather hurtful than otherwise. The patient is disconcerted by
their withdrawal, and prone to recommence his inopportune movements. It
is preferable to allow him to adopt his own attitudes independently of
the physician. An accessory not always at hand must not be allowed to
become indispensable to the control of his tic, else he may make its
absence a pretext for the discontinuation of his exercises.

Excellent results, it is true, have been obtained in chorea by recourse
to apparatus of restraint. According to the recent descriptions of
Huyghe[218] and of Verlaine,[219] after the administration of a few
whiffs of chloroform to the patient, the affected limbs are massaged
vigorously enough to enable him to have some conception of what is being
done. Light anæsthesia is continued while they are immobilised in duly
padded splints and covered closely with bandages. At the end of five or
six days the dressings are removed, when all choreic twitching will be
found, as a general rule, to be gone; should it persist, the treatment
must be repeated. In numerous instances the method has been eminently
successful.

So favourable an issue is scarcely to be looked for in the case of tics.
Rather are these forms of apparatus liable to do harm in the direction
of fresh outbursts.



CHAPTER XIX

TREATMENT BY RE-EDUCATION


The author of the article "Tic" in the Dictionary in Sixty Volumes of
1822 urges the necessity of care and perseverance in the correction of
the involuntary movements characteristic of the disease. In 1830 Jolly
recommended different exercises in the treatment of convulsions, as a
means of interrupting the sequence of certain spasmodic phenomena.
Blache's[220] adoption, in 1851, of medical gymnastics in cases of
"abnormal chorea" was attended with excellent results; and Trousseau, as
we have seen, extolled the value of exercises systematically applied to
the muscles involved in non-dolorous tic. The principle of the treatment
consisted in the regular execution of given movements by the muscular
groups affected, to the rhythmical accompaniment of a metronome or the
pendulum of a clock.

In these instances we have a forecast of the modern methods of
re-education, so successfully employed to combat tic.

Letulle advises an appeal to the intelligence, good sense, and will of
the patient in the endeavour to provoke an inverse effort at the moment
when the tic begins, or even before. It is the prerogative of the
physician to indicate suitable exercises and to encourage and aid the
patient in his attempts. Even the most inveterate of tics may thus be
controlled and made to disappear. On the other hand, the _Traité de
médecine_ ignores the subject, while Lannois' paper in the _Traité de
thérapeutique_ contains the statement that in the treatment of
myoclonus--under which term various indefinite convulsive movements are
comprehended--no method has hitherto been of any avail. Yet in another
section of the same book we discover some sound advice anent tics and
choreas of hysterical origin, emanating from the pen of Pierre Janet.

     It is well to study the influence of the attention on these
     conditions; some tics are contingent on the direction of the
     patient's attention to them, others appear solely during times of
     distraction.... Education of movements by some form of drill may be
     of the greatest utility.

These general therapeutic indications are applicable to all kinds of
tic, independently of their form and localisation. Moreover, they
conform to the procedures advocated by Brissaud since 1893.

So long as tic is regarded as a purely external phenomenon, treatment is
bound to be insufficient; but recognition of the relations between the
convulsion and the mental state of the subject has made possible a
rational therapeusis. There can be no doubt, thanks to the laborious
work of Bourneville, that systematised mental discipline has sometimes a
surprising effect on congenital psychical imperfections; and where the
patients have attained a higher level of mental development,
re-education has shown itself to be the method _par excellence_.

The credit of initiating treatment by forced immobility is due to
Brissaud, who in the year 1893 first utilised the method in cases of
mental torticollis. In the face of the risks of surgical intervention
and the unsatisfactory nature of existing therapeutic measures, Brissaud
emphasised the value of motor discipline in tic,[221] and it was not
long ere rules were formulated and precision introduced into the
application of the method.[222] The results were certainly encouraging,
so much so that improvement could be promised if treatment was
sufficiently protracted; cure, indeed, followed in various instances.

Brissaud's method is a combination of immobilisation of movements with
movements of immobilisation. Speaking generally, the patient is directed
to perform certain appropriate exercises under given conditions. Some of
these exercises are intended to teach him how to preserve immobility,
while the object of others is to replace an incorrect movement by a
normal one. In the case of the former, immobility is alike the goal in
view and the means of attaining it, while by recourse to suitable
movements, in the latter instance, the same end is sought.

It is essential to remember that the exercises must be graduated. To
begin with, the subject of tic is required to remain absolutely
motionless, as for a photograph, for one, two, three seconds--in fact,
as long as he can without fatigue. Very gradually the period is
increased, for patients have their good and their bad days, and too
great a demand on one day is apt to be succeeded by a relapse on the
next. One must rest content with even the most insignificant gain at
first, and soon the seconds will grow into minutes, and the minutes into
hours. It is desirable to specify on each occasion the duration of the
expected immobility. Place the patient at the outset in the position in
which his tic manifests itself least often, and do not cease to
encourage him by affirming that he can and must remain immobile. Once
the séance of immobilisation can be maintained for as much as five or
six minutes, begin to modify the patient's attitudes. If he has been
comfortably seated during the opening performances, try him when he is
standing, and as soon as he has accomplished this, vary the position of
his head, arms, trunk, and legs, repeating the séance in each case.
Eventually he will learn to maintain immobility of certain parts of his
body while he is walking, or while he is executing given movements with
his arms or legs. In all these performances direction must be specially
directed to the patient's tic. The method is obviously simple, so much
so that he may be inclined to question its utility and may fail to grasp
its import. One must not hesitate, however, to explain its purpose;
indeed, the rapid and intelligent appreciation of the method on the part
of the patient is a _sine qua non_ for success. Patient and doctor most
co-operate in defence and attack; and their union will culminate in
triumph. Simultaneously with this discipline of immobilisation the
subject must be taught the discipline of movements. The idea is to make
him perform slow, regular, and accurate movements to order, addressing
oneself to the muscles of the area in which the tic is localised. They
must be very simple at first, and the exercises must be very short. The
séance should never be prolonged beyond a few minutes, making, with the
immobilisation, not more than half an hour. This time will, of course,
soon be increased, but it is of prime importance to avoid fatigue. The
performances should be gone through three, four, or five times a day,
and always at the same hours. One of them at least ought to be under the
personal direction of the physician, whose duty it is to modify,
instruct, exhort, reprimand, as the case may be. In his absence the
supervision of the exercises must be left to some responsible
individual, who has an eye for faults as well as for progress.
Statements by the patients themselves are to be considered with reserve.

The repetition of the prescribed exercises should take place in front of
a looking-glass, whereby the patient may be exactly informed of any
mistakes in gesture or attitude. He cannot otherwise judge of the degree
of immobility attained, and may deceive himself, although he has the
best intentions in the world, as to the real state of affairs. He does
not know whether he is holding himself straight or not, as a general
rule, but a glance in the mirror will correct his fault. A careful
register must be kept of the progress he makes. Little by little the
jurisdiction of the physician will be reduced, provided the patient
maintains his interest in his own treatment. Indifference and
discouragement are fatal, and it must be the physician's aim to prevent
their occurrence.

Séglas has reported the history of a woman with mental torticollis, who
submitted to treatment by Brissaud's method, and a remarkably quick
alleviation was the result. At the end of three weeks, however, she
allowed her interest to slacken, and ere long the benefits obtained were
entirely frustrated.

It cannot be too often repeated that even though the tic disappear, the
patient must not be abandoned to himself, but must be persuaded to
continue his exercises. This is the price of success. As time goes on,
it is true, he encounters fewer difficulties in his way, and once he is
conversant with the method, he may be able to work out his own
salvation.

In the case of children, the efforts of the medical man may often be
seconded by parent or teacher, who has assisted at the first lessons and
is in a position to superintend their repetition. On the other hand,
treatment may be nullified by deplorable weakness on the part of father
or mother. One of the reasons for the existence or at least the
persistence of tics in children is that there has been no attempt at
their correction when they were still "bad habits." Neglect or
indulgence is an etiological factor of the first importance, as we have
already seen. Many a time we have had occasion to note this,
notwithstanding the protestations of the family. Fear of aggravating the
mischief is sometimes advanced as a reason for non-interference. Nothing
could be more misleading.

The method which seeks to check the youthful _tiqueur_ by the
multiplication of threats and penalties is not to be countenanced; it
produces the opposite effect to what is intended. Clearly the
educational therapeutic measures we have been advocating demand a
patience and an ingenuity on the part of both doctor and patient which
we have no desire to minimise, but it is along these lines that success
is to be reached.

A noteworthy adjunct to treatment is to sketch out a daily routine for
the patient to follow regularly and punctually. His mental disarray is
patent not merely from his disorders of motility, but in the
unmethodical and changeable habits of his everyday life. To introduce
discipline into his manner of living is a most wholesome step. To find
something with which to employ his leisure time, to direct his energies
into suitable channels, will prove to be eminently beneficial, not
merely for the child but also for the adult. Those who tic ought to be
able to contract good habits as readily as bad, provided their
instructor be sufficiently persevering and inventive.

There is an infinity of occupations for the patient to put his hands to,
and this variety suits his unsettled mood and his wavering attention;
but longer efforts will be secured from him if his interest in his task
can be engaged and stimulated as well. It is a good plan to make him
write down each day what he does and how it is done, and to have him
rehearse from time to time. Such pedagogical details are far from being
superfluous; adults, moreover, are quick to gather their significance
and to demonstrate their advantages in practice. That their fickle will
must be reinforced they know well; how to achieve this end they are
unaware. This fact explains their eager acceptance of the support
furnished by these "moral crutches."

Generally speaking, there is no call to interrupt treatment once it is
commenced, although occasionally we have found this desirable. The
fatigue of the first few days, almost unavoidable as it is, and
accompanied by new sensations, need occasion no alarm. We should
acquaint our patient of its explanation, and so obviate the mental
depression which its existence is apt to engender. Its ephemeral nature
will soon become plain, for a rest of a few days suffices for its
disappearance.

In some instances resort to procedures reminiscent of antagonistic
gestures seems to have been of avail.

One of our patients,[223] suffering from facial tic, was directed to
perform, as far as practicable, the opposite movements to her grimaces.
If her mouth was drawn to the right, she forthwith made a corresponding
twitch to the left; if her mouth was shut spasmodically, she was
instructed to open it widely and quickly. By such simple methods,
applied to all her tics, speedy control was regained, and once she had
mastered the theory of the process, the practice of regular exercises
and the development of antagonistic movements soon effected a complete
cure.

Training of the antagonists has also been recommended by
Hartenberg,[224] in a case of scratching tic. The patient was urged to
approximate the hand to the affected cheek very slowly, and almost at
the moment of contact the order was given to extend the arm briskly;
this gesture of opposition, moreover, was stimulated by faradisation to
the extensors of the forearm. The method, of course, is practically
identical with that adopted by Frenkel,[225] of Heiden, who provoked
energetic contractions of antagonistic groups by teaching the patients
to overcome increasing resistances. Prudence, however, must be observed
in carrying out these ideas, otherwise we run the risk of replacing one
tic by another.

       *       *       *       *       *

After the above general sketch of the essentials of the method, we may
give examples of its application to particular instances.

For a tic of the eyelids, in especial for blinking tics, we make the
patient open and shut the eyes to order, keep them closed or apart for a
space, shut one eye and then the other, and repeat the same sequence in
different positions of the head. It is a good plan to enjoin
simultaneous action of the oral musculature. The cessation of tonic
contractions of the eyelids with opening of the mouth has been remarked
several times, and Oppenheim finds an analogy in the observations of
Gunn and Helfreich, who have seen ptosis disappear as the mouth is
opened.

If the eyeballs are involved in a tic, insist on dissociating the
movements of head and eyes; make the patient follow an object slowly
with his eyes while the head is stationary; or let the head deviate to
right or left, up or down, while the eyes remain fixed on some
particular point.

When the lips are the seat of involuntary muscular action, have the
patient show his teeth, open and shut his mouth, purse his lips; make
him speak and conform his expression to his speech; let him read aloud
slowly, and fix his attention on his subject.

As a specimen of treatment for a facial tic, we may cite the subjoined
programme:

     Every day, and three times a day, at the same hours--nine, one, and
     six--the patient is to look at himself for two minutes in a mirror,
     preserving absolute immobility the while; to read aloud for two
     minutes, to speak in front of the glass for two minutes, to walk
     backwards and forwards in front of the mirror for two minutes.
     During the ten minutes of these exercises he will endeavour to keep
     his facial musculature under control. If the tic assert itself in
     the course of one of the exercises, he will recommence the latter,
     if necessary twice; the third time he will leave it till the next
     séance.

For tics of the head and neck, such as tossing tics and mental
torticollis, inclination and rotation movements are indicated, of which
an instance may be quoted:

     Mademoiselle R. is quick in learning how to correct her muscular
     faults. Her actions are gradually becoming more complete and ample,
     and if she performs her allotted task with little animation, at the
     least there is no question of her indefatigable willingness. In
     less than a month she has been able to fix her regard, open her
     eyes widely, turn her head, uninterrupted either by halts or
     twitches; she can remain motionless in front of a looking-glass for
     as long as a minute. Equally satisfactory progress hat been made
     in the art of reading aloud; she breathes more regularly, and
     articulates more distinctly.

     Thus the patient has come to realise that she need but give her
     attention to the involuntary movements for them to cease, and there
     has been a synchronous advance in her mental activity and power of
     concentration. Her nonchalance and timidity have diminished; she is
     no longer indifferent to her surroundings, nor furtive in her
     glances; she enters into conversation with zest, and her movements
     are characterised by decision.

Take another example of treatment, for a case of mental torticollis:

     Stand or sit in front of a mirror and endeavour to maintain an
     absolutely correct position of trunk and shoulders.

     Lift the arms vertically and turn the head to the right, then lower
     the arms while the head remains as it is.

     Bend the body forward, and stretch the arms out till they touch the
     ground, the head meantime being rotated to the right. Then rise up
     again with the head in the same attitude. After two or three
     efforts it will be found that the head can be kept straight for a
     few seconds.

In tics of the limbs, shoulders, hands, feet, innumerable movements will
suggest themselves for practice. The young girl with a tic of
genuflexion, under the care of Oddo, supplies an excellent proof of the
value of Brissaud's method:

     The immobilisation of movements was realised by the mother forcing
     the child to remain motionless in a fixed position for augmented
     periods. As for movements of immobilisation, the patient made
     peregrinations of increasing length under the mother's eye, the
     order being repeatedly given to suppress the genuflexions. At the
     same time, massage and passive movements to the limbs and joints
     were prescribed, with a view to diminishing the articular
     cracks--the exciting cause of the bizarre tic from which the girl
     suffered.

     In the course of ten or twelve days the genuflexions had entirely
     vanished, and a return of the pain in the coxo-femoral articulation
     aided materially in consolidating the effects of the treatment.

Tics of speech should be handled in the same way as stammering. "We do
not treat stammerers, we educate them," says Moutard-Martin. There can
be no gainsaying the convincing results obtained by Chervin's technique.

For years there has been unanimity of opinion on the value of
respiratory gymnastics in the treatment of stammering. The plan is to
make the patient inspire deeply and quickly, and follow this with a
prolonged expiration. Difficulties of articulation and phonation may be
overcome by recitation, by declaiming, by scanning utterance, by
dwelling on the vowels, etc. Various authors have laid stress on the
advisability of concomitant therapeutic treatment.

     In cases of stammering (says Olivier), all surgical interference is
     to be deprecated. Operations on the nose or throat are directed
     toward the removal of obstructions in the air-ways, but they are
     merely a preparatory step to the adoption of the education method.
     No one of the vaunted "cures" for stammering is infallible, since
     all depend in the last resort on the will power of the patient, nor
     is there anything mysterious about them. Isolation is not always
     indicated; what is indispensable is reinforcement of the will.

The intimate relation between tics of speech and various kinds of
stammering has led to the application to both of the same re-education
methods. Pitres,[226] in particular, bases his line of treatment for
tics in general on regulation of respiratory activity, as he has
observed that tics diminish or die away with a deep and regular
respiratory rhythm. His plan is as follows:

     Supported against a wall, with shoulders braced back, the patient
     is instructed to take slow and deep inspirations, raising his arms
     the while, and letting them fall with expiration. This performance
     is repeated three times a day, for ten minutes at a time.

The method has been elaborated by Tissié, and Cruchet also has thereby
obtained excellent results, which he has put on record in his thesis.

     The patient is placed upright against some support, his heels
     together and his arms by his side. For the first three minutes he
     recites aloud, drawing a slow deep breath at frequent and regular
     intervals. Then he proceeds to make similar long inspirations and
     expirations, elevating his arms synchronously with the former, and
     depressing them with the latter. The exercises may advantageously
     be repeated every three hours to begin with, then their duration
     may be increased and the intervals lengthened, until the séances
     are extended to fifteen minutes three times a day. Their
     continuance will vary with the individual, but the ultimate aim is
     to reduce the period and to spin out the interval still more, until
     eventually their object has been attained and they may cease.

A concrete example may be given:

     A young man had suffered for eleven years from generalised tics of
     peculiar intensity. Every few seconds violent twitches of an
     electric-like rapidity seized the muscles of his head, trunk, and
     limbs, to the accompaniment of abrupt cries and inarticulate
     growls. A sojourn of a few weeks in hospital, and the acquisition
     of the most elementary technique in athmotherapy, resulted in a
     complete cure ere many months had passed.

Tissié explains the action of this method on tics by a special action of
regular respiration on psychomotor centres. Raymond and Janet incline to
the opinion that attention depends on respiratory activity, but
Tissié[227] argues there is antagonism between deep respiration and
maintenance of attention, and Cruchet supports this hypothesis.

     If we prescribe respiratory exercises, we are temporarily
     suppressing the attention, and reducing psychical activity to a
     minimum. Thus tic, which is a reflex of thought, does not occur,
     and if the exercises are renewed often enough, the habit will
     gradually be lost.

In our opinion, it is precisely the bestowal of the attention on the
allotted task that has such a salutary effect. Whatever be the
movements, they demand of the patient a momentary halt, a momentary
interruption of those ill-timed motor reactions that make concerted
action impossible. Observation shows that the degree of successful
control is in proportion to the degree of concentration of the
attention. The novelty of the exercise in itself acts as a stimulus, but
when this novelty wears off, faults are prone to reappear. Hence the
necessity of varying the procedures, and of rendering them always
interesting; in the end the habit of supervision is contracted, and the
patient feels increasing satisfaction in watching his physical
infirmities daily diminish and the resources of his will daily widen.

Respiratory drill is an admirable method of procuring this result; it
acts in the same way as any of the other exercises. Its use is not
confined to tics of speech or of respiration, for thoracic muscles are
involved in tic much more frequently than is commonly supposed. By
resort to this technique Madet cured an expiratory hiccough[228] in a
man of forty-six, who was afflicted in addition with twitches of head,
trunk, and hands.

Systematized exercises have of course the advantages of exercise in
general; motor, sensory, and psychical functions alike are stimulated
and regulated, and tend to become normal. In particular, muscular
exercise is a striking way of disciplining volition. Accordingly, we
never fail to prescribe such pastimes as gymnastics, in any of its
forms, rowing, fencing, cycling, lawn tennis, etc.; games which demand
attention, skill, and decision are useful auxiliaries, and manual
occupations of a more delicate nature ought not to be forgotten,
provided they require of the patient a certain amount of immobility.
Every case, needless to say, must be treated on its merits, but the
general indications we have supplied can easily be modified to suit the
individual.

The various procedures directed, under different names, to the
suppression of tic by re-education, are all modelled on the same plan.
Köster attributes the disease to exhaustion of higher co-ordinating
centres, and counsels their reinforcement by appropriate exercise.
Oppenheim, in his _Lehrbuch der Nervenkrankheiten_, adduces evidence of
the value of what he calls _Hemmungstherapie_, which is merely an
application of the principles and therapeutic rules laid down by
Brissaud in 1893, and described by one of us in 1897, apropos of mental
torticollis. The same may be said of the line of treatment pursued by
Dubois, which appears to be based on the pathogenic interpretation given
by Oettinger,[229] according to whom the brain of tic patients is
incapable of conserving the image of sustained immobility, and thereby
loses the habit of voluntary immobilisation. The essence of treatment,
therefore, consists in habituating the subject to rest motionless like a
statue in a position conducive to repose, and for a given time.

As has been already remarked, the polymorphism of tics is such that the
plan of treatment selected must be necessarily elastic if it is to be
altered to suit individual cases. What is the point in enjoining
absolute immobility on a patient whose blepharotic is never in evidence
unless he is walking about?

       *       *       *       *       *

We may now proceed to narrate the details of various cases of tic
treated by the combined method of disciplinary movements and immobility,
taking the history of O. as our first example.

     _October 15, 1901._--Séance of absolute immobility in the upright
     position, with the head straight, for five seconds; to be repeated
     in front of a mirror for five minutes, with intervals for rest of
     fifteen seconds. Movements of rotation of the head to left and
     right, with progressively lengthening pauses in each of the extreme
     positions. Respiratory exercises with elevation and depression of
     the arms eight times a minute, decreasing steadily to four a
     minute. These exercises are to occupy a quarter of an hour morning
     and evening. Explain to the patient the action of the
     sternomastoids and how they combine to fix the head. Make the
     patient lie on his back and move his head antero-posteriorly.

     _October 19._--O. has still his tics, but he can already remain
     motionless on command, and is conscious of satisfaction in so
     doing. Just as his exercises come to an end there is always a
     momentary recrudescence of the tics, but a very appreciable calm
     follows.

     _October 21._--Immobility is maintained well for half a minute. The
     patient is to resume his cycling and fencing, physical exercises
     which he has abandoned for more than a year.

     _October 25._--O. considers himself greatly improved. He has gained
     insight into the way of combating his tics, and his self-confidence
     is on the up grade. For several days he has devoted his attention
     to his tic of blinking, with the result that he can open his eyes
     longer and more easily.

     _October 28._--He evinces a preference for certain of the
     exercises: if they please him, he performs them accurately; if they
     do not, they are neglected.

     _November 20._--The head tics are still rather violent at times. A
     period of intellectual and bodily fatigue has supervened, but he
     tries his fencing again, and to his profound satisfaction he has
     managed to keep free of tics during the bouts. He is recommended to
     avoid all possible causes of cerebral and physical exhaustion.

     _December 3._--He continues to make satisfactory progress. His
     habit of supporting his chin on his cane is abandoned, though an
     attempt to dispense with the latter entirely, when he is out in the
     street, has ended disastrously. He is content to hold it in his
     hand and strike his leg with it from time to time.

     _December 13._--Whenever O. is tempted to tic again, he stands in
     front of a mirror and commences to sing, and while the song lasts
     his tics remain in abeyance. His trick of sitting crossways on a
     chair and rubbing his chin against the back is also discarded, with
     the result that the callosities have vanished. As far as his
     walking is concerned, he has adopted the plan of endeavouring to
     get from one point to another without allowing his tics to assert
     themselves, and his efforts have been crowned with success.

     _February 3._--The patient has recovered his self-confidence, and
     the compliments of his friends prove an additional restorative. It
     is true the tics still recur, but their number is less, their
     duration shorter, their severity considerably diminished. What O.
     is best able to appreciate is the disappearance of the state of
     _mal obsédant_ that accompanied them.

Take another example in the person of young J.:

     In his case our object was to discipline him by successive
     modifications of his caprices. The first important result achieved
     was the suppression of his precious mattress--a result not obtained
     without difficulty, for the mere mention of it sufficed to provoke
     floods of tears and ebullitions of anger. He was then sent into the
     country for a few days to forget his heart's desire, but the labour
     was lost. No sooner had he arrived than he discovered another
     mattress in a barn, and transferred his affections to it.

     Eventually the day came when he was finally convinced of the
     absurdity and inconvenience of his practice, and when the tender
     yet firm remonstrances of his parents prevailed. The prospect of
     congratulations awaiting him, and his own keenness to get better,
     stimulated him to fresh efforts, and the reward was success.

     Not long after, however, he began to complain of mental suffering
     from the restraint laid on him, and the distress was undoubtedly
     genuine. We accordingly gave him permission to stretch himself on
     his bed at certain fixed times and for a fixed period, which was to
     be reduced each day by some minutes. He entered into the spirit of
     the regulations so happily that in less than a month the period
     spent in the horizontal position had sunk from two hours and three
     quarters to an hour and a half daily, and at last it was dispensed
     with altogether.

     On his "nervous movements" re-education by immobility and
     methodical exercises had a beneficial influence, and he acquired
     the faculty of controlling his variable and attitude tics.
     Repetition of the séances under the eye of the physician, drill in
     front of a looking-glass, symmetrical and synchronous exercises for
     the arms, as well as ordinary practice in dressing and undressing,
     buttoning and unbuttoning clothes, eating, drinking, etc, with the
     left hand--all contributed materially to his progress. Many other
     re-educative prescriptions were enjoined on the patient; suffice it
     to say that in three months he was able to dress and feed himself,
     to behave properly at table, and to restrain himself generally, in
     spite of the obstacles provided by his babyish tricks and natural
     weakness.

     Further, the advance he has made has reacted profitably on his
     mental condition, and if his fickleness and vacillation persist, at
     the least the trend of the educative exercises has been in the
     direction of reinforcement of the will. Hence is it that he is now
     more attentive, less introspective, less capricious; he is no
     longer overwhelmed at the gravity of his condition; he is
     conscious of having taken its measure, and of his power to master
     it.

We have also applied Brissaud's method to the treatment of variable
chorea, with no less encouraging results. Its worth in cases of mental
torticollis has been noted by several authors as well as by ourselves. A
cure resulted in a peculiarly difficult instance recorded by
Martin[230]:

     A young man of twenty-six suffered from melancholia and
     hypochondriasis. He used to complain that his limbs were hopelessly
     rotten, that his hands, feet, legs, were gone, vanished; his head
     and neck had ceased to exist. So easily was he irritated that to
     most questions he vouchsafed no answer. His sentiments of affection
     were much blunted; a visit from his mother evoked no pleasurable
     sensation. All day long he used to lounge on a couch, his head sunk
     on his breast, and inclined somewhat to the right. The attitude was
     exaggerated if he was addressed, but while he could raise his head,
     by the help of his hand, to regard his interlocutor, it resumed its
     position of flexion as soon as he withdrew the support. Confined to
     the left side of his face was a tic which consisted in abrupt and
     jerky elevation of the corner of the mouth. On request, he would
     gain his feet laboriously and walk with abdomen protuberant, back
     arched, and legs apart. From time to time the neck musculature on
     the left side was the seat of convulsive movements. The left
     sternomastoid and trapezius were in a state of tonic contraction,
     and on any attempt being made to correct this vicious attitude,
     spasm occurred, and the patient resisted to his utmost.

     On March 10, 1900, treatment was begun; an effort was made to gain
     the patient's confidence by explaining that a cure was within the
     bounds of possibility, and by demonstrating to him that his limbs,
     which were in a state of slight contracture, could be moved by his
     hand. The procedure was renewed three times a day, and followed by
     baths and massage.

     By April 15 the contractures had disappeared, and he could perform
     any movement of relaxation himself. His attention was now drawn
     more particularly to his head, which was still in a faulty
     position, and annoyed him considerably. Advantage was taken of an
     improvement in his tractability to make him perform some movements
     of his neck. At first the mere effort produced a spasmodic
     contraction, but he was able to move his head very slightly up and
     down. After five months of such treatment, occupying on an average
     three hours a day, his mental torticollis was finally reduced to
     subjection, an interesting feature of the case being the
     parallelism between the physical and the psychical improvement.

     On three occasions since we have noted a recurrence of the
     torticollis, but each time it has been both brief and easily
     overcome. The cure has been maintained now for upwards of a year,
     and four months ago the patient resumed his work.

We must impress ourselves with the importance of recognising the
proneness of tics to relapse. Any triviality which may have a
prejudicial effect on the patient's will-power is calculated to
facilitate the reawakening of a bad habit. Such relapses are commonly
transient, and are instructive in so far as their manifestation
sometimes differs from the original tic and entails alterations in
treatment.

     L., for instance, whose condition was one of permanent rotation of
     the head to the right, had a fit of depression after eight days of
     treatment and noteworthy improvement, a depression so severe that
     she questioned the practicability of a cure, and forthwith her head
     began to turn to the right again. On this occasion, however, the
     tic was an intermittent one, consisting of clonic contractions of
     the cervical muscles chiefly, without antagonistic gesture. For
     five days the fit persisted, and was sufficiently acute to render
     omission of the exercises advisable.

     After some days' rest a beginning was made with the treatment
     again, under the direction of one of us and in the presence of her
     father. We took care to place ourselves always in front and to the
     left of the patient, on the side opposed to her torticollis. The
     position allotted her at table was such that in order to converse
     with her parents she had to turn to the left.

     Not long thereafter a second fit of depression occurred, but on
     this occasion her head began to rotate to the left. She had been
     under treatment for six weeks, when she made the remark one day
     that her head seemed once more to be drawn to the right. She
     hastened to add, moreover, that she had discovered a means of
     remedying the mischief--viz. by putting her left hand to her left
     cheek--a corrective proceeding nothing short of paradoxical.

     It was about this time that the pains and dragging sensations in
     the muscles of the neck subsided. On the other hand, for days on
     end, then for gradually diminishing periods, there existed a
     slight trembling of the head, due to muscular exertion, and
     explicable by the contraction of small cervical muscles on one side
     and their antagonists on the other.

On more than one occasion we have remarked this trembling as the
forerunner of a cure. It vanishes spontaneously as the amelioration of
the patient's condition becomes more definite.

Several months may intervene between relapses. Descroizilles cites a
case of convulsive movements of the head and shoulder of three years'
duration, which yielded to exercises in a few weeks. The tic reappeared
six months later, and, resisting treatment by gymnastic discipline, was
cured by suspension. Three months later it returned once more.

Facts of this description emphasise the desirability of considering
rapid cures with reserve; where the improvement, on the contrary, is
insensible, the results are much more likely to be permanent. Unforeseen
complications, again, may arise once a cure is affected.

     One of our patients[231] had been rather quickly relieved of a
     mental torticollis by the usual therapeutic measures, and we had
     allowed him to resume his avocation, when he suddenly appeared in a
     depressed and despairing mood a month later to say that he was
     worse than ever. The rotatory tic had not returned, it is true, but
     its place was taken by another phenomenon. If, as he walked along
     with head straight, his attention was suddenly directed to the
     right, he seemed at once to become "crystallised"; he halted, and
     could not deviate his head as he wanted, and at the same moment
     something appeared to choke him; in three or four seconds all was
     over, and his action unimpeded. As a result of these attacks he
     sank into a wretched state of more or less permanent anguish. A
     visit to his country home was of little avail; no sooner had he
     arrived than his head began to twist about in every direction,
     although, try as he would, he could not move it backwards. We
     accordingly prescribed absolute rest in bed, a strict regime,
     hydrotherapy, and unfailing regularity in the performance of
     gymnastic exercises. Not long after a fresh torticollis developed,
     by which the chin was deviated to the left and the head tilted to
     the right. Once more we initiated a scheme of regular drill, and in
     the course of a short time a satisfactory cure ensued. During the
     last three years we have had frequent opportunities of seeing our
     patient, and can certify that he remains mentally and physically
     normal.

Facts such as these teach us two things: the task of the physician is
not ended with the disappearance of the tic, for it is the pathological
mental state of the patient which renders him so easy a prey, and if we
can modify that state by re-education, we may count on the cure being
permanent. For a long time, however, we shall be well advised to talk
simply of improvement. In the second place, relapse or slowness of
progress is no reason for despair; treatment may have to be persevered
with for a year or years, till the patient learns how his muscles act,
how to maintain immobility, and how to effect a voluntary
movement--notions which his fickle mind has hitherto neglected to grasp.
Education of the will in the direction of control is calculated to bring
him into line with normal individuals.

A radical cure is not without the bounds of possibility, but it depends
greatly on the patient himself; his success is contingent on his
faithful repetition of exercises long after the tic is gone; for while a
cure results whenever the tic ceases to incommode its subject, fatigue
or emotion on some future occasion may reawaken the tendency to
involuntary movements, and only a methodically trained will can triumph
over the temptation to relapse.

With this reservation, one may expect permanence in the cure, provided
the affection is of recent date and the patient gives evidence of his
assiduity and desire for relief.


MIRROR DRILL

Among various re-educational procedures which are worth mentioning for
their practical value, a place must be given to what has been called
mirror drill by one of us.

We all know that the term mirror writing is in use to specify that mode
of caligraphy which looks exactly like ordinary writing when it is
reflected in a mirror or if the paper is held to the light and seen from
the reverse side. Mirror handwriting may be done with either hand. If
the right hand be employed, the characters are traced from right to left
and are centripetal in relation to the axis of the body. If, on the
contrary, it is the left hand that we use, the letters go from right to
left, but they are centrifugal.

Innumerable examples of this condition have been described and various
theories elaborated. Apart from such cases, it is a matter of common
observation that if any one be asked to write synchronously with the two
hands, his left hand will tend spontaneously to adopt the mirror
form.[232] The experiment may be tried on some one who has never made
the attempt to write with the left hand, and has never heard of mirror
writing. Ask him to abandon his left hand completely to the movements it
may be constrained to fashion while the right hand is tracing the
required words, and let his eyes be closed; in practically every case
the left will make mirror characters. It may therefore be contended that
mirror writing is the natural writing of the left hand, an opinion
supported by Vogt, Durand, etc., and more recently by Ballet,[233] who
remarks that this variety of writing for the left hand is natural in
left-handed people who have not been influenced by education.

The actual form of the characters is of little significance. We have
often repeated the experiment and substituted Greek, German, typographic
and stenographic letters, but always with the same result. It is perhaps
worthy of note that in simultaneous writing considerable modification of
the letters traced by the right hand occurs; they become hesitating and
childish; the lines are sinuous and irregular, and the characters
themselves ill distinguished. The same holds good for drawings.

On the other hand, the first attempt of the left to make mirror writing
to order is frequently laborious. Mingled with true mirror characters
will be found ordinary letters automatically traced, for automatism of
left-hand movements is not the inevitable sequel of automatism of
right-hand movements. From time to time the visual image of a normal
letter rises in the mind, an image which does not correspond to that
which the hand is endeavouring to express, whence doubt, reflection,
arrest, and, usually, error. If, however, the subject allows his left
hand to write, without preoccupying himself with the shape of the
letters it is making, or with his eyes shut, automatism reasserts its
sway and mirror writing results.

Of course a person who is asked for the first time to use his left hand
in writing may force himself to trace ordinary characters, but to do so
he must evoke the visual image of each letter and seek to reproduce the
contours of this image slowly, yet often inaccurately. There is nothing
automatic in this. Hence it is that ordinary writing with the left hand
demands prolonged education and patient effort, and may never attain any
rapidity, whereas mirror writing with the same hand is acquired with
facility in a more or less automatic manner.

It may well be that the natural left-hand mirror writing of which we are
speaking is a purely motor phenomenon, since the calling up of the
visual images of letters, so far from proving of assistance, is
calculated rather to obscure and hamper it.

It has been pointed out by Ballet that variations in the aptitude for
left-hand mirror writing exist, especially in the case of those who
cannot write without the aid of the visual image of letters. Since they
copy this image in using the right hand for caligraphical purposes, they
are tempted to do the same when the left is in use. In fact, the
facility with which one learns mirror writing seems to depend on one's
power of writing without recourse to these images. The explanation of
the ease with which the left hand reproduces, in the guise of mirror
writing, the movements of the other, is to be sought in the symmetrical
arrangement of the muscles in relation round the body axis.
Physiologists tell us, further, that the simultaneous contraction of two
symmetrical muscles is more readily attained than that of two
asymmetrical muscles. The law of symmetry and the law of least effort
correspond.

What is true of writing is no less true of all other forms of motor
activity. In physical exercises the surest results are achieved by the
synchronous contractions of symmetrical muscles, whereas education is
much more arduous should this lesson from experience be ignored. For
instance, nothing is easier than to make the arms describe circles in
the same direction, but rotation in opposite directions is very
difficult. Few people can revolve their thumbs in opposite ways. This is
a matter of common observation among teachers of physical culture. The
rapidity with which the action of swimming can be learned is in
striking contrast to the slowness with which the art of fencing is
apprehended. Little effort is required of the music beginner if his
pianoforte exercises demand the activity of symmetrical muscles for
their execution; on the other hand, the playing of a scale by the two
hands in unison comes only with long practice, since it entails the
simultaneous use of asymmetrical muscles.

Facts such as these are of more than passing interest. One cannot afford
to neglect their import where muscular education is concerned, whatever
be its nature, whatever be its object. Yet there is an unfortunate
tendency to concentrate attention on the development of the skill of one
arm only, and that the right. Sometimes the use of the left arm for
certain purposes is criticised adversely, and of course most people are
congenitally less able to work with it. But habit, example, and even
fashion, combine to render the right arm preponderant in everything, to
the detriment of the other. It is a common occurrence to attribute
awkwardness to this left arm, when its inferiority is really nothing
else than a sign of faulty education. In many cases the left is as good
as the right; its apparent _gaucherie_ is because of its attempt at
executing movements which are similar to those of the right, instead of
those which are correspondingly opposite.

Thus experience shows that the education of the right upper limb is
reflected on the left upper limb, although the subject may be sublimely
ignorant of the fact. But though this influence be latent, it is none
the less real, and may prove of service if occasion arise. Weber,
Fechner, and Féré[234] have all devoted attention to this subject.

From the therapeutic point of view, considerable significance attaches
to these facts. Temporary disablement of the right arm, such as follows
fracture or arthritis or writers' cramp, need not be disconcerting, for
the patient can proceed to utilise the faculty for mirror writing which
his left hand has unconsciously acquired. In all affections which are
accompanied by troubles of motility it is an excellent plan to apply the
prescribed muscular exercises to both sides of the body, and the
regularity with which they are performed on the sound side will have a
corrective influence on the mirror movements of the affected side. We
assume, of course, that there is no irremediable destructive lesion
which interferes with the continuity of paths joining functional
centres, otherwise the education of the normal limbs could not be
expected to produce any beneficial effect on the other. It is especially
in motor disorders of functional origin that mirror movements prove
useful, and the frequent unilaterality of these disorders readily allows
of the institution of a re-educative mirror drill. Speaking generally,
the faculty of writing supplies us with the best means of attaining our
end, for the variety of exercises it offers is likely to rivet the
patient's attention, and he has proofs of his progress under his eyes.
The goal in view is not, of course, the attainment of caligraphical
perfection--the subjects of tic are seldom guilty of bad penmanship; but
the execution of the required movements demands a voluntary constraint
that cannot but be profitable.

After the séances of absolute immobility, then, our custom is to set
daily exercises in writing, drawing, painting, tracing, ornamentation,
etc., varying the indications in accordance with individual tastes and
aptitudes. At the same time, we insist on the patient's devoting both
hands simultaneously to his task. It will be found advantageous to
devise movements for the fingers, then for the hand, the forearm, and so
on, and to instruct him in each successively. Thus, one may begin by
having him make the movements in space, then with chalk on a blackboard
placed vertically, then on the same placed horizontally, or on the
ground; or he can be asked to trace symmetrical designs and ornaments on
a wall. The essential points are that he use both arms simultaneously,
symmetrically, and accurately, and that all inopportune gestures be
inhibited.

In several of our cases procedures such as these have been adopted. O.
was not long in acquiring the faculty of writing with both hands, the
left tracing mirror characters. The object of the exercise was to oblige
him to maintain tranquillity and a correct position of his head and
neck, while his hands were simultaneously employed. By this means, as
well as by synchronous drawing exercises, he soon became so deft that he
learned to conserve almost complete immobility during the performance,
to his great satisfaction. No less creditable results were attained with
L. and with young J.

The method appears to us to be indicated above all in cases where the
left arm is the seat of tic. Any one who can use a pen with his right
hand is not long in acquiring the faculty of mirror writing with his
left. In this way the simultaneous execution of a normal movement with
right hand and left is facilitated, and the sound limb imposes
regularity on the other. Whatever be the localisation of the tic or
tics, this is the technique to adopt. It presents this advantage, that
its combinations and permutations serve to stimulate the patient's
interest, and he, at the same time, is required to keep a watchful eye
on his involuntary actions; so is his will disciplined.


REST IN BED

In the majority of cases absolute rest in bed is not desirable, but a
youthful patient should always be sent to bed early, and be allowed to
lie long; twelve hours in bed is not excessive. This rule is one which
must not permit of exceptions; whatever be the excuses invented by the
parents, we should see that it is rigorously obeyed. Two or three hours'
rest some time in the course of the day may be enjoined, provided the
period be fixed and uninterrupted. To break in on frequent siestas with
little promenades or with times of unrest is not productive of any good.

If it is impossible to maintain discipline during the day, absolute rest
in bed for a longer or a shorter period may be counselled; the sedative
effect of this measure cannot be gainsaid, especially when, for no
apparent reason, exacerbations develop, with increase of emotional,
obsessional, or other psychical phenomena.


ISOLATION

Isolation is a rather severe proceeding, which, however, one must not
hesitate to utilise in rebellious cases, or if the patient's mental
state precludes the possibility of prolonged application of systematic
discipline. Wyemann[235] cites a successful case, where a youth of
seventeen, with a bad family history, suffered from convulsive movements
in association with coprolalia, and was cured of the latter by
isolation. Some would even recommend the removal of the patient to a
hospital for mental disease. Such a step, however, is rather premature,
for he may already have begun to improve where he happens to be, and it
is not always certain that a sojourn of this character will be
beneficial.

Before isolation is resorted to, it is important to familiarise oneself
with the patient's mode of life, to ascertain whether it is capable of
modification in accordance with one's ideas for treatment, and to
determine the exact influence of his environment on him. We have
frequently had occasion to remark how potent is this environment as an
etiological factor; with young people, in particular, negligence on the
part of parent or guardian places the child in jeopardy. To combat this
unfortunate tendency must be our aim, as soon as we are convinced of the
risk.

Sometimes it is sufficient to draw the attention of the parents to the
disastrous consequences of indulgence or indifference; but we shall show
our wisdom in not relying too much on promises, however sincere and
solemn. These parents may be perfectly honest in their protestations,
but they are often as changeable and weak as their offspring, and lack
that very firmness and perseverance which they imagine themselves
capable of exhibiting. Thus, in spite of their undoubted intelligence
and good will, their efforts at control are unsatisfactory, and under
such circumstances the withdrawal of the patient from his family circle
is urgently indicated.

We cannot think, nevertheless, that the asylum is the ideal--there is
risk in the contiguity of other neuropaths or psychopaths; and while the
value of rigorous isolation consists in its stimulating and quickening
effect on the patient's self-control, whereby the day of his return to
ordinary life is hastened, yet it too frequently happens that the old
temptations are as powerful as of yore, and that the same causes which
operated when his tics first made their appearance reawaken vicious
tendencies more or less imperfectly masked.

Most subjects learn to still their tic during the physician's brief
visit; further, most achieve a similar result while they remain inmates
of a special institution; but as soon as they find themselves in their
old quarters, so soon does the impulse to tic dominate them again. In
fact, their victory is incomplete; the ground they gain is not held. The
goal to strive after is the repression of their tic under all
conditions, apart from extraneous intervention and influence. Once he
has been instructed in the methods of inhibition, the _tiqueur_ has no
one but himself to fall back on when face to face with the allurements
of his daily life.

These reserves made, it is clear that removal of the patient from his
environment has its advantages, but it is better to maintain only a
degree of isolation, and to allow him to come into his own circle from
time to time, under a wise supervision. The ideal measure would be to
consign him to the care of an attentive and devoted teacher, whose
superintendence would be permanent. In this respect, unfortunately, all
that we can do at present is to indicate what we think a desideratum,
for while well-to-do families may have their tutor, we do not know of
any one who has held a corresponding office as an instructor of children
with tic. The realisation of this novel proceeding might present genuine
difficulties in practice, but we may hope that once parents, patients,
and physicians are acquainted with the nature of tics and the efficacy
of the re-education method, many prejudices against that fruitful
therapeutic contrivance will vanish.


PSYCHOTHERAPY

Immobilisation and regulation of exercise and occupation do not
constitute the whole of the treatment; they form merely its objective
side. Psychotherapy is another factor, of capital importance.

     In the words of Brissaud, psychotherapy is an _ensemble_ of
     agencies calculated to demonstrate to the patient where his will is
     at fault, and how to exercise to the best advantage what of it is
     left. To come to particulars, his defect lies in his inability to
     check a cortical caprice. These are not rhetorical unrealities, nor
     is there anything mysterious about the method; it demands no
     special competence beyond the gentle and encouraging firmness of
     the ideal teacher. The physician can constitute himself instructor
     without having to borrow from the more or less occult practices of
     hypnotic suggestion. In fact, we must make it clear to the patient
     that the co-operation of the latter is indispensable, and that it
     is his will which is to come into action. The personal influence of
     the teacher will be exerted in sustaining his pupil's efforts, in
     making him take note of the progress effected, in keeping him to
     the allotted times for exercise and drill.

Thus, and thus only, is psychotherapy to be applied to tic. Lucid and
sincere explanations and kindly counsels are wanted, not ceremonies and
mysterious paraphernalia. Resoluteness, patience, clemency, and good
sense are the weapons in the physician's armamentarium; docility, faith,
and perseverance, on the patient's part, will enable him to emerge
victorious. As soon as the compact is made, the battle against bad
habits, where there is neither truce nor quarter, commences in earnest.
The victim to tic will speedily unlearn the habit of perpetuating bad
habits; he will, in addition, learn the habit of not contracting bad
habits. In this way a double benefit--physical as well as moral--will
accrue.

As a consequence, psychotherapeutical treatment directed specially to
the subject's mental condition is scarcely necessary. The plans adopted
to inhibit inopportune motor manifestations will prove of value for
psychical imperfections.

Education might almost be considered a species of prophylactic
treatment, intended to obviate the possible development of tics.
Bourneville has verified this statement in his experience at Bicêtre:

     Gymnastic exercises, and other measures directed towards the
     development of the child's faculties, ought to be conducted with
     kindness and gentleness, and by the aid of boundless devotion and
     patience the methods of the authorities are bearing unexpected
     fruit every day. We are convinced that the infrequency of tic in
     such as have reached puberty is attributable rather to the zealous
     application of a sound pedagogical method than to anything
     connected with the age and physical development of the child.

Results that steadfast and patient nurses and teachers are obtaining in
an institution like Bicêtre may surely be obtained by the physician in
his private practice, if the parents of a youthful candidate for tic
would appreciate the importance of discipline and unite, intelligently
and assiduously, in the task of education. How common it is to find them
solicitous only of loading his tender brain with learning, instead of
endeavouring, with all their mind and heart, to restrain deplorable bad
habits that may one day blossom into tics, to the distress of all
concerned! The physician's earliest duty is to warn the parents of the
dangers of indifference, and thereafter to install himself as teacher,
if the disease should manifest itself in spite of his precautions. He
has no choice in the matter, and he should have the frankness to say so,
indicating at the same time on what his convictions rest. He need have
no fear of damaging his professional prestige by the simplicity of his
methods. Let him not promise what he may not be able to perform;
encouragement, not deception, must be his watchword. Along these lines
lies his duty as a physician; there, too, will he find that his
treatment will be fraught with success.



APPENDIX


_Les tics et leur traitement_, of which an English translation is here
presented to the medical profession, was published at the close of the
year 1902. In it our knowledge of the vexed subject of tics and spasms
has been summarised and reviewed, and its reception in France, together
with the fact of its having been translated into German without delay,
prove that it has been regarded as the standard work on a topic the
importance of which is being daily emphasised. At all the recent
Congresses on the Continent the tics in one or other of their aspects
have provided fruitful matter for discussion, whereas in England they
have hitherto been greatly neglected. In the brief space of time that
has elapsed since the book was produced there have been many and varying
contributions to the subject, as a reference to the Bibliography
herewith appended will show. Without doubt the reawakening of interest
is in considerable measure due to the stimulus provided by the labours
of MM. Meige and Feindel, yet it cannot be maintained that they have
said the last word. In order that English readers may have before them
the latest available information on the tics, various paragraphs from
Meige's monograph (1905) have been incorporated, as has already been
remarked in the Prefatory Note.

It is desirable, however, to indicate briefly certain points on which
opinion is still divided, points on which the results of the most recent
observations help to shed some light. Probably it has not escaped the
reader's attention that the authors have with commendable wisdom
refrained from dogmatising on some of these, although they are always
able to give reasons for their adherence to one or other view. But in
one respect at least the attitude which they have adopted has been
unmistakable, and that is in regard to the fundamental importance of
agreement in the matter of terminology.

The amount of misconception that exists about what constitutes a tic is
almost beyond credence; indeed, only those who have had occasion to
examine the literature can have any adequate idea of it. Discussions at
neurological and other societies not infrequently reveal how vague are
the notions of many who must have more than a passing acquaintance with
the disease clinically. Now, a great deal of this misconception would
disappear if the distinction between a tic and a spasm elaborated by
Brissaud were adhered to, as the authors so strenuously advocate. It is
quite unnecessary to insist further on this point, but, on the other
hand, it is only fair to state that even in France the views of
Brissaud, Meige, and Feindel do not command universal acceptance.

M. Cruchet, of Bordeaux, to whom frequent reference is made in this
volume, has in several communications on tic expressed himself at some
length, and some of these have made their appearance since the
publication of _Les tics et leur traitement_. According to him, the
original meaning of the word "tic" is a movement arising in a "bad
habit," and there would never have been any confusion had the term "tic
douloureux" not been introduced. We know well enough the exact
significance of this term, but its use led to, the adoption of the
cognate term "tic non-douloureux," and in the latter group two
absolutely different conditions have been confused--viz. true tics, and
spasms in Brissaud's sense. The difference between the two is now
recognised everywhere in France; but in England and America, as Risien
Russell points out in his article in Clifford Allbutt's _System of
Medicine_, tic is still applied to such conditions as facial spasm and
the involuntary movements of trigeminal neuralgia, whereas it should be
reserved for what we usually call "habit spasm" and "habit chorea." The
advantage of the word "tic" over these rather cumbrous terms must be
patent to the unbiassed mind.

It is, however, in his persistent affirmation that a tic, to be a tic,
must be clonic, that Cruchet disagrees with the tenets of Meige and
Feindel. He has abandoned the use of the term "organic tic" in favour of
spasm; and he maintains that "tonic tic" and "tic of attitude" should
give place to "habit attitude" and "convulsive attitude," as the case
may be. His definition of tic is in the following terms:

     Tic consists in the execution--short, abrupt, sudden, irresistible,
     involuntary, inapposite, and repeated at irregular but frequent
     intervals--of a simple isolated or complex movement, which
     represents objectively an act intended for a particular purpose.

Curiously enough, however much this definition emphasises the clonic
element in tic, Cruchet makes a subdivision into habit tics and
convulsive tics, of which the former "are exactly comparable to normal
movements, except that they are involuntary at the moment of their
execution, are performed for no reason or purpose, and their frequency
is unusual." Their difference from convulsive tics is merely one of
degree; a habit tic may become a convulsive tic, and some are convulsive
from the beginning. A habit tic, if the movement be a slow one, is
closely allied to the "attitude"; and it is not always practicable to
draw a distinction between them.

Thus Cruchet himself admits that the clonic element in tic may be
minimal, so that the differences between him and our authors are by no
means so insuperable as might be imagined. What he calls a habit tic is
equivalent to the stereotyped act of the others, who hold, it will be
remembered, that the movement of tic differs from the normal movement
not merely by being involuntary, irresistible, inapposite, and so on,
but also by being exaggerated.

It cannot be denied that in many cases of tic this exaggeration of the
normal movement is anything but obvious; many conform absolutely to the
definition of Meige and Feindel, except that the movements are not
violent, or grotesque, or "caricatures." To withhold the term "tic" on
this account would be rather unfortunate, especially since no standard
exists whereby to estimate exaggeration. Enough has been said, however,
to demonstrate how insignificant are the discrepancies between the rival
definitions.

Another question recently raised by Cruchet is the possibility of the
persistence of tic during sleep.

The evidence he has adduced in favour of this has now been accepted, as
far as tics of the neck are concerned, by Meige. They are leas abrupt
and less frequent, it is true; otherwise, they are identical with the
movements of the waking hours. A case of a hiccoughing tic persisting in
sleep has come under my own observation within the last few months. Now,
it is not difficult to understand that a movement such as tic, which
occurs during the conscious state in spite of the will of the subject,
may arise when consciousness is diminished. In fact, one wonders why
they are not more frequently remarked, seeing that they are habitual
movements, and habit movements are by no means uncommon in sleep. It is
highly probable, of course, that the observation of the watcher is not
minute enough, but there is another reason. The peculiarity of all, or
almost all, of these habitual movements in sleep is that they are
rhythmical--we may instance the head nodding and head rolling of
children; but it is a noteworthy fact that they are often regulated by
respiration. When it is recalled how respiratory drill is eminently
calculated to diminish the frequency and lessen the severity of very
many tics, it will be admitted that the regularity of the respiratory
movement in sleep is the most likely explanation of the infrequency of
tic during that period.

One other matter may be shortly alluded to. In Cruchet's terminology, a
tic is an anomalous gesture, and cannot be applied to an anomalous
attitude, since the latter is tonic rather than clonic. For an anomaly
of attitude he suggests the use of the word "deformity." Hence "habit
deformity" is comparable to habit tic, and "convulsive deformity" to
convulsive tic. As a habit tic may develop into a convulsive tic, so a
habit torticollis may degenerate into a convulsive torticollis. There is
no reason why the operation of habit as a factor should not effect the
latter transformation exactly as it does the former; and as habit is
held to be a psychical phenomenon, it is easy to conceive why the term
"mental torticollis" should have arisen, and been so widely accepted.
But it will be readily understood that while Cruchet affirms that no
mental torticollis can ever be a tic, in his sense of the word, this is
due solely to his refusal to consider any movement which is tonic as
partaking of the nature of tic. In all other respects, the description
which he gives of mental torticollis shows that it is nought else than a
tic in Meige's sense.

In an article on convulsive torticollis which has been contributed by
Meige to the _Pratique medico-chirurgicale_ (1907) he emphasises afresh
the distinction between torticollis-spasm and torticollis-tic. The
former is provoked by an irritative lesion in the motor nerves supplying
the muscles of the neck, or in their nuclei of origin, and the character
of the contractions ("contracture frémissante" [Meige], "contractions
parcellaires," "contractions paradoxales" [Babinski]) in a definite
peripheral nerve area is not likely to be mistaken. In other cases the
objective phenomena distinctive of spasm are awanting: the
characteristics of tic, on the contrary, are conspicuously present, and
among these cases, where psychical disturbance plays a preponderant
rôle, are to be found those described by Brissaud as mental torticollis.

It is to be noted that these writers alike decry the surgical treatment
of torticollis, and perhaps not without good reason. Nevertheless the
method must not be condemned on theoretical grounds merely, and it is
permissible to believe that their experience may have been unfortunate.
The records of the National Hospital provide many instances of surgical
interference in torticollis and allied conditions of the neck, the
results of which make one hesitate in expressing a dogmatic opinion. It
is, however, impossible to enlarge further on the subject in this place.

S. A. K. WILSON.



BIBLIOGRAPHY


     [In one or two instances, where the original paper has been
     inaccessible, its title is reproduced as given in the French
     edition, but in brackets. Through the kindness of M. Cruchet, of
     Bordeaux, I have seen the proofs of his new volume of 800 pages on
     _Les torticolis spasmodiques_, which is at present in the press
     (Masson: Paris). It is a splendid monograph on the subject, and
     contains many references to the literature.--S. A. K. W.]

     ABADIE AND DUPUY-DUTEMPS, "Hémispasme facial guéri par une
     injection profonde d'alcool," _Société de neurologie de Paris_,
     February 1, 1906.

     ABT, "Spasmus Nutans," _Journal of the American Medical
     Association_, February 3, 1900, p. 269.

     ACHARD AND SOUPAULT, "Tremblement héréditaire et tremblement
     sénile," _Gazette hebdomadaire_, April 22, 1897, p. 373.

     AIMÉ, "Un cas de tic élocutoire guéri par la méthode de rééducation
     et d'entraînement," _Revue médicale de l'Est_, January 1, 1901, p.
     25.

     ---- "Traitement de certains tics considérés comme des syndromes
     émotionnels," _Revue de psychologie clinique et thérapeutique_,
     September, 1901.

     ALDRICH, "Tic," _Medical Record_, July 30, 1904, p. 169.

     ALLARD, "Tics chez les aliénés," _Thèse de Lyon_, 1886.

     D'ALLOCCO, "Parecchi casi di mioclonia, la maggior parte
     familiari," _Riforma medica_, 1897, p. 223.

     ALTHAUS, "Two Cases of Wryneck successfully treated by
     Electricity," _Medical Times and Gazette_, May 25, 1861, p. 544.

     AMUSSAT, "Torticolis datant de six ans; section du muscle
     sternomastoïdien; guérison," _Gazette médicale_, 1834, p. 829.

     ANDERSON, "Sternomastoid Torticollis," _Lancet_, January 7, 1893,
     p. 9.

     ANDRIANJAFY, "Le Ramanenojana à Madagascar (choréomanie d'origine
     palustre)," _Thèse de Montpellier_, 1902.

     ANNANDALE, "Case of Spasmodic Wryneck successfully treated by
     Division of the Spinal Accessory, after Failure of Stretching,"
     _Lancet_, April 19, 1879, p. 555.

     (Contains references to early literature.)

     APPLEYARD, "Spasmodic Torticollis treated by Neurectomy," _Lancet_,
     January 2, 1892, p. 26.

     ASTOLFONI. _See_ DOSE.

     AUSCH, "Zur Casuistik des Spasmus Nutans," _Archiv f.
     Kinderheilkunde_, Bd. 28, Hft. 3-4, 1899, p. 161.


     BABES, "Myokymie in einem Falle von Bleilähmung," _Neurologisches
     Centralblatt_, 1897, p. 684.

     BABINSKI, "Contribution à l'étude du torticolis spasmodique,"
     _Société de neurologie de Paris_, February 1, 1900.

     ---- "Hémispasme et torticolis spasmodique," _Société de neurologie
     de Paris_, July 4, 1901.

     ---- "Sur la paralysie du mouvement associé de l'abaissement des
     yeux," _Société de neurologie de Paris_, June 7, 1900.

     ---- "Hémispasme facial périphérique," _Société de neurologie de
     Paris_, April 6, 1905.

     ---- "Spasme du trapèze droit et tic de la face," _Société de
     neurologie de Paris_, July 6, 1905.

     ---- "Hémispasme facial périphérique," _Nouvelle iconographie de la
     Salpêtrière_, July-August, 1905, p. 419.

     BALLANCE, "A Case of Spasmodic Wryneck treated by Excision of a
     Portion of the Spinal Accessory Nerve," _St. Thomas's Hospital
     Reports_, vol. xiv. 1884, p. 95.

     BALLET, "Tic non douloureux de la face datant de trente-sept ans,
     guéri par une paralysie faciale," _Société de neurologie de Paris_,
     July 4, 1901.

     ---- "L'écriture de Leonard de Vinci; contribution à l'étude de
     l'écriture en miroir," _Nouvelle iconographie de la Salpêtrière_,
     1900, p. 597.

     BALLET AND ROSE, "Spasme fonctionnel chez un ciseleur," _Société de
     neurologie de Paris_, June 2, 1904.

     BALLET AND TAGUET, "Tic inhibitoire du langage articulé datant de
     l'enfance," _Société de neurologie de Paris_, November 9, 1905.

     BARR, "Some Notes on Echolalia, with the Report of an Extraordinary
     Case," _Journal of Nervous and Mental Disease_, 1898, p. 20.

     BASTIANELLI, "Sopra un tipo di mioclonia fibrillare," _Rivista di
     psicologia, psichiatria e neuropatologia_, vol. i. fasc. 3, June,
     1897. p. 33.

     BATTELLI. _See_ PRÉVOST.

     BAYLAC, "Un cas de torticolis mental ou tic du typographe,"
     _Archives médicales de Toulouse_, November 1, 1903, p. 481.

     BEARD, "Experiments with the 'Jumpers' or 'jumping Frenchmen' of
     Maine," _Journal of Nervous and Mental Disease_, 1880, p. 487.

     BECHTEREW, "Ueber die psychischen Schluckstörungen,"
     _Neurologisches Centralblatt_, 1901, p. 642.

     ---- ["Sur deux cas de tic de la face,"] _Oborenje psychiatrii_,
     1899, No. 12.

     ---- "Eine Neurose unter dem Bilde tonischer Intentionszuckungen,"
     _Monatsschrift f. Psychiatric u. Neurologie_, May, 1905, p. 460.

     BEDUSCHI AND BOSSI, "Sulla patogenesie del cosidetto torcicollo
     mentale," _Archivio di ortopedia_, 1903, fasc. 2, p. 81.

     BENEDIKT, "Zwei Fälle von Torticollis," _Wiener medicinische
     Wochenschrift_, 1888, p. 1613.

     ---- "Ueber den Begriff 'Krampf,'" _Wiener medicinische
     Wochenschrift_, 1895, p. 505.

     BENNET, "Case in which attacks of Intermittent Tonic Muscular
     Spasms, immediately followed by complete temporary Paralysis, have
     frequently and periodically occurred during the entire Life of the
     Patient, the Health in the Intervals being normal," _Brain_,
     January, 1885, p. 492.

     BERG, "Einige Reflexionen über die operative Behandlung des
     Torticollis spasticus," _Nord. med. Archiv._, 1905, afd. 1, nr. 2,
     p. 1.

     BÉRILLON, "Le traitement psycho-mécanique de la chorée, des tics,
     et des habitudes automatiques," _Société d'hypnologie et de
     psychologie de Paris_, July 16, 1901.

     BERLAND, "Traitement par le tartre stibié d'une forme de chorée
     dite électrique," _Thèse de Paris_, 1880.

     BERNARD, "Myoclonie du type Bergeron chez un dégénéré hystérique,"
     _Nouvelle iconographie de la Salpêtrière_, July-August, 1901, p.
     316.

     BERNHARDT, "Ein ungewöhnlicher Fall von Facialiskrampf (Myokymie)
     beschränkt auf das Gebiet des linken Facialis," _Neurologisches
     Centralblatt_, 1902, p. 689.

     BERTRAND, "Sur un cas de paramyoclonus multiplex," _Revue de
     médecine_, November 10, 1902, p. 941.

     BETTRÉMIEUX, "Contribution a l'étude des névralgies et des tics de
     la face considérés dans leurs rapports avec un état pathologique
     des voies lacrymales," _Archives d'ophtalmologie_, April, 1899, p.
     246.

     BÉZY, "Laryngospasme et signe du facial chez les enfants,"
     _Archives médicales de Toulouse_, March 15, 1903, p. 121.

     BIANCONE, "Contributo clinico allo studio della miokimia," _Rivista
     sperimentale di freniatria_, 1898, p. 313.

     BINETTI, "Contributo allo studio delle nevrosi professionali,"
     _Gazzetta degli ospedali e delle cliniche_, July 7, 1901, p. 844.

     BITTORF, "Ein Beitrag zur Lehre von den Beschäftigungsparesen,"
     _Münchener medicinische Wochenschrift_, July 4, 1905, p. 1278.

     BLACHE, "Chorées graves; guérison rapide par les massages et la
     gymnastique méthodique appliqués," _Gazette hebdomadaire_, 1864, p.
     787.

     BOMPAIRE, "Du torticolis mental," _Thèse de Paris_, 1894.

     BONNET DE MALHERBE, "Tic rotatoire de la tête et du cou," _Union
     médicale_, 1876, p. 340.

     BONNIOT. _See_ LEVI.

     BONNUS, "Spasme fonctionnel du triceps sural gauche chez une
     harpiste jouant de la harpe chromatique," _Société de neurologie de
     Paris_, May 5, 1904.

     ---- "Crampe des écrivains et torticolis d'origine mentale,"
     _Nouvelle iconographie de la Salpêtrière_, May-June, 1905, p. 285.

     BOOTH, "Toxic Tremor and Hysteria in a Male," _New York
     Neurological Society_, November, 1897.

     BORCHARDT, _Der Schreibkrampf und die ihm verwandten
     Bewegungsstörungen; ihr Entstehung, Bedeutung, und zwecktmässige
     Behandlung_, Berlin, 1904.

     BOSSI. _See_ BEDUSCHI.

     BOUCARUT, "Observation de tremblement hystérique," _Revue de
     médecine_, July, 1904, p. 601.

     BOULENGER, "Tic clonique et tonique," _Journal de neurologie_,
     1904, p. 132.

     BOURNEVILLE AND NOIR, "Idiotie congénitale; atrophie cérébrale;
     tics nombreux," _Archives de neurologie_, 1893, p. 228.

     BREITMANN, "Contribution à l'étude de l'écholalie, de la coprolalie
     et de l'imitation des gestes chez les dégénérés et les aliénés,"
     _Thèse de Paris_, 1888.

     VAN BRERO ["Le latah, névrose des Indes néerlandaises"],
     _Allgemeine Zeitschrift f. Psychiatrie_, 1895, p. 939.

     ---- ["Observations sur les affections mentales des populations de
     l'archipel malaisien"], _Allgemeine Zeitschrift f. Psychiatrie_,
     1896, p. 24.

     BRESLER, "Beitrag zur Lehre von der Maladie des Tics convulsifs
     (mimische Krampfneurose)," _Neurologisches Centralblatt_, 1896, p.
     965.

     BRIAND, "Tics" (Congrès de Limoges), _Revue neurologique_, August
     30, 1901, p. 790.

     BRIGNONE, "Paramyoclonus multiplex," _Riforma medica_, 1886, p.
     1155.

     BRISSAUD, "Tics et spasmes cloniques de la face," _Journal de
     médecine et de chirurgie pratiques_, January 25, 1894.

     ---- "Tics et spasmes cloniques de la face," _Leçons sur les
     maladies nerveuses_, 1re série, 1895, p. 502.

     ---- "Contre le traitement chirurgical du torticolis mental," _Revue
     neurologique_, January 30, 1897, p. 34.

     ---- "Chorée variable," _Presse médicale_, February 15, 1899.

     ---- "La chorée variable des dégénérés," _Revue neurologique_, 1896,
     p. 417.

     ---- "La chorée variable des dégénérés," _Leçons sur les maladies
     nerveuses_, 2e série, 1899, p. 516.

     BRISSAUD AND FEINDEL, "Sur le traitement du torticolis mental et
     des tics similaires," _Journal de neurologie_, April 15, 1899.

     BRISSAUD AND MEIGE, "Trois nouveaux cas de torticolis mental,"
     _Revue neurologique_, December 10, 1894, p. 697.

     ---- ---- "Tics, stéréotypies, aërophagie, catatonisme," _Société de
     neurologie de Paris_, January 15, 1903.

     ---- ---- "La discipline psycho-motrice," _Archives générales de
     médecine_, May 26, 1903, p. 1319.

     BRISSAUD, HALLION, AND MEIGE, "Acrocyanose et crampe des
     écrivains," _Archives générales de médecine_, September 15, 1903,
     P. 2305.

     BRISSAUD, SICARD, AND TANON, "Essai de traitement de certains cas
     de contractures, spasmes, et tremblements des membres par
     l'alcoolisation locale des troncs nerveux," _Revue neurologique_,
     July 30, 1906, p. 633.

     BROUARDEL AND LORTAT-JACOB, "Aërophagie, hoquet hystérique,"
     _Gazette des hôpitaux_, October 25, 1902, p. 1191.

     BROWN (SANGER), "A Neurologic Clinic; Spasmodic Torticollis, etc.,"
     _Medical Standard_, March, 1904.

     BRUANDET, "Un cas d'hémispasme facial," _Revue neurologique_, 1900,
     p. 658.

     BRUEL, "Traitement des chorées et des tics de l'enfance," _Thèse de
     Paris_, 1906.

     BRUNON, "Tics et tiqueurs," _Normandie médicale_, 1892, p. 169.

     BUCHANAN, "Two Cases of Spasmus Nutans," _Annals of Ophthalmology_,
     July, 1905, p. 435.

     BUCK, "Quelques réflexions sur un cas de spasme fonctionnel du cou;
     torticolis spasmodique; tic rotatoire," _Belgique médicale_, 1897,
     No. 51.

     ---- "A propos d'un tic," _Journal de neurologie_, 1903, No. 6.

     BÜHRER, "Ueber einen Fall von Unverricht'scher Myoclonie,"
     _Correspondenzblatt f. Schweizer Aerzte_, April 1, 1901, p. 201.

     BURZIO, "Contributo clinico allo studio delle mioclonie," _Annali
     di freniatria_, 1898, p. 165.

     BUSS, "Beitrag zur Lehre von der Aetiologie des Tic convulsif,"
     _Neurologisches Centralblatt_, 1886, p. 313.

     BUZZARD, "Case of Clonic Spasms of Neck and Shoulders treated by
     Liquor Arsenicalis," _British Medical Journal_, 1881, p. 937.


     CABANNES AND TOULIÈRES, "Sur un cas de tic de la face à la suite
     d'une paralysie faciale," _Journal de médecine de Bordeaux_,
     January 15, 1905, p. 46.

     CADE, "Myoclonie à type de chorée de Bergeron," _Revue
     neurologique_, 1903, p. 80.

     CADIOT, GILBERT, AND ROGER, "Note sur l'origine bulbaire du tic de
     la face," _Revue de médecine_, 1890, p. 431.

     CAHEN, "Contribution a l'étude des stéréotypies," _Archives de
     neurologie_, December, 1901, p. 476.

     (References to the literature on the subject.)

     CAILLAUD, "Contribution a l'étude des torticolis convulsifs,"
     _Thèse de Paris_, 1903.

     CAILLÉ, "Two Cases of Nystagmus associated with Choreic Movements
     of the Head in Rachitic Babies," _Archives of Pediatrics_, 1890, p.
     171.

     CALMETTE. _See_ SABRAZÈS.

     CANTILENA, "Ecolalia, emiplegia destra, cerebrale, corticale," _Lo
     sperimentale_, 1880, p. 274.

     CANTONNET, "Deux cas de goitre exophtalmique fruste avec troubles
     psychiques (torticolis mental et psychasthénie)," _Société de
     neurologie de Paris_, June 2, 1904.

     CARRIÈRE, "Le paramyoclonus multiplex," _Presse médicale_, August
     7, 1901, p. 57.

     ---- "Sur un cas de paramyoclonus multiplex et de lordoscoliose
     hystériques chez un enfant," _Nord médical_, May 1, 1902.

     CARRIÈRE AND SONNEVILLE, "La chorée arythmique hystérique de
     l'enfance," _Archives générales de médecine_, September, 1901, p.
     257.

     CATROU, "Étude sur la maladie des tics convulsifs," _Thèse de
     Paris_, 1890.

     CAUDMONT, _Le torticolis mental; état mental du tiqueur_, Morel,
     Lille, 1904.

     CHABBERT, "De la maladie des tics," _Archives de neurologie_,
     January, 1893, p. 10.

     CHARCOT, "Intorno ad alcuni casi di tic convulsive con coprolalia
     ed echolalia," _Riforma medica_, 1885.

     ---- "Hystérie et tics; diagnostic," _Semaine médicale_, 1886, p.
     363.

     ---- _Leçons du mardi_, 1887-8 and 1888-9.

     ---- "Toux et bruits laryngés chez les hystériques, les choréiques,
     et les tiqueux," _Archives de neurologie_, 1892, p. 69.

     CHATIN, "Note sur un cas de trismus mental," _Revue neurologique_,
     May 15, 1900, p. 310.

     CHAUFFARD, "Maladie de Friedreich avec attitudes athetoïdes,"
     _Semaine médicale_, 1893, p. 409.

     CHAUVREAU, "Tics coordonnés avec emission brusque et involontaire
     de mots articulés," _Thèse de Bordeaux_, 1888.

     CHERVIN, "Du bégaiement et de son traitement," _Congrès périodique
     international des sciences médicales, Amsterdam_, 1879.

     CHIPAULT, "Sur une série de trente-neuf cas de chirurgie du
     sympathique cervical," _Travaux de neurologie chirurgicale_, 1901,
     p. 220.

     CHIPAULT AND LE FUR, "Névralgie des 8e, 9e, et 10e racines
     dorsales avec tic abdominal; lésion méningée localisée; résection
     radiculaire," _Gazette des hôpitaux_, March 20, 1902, p. 325.

     CHOMEL. _See_ RUDLER.

     CLARK AND PROUT, "Nature and Pathology of Myoclonus-Epilepsy,"
     _American Journal of Insanity_, October, 1902, p. 185.

     (Twenty-two references to the literature of myoclonus-epilepsy.)

     CLAUS AND SANO, "Spasme bilatéral de la face et du cou," _Journal
     de neurologie_, 1899, p. 51.

     COHN, "Facialistic als Beschäftigungsneurose," _Neurologisches
     Centralblatt_, 1897, p. 21.

     COLLIER (MAYO), "Spasmodic Torticollis treated by Nerve Ligature,"
     _Lancet_, June 21, 1890, p. 1354.

     COLLINS, "The Clinical and Pathologic Interpretation of Tic, with
     special Reference to its Treatment," _Medical News_, 1897, vol. ii.
     p. 747.

     CONTI, "Nota clinica sopra un caso di spasmo clonico nel distretto
     dell' accessorio del Willis, da malaria," _Gazzetta degli ospedali
     e delle cliniche_, January 7, 1906, p. 21.

     (Twenty-eight references to the literature.)

     CORNING, "Eleomyenchisis; or, the Treatment of Chronic Local Spasms
     by the Injection and Congelation of Oils in the Affected Muscles,"
     _New York Medical Journal_, April 14, 1894, p. 449.

     COUDRAY, "Torticolis spasmodique; résection du spinal," _XIIe
     Congrès de l'association française de chirurgie_, October 17-24,
     1898.

     CRAMER, "Tic de Guinon," _Deutsche medicinische Wochenschrift_,
     September 14, 1899, p. 210.

     CRISP, "Torticollis in the Common Fowl," _Transactions of the
     Pathological Society_ (of London), vol. xxvi. p. 252.

     CRONBACH, "Die Beschäftigungsneurose der Telegraphisten," _Archiv
     f. Psychiatrie u. Nervenkrankheiten_, 1903, p. 243.

     CROSS, "Spasmodic Action of the Sternomastoid Muscles," _British
     Medical Journal_, March 13, 1880, p. 425.

     CROUZON, "Tic d'élévation des deux yeux," _Société de neurologie de
     Paris_, January 11, 1900.

     CRUCHET, "Étude critique sur le tic convulsif et son traitement
     gymnastique," _Thèse de Bordeaux_, 1902.

     ---- "Délimitation du tic" (Congrès de Grenoble), _Revue
     neurologique_, 1902, p. 789.

     ---- "Formes cliniques des tics unilatéraux de la face," _Congrès de
     Pau_, 1904.

     ---- "Sur un cas de tic de la tête et du tronc n'existant que
     pendant le sommeil," _Gazette hebdomadaire des sciences médicales
     de Bordeaux_, July 3, 1904, p. 319.

     ---- "Hémispasme facial périphérique postparalytique," _Revue
     neurologique_, October 30, 1905, p. 985.

     ---- "Tics et sommeil," _Presse médicale_, January 18, 1905, p. 33.

     ---- "Sur deux cas de tics convulsifs persistant dans le sommeil,"
     _Société de neurologie de Paris_, March 1, 1906.

     ---- "Contribution à l'étude des rythmies d'habitude du sommeil,"
     _Gazette hebdomadaire des sciences médicales de Bordeaux_, February
     18, 1906.

     ---- "Sur un cas de maladie des tics convulsifs," _Archives
     générales de médecine_, May 8, 1906, p. 1180.

     CRUCHET. _See_ PITRES.

     CUGINI, "Un raro caso di policlonia," _Rivista sperimentale di
     freniatria_, 1902, p. 112.

     CUIGNET, "Des attitudes dans les maladies des yeux et du torticolis
     oculaire," _Revue d'ophtalmologie_, April, 1874, p. 190.

     CURCIO ["Paramyoclonus symptomatique"], _Annali di medicina
     navale_, July, 1901, p. 86.


     DALEY, "Primary Myokymia, with Report of a Case," _Medical News_,
     July 2, 1904, p. 12.

     DAMAIN. _See_ TOURETTE.

     DANA, "Myoclonus Multiplex and the Myoclonias; Report of Cases and
     an Attempt at Classification," _Journal of Nervous and Mental
     Disease_, August, 1903, p. 449.

     DEBOUT, "Torticolis par contracture des muscles splenius droit et
     sterno-cléido-mastoïdien du côté gauche, guéri par l'électrisation
     des muscles sains," _Bulletin de la société de chirurgie de Paris_,
     1854.

     DEBROU, "Sur le tic non douloureux de la face," _Archives générales
     de médecine_, June, 1864, p. 641.

     DECROLY, "Contribution à la symptomatologie du spasme salutatoire
     (epilepsia nutans)," _Journal de neurologie_, October 20, 1904, p.
     390.

     DELVART, "Le paramyoclonus multiplex chez l'enfant," _Thèse de
     Lille_, 1902.

     DERCUM, "Spasmodic Torticollis and its Medical Relations," _Medical
     and Surgical Report_, 1894, p. 39.

     DERSCHEID-DELCOURT, "Un torticolis d'origine oculaire," _La
     clinique belge_, December 23, 1897.

     DESCROIZILLES, "De quelques cas de tics convulsifs," _Revue
     mensuelle des maladies de l'enfance_, August, 1890, p. 337.

     DESNOS, "Spasme du sternomastoïdien gauche," _Union médicale_,
     March 16, 1880, p. 422.

     DESTERAC, "Torticolis spasmodique et spasmes fonctionnels," _Revue
     neurologique_, 1901, p. 591.

     ---- "Syndrome du torticolis spasmodique," _Congrès de Toulouse_,
     April, 1902.

     ---- "Le syndrome du torticolis spasmodique," _Nouvelle iconographie
     de la Salpêtrière_, Sept.-Oct. 1902, p. 385.

     DIDE, "La myoclonie dans l'épilepsie," _Annales
     medico-psychologiques_, Sept.-Oct. 1899, p. 270.

     DONATH, "Beitrag zu den Clavier-u. Violinspielerneurosen," _Wiener
     medicinische Wochenschrift_, 1902, p. 355.

     DORNBLUTH, "Zur Behandlung gewissen spastischer Neurosen,"
     _Münchener medicinische Wochenschrift_, February 11, 1896, p. 128.

     DOSE AND ASTOLFONI, "Di un caso di miotonia essenziale," _Rivista
     sperimentale di freniatria_, 1900, p. 420.

     DREHER, "Tics im Kindesalter und ihre Behandlung," _Jahrbuch f.
     Kinderheilkunde_, 1904, p. 253.

     DROMARD, "Psychologie comparée de quelques manifestations motrices
     communément désignées sous le nom de 'tics,'" _Journal de
     psychologie normale et pathologique_, Jan.-Feb. 1905, p. 16.

     DUBOIS, "Traitement des tics convulsifs par la rééducation des
     centres moteurs," _Bulletin général de thérapeutique_, April 30,
     1901, p. 617.

     ---- "Du trouble de l'attention chez les tiqueurs," _Bulletin de
     l'institut psychologique_, 1902.

     DUBREUIL, "Spasme fonctionnel du sternomastoïdien et du trapèze,"
     _Gazette hebdomadaire des sciences médicales de Montpellier_, 1882.

     DUFOUR, "A propos des tics et des troubles moteurs chez les
     délirants chroniques; du syndrome musculaire comme signe
     pronostic," _Revue neurologique_, 1901, p. 1069.

     DUPRÉ, "Hémispasme tonique de la face," _Congrès de Bruxelles_,
     1903.

     DUPUY-DUTEMPS. _See_ ABADIE.


     EHRET, "Ueber eine functionelle Lähmungsform der Peronealmuskeln
     traumatischen Ursprunges," _Archiv f. Unfallheilkunde_, 1897, p.
     32.

     ELIOT, "The Surgical Treatment of Torticollis, with especial
     Reference to the Spinal Accessory Nerve," _Annals of Surgery_,
     1895, p. 493.


     FALDELLA, "Paramyoclonus multiplex," _Rivista sperimentale di
     freniatria_, 1888, p. 193.

     FAURE, "Traitement de la paralysie faciale d'origine traumatique
     par l'anastomose spino-faciale," _Presse médicale_, November 6,
     1901, p. 259.

     FEINDEL, "Le traitement médical de torticolis mental," _Nouvelle
     iconographie de la Salpêtrière_, Nov.-Dec. 1897, p. 404.

     FEINDEL, "Le torticolis mental, et son traitement," _Gazette
     hebdomadaire_, February 20, 1898, p. 169.

     ---- "Spasmes grimaçants de la face datant de trois mois; traitement
     et guérison en quatre jours," _Revue de psychologie clinique et
     thérapeutique_, April, 1899.

     ---- "Le torticolis mental," _Gazette hebdomadaire_, August 28,
     1903, p. 805.

     ---- _See_ BRISSAUD.

     ---- _See_ MEIGE.

     FEINDEL AND MEIGE, "Tic ou spasme de la face," _Revue
     neurologique_, March 15, 1898, p. 125.

     ---- "Revision iconographique du torticolis mental; trois cas
     nouveaux; traitement," _XIIIe Congrès international de médecine,
     section de neurologie, Paris_, August, 1900.

     ---- "Quatre cas de torticolis mental," _Archives générales de
     médecine_, January, 1901, p. 60.

     ---- "Torticolis mental surajouté à des mouvements hémichoréiformes;
     guérison du torticolis; amélioration générale," _Société de
     neurologie de Paris_, November 7, 1901.

     FÉRÉ, "Tic non douloureux de le face du côté gauche," _Archives de
     physiologie_, 1876, p. 267.

     ---- "Tic de la face du côté gauche," _Comptes rendus de la société
     de biologie de Paris_, 1876, p. 62.

     ---- "Le tic de salaam; les salutations névropathiques," _Progrès
     médical_, December, 1883, p. 970.

     (References to early literature.)

     ---- "Crampe fonctionnelle du cou," _Revue de médecine_, 1883, p.
     769.

     ---- "Contribution à la pathologie des spasmes fonctionnels du cou,"
     _Revue de médecine_, September, 1894, p. 755.

     ---- "Note sur un cas de chorée variable, avec contractions
     fasciculaires des deltoïdes," _Nouvelle iconographie de la
     Salpêtrière_, Nov.-Dec. 1898, p. 454.

     ---- "L'épilepsie choréique," _La médecine moderne_, 1899, p. 209.

     ---- "L'épilepsie et les tics," _Journal de neurologie_, September
     5, 1900.

     ---- "L'influence sur le travail volontaire d'un muscle de
     l'activité d'autres muscles," _Nouvelle iconographie de la
     Salpêtrière_, Sept.-Oct. 1901, p. 432.

     FÉRON, "Tic guéri par suggestion," _Journal de neurologie_, 1899,
     p. 246.

     FIERSINGER. _See_ HUCHARD.

     FILIPPO, "Mioclono multiplex in un lattante," _Gazzetta degli
     ospedali e delle cliniche_, March 12, 1905, p. 329.

     FISCHER, "Les chorées électriques; paramyoclonus; myoclonie,"
     _Gazette des hôpitaux_, May 2, 1903, p. 513.

     FOLLET. _See_ RÉNON.

     FORCHHEIMER, "Torticollis intermittens," _Archives of Pediatrics_,
     1887, p. 96.

     FORNACA ["Observations cliniques sur le torticolis mental"],
     _Clinica medica italiana_, November, 1901, No. 15.

     FOURNIER, "Quelques considérations sur le tic rotatoire," _Thèse de
     Strasbourg_, 1870.

     FRANCIS, "Case of spasmodic torticollis; section of spinal
     accessory nerve; recovery," _Lancet_, November 11, 1893, p. 1184.

     FRANÇOIS, "Essai sur les convulsions idiopathiques de la face,"
     _Mémoire présenté à l'Académie royale de Belgique_, 1843.

     FRENKEL, "De l'exercice cérébral appliqué au traitement de certains
     troubles moteurs," _Semaine médicale_, 1896, p. 123.

     ---- "Spasme primitif du facial avec mouvements fibrillaires
     continus ('myokymie')," _Revue neurologique_, 1903, p. 609.

     FRIEDREICH, "Ueber coordinirte Erinnerungskrämpfe," _Virchow's
     Archiv_, 1881, p. 430.

     FUR (LE). _See_ CHIPAULT.


     GALLAVARDIN AND SAVY, "Sur un cas de torticolis congénital avec
     autopsie et examen histologique du système nerveux," _Lyon
     médical_, November 22, 1903, p. 767.

     GARDNER AND GILES, "Neurectomy in Spasmodic Torticollis and in
     Retrocollic Spasm, or 'torticolis postérieur,'" _Australian Medical
     Journal_, December 15, 1892, p. 613.

     GAUSSEL, "Spasme bilatéral des muscles du cou et de la face,"
     _Nouvelle iconographie de la Salpêtrière_, Sept.-Oct. 1904, p. 337.

     GAUTHIER, "Des mouvements automatiques rythmiques," _Thèse de
     Paris_, 1898.

     GAUTIEZ, "Contribution a l'étude des spasmes du cou," _Thèse de
     Paris_, 1884.

     GEHUCHTEN (VAN), "Mouvements spasmodiques du membre supérieur droit
     propagés au sterno-cléido-mastoïdien du même côté," _Société belge
     de neurologie_, October 29, 1898.

     ---- "Un curieux cas de tic," _Journal de neurologie_, 1899, No. 3.

     GELLÉ, "Du torticolis ab aure laesa," _Tribune médicale_, 1894,
     Nos. 50 and 51.

     GERHARDT, "Accessoriuskrampf mit Stimmbandbeteiligung," _Münchener
     medicinische Wochenschrift_, 1894, p. 181.

     GIGLIOLI, "Del torcicolle mentale," _Rivista critica di clinica
     medicina_, February 13, 1904, p. 104.

     GILBERT. _See_ CADIOT.

     GILES. _See_ GARDNER.

     GILLET, "Tic douloureux de la face," _Thèse de Paris_, 1903.

     GILMOUR, "'Latah' among South African Natives," _Scottish Medical
     and Surgical Journal_, January, 1902, p. 18.

     GONZALES. See ROSSI.

     GOWERS, "On Saltatoric Spasm," _Lancet_, July 14, 1877, p. 42.

     GRAFF, "Ein Fall von spastischen Krampfen der Halsmuskulatur,"
     _Deutsche medicinische Wochenschrift_, March 22, 1900, p. 66.

     GRASSET, "Un cas de maladie des tics et un cas de tremblement
     singulier de la tête et des membres gauches," _Leçons de clinique
     médicale_, 1891, p. 466.

     ---- "Tic du colporteur (spasme polygonal post-professionnel),"
     _Nouvelle iconographie de la Salpêtrière_, July-August, 1897, p.
     217.

     ---- "Pathogénie du tic" (Congrès de Grenoble), _Revue
     neurologique_, 1902, p. 782.

     GROLHOUX, "Le spasme facial," _Thèse de Paris_, 1904.

     GUERTIN, "D'une névrose convulsive et rythmique déjà nommée; forme
     de chorée dite électrique," _Thèse de Paris_, 1881.

     GUIBERT, "Crampe fonctionnelle du cou," _Revue de médecine_, 1892,
     p. 317.

     GUILLAIN. _See_ MARIE.

     GUINON, "Maladie des tics convulsifs," _Revue de médecine_, 1886,
     p. 50.

     ---- "Tics convulsifs et hystérie," _Revue de médecine_, 1887, p.
     509.


     HABEL, "Ueber Fortbestehen von Tic convulsif bei gleichseitiger
     Hemiplegie," _Deutsche medicinische Wochenschrift_, March 24, 1898,
     p. 189.

     HADDEN, "On Head-nodding and Head-jerking in Children, commonly
     associated with Nystagmus," _Lancet_, June 14, 1890, p. 1293.

     HAJOS, "Ein Fall von Myospasmia Spinalis," _Ungarische medicinische
     Presse_, 1898, No. 34.

     HALLION. _See_ BRISSAUD.

     HAMMOND, "Myriachit, nova malattia del sistema nervoso," _La
     medicina contemporanea_, March, 1884.

     HANKE, "Ein Beitrag zur Aetiologie des Caput obstipum musculare,"
     _Inaugural Dissertation, Kiel_, 1900.

     HARTENBERG, "Traitement et guérison d'un cas de tic sans angoisse,"
     _Revue de psychologie clinique et thérapeutique_, January, 1899, p.
     17.

     ---- "Tic de déglutition chez un hystérique; traitement et guérison;
     considérations," _Revue de psychologie clinique et thérapeutique_,
     June, 1899, p. 175.

     ---- "La psycho-thérapie nouvelle," _Revue de psychologie clinique
     et thérapeutique_, February, 1901.

     HASSLAUER, "Ueber phonischen Stimmritzenkrampf," _Deutsche
     militär-ärtzliche Zeitschrift_, 1900, p. 417.

     HAUSER AND LORTAT-JACOB, "Contribution à l'étude des paralysies
     psychiques," _Revue de médecine_, November, 1901, p. 995.

     HEATON, "Involuntary Rotation of the Head cured by continued
     Pressure on the Neck," _British Medical Journal_, February 17,
     1879, p. 228.

     HELDENBERGH, "Myoclonus fonctionnel intermittent et paradoxal,"
     _Semaine médicale_, June 7, 1899, p. 194.

     ---- "Un cas de tremblement fonctionnel de la main droite," _Journal
     de neurologie_, November 5, 1901.

     ---- "Spasme tonique involontaire et intermittent du cou," _Belgique
     médicale_, 1902, No. 23.

     HELMICH, _Ueber Wesen u. Behandlung des Schreibkrampfes u.
     verwandter Krankheiten_, Bielefeld, 1902.

     HENOCH, "Ueber Chorea," _Berliner klinische Wochenschrift_,
     December 24, 1883, p. 801.

     HERMANN, "Myoclonische Zuckungen bei progressiver Paralyse,"
     _Neurologisches Centralblatt_, 1901, p. 498.

     HEVEROCH, "Paramyoclonie de Friedreich, combinée avec l'épilepsie,"
     _Revue neurologique_, 1902, p. 198 (reference).

     HIRSCHFELD, _Ueber die Maladie des Tics convulsifs_, Berlin, 1891.

     HUCHARD AND FIERSINGER, "Le syndrome myoclonique," _Revue de
     médecine_, October, 1905, p. 741.

     (Thirty-four references to the literature of myoclonus.)

     HUYGHE, "Du traitement de la chorée hystérique par
     l'immobilisation," _Nord médical_, August 1, 1901, p. 173.

     ---- "Chorée arythmique hystérique unilatérale droite; torticolis
     mental," _Nord médical_, December 15, 1903, p. 283.

     INGELRANS, "Les spasmes de la face," _Écho médical du nord_, June
     11, 1905, p. 277.

     INNFELD, "Ein chronische, progressive Fall von Muskelkrämpfen,"
     _Wiener klinische Wochenschrift_, 1898, p. 17.

     IOTEYKO, "Un cas de tics de la face guéri par suggestion," _Journal
     de neurologie_, January, 1906, p. 1.

     ISCOVESCO. _See_ ROUILLARD.

     ISIDOR, "Étude du torticolis spasmodique, et son traitement
     chirurgical," _Thèse de Paris_, 1895.

     ITARD, "Mémoire sur quelques fonctions involontaires des appareils
     de la locomotion, de la préhension, et de la voix," _Archives
     générales de médecine_, July, 1825, p. 385.


     JACCOUD, "Des impulsions locomotrices systematisées; spasmes
     rythmiques," _Gazette des hôpitaux_, 1886, p. 1185.

     JACQUET, "Le tic de salaam," _Thèse de Paris_, 1903.

     JANET. _See_ RAYMOND.

     JANKE, "Sur les mouvements musculaires conscients et inconscients
     dans le bégaiement," _IIIe Congrès des médecins tchèques à
     Prague_, 1901.

     JANOWITZ, "Tic convulsif, paramyoclonus multiplex, et chorée
     électrique," _Thèse de Paris_, 1891.

     JANTZEN, "Tonisch-klonische Krämpfe in Gefolge einer
     Zahnextraktion," _Deutsche zahnärtz. Wochenschrift_, 1900, p. 1399.

     JAROCHEVSKY, "Sur l'étiologie et la thérapie de la chorée
     rythmique," _Revue (russe) de psychiatrie_, 1902, p. 736.

     JOFFROY, "Des myopsychies," _Revue neurologique_, April 15, 1902,
     p. 289.

     JOLLY, "Ueber die sogenannte Maladie des Tics convulsifs," _Charité
     Annalen_, vol. xii. 1892, p. 740.


     KEEN, "A New Operation for Spasmodic Wryneck," _Annals of Surgery_,
     January, 1891, p. 44.

     KENNEDY, "On the Restoration of Co-ordinated Movements after
     Nerve-crossing, with Interchange of Function of the Cerebral
     Cortical Centres," _Proceedings of the Royal Society_, 1900, p.
     431.

     KNAPP, "Functionelle Contractur der Halsmuskeln," _Archiv f.
     Psychiatrie u. Nervenkrankheiten_, 1905, p. 1263.

     KNY, "Ueber ein dem Paramyoclonus Multiplex (Friedreich)
     nahestehendes Krankheitsbild," _Archiv f. Psychiatrie u.
     Nervenkrankheiten_, 1888, p. 577.

     KODYM, "Une nouvelle espèce de spasme fonctionnel," _Revue
     neurologique_, 1895, p. 155 (reference).

     KOPCZINSKI, "Un cas de névrose motrice sous forme du tic
     convulsif," _Revue neurologique_, 1902, p. 582 (reference).

     KOPPEN, _Ueber das psychische Moment bei der
     Beschäftigungsneurosen, im besonderen beim Schreibekrampf_,
     Göttingen, 1903.

     KÖSTER, "Ueber die Maladie des Tics impulsifs," _Deutsche
     Zeitschrift f. Nervenkeilkunde_, 1899, Hft. 3-4, p. 147.


     LABBÉ, "Débilité mentale et tremblement," _Presse médicale_, 1897,
     p. 185.

     LAGRANGE, _La médication par l'exercice_, Paris, 1894.

     ---- _Les mouvements méthodiques et la mécanothérapie_, Paris,
     1899.

     LAMBRANZI, "Due casi di policlonie nella demenza precoce," _Rivista
     di patologia nervosa e mentale_, 1901, p. 241.

     ---- "Su le policlonie nella demenza paralitica," _Rivista di
     patologia nervosa e mentale_, August, 1902, p. 360.

     LAMY, "Myoclonie avec hémianesthésie sensitivo-sensorielle chez un
     sujet atteint de monoplégie infantile du membre inférieur,"
     _Société de neurologie de Paris_, May 5, 1904.

     ---- "Hémispasme clonique facial; spasmes cloniques chez l'homme et
     chez le chien," _Société de neurologie de Paris_, July 6, 1905.

     LANDOLT, "Torticolis oculaire," _Bulletin médical_, 1890, p. 573.

     LANNOIS AND POROT, "Sur les hémispasmes de la face; hémispasme
     facial vrai, hémispasme hystérique," _Lyon médical_, February 7,
     1904, p. 234.

     LASÈGUE, "De la toux hystérique," _Société médicale des hôpitaux de
     Paris_, 1855, p. 269.

     LEGRAIN, "Du délire des dégénérés," _Thèse de Paris_, 1885.

     LEMAIRE. _See_ LEMOINE.

     LEMBO, "Paramyoclonus multiplex di Friedreich," _Giornale di
     neuropatologia_, 1887, p. 261.

     LEMOINE, "Note sur un cas de paramyoclonus multiplex suivi de
     troubles psychiques et de l'écholalie," _Revue de médecine_,
     November, 1892, p. 882.

     LEMOINE AND LEMAIRE, "Étude clinique et séméiologique du
     paramyoclonus multiplex," _Revue de médecine_, December, 1889, p.
     1018.

     (Thirty-nine references to the literature of paramyoclonus
     multiplex.)

     LENTZ, "Rotation permanente de la tête à droite," _Journal de
     neurologie_, 1897, p. 502.

     LERCH ["Tics convulsifs"], _American Medicine_, November 2, 1901.

     LEROUX, "Du tic post-choréique," _Revue mensuelle des maladies de
     l'enfance_, June, 1891, p. 251.

     LESZYNSKY, "Spasmodic Wryneck and its Treatment; Report of two
     Cases with Recovery," _Journal of Nervous and Mental Disease_,
     February, 1901, p. 103.

     LETULLE, "Note à propos d'un cas de bégaiement compliqué de tics
     coordinés multiples," _Gazette médicale de Paris_, 1883, p. 536.

     LEVI AND BONNIOT, "Un cas de myospasme clonique et tonique
     (myoclonotonie acquise)," _Société de neurologie de Paris_, May 11,
     1905.

     ---- "Myoclonotonie acquise," _Revue d'hygiène et de médecine
     infantile_, 1905, p. 569.

     LEVY, "Ererbte Mitbewegungen," _Neurologisches Centralblatt_, July,
     1901, p. 605.

     ---- "Angeborenen Mitbewegungen bei willkürlichen Bewegungen,"
     _Archiv f. Psychiatrie u. Nervenkrankheiten_, 1903, p. 927.

     LEWIN, "Phosphaturie mit Tic convulsif bei einem 3-1/2-jahrigen
     Kinde," _Archiv f. phys.-diat. Therapie_, 1900, p. 281.

     LINZ, "Ueber spastische Torticollis," _Inaugural Dissertation_,
     Bonn, 1897.

     LONDE. _See_ ROBIN.

     LORENZETTI, "A proposito di alcuni casi di tic convulsivo,"
     _Gazzetta degli ospedali e delle cliniche_, November 22, 1903, p.
     1478.

     LORTAT-JACOB. _See_ HAUSER.

     LUGARO, "Sulla mioclonia," _Rivista di patologia nervosa e
     mentale_, 1896, p. 389.

     LUNDBORG, _Die progressive Myoklonus-Epilepsie (Unverricht's
     Myoklonie)_, Upsala, 1903.

     ---- "Ist Unverricht's sogenannte familiäre Myoklonie eine klinische
     Entität?" _Neurologisches Centralblatt_, February 15, 1904, p. 162.

     LUZENBERGER, _Tic muscolari simplici, tic emotivi, e malattia di
     Gilles de la Tourette_, Naples, 1897.

     ---- "'Absences' psichichi in isterici," _Rivista sperimentale di
     freniatria_, December, 1900, p. 822.

     LYMAN, "Torticollis and Nodding Spasm," _International Medical
     Magazine_, vol. ii. 1894, p. 741.


     MADER, "Myoklonie in der Art eines expiratorischen Singultus,"
     _Wiener med. Blätter_, 1899, No. 30.

     MALM ["Tic rotatoire"], _Allgemeine medicinische Centralzeitung_,
     1899, No. 64.

     MANNINI, "Policlonia ed epilessia," _Gazzetta degli ospedali e
     delle cliniche_, September 30, 1900, p. 1220.

     ---- "Coree, policlonie, tic e malattia dei tic," _Riforma medica_,
     July, 1902, p. 137.

     MARÉCHAL, "Un cas de torticolis spasmodique," _Journal de
     neurologie_, May 20, 1899, p. 206.

     MARIE (PIERRE), "Spasme névropathique d'élévation des yeux,"
     _Société de neurologie de Paris_, April 18, 1901.

     MARIE AND GUILLAIN, "Mouvements athetoïdes de nature indéterminée,"
     _Société de neurologie de Paris_, April 17, 1902.

     MARINA, "Delle miospasie in generale e della miospasia atetosica in
     particolare," _Il policlinico, sezione pratica_, 1902, p. 577.

     MARROTTE, "Tic non douloureux de nature hystérique reparaissant
     sous le type quotidien," _Société médicale des hôpitaux de Paris_,
     1851.

     MARTAUD, "Étude sur le tic convulsif simple," _Thèse de Bordeaux_,
     1897.

     MARTIN (CLAUDE), "Tic congénital associé à du bégaiement," _Journal
     de médecine de Bordeaux_, 1900, p. 172.

     ---- _See_ DAVESAC.

     ---- (ÉTIENNE), "Deux cas de torticolis mental chez les aliénés:
     observations relatives au traitement de cette affection," _Écho
     médical de Lyon_, September 15, 1901.

     MASSALONGO, "Corea elettrica o mioclonia elettroide di origine
     gastrica," _Riforma medica_, vol. iii. 1892, p. 471.

     (References to the literature of electric chorea.)

     ---- "Contribution à l'origine corticale des tremblements," _Revue
     neurologique_, 1903, p. 455.

     MASSARO ["Vingt-six cas de géniospasme en cinq générations"], _Il
     pisani_, 1894, fasc. I.

     MASSARY AND TESSIER, "Torticolis mental ou torticolis spasmodique
     (torticolis-tic ou torticolis-spasme)," _Revue neurologique_,
     December 30, 1904, p. 1204.

     MAYER ["Tic convulsif remplaçant une névralgie sus-orbitaire"],
     _Alienist and Neurologist_, July, 1897.

     MEIGE, "Tics variables; tics d'attitude," _Société de neurologie de
     Paris_, July 4, 1901.

     MEIGE, "Les mouvements en miroir; leurs applications pratiques et
     thérapeutiques," _Revue neurologique_, 1901, p. 280.

     ---- "Histoire d'un tiqueur; tics variables; tics d'attitude,"
     _Journal de médecine et de chirurgie pratiques_, August 25, 1901,
     p. 609.

     ---- "Sur les tics," _Gazette hebdomadaire_, May 1, 1902.

     ---- "Spasme facial franc," _Société de neurologie de Paris_, April
     17, 1902.

     ---- "Tic et fonction," _Revue neurologique_, 1902, p. 383.

     ---- "Tic et écriture," _Gazette hebdomadaire_, June 12, 1902, p.
     541.

     ---- "La genèse des tics," _Journal de neurologie_, June 5, 1902.

     ---- "La correction des tics par le contrôle du miroir," _Journal de
     médecine et de chirurgie pratiques_, October 25, 1903, p. 769.

     ---- "Micropsie chez un tiqueur bègue," _Société de neurologie de
     Paris_, January 15, 1903.

     ---- "L'aptitude catatonique et l'aptitude échopraxique des
     tiqueurs; les exercices thérapeutiques de détente," _Congrès de
     Madrid_, April, 1903.

     ---- "Tics des yeux," _Annales d'oculistique_, 1903, p 167.

     ---- "Neue Beiträge zur Prognose und Behandlung des Tic; die
     psycho-motorische Selbsterziehung unter Spiegelkontrolle," _Journal
     f. Psychologie u. Neurologie_, 1903, p. 53.

     ---- "Le phénomène de la chute du bras," _Revue neurologique_,
     August 30, 1903.

     ---- "Tics des lèvres; cheilophagie, cheilophobie," _Journal de
     neurologie_, October 20, 1903, p. 481.

     ---- "Le spasme facial; ses caractères cliniques distinctifs,"
     _Revue neurologique_, October 30, 1903.

     ---- "Les tics," _Revue scientifique_, May 15, 1904.

     ---- "Migraine ophtalmique; hémianopsie et aphasie transitoires;
     hémiface succulente; photophobie et tic de clignement," _Revue
     neurologique_, September 30, 1904, p. 961.

     ---- "Génio-tics et génio-spasmes," _Société de neurologie de
     Paris_, April 6, 1905.

     ---- "Tics de sphincters," _Congrès de Rennes_, August, 1905.

     ---- _See_ BRISSAUD.

     ---- _See_ FEINDEL.

     MEIGE AND FEINDEL, "Traitement des tics; traitement par
     l'immobilisation des mouvements et les mouvements
     d'immobilisation," _Presse médicale_, March 16, 1901, p. 125.

     MEIGE AND FEINDEL, "Les causes provocatrices et la pathogénie des
     tics de la face et du cou," _Société de neurologie de Paris_, April
     18, 1901.

     ---- ---- "Sur la curabilité des tics," _Gazette des hôpitaux_, June
     20, 1901, p. 673.

     ---- ---- "L'état mental des tiqueurs," _Progrès medical_, September
     7, 1901, p. 146.

     ---- ---- "Les associations du torticolis mental," _Archives
     générales de médecine_, February, 1902, p. 168.

     ---- ---- "Remarques cliniques et thérapeutiques sur quelques tics de
     l'enfance," _Journal de neurologie_, September 20, 1904, p. 341.

     MEINERTZ, "Zur Casuistik der Myokimie," _Neurologisches
     Centralblatt_, February 1, 1904, p. 101.

     MEIROWITZ, "A Case of Habit Spasm," _The Post-graduate_, 1900, p.
     643.

     METTLER, "Occupation Neuroses," _Clinical Review_, October, 1904.

     MEYER, "Zur Casuistik des Tic rotatoire," _Deutsche medicinische
     Wochenschrift_, December 30, 1897, p. 849.

     MILLER, "Three Cases of Head-nodding and Head-rotation in Rachitic
     Infants," _Archives of Pediatrics_, August, 1900, p. 561.

     (Twenty-one references to the literature.)

     MITCHELL (JOHN), "An Instance of Spasmodic Affection of the Tongue
     and Mouth successfully treated," _Transactions of the
     Medicochirurgical Society_, 1813, p. 25.

     ---- (WEIR), "On Functional Spasms," _American Journal of the
     Medical Sciences_, October, 1876, p. 321.

     MOTT, "Tremors," _Practitioner_, September, 1904, p. 293.

     MOURIER, "L'hémispasme vrai, non douloureux," _Thèse de Lyon_,
     1903.

     MOUSSOUS, "A propos de la chorée des dégénérés," _Revue
     neurologique_, 1902, p. 517 (reference).

     MURRI, "Policlonie e coree," _Il policlinico_, November, 1899, p.
     487.


     NEFF, "Report of a Case of Myoclonus Epilepsy," _American Journal
     of Insanity_, January, 1904, p. 467.

     NÈGRE, "Du torticolis fonctionnel," _Thèse de Montpellier_, 1883.

     NEGRO ["Sur un cas de blépharospasme unilatéral, probablement de
     nature épileptique"], _Archivio di psichiatria_, 1904, p. 84.

     NEWMARK, "Ein Fall von primaerem tonischen Gesichtskrampf mit
     Muskelwogen," _Neurologisches Centralblatt_, 1903, p. 461.

     NOGUÈS, "Torticolis mental," _Revue de psychologie clinique et
     thérapeutique_, July, 1899, p. 215 (reference).

     ---- "Des tics en général" (Congrès de Grenoble), _Revue
     neurologique_, 1902, p. 766.

     NOGUÈS AND SIROL, "Torticolis mental," _Nouvelle iconographie de la
     Salpêtrière_, Nov.-Dec. 1899, p. 483.

     ---- ---- "Un cas de paralysie associée des muscles droits supérieurs
     de nature hystérique," _Société de neurologie de Paris_, March 7,
     1901.

     NOIR, "Étude sur les tics chez les dégénérés, les idiots, et les
     imbéciles," _Thèse de Paris_, 1893.

     ---- _See_ BOURNEVILLE.

     NONNE, "Zwei Fälle von Maladie des Tics," _Neurologisches
     Centralblatt_, 1898, p. 327 (reference).

     NORSTROM, "A Study of the Affection 'Writers' Cramp,'" _New York
     Medical Journal_, March 12, 1904, p. 491.

     NOVÉ-JOSSERAND, "Torticolis spasmodique," _Lyon médical_, September
     4, 1898, p. 12.


     ODDO, "Le diagnostic différentiel de la maladie des tics et de la
     chorée de Sydenham," _Presse médicale_, September 30, 1899.

     ---- "Tic de la génuflexion," _Marseille Médical_, March 15, 1902.

     OETTINGER, "The Disease of Convulsive Tic," _American Journal of
     the Medical Sciences_, September, 1899, p. 303.

     OLIVIER, "Le bégaiement dans la littérature médicale," _La parole_,
     1899, No. 10.

     OPPENHEIM, "Bemerkungen zur Lehre vom Tic," _Journal f. Psychologie
     u. Neurologie_, 1902, p. 139.

     OPPOLZER, "Krampf des Gesichtsnerven; Tic convulsif," _Allgemeine
     wiener medicinische Zeitung_, 1861, p. 73.

     OWEN, "Spasmodic Wryneck treated by Resection of the Spinal
     Accessory Nerve," _Lancet_, June 18, 1892, p. 1361.

     OZENNE, "Tic non douloureux de la face datant de trois ans chez un
     hérédo-syphilitique; guérison par le traitement hydrargyrique,"
     _Société de médecine et de chirurgie pratiques de Paris_, February
     6, 1902.


     PAGET, "Cases of Morbid Rhythmical Movements, with Observations,"
     _Edinburgh Medical and Surgical Journal_, January, 1847, p. 60.

     (Contains many interesting references to the early literature.)

     PARANT, "Les tics chez les aliénés," _Congrès de Grenoble_, 1902.

     PARRY, "Cases of Spasmodic Torticollis," _British Medical Journal_,
     November 5, 1898, p. 1403.

     PATELLA, "Studio anatomo, patologico e clinico sul policlono," _Il
     policlinico_, November, 1901, p. 535.

     PATRICK, "Imperative Conceptions," _New York Medical Journal_,
     September 7, 1901, p. 445.

     ---- "Convulsive Tic," _Journal of the American Medical
     Association_, February 11, 1905.

     PATRY, "De la chorée variable ou polymorphe, chorée des dégénérés,"
     _Thèse de Paris_, 1897.

     PAULY, "Spasmes fonctionnels du cou," _Semaine médicale_, 1894, p.
     486.

     ---- "Théorie réflexe du torticolis spasmodique," _Revue de
     médecine_, February, 1897, p. 130.

     PECKHAM, "Rhythmical Myoclonus," _Archives of Medicine_, April,
     1883, p. 97.

     PELI, "Lo stato mentale dei pazienti di tic," _Rivista sperimentale
     di freniatria_, May 25, 1903, p. 377.

     PERRODY, "De l'aérophagie," _Thèse de Paris_, 1901.

     PERSONALI ["La crampe idiopathique de la langue"], _Clinica medica
     italiana_, January 1, 1898.

     PETERSON, "Gyrospasm of the Head in Infants," _Medical News_,
     October 1, 1892, p. 374.

     PETIT, "Traitement du torticolis spasmodique par la résection du
     nerf spinal," _Union médicale_, 1891, p. 37.

     PHOCAS, "Torticolis musculaire aigu; son traitement," _Revue
     mensuelle des maladies de l'enfance_, 1891, p. 448.

     PICK, "Beiträge zur Lehre von der Echolalie," _Jahrbücher f.
     Psychiatrie u. Neurologie_, 1902, p. 283.

     PITRES, "Spasmes rythmiques hystériques," _Gazette médicale_, 1888,
     p. 145, &c.

     (Many references to the literature.)

     ---- "Tics convulsifs généralisés, traités et guéris par la
     gymnastique respiratoire," _Journal de médecine de Bordeaux_,
     February 17, 1901, p. 106.

     ---- "Étiologie et symptomatologie des tics," _Congrès de Grenoble_,
     1902.

     ---- "Sur un cas de torticolis mental, traité sans succès par
     plusieurs médecins, et guéri à la suite des manœuvres d'un
     rébouteur," _Journal de médecine de Bordeaux_, September 11, 1904,
     p. 665.

     PITRES, "Note sur quelques cas de torticolis spasmodique," _Journal
     de médecine de Bordeaux_, August 13, 1905, p. 589.

     PITRES AND CRUCHET, "Traitement des tics," _Congrès de Grenoble_,
     1902.

     PITRES AND TISSIÉ, "Tic oculaire," _Journal de médecine de
     Bordeaux_, July 9, 1899, p. 330.

     PLAVEC, "Tic convulsif," _Weiner medicinische Presse_, 1904, p.
     1622.

     POGGIO, "Ricerche isto-patologiche sul paramioclono molteplice,"
     _Rivista di patologia nervosa e mentale_, 1905, p. 175.

     POLIDORI, "Un caso di 'chorea laryngea' in un' istero-coreica," _Il
     policlinico_, June 29, 1901, p. 1103.

     POPOFF, "Contraction de longue durée des masseters," _Revue
     neurologique_, 1899, p. 611 (reference).

     POROT. _See_ LANNOIS.

     PRÉVOST AND BATTELLI, "De la production des convulsions toniques et
     cloniques chez les différentes espèces animales," _La
     policlinique_, October 15, 1904.

     PRINCE, "Case of Multiform Tic, including Automatic Speech and
     Purposive Movements," _Journal of Nervous and Mental Disease_,
     January, 1906, p. 29.

     PROUT. _See_ CLARK.

     POWER (D'ARCY), "Cases to illustrate the Relationship which exists
     between Wryneck and Congenital Hæmatoma of the Sterno-Mastoid
     Muscle," _Medico-chirurgical Transactions_, vol. lxxvi. 1893, p.
     137.

     (Thirty-four references to the subject.)


     QUERVAIN (DE), "Le traitement chirurgical du torticolis spasmodique
     d'après le méthode de Kocher," _Semaine médicale_, 1896, p. 405.


     RABOT, "La myoclonie épileptique," _Thèse de Paris_, 1899.

     RAILTON, "Note on a Case of Involuntary Muscular Movements
     accompanied with Coprolalia," _Manchester Medical Chronicle_,
     April, 1886.

     RAUDNITZ, "Zur Lehre vom Spasmus Nutans," _Jahrbuch f.
     Kinderheilkunde_, October, 1897, p. 145.

     (Sixty-three references to the literature of spasmus nutans and
     eclampsia nutans, with analysis of recorded cases.)

     RAYMOND, "Crampe des écrivains," _Journal de médecine et de
     chirurgie pratiques_, June 10, 1895.

     RAYMOND, "Des myoclonies," _Clinique des maladies du système
     nerveux, Ire série_, 1896, p. 551.

     ---- "Exemple de spasmes hystériques et example de tics," _Journal
     de médecine interne_, September 1, 1902, p. 169.

     RAYMOND AND JANET, _Névroses et idées fixes_, vols. i. and ii.
     _passim_.

     ----- ---"Note sur deux tics du pied," _Nouvelle iconographie de la
     Salpêtrière_, Sept.-Oct. 1899, p. 353.

     RÉDARD, _Le torticolis et son traitement_, Paris, 1898.

     REMAK, "Ueber localisirte Krämpfe," _Deutsches Klinik_, 1905, p.
     775.

     RENDU, "Hystérie chez un saturnin; hémispasme facial," _Bulletin de
     la société médicale des hôpitaux de Paris_, 1891, p. 618.

     RÉNON AND FOLLET, "Hémispasme facial total d'une extrême
     intermittence chez une hystérique," _Bulletin de la société
     médicale des hôpitaux de Paris_, December 23, 1898, p. 920.

     RENTERGHEM (VAN), "Un cas de tic rotatoire guéri par la
     psycho-thérapie," _Journal de neurologie_, May 20, 1898, p. 213.

     REYNOLDS, "Paramyoclonus epilepticus," _Review of Neurology and
     Psychiatry_, January, 1906, p. 19.

     RHODES, "Spasm of the Tensors of the Vocal Cords," _New York
     Medical Journal_, 1899, p. 267.

     RICKLIN, "Sur le paramyoclonus multiplex," _Gazette médicale de
     Paris_, 1888, p. 19.

     ROBIN AND LONDE, "Torticolis et lumbago d'origine articulaire et
     rhumatismale," _Revue de médecine_, 1894, p. 837.

     ROGER. _See_ CADIOT.

     ROSE. _See_ BALLET.

     ROSSI AND GONZALES ["Autopsie d'un cas d'épilepsie avec
     myoclonie"], _Annali di nevrologia_, 1900, fasc. 4.

     ROSSOLIMO, "Ueber Dysphagia amyotactica," _Neurologisches
     Centralblatt_, 1901, p. 146.

     ROTH, _Histoire de la musculation irrésistible ou de la chorée
     anormale_, Paris, 1850.

     ROUILLARD AND ISCOVESCO, "L'obsession en pathologie mentale,"
     _Gazette des hôpitaux_, 1896, p. 503.

     (References to the literature on the psychical side of the
     subject.)

     RUDLER, "Tic tonique du membre supérieur droit," _Nouvelle
     iconographie de la Salpêtrière_, July-Aug. 1903, p. 218.

     RUDLER AND CHOMEL, "Tic de l'ours chez le cheval, et les tics
     d'imitation chez l'homme," _Revue neurologique_, June 15, 1903, p.
     541.

     RUDLER AND CHOMEL, "Analogies entre les ties et stéréotypies de
     léchage chez l'homme et chez le cheval." _Société de neurologie de
     Paris_, January 7, 1904.

     ---- ---- "Des stigmates anatomiques, physiologiques, et psychiques
     de la dégénérescence chez l'animal, en particulier chez le cheval,"
     _Nouvelle iconographie de la Salpêtrière_, Nov.-Dec. 1904, p. 471.

     ---- ---- "Une observation de 'tic du chiqueur,'" _Société de
     neurologie de Paris_, January 7, 1904.

     RUSSELL (RISIEN), "An Experimental Investigation of the Cervical
     and Thoracic Nerve-roots in relation to the Subject of Wryneck,"
     _Brain_, 1897, p. 35.


     SABRAZÈS, "Mouvements involontaires stéréotypés des doigts
     s'organisant en tics dans le tabes," _Congrès de Rennes_, 1905.

     SABRAZÈS AND CALMETTE, "Tics de doigts et mouvements athetoïdes des
     tabétiques," _Gazette hebdomadaire des sciences médicales de
     Bordeaux_, July 2, 1905, p. 315.

     ---- ---- "Tic d'attitude chez un aveugle," _Gazette hebdomadaire des
     sciences médicales de Bordeaux_, June 4, 1905, p. 271.

     SACHS, "The Educational Treatment of Tics," _Medical News_, July 1,
     1905, p. 3.

     SAMAJA, "Le siège des convulsions épileptiformes toniques et
     cloniques," _Revue médicale de la Suisse romande_, February 20,
     1903, p. 77.

     SANO, "Tic de la face et du cou," _Société belge de neurologie_,
     November 26, 1898.

     ---- _See_ CLAUS.

     SARBO, "Ein Fall von clonischen Masseterkrampf," _Monatsschrift f.
     Psychiatrie u. Neurologie_, June, 1900, p. 493.

     SAVILL, "De la crampe des écrivains et des autres affections
     nerveuses professionnelles," _Nouvelle iconographie de la
     Salpêtrière_, March-April, 1901, p. 149.

     SAVY. _See_ GALLAVARDIN.

     SCHAPRINGER, "Zur Pathologie des Spasmus Nutans," _Centralblatt f.
     praktischen Augenheilkunde_, August, 1905, p. 225.

     SCHEIBER, "Ueber einen Fall von durch Spleniuskrampf bedingten
     Torticollis," _Wiener medicinische Wochenschrift_, 1900, p. 261.

     SCHELATOW, "Ein Fall von Paramyoclonus Multiplex," _Münchener
     medicinische Wochenschrift_, 1895, p. 696.

     SCHERB, "Hémispasme tonique du côté droit constituant un tic mental
     professionnel; tic de la mendiante," _Société de neurologie de
     Paris_, May 3, 1900.

     ---- "Un nouveau cas de torticolis mental," _Revue neurologique_,
     September 15, 1902, p. 841.

     SCHULTZE, "Ueber Poly-Para-und Monoclonien," _Deutsche Zeitschrift
     f. Nervenheilkunde_, 1898, p. 409.

     ---- "Ueber Chorea, Poly-and Monoklonie," _Neurologisches
     Centralblatt_, 1897, p. 611.

     ---- "Beiträge zur Muskelpathologie," _Deutsche Zeitschrift f.
     Nervenheilkunde_, 1895, p. 65.

     SCHUPFER, "Sulle mioclonie," _Il policlinico_, 1901, p. 1.

     (One hundred and sixteen references to the literature of
     myoclonus.)

     SCHUSTER, "Tonische und klonische Krampf des ganzen rechten
     Facialis," _Archiv f. Psychiatrie u. Nervenkrankheiten_, 1904, p.
     288.

     SEE, "Des pseudo-chorées rythmiques, spasmes toniques et tics,"
     _Semaine médicale_, March 26, 1884.

     SEELIGMÜLLER, "Ueber Myoclonie (Paramyoclonus Multiplex) und
     Convulsibilität (Spasmophilie)," _Deutsche medicinische
     Wochenschrift_, 1887, p. 1117.

     SÉGLAS, "Tic aérophagique et paralysie générale," _Semaine
     médicale_, January 11, 1899, p. 9.

     ---- "Un cas de torticolis mental," _Revue neurologique_, 1901, p.
     114.

     SÉRIEUX, "Les hallucinations motrices verbales dans la paralysie
     générale," _Gazette hebdomadaire_, June 19, 1898, p. 577.

     SEVESTRE, "Un cas de spasme fonctionnel du sternomastoïdien,"
     _Union médicale_, September 1, 1882, p. 383.

     SGOBBO, "Un caso di torcicollo mentale," _Il manicomio moderno_,
     1898, p. 424.

     SICARD. _See_ BRISSAUD.

     SICCARDI, "Considerazioni su la fisiopatologia e su la teoria del
     tic," _Annuario del manicomio provinciale di Ancona, Anno II_,
     1904.

     (Eighty-eight references to the literature, chiefly Italian.)

     SICURIANI, "Contributo allo studio del tonomioclono," _Riforma
     medica_, January 20, 1904, p. 57.

     SILVESTRINI, "Spasmo clonico diffuso," _Medicina contemporanea_,
     1884, p. 83.

     SIMON, "Une nouvelle variété de spasmes musculaires fonctionnels,"
     _Thèse de Paris_, 1875.

     SINKLER, "Habit Chorea," _American Journal of the Medical
     Sciences_, May, 1897, p. 559.

     SMITH (NOBLE), "Spasmodic Torticollis: its Cure by Operation,"
     _International Medical Congress_, Rome, 1894, _Section of Surgery_,
     p. 273.

     ---- "A Case of Spasmodic Torticollis associated with Chorea,"
     _Clinical Journal_, May 10, 1899, p. 41.

     ---- "Spasmodic Torticollis," _British Medical Journal_, vol. i.
     1899, p. 908.

     SOLGER. _See_ STEYERTHAL.

     SOMA, "Contributo allo studio delle mioclonie," _Gazetta degli
     ospedali e delle cliniche_, December 18, 1904, p. 1596.

     SONNEVILLE. _See_ CARRIÈRE.

     SORGO, "Ueber subcorticale Entstehung isolirter Muskelkrämpfe,"
     _Neurologisches Centralblatt_, July, 1902, p. 642.

     SOUPAULT. _See_ ACHARD.

     SOURY, "Les myoclonies, physiologie pathologique," _Annales
     médico-psychologiques_, 1897, p. 398.

     SPEHL, "A propos du traitement de la maladie des tics," _Journal de
     neurologie_, 1899, p. 289.

     STEVENS, "Facial Spasm and its relation to Errors of Refraction,"
     _American Journal of the Medical Sciences_, 1900, p. 33.

     STEYERTHAL, "Zur Geschichte des Torticollis Spasmodicus," _Archiv
     f. Psychiatrie u. Nervenkrankheiten_, Bd. xli. 1906, p. 31.

     (Many interesting references to ancient writers.)

     STEYERTHAL AND SOLGER, "Ueber Torticollis Spasmodicus," _Archiv f.
     Psychiatrie u. Nervenkrankheiten_, Bd. xxxviii. 1904, p. 949.

     STICH, "Zwei Fälle von Krampf im Bereiche des N. accessorius
     Willisii," _Deutsche Archiv f. klinische Medicin_, 1873, p. 525.

     STILL, "Habit Spasm in Children," _Lancet_, December 16, 1905, p.
     1754.

     ---- "Head-nodding with Nystagmus in Infancy," _Lancet_, July 28,
     1906, p. 207.

     ---- "On Head-rolling and Other Curious Movements in Children," _The
     Clinical Journal_, November 21, 1906, p. 87.


     TAGUET. _See_ BALLET.

     TAMBURINI, "Fisiopatologia e cura del tic," _Rivista sperimentale
     di freniatria_, December 15, 1903, p. 870.

     TANON. _See_ BRISSAUD.

     TESSIER. _See_ MASSARY.

     TESTI, "Storia di un caso singolarissimo di spasmo muscolare
     diffuso," _Giornale di neuropatologia_, 1886, Nos. 3 and 4.

     THOMAS, "Contribution à l'étude de la maladie des tics chez
     l'enfant," _Gazette des maladies infantiles_, October 21, 1901.

     THORNTON, "Some Curious Facts concerning 'the Jumpers,'" _New York
     Medical Record_, 1885, p. 713.

     TISSIÉ, "Tic oculaire et facial droit accompagné de toux
     spasmodique, traité et guéri par la gymnastique medicate
     respiratoire," _Journal de médecine de Bordeaux_, July 9, 1899.

     ---- _See_ PITRES.

     TOKARSKI, "Maladie des Tics convulsifs," _Neurologisches
     Centralblatt_, November 1, 1890, p. 662 (reference).

     TOULIERES. _See_ CABANNES.

     TOURETTE (GILLES DE LA), "Jumping; latah; myriachit," _Archives de
     neurologie_, 1884, p. 68.

     ---- ---- "Étude sir une affection nerveuse caractérisée par de
     l'incoordination motrice accompagnée d'écholalie et de coprolalie,"
     _Archives de neurologie_, 1885, p. 19.

     ---- ---- "Torticolis hystérique," _Nouvelle iconographie de la
     Salpêtrière_, 1889, p. 182.

     ---- ---- "La maladie des tics convulsifs." _Semaine médicale_, May
     3, 1899, p. 153.

     TOURETTE (GILLES DE LA) AND DAMAIN, "Un danseur monomane," _Progrès
     médical_, January 14, 1893.


     UCHERMANN, "Ein Fall von alternirenden, rhythmischen, und
     clonischen Krämpfen der Glottisschliesser und der Glottisweiterer,"
     _Archiv f. Laryngologie_, 1898, p. 326.

     UNVERRICHT, "Ueber familiäre Myoclonus," _Deutsche Zeitschrift f.
     Nervenheilkunde_, 1895, p. 32.


     VALOBRA, "Policlono infettivo; contributo allo studio delle
     mioclonie," _Il morgagni_, 1904, p. 774.

     VANLAIR, "Myoclonies rythmiques," _Revue de médecine_, 1889, p. 1.

     VARIOT, "Un cas de chorée électrique (variété de tic juvenile
     curable)," _Gazette des hôpitaux_, December 19, 1901, p. 1401.

     VERGOZ, "Du torticolis spasmodique," _Thèse de Bordeaux_, 1888.

     VITEK, "Paramyoclonus multiplex," _Congrès des médecins tchèques à
     Prague_, 1901.

     VITEK, "Tic de la main; contribution a la question des obsessions
     motrices," _Revue neurologique_, 1905, p. 50 (reference).

     VLAVIANOS, "Tic nerveux, traité avec succès par la suggestion
     hypnotique," _Journal de neurologie_, 1899, p. 318.

     VOGT ["Les exercices dans la thérapeutique des affections nerveuses
     fonctionnelles"]. _Psychiatrische Wochenschrift_, Sept.-Oct. 1899.

     VURPAS, "Les myopsychies de Joffroy; association des troubles
     musculaires et des troubles psychiques," _Revue de psychiatrie_,
     October, 1904, p. 413.


     WALTON, "Nature and Treatment of Spasmodic Torticollis," _American
     Journal of the Medical Sciences_, March, 1898, p. 295.

     WILLE, "Ueber einen Fall von Maladie des Tics impulsifs,"
     _Monatsschrift f. Psychiatrie u. Neurologie_, 1898, p. 210.

     WILLIAMSON, "Myokymia, or Persistent Muscular Quivering," _British
     Medical Journal_, 1900, p. 1705.

     WYEMANN, "Ueber einen Fall von Tic de Guinon," _Göttinger
     Dissertation, 1900_.


     ZABLUDOWSKI, "Zur Prophylaxe und Therapie des Schreib-und
     Musik-krampfes," _Prager medicinische Wochenschrift_, April 21,
     1904, p. 195.

     ZIEHEN, "Ueber Mioclonus und Mioclonie," _Archiv f. Psychiatrie u.
     Nervenkrankheiten_, 1888, p. 415.



INDEX OF NAMES

A., 166

Achard, 291

Aimé, 212

Allocco (d'), 286

Amussat, 169

André, 26

Appleyard, 308

Atkins, 308

Axenfeld, 26, 246, 299


B., 131, 134

B. (Séglas), 265

Babinski, 135, 136, 137, 152, 276

Bain, 60

Ball, 216

Ballance, 309

Ballet, 76, 152, 335, 337

Bamberger, 196

Beard, 196, 250

Bechterew, 143, 198, 288

Bergeron, 251, 284

Bernhardt, 98, 145

Biaggi, 209

Billot, 162

Blache, 99, 315

Blocq, 55, 64

Bompaire, 169, 175, 317

Bonnier, 127

Bouchut, 246

Bourneville, 27, 127, 257, 316, 344

Brener, 267

Bresler, 92, 267

Briand, 170, 182, 207

Brif., 149

Briquet, 246

Brissaud, 27, 37, 40, 55, 59, 67, 68, 74, 100, 108, 111, 119, 123, 124,
139, 166, 167, 172, 174, 177, 181, 210, 218, 220, 228, 229, 234, 238,
268, 271, 281, 295, 296, 312, 316, 319, 324, 328, 331, 333, 343

Brodie, 256

Bruandet, 275

Buck (de), 128, 169

Buss, 113


C. (Noir), 258

Cadiot, 112

Cahen, 264

Campbell, 307

Cantilena, 218

Cestan, 153

Chabbert, 225, 247

Charcot, 27, 34, 39, 40, 48, 58, 60, 62, 74, 75, 80, 87, 98, 108, 116,
125, 167, 207, 227, 246, 251, 281, 300, 304

Chatin, 162, 240

Chauffard, 278

Chervin, 325

Chipault, 111, 114, 310

Chomel, 94

Claus, 143

Cohn, 148

Collier, 307

Colombat, 303

Constant, 101

Corning, 312

Coudray, 308

Crouzon, 151

Cruchet, 25, 32, 39, 65, 68, 101, 102, 113, 115, 116, 122, 199, 220,
250, 257, 295, 326


D., 106

Dalwig, 311

Debrou, 110, 114

Déjérine, 171

Delasiauve, 99

Demosthenes, 303

Derevoge, 209

Descroizilles, 333

Desterac, 136, 276, 277

Dide, 252

Dornbluth, 301

Dubini, 284

Dubois, 53, 87, 328

Duchenne, 114, 167, 177, 178

Dufour, 296

Dupré, 54, 56, 86

Durand, 335


E., 186

E. (Noir), 289

Edel, 204

Ehret, 193

Eliot, 308

Erb, 32

Esquirol, 257

Etmuller, 33


F., 86, 150

Faure, 312

Fechner, 338

Feindel, 121, 123, 166, 169, 173, 185, 238, 239, 317, 321, 333

Féré, 111, 170, 234, 244, 253, 254, 338

Féron, 305

Ferrand, 32

Ferrier, 111

Flatau, 100

Flechsig, 301

Fornaca, 276

Fournier, 238

Fraenkel, 313

François, 26

Francotte, 162

Frenkel, 322

Freud, 267

Friedreich, 251, 285, 287

Fur (le), 114


G., 86, 98, 148, 155, 166

Gardner, 307, 308

Gaupp, 242

Gehuchten (van), 178, 291

Geyer, 213

Gilbert, 112

Giles, 307

Gintrac, 99

Gonzalès, 116, 253

Gowers, 98, 257, 281

Graefe (von), 147

Graff, 170

Grasset, 27, 60, 65, 66, 67, 68, 84, 91, 93, 106, 132, 169, 173, 175,
177, 214, 239, 242, 291, 301, 302

Graves, 26

Guibert, 169

Guillain, 181, 277

Guinon, 27, 39, 45, 46, 47, 51, 56, 58, 63, 80, 87, 90, 102, 104, 119,
156, 164, 189, 195, 196, 197, 206, 215, 216, 219, 224, 300

Gunn, 323


Hajos, 288

Hall, 33

Hallion, 270

Hammond, 196

Hartenberg, 198, 302, 322

Haskowec, 83

Hasslauer, 211

Heldenbergh, 287

Helfreich, 323

Hénoch, 251

Hermann, 286

Hitzig, 114

Holland, 216

Hoppe-Seyler, 201

Huntington, 281

Huyghe, 314


Ibsen, 213

Innfeld, 228

Itard, 76, 303


J., 52, 54, 76, 78, 81, 84, 98, 100, 105, 121, 131, 139, 155, 160, 183,
185, 186, 221, 240, 243, 330, 340

J. (Noir), 289

Jaccoud, 34

Jacoby, 193

Jancowicz, 287

Janet, 64, 65, 86, 121, 162, 169, 172, 173, 175, 183, 187, 193, 195,
199, 223, 238, 240, 241, 248, 305, 306, 316, 317, 326

Janke, 210

Joffroy, 269, 296

Jolly, 315

Jourdin, 26, 33


K., 239

Kaiser, 289

Keen, 309

Kennedy, 312

Kny, 288

Kocher, 162, 309, 310

Kopczynski, 212, 228

Koster, 227, 328


L., 58, 79, 105, 126, 135, 136, 178, 190, 233, 255, 273, 274, 292, 332,
340

L. (Noir), 258

Labbé, 291

Lam., 84

Lange, 159

Langlois, 39

Lannois, 170, 316

Legenmann, 170

Legouest, 169

Legrain, 28

Lemoine, 286

Lentz, 175

Lerch, 150, 198

Letulle, 27, 46, 47, 57, 63, 64, 91, 99, 158, 204, 208, 213, 264, 291,
315

Leube, 159

Lewin, 38

Linz, 310

Littré, 36, 45, 56, 102, 122

Luzenberger, 256


M., 78, 98, 100, 134, 145, 186

Madet, 327

Magnan, 27, 28, 30, 75, 108, 227

Malm, 253

Mannini, 252

Maréchal, 177, 306

Marie (A.), 266

---- (P.), 151, 153, 165, 181, 273, 277

Marina, 290

Martin, 175, 331

Massaro, 157

Mayer, 274

Mayor, 307

Meige, 124, 140, 169, 172, 185, 238, 239, 261, 269, 317, 335

Meirowitz, 145

Mills, 291

Mitchell, 281

Molière, 100

Monakow (von), 39

Montaigne, 44

Morel, 28, 296

Morin, 303

Morvan, 251, 284, 285

Moutard-Martin, 325

Muratow, 39

Murri, 116


N., 134, 173, 180, 185, 190, 239

N. (Noir), 257

Napoleon, 101

Nieden, 171

Niemeyer, 26

Noguès, 154, 169, 175, 203, 239

Noir, 27, 53, 55, 90, 93, 98, 109, 127, 148, 217, 218, 222, 227, 257,
259, 284, 291

Nonne, 283

Nothnagel, 112

Nové-Josserand, 310


O., 1 _et seq._, 52, 59, 76, 79, 121, 134, 135, 140, 144, 145, 155, 160,
183, 186, 189, 193, 222, 236, 243, 328, 329, 330, 340

O'Brien, 103, 196

Oddo, 89, 195, 279, 296, 324

Oettinger, 328

Olivier, 208, 325

Onanoff, 55, 64

Oppenheim, 32, 98, 112, 139, 144, 164, 169, 170, 175, 197, 204, 256,
276, 294, 302, 311, 312, 322, 328

Oppolzer, 114

Oxen, 308


P., 134, 139, 180, 186, 190

Parinaud, 147, 152

Patella, 117

Patry, 230

Pauly, 308, 309

Pearce-Gould, 307

Peter the Great, 100, 151

Pick, 212

Piedagnel, 99

Pinel, 257

Pitres, 27, 32, 33, 199, 200, 201, 215, 216, 221, 246, 247, 325

Ponagen, 201

Popoff, 310

Pujol, 26, 299


Quervain (de), 310


R., 78, 119, 126, 134, 144, 150, 323

R. (Noir), 257

Ramisiray, 196

Ranschburg, 159

Rauzier, 301, 302

Raymond, 30, 121, 153, 162, 169, 172, 173, 175, 187, 193, 195, 199, 233,
240, 241, 248, 251, 305, 306, 326

Redard, 177

Régis, 83, 138

Renterghem (van), 305

Ribot, 55

Richet, 39

Ricklin, 284

Rivière, 201

Roger, 112

Romberg, 26, 114, 145, 171

Ros., 259

Rossi, 116, 253

Rossolimo, 198

Roth, 83

Rudler, 94

Russell (Rizien), 309


S., 79, 88, 104, 125, 126, 134, 139, 140, 141, 155, 162, 180, 190, 222,
237

Sabrazès, 201

Saenger, 204

Saint-Simon, 100

Sano, 143

Sarbo (von), 159

Saury, 28

Sauvages, 33

Schapiro, 204

Scheiber, 125

Scherb, 248

Schultze, 111, 114, 288

Schupfer, 253, 287

Sciamanna, 227

Seeligmüller, 145

Séglas, 57, 63, 83, 173, 175, 188, 197, 199, 201, 202, 214, 215, 220,
265, 296, 319

Sgobbo, 169, 173, 175, 237

Siemerling, 197

Sinkler, 281

Sirol, 154, 169, 175, 203, 239

Smith, 309

Sollier, 257

Soupault, 291

Souques, 169, 172, 278

Southam, 307

Spencer, 60

Stewens, 312

Strümpell, 159

Sydenham, 279


T., 185, 186, 295

Thiem, 193

Thomson, 288

Tichoff, 311

Tissié, 99, 103, 129, 205, 223, 326

Tordeus, 284

Tourette, 27, 45, 196, 216, 219, 223, 224, 229, 232, 233, 293, 299, 300

Troisier, 32, 299

Trousseau, 26, 58, 108, 118, 167, 251, 298, 315


Uchermann, 212


Valleix, 26, 33, 147

Verga, 219

Verlaine, 314

Vigny (de), 107

Virchow, 41

Vlavianos, 305

Vogt, 335


W., 186

Walton, 171, 311

Weber, 338

Welterstrand, 305

Widal, 32

Wille, 92

Willis, 31, 33, 34, 167

Wolff, 193

Wutzer, 303

Wyemann, 341


X., 79, 231



INDEX OF SUBJECTS

Aerophagia, 199 _et seq._

Affirmation tics, 163

Antagonistic gestures, 168, 236 _et seq._

Aphonia, 211

Arithmomania, 87

Athetosis, 288

Attacks, 128

Attitude tics, 63, 122

Auditory tics, 145

Automatic movements, 41, 43, 259


Beating tics, 185

Beggar's tic, 248

Biting tics, 11, 159

Blepharospasm, 147

Blinking tics, 3, 148, 149

Blowing tics, 303


Catatonic aptitudes, 124

Cheilophagia, 160

Chin tics, 157

Chorea, Dubini's, 284

---- electric, 252, 284

---- fibrillary, 251, 284, 285

---- gravidarum, 283

---- Hénoch-Bergeron's, 251, 284

---- Huntington's, 281

---- hysterical, 282

---- of degenerates, 230

---- paralytic, 285

---- polymorphous, 230

---- rhythmical, 283

---- Sydenham's, 279

---- variable, 119, 228 _et seq._, 281

Clonic tic, 118

Colporteur tic, 106, 173

Complications of tic, 242 _et seq._

Consciousness and tic, 63

Convulsion, 39

Convulsive tic, 31

---- ---- clonic, 31

---- ---- tonic, 31, 63

Co-ordination and tic, 46, 126

Coprolalia, 13, 219 _et seq._, 258

Coughing tics, 203

Curability of tic, 298 _et seq._


Definition of tic, 260

Degeneration, 28, 29

Diagnosis, 264 _et seq._

Diaphragmatic tics, 205

Diet, 302


Ear tics, 145

Echokinesia, 103, 124, 217

Echolalia, 216 _et seq._

Echomimia, 124

Echopraxis, 124

Electrical reactions, 138

Electrolepsy, 284

Electrotherapy, 303

Epilepsy and tic, 251 _et seq._

Eructation tics, 196

Etiology of tic, 96 _et seq._

Etymology of tic, 25

Evolution of tic, 221 _et seq._

Expectoration tics, 197

Eye tics, 146, 151

Eyeball tics, 150, 323

Eyelid tics, 146, 322


Facial spasm, 110, 111, 143, 268, 270 _et seq._, 312

---- tic, 143, 220 _et seq._, 312, 323

Fixed tics, 130

_Folie du pourquoi_, 87

Function, 70


Genesis of tic, 48 _et seq._

Geniospasm, 157


Habit, 56

Heredity, 98

Hiccoughing tics, 203

Hydrotherapy, 302

Hygiene, 302

Hysteria, 246 _et seq._, 282


Idiocy, 256

Imitation, 2, 101

Immobilisation of movements, 317

Impulsive tics, disease of, 227

Insanity, 256

Isolation, 341


Jacksonian epilepsy, 38, 251, 263

Jaw tics, 169


Krouomania, 258


Laryngospasm, 212

Latah, 103

Leaping tics, 193

Licking tics, 157

Lip tics, 155


Massage, 303

Mastication tics, 159

Mechanotherapy, 303

Medicinal treatment, 301

Mental condition of the subjects of tic, 74 _et seq._

---- infantilism, 76 _et seq._, 133, 171

---- tic, 94

---- torticollis, 121, 137, 167 _et seq._, 257, 267, 307, 313, 323, 324,
331, 333

---- triamus, 121, 161 _et seq._, 240

Mimicry, 60, 103

---- tics, 143

Mirror drill, 335 _et seq._

---- writing, 335 _et seq._

Monoclonus, 287

Motor reaction, 41

---- ---- classification of, 44

---- ---- localisation of, 130

---- ---- study of, 118

Movements of immobilisation, 317

Mutism, 211

Myoclonus, 30, 116, 252 _et seq._, 285 _et seq._, 288

Myokymia, 288

Myospasm, 290

Myospasmia spinalis, 288

Myotonia, 288


Neck tics, 5, 163, 323

Negation tics, 163

Neurasthenia, 250 _et seq._

Nictitation tics, 146

Nodding tics, 163

Nose tics, 3, 154


Obsessions, 82 _et seq._

Occupation neuroses, 70, 72, 159, 291 _et seq._

Onomatomania, 87

Onychophagia, 161

Orthopædic treatment, 314


Palpebral tics, 147

Paramyoclonus multiplex, 252, 285

Para-tics, 6, 7

Pathogeny of tic, 36 _et seq._

Pathological anatomy, 108 _et seq._

Phobias, 20, 88

Polyclonus, 116, 117, 252, 256, 287

Polygon, 65

Procollis, 177

Professional acts, 69, 71, 291

Prognosis, 293 _et seq._

Psychical tic, 29, 94

Psychomental tic, 68, 94, 250

Psychotherapy, 343


Re-education, 315 _et seq._

Reflexes, 15, 134

Relapses, 332

Respiration tics, 203

Respiratory drill, 325 _et seq._

Rest, 340

Retrocollis, 177

Rhincho-spasm, 204

Rhythm, 70, 127

Rhythmic tics, 127


Salaam tic, 164

Salutation tics, 163

Scratching tics, 186

Secretory affections, 138

Sensation, affections of, 140

Shoulder tics, 9, 183

Sniffing tics, 154, 203

Snoring tics, 203

Sobbing tics, 203

Spasm, definition of, 36

Spasms and tics, 36 _et seq._, 267 _et seq._

Spasmus nutans, 127, 164

Speech, tics of, 206 _et seq._, 324

Sphincter tics, 140

Stammering, 208 _et seq._, 324, 325

Starting tics, 291

Stereotyped acts, 57, 122, 188, 264 _et seq._

Striking tics, 185

Sucking tics, 155

Swallowing tics, 196


Thomsen's disease, 288

Tic and function, 68

---- idea, 59

---- will, 55

---- writing, 187, 190

Tic douloureux, 112, 275

Tic non douloureux, 110

Tics of idea, 94

---- idiots, 53, 256

---- wind sucking, 196

Tongue tics, 157

Tonic tic, 118, 121

Torticollis tic and spasm, 136, 137, 275 _et seq._, 307

Tossing tics, 163, 323

Tourette's disease, 92, 223, 228, 251, 258, 296

Treatment, 298 _et seq._

Tremors, 290

Trunk tics, 182


Variable tics, 130

Visceral instability, 139

Vision tics, 146

Vomiting tics, 196


Whistling tics, 203

Writers' cramp, 69, 72, 192, 292

       *       *       *       *       *

These typographical errors have been corrected by the etext transcriber:

which may be situate in peripheral end organ=>which may be situated in
peripheral end organ

tennis without protuding his tongue=>tennis without protruding his
tongue

The sectio showed a hæmorrhage of the dimensions=>The section showed a
hæmorrhage of the dimensions

since the twitches are limited perferably=>since the twitches are
limited preferably

Weiner medic. Blätter=>Wiener medic. Blätter

like a statute in a position conducive=>like a statue in a position
conducive

Unforeseen complications, a again, may arise once a cure is
affected.=>Unforeseen complications, again, may arise once a cure is
affected.

       *       *       *       *       *


FOOTNOTES:

[Footnote 1: RENÉ CRUCHET, "Étude critique sur le tic convulsif et son
traitement gymnastique," _Thèse de Bordeaux_, 1902.]

[Footnote 2: TROUSSEAU, _Clinique médicale de l'Hôtel Dieu_, 1873, vol.
ii. p. 267 _et seq._]

[Footnote 3: CHARCOT, _Leçons du mardi_, 1887-8, p. 124.]

[Footnote 4: LEGRAIN, "Du délire des dégénérés," _Thèse de Paris_,
1885-6.]

[Footnote 5: RAYMOND, _Clinique des maladies du système nerveux_, vol.
i. 1896, p. 551.]

[Footnote 6: TROISIER, _Dictionnaire Dechambre_, art. "Face."]

[Footnote 7: HALL, _On the Disease and Derangement of the Nervous
System_, London, 1841.]

[Footnote 8: JACCOUD, _Pathologie interne_, t. i. 1879, pp. 595-8.]

[Footnote 9: BRISSAUD, _Leçons sur la maladies nerveuses_, 1st series,
chap. xxiv. p. 506.]

[Footnote 10: LEWIN, _Arch. d. phys. diat. Therapie_, 1900, p. 281.]

[Footnote 11: CHARCOT, _Leçons du mardi_, 1889, p. 464.]

[Footnote 12: DUBOIS, "Traitement des tics convulsifs par la rééducation
des centres moteurs," _Bulletin général de thérapie_, April 30, 1901.]

[Footnote 13: DUPRÉ, _Soc. de neur. de Paris_, April 18, 1901.]

[Footnote 14: DUPRÉ, _loc. cit._]

[Footnote 15: BLOCQ and ONANOFF, _Maladies nerveuses_, 1892.]

[Footnote 16: GRASSET, _Anatomie clinique des centres nerveux_, Paris,
1900, p. 5.]

[Footnote 17: GRASSET, _Leçons de clinique médicale_, 3rd series, fasc.
i. 1896, pp. 5, 38.]

[Footnote 18: CHARCOT, _Leçons du mardi_, 1887-8, p. 124.]

[Footnote 19: _Communication faite au Congrès de Limoges_, August, 1901;
_Soc. de neur. de Paris_, April 18, 1901; _Gazette des hôpitaux_, June
20, 1901, p. 673; _Progrès médical_, Sept. 7, 1901, p. 146.]

[Footnote 20: MAGNAN, _Recherches sur les centres nerveux_, 2nd series,
p. 116.]

[Footnote 21: CHARCOT, _Leçons du mardi_, October 23, 1888.]

[Footnote 22: BALLET, _Traité de médecine_, vol. vi. p. 1158.]

[Footnote 23: CHARCOT, _Leçons du mardi_, October 23, 1889.]

[Footnote 24: NOIR, _Thèse de Paris_, obs. xviii. p. 40.]

[Footnote 25: DUPRÉ, _Soc. de neur. de Paris_, April 18, 1901.]

[Footnote 26: NOIR, _Thèse de Paris_, obs. lix. p. 121.]

[Footnote 27: WILLE, _Monatschr. f. Psychiat. u. Neurol._ 1898, p. 210;
1899, p. 873.]

[Footnote 28: BRESLER, "Beitrag zur Lehre von der Maladie des Tics
convulsifs," _Neurolog. Centralb._ 1896, p. 965.]

[Footnote 29: RUDLER AND CHOMEL, "Tic de l'ours chez le cheval," _Rev.
neur._ 1903, p. 541; "Analogies entre les tics de léchage chez l'homme
et chez le cheval," _Soc. de neur. de Paris_, January 7, 1904; "Des
stigmates de la dégénérescence chez l'animal," _Congrès de Pau_, 1904;
_Nouv. icon. de la Salpêtrière_, 1904, p. 471.]

[Footnote 30: JANET, _Néuroses et idées fixes_, vol. i. p. 397.]

[Footnote 31: CHARCOT, _Leçons du mardi_, December 13, 1887.]

[Footnote 32: FLATAU, _Centralb. f. Nervenheilk._, August, 1897.]

[Footnote 33: _Vie de Molière_, 1705, pp. 206-7 (quoted by Cruchet).]

[Footnote 34: _Mémoires de Saint-Simon_, year 1707, vol. xiv. p. 427
(Hachette, 1857).]

[Footnote 35: CONSTANT, _Mémoires_, vol. i. p. 340.]

[Footnote 36: TISSIÉ, "Tic oculaire et facial," _Journ. de méd. de
Bordeaux_, July 9 and 16, 1899.]

[Footnote 37: GRASSET, "Tic du colporteur; spasme polygonal
post-profesionnel," _Nouv. icon. de la Salpêtrière_, July-August, 1897,
p. 217.]

[Footnote 38: ALFRED DE VIGNY, _Servitude militaire_, chap. vi.]

[Footnote 39: MAGNAN, _loc. cit._ p. 144.]

[Footnote 40: _Id., loc. cit._ p. 145.]

[Footnote 41: DEBROU, "Sur le tic non douloureux de la face," _Arch.
gén. de méd._, June, 1864, p. 641.]

[Footnote 42: CHIPAULT AND A. CHIPAULT, _Rev. neurologique_, 1893, p.
149.]

[Footnote 43: FÉRÉ, _Arch. de physiol._, 1876, p. 267.]

[Footnote 44: GILBERT, CADIOT, AND ROGER, "Note sur l'origine bulbaire
du tic de la face," _Rev. de méd._, 1890 p. 431.]

[Footnote 45: BUSS, quoted by CRUCHET, _Thèse de Paris_, p. 19.]

[Footnote 46: DEBROU, _loc. cit._ p. 641.]

[Footnote 47: CHIPAULT AND LE FUR, "Névralgie des huitième, neuvième, et
dixième racines dorsales avec tic abdominal," _Gaz. des hôpitaux_, March
20, 1902, p. 325.]

[Footnote 48: PATELLA, "Studio anatomo-patologico e clinico sul
policlono," _Il policlinico_, vol. viii. November, 1901, p. 535.]

[Footnote 49: FEINDEL, "Spasmes grimaçants de la face," _Revue de
psychologie_, April, 1899, p. 118.]

[Footnote 50: BRISSAUD AND FEINDEL, "Sur le traitement du torticolis
mental et des tics singulaires," _Journ. de neurologie_, April 15,
1899.]

[Footnote 51: MEIGE, "L'aptitude catatonique et l'aptitude echopraxique
des tiqueurs," _Congrès de Madrid_, April, 1903.]

[Footnote 52: MEIGE, "Le phénomène de la chute du bras," _XIII Congrès
des neurologistes_, etc., Brussels, 1903.]

[Footnote 53: SCHEIBER, "Über einen Fall von durch Spleniuskrampf
bedingten Torticollis," _Wiener med. Wochenschrift_, 1900, p. 261.]

[Footnote 54: BONNIER, _L'orientation_, Paris, 1900; _Le sens des
attitudes_, Paris, 1904.]

[Footnote 55: DE BUCK, "Note sur un cas de spasme rythmique," _Belgique
médicale_, 1899.]

[Footnote 56: BABINSKI, "Sur un cas d'hémispasme (contribution à l'étude
du torticolis spasmodique)," _Rev. neurologique_, 1900, p. 142.]

[Footnote 57: BABINSKI, "Sur le spasme du cou," _Rev. neurologique_,
1901, p. 693.]

[Footnote 58: OPPENHEIM, _Medecinskoe Obozrenje_, 1901.]

[Footnote 59: BRISSAUD, "La polyurie des dégénérés," _Presse méd._,
April, 1897.]

[Footnote 60: MEIGE, "Neue Beiträge zur Prognose und Behandlung der
Tics," _Journ. f. Neurolog. u. Psychiat._, Bd. II, Hft. 2-3; "Tics des
sphincters," _Congrès de Rennes_, 1905.]

[Footnote 61: CLAUS AND SANO, "Spasme bilatéral de la face et du cou,"
_Journ. de neurologie_, 1899.]

[Footnote 62: MEIROWITZ, "A Case of Habit-spasm," _The Post-graduate_,
1900, p. 643.]

[Footnote 63: SEELIGMÜLLER, "Zur Pathogenese der peripheren Krampfe,"
_St. Petersburger med. Wochenschrift_, 1881, No. 2, p. 13.]

[Footnote 64: VALLEIX, _Guide du médecin praticien_, 1853, vol. iv. p.
617.]

[Footnote 65: PARINAUD, _Soc. de neur. de Paris_, April 18, 1901.]

[Footnote 66: TOBY COHN, "Facialistic als Beschäftigungsneurose," _Neur.
Centralb._, 1897, p. 21.]

[Footnote 67: LERCH, "Convulsive Tics," _American Medicine_, November 2,
1901.]

[Footnote 68: CROUZON, "Tic d'élévation des yeux," _Soc. de neur. de
Paris_, January 11, 1900.]

[Footnote 69: BABINSKI, "Sur la paralysie du mouvement associé de
l'abaissement des yeux," _Soc. de neur. de Paris_, June 7, 1900.]

[Footnote 70: MARIE, "Spasme névropathique d'élévation des yeux," _Soc.
de neur. de Paris_, April 18, 1901.]

[Footnote 71: RAYMOND AND CESTAN, _Rev. neurologique_, 1902, p. 52]

[Footnote 72: NOGUÈS AND SIROL, "Un cas de paralysie associée des
muscles droits supérieurs de nature hystérique," _Soc. de neur. de
Paris_, March 7, 1901.]

[Footnote 73: MASSARO, _Il pisani_, fasc. i. 1904.]

[Footnote 74: A. VON SARBO, "Ein Fall von klonischem Masseteren Krampf,"
_Monatsch. f. Psych. u. Neur._, 1900, p. 493.]

[Footnote 75: RAYMOND AND JANET, _Névroses et idées fixes_, vol. ii. p.
381.]

[Footnote 76: CHATIN, _Rev. neurologique_, 1900, p. 310.]

[Footnote 77: PIERRE MARIE, _Rev. neurologique_, 1901, p. 426.]

[Footnote 78: BRISSAUD AND FEINDEL, _Journ. de neurologie_, April 15,
1888.]

[Footnote 79: BRISSAUD, "Tics et spasmes chroniques de la face," _Journ.
de méd. et de chir. pratiques_, January 25, 1894.]

[Footnote 80: DE BUCK, "Spasme fonctionnel du cou," _Belgique médicale_,
1897, No. 51.]

[Footnote 81: BRISSAUD AND MEIGE, "Trois nouveaux cas de torticolis
mental," _Rev. neurologique_, 1894, p. 697.]

[Footnote 82: GRAFF, "Ein Fall von spastischen Krämpfen der
Halsmuskulatur," _Deutsch. med. Wochenschrift_, March 22, 1900, p. 66.]

[Footnote 83: Cited by BOMPAIRE, _Thèse de Paris_, 1894.]

[Footnote 84: BRISSAUD AND MEIGE, _Rev. neurologique_, December 30,
1894, p. 697.]

[Footnote 85: RAYMOND AND JANET, _Névroses et idées fixes_, vol. ii. p.
378.]

[Footnote 86: RAYMOND AND JANET, _loc. cit._ p. 380.]

[Footnote 87: SGOBBO, "Un caso di torticollo mentale," _Il manicomio
moderno_, 1898, fasc. 3.]

[Footnote 88: FEINDEL, "Le torticolis mental," _Gazette hebdomadaire_,
February 20, 1898, p. 169.]

[Footnote 89: SÉGLAS, "Un cas de torticolis mental," _Rev.
neurologique_, 1901, p. 114.]

[Footnote 90: BRISSAUD, _Leçons sur les maladies nerveuses_, 1895, p.
514.]

[Footnote 91: BOMPAIRE, "Du torticolis mental," _Thèse de Paris_, 1894.]

[Footnote 92: LENTZ, "Rotation permanente de la tête à droite," _Journ.
de neurologie_, 1897, p. 502.]

[Footnote 93: GRASSET, "Tic du colporteur; spasme polygonal
post-professionnel," _Nouv. icon. de la Salpêtrière_, July-August, 1897,
p. 217.]

[Footnote 94: MARÉCHAL, "Un cas de torticolis spasmodique," _Journ. de
neurologie_, 1899, No. 11.]

[Footnote 95: REDARD, _Le torticolis et son traitement_, Paris, 1898.]

[Footnote 96: VAN GEHUCHTEN, "Un curieux cas de tic," _Journ. de
neurologie_, 1899.]

[Footnote 97: PIERRE MARIE AND GUILLAIN, "Torticolis mental avec
mouvements des membres supérieurs de nature spasmodique," _Soc. de neur.
de Paris_, April 17, 1902.]

[Footnote 98: PIERRE JANET, _Névroses et idées fixes_, vol. i. p. 311.]

[Footnote 99: MEIGE AND FEINDEL, "Remarques cliniques et thérapeutiques
sur quelques tics de l'enfance," _Journ. de neurologie_, 1904.]

[Footnote 100: RAYMOND AND JANET, _Névroses et idées fixes_, vol. ii. p.
390.]

[Footnote 101: _Id., loc. cit._ p. 388.]

[Footnote 102: SÉGLAS, _Les troubles de langage chez les aliénés_,
Paris, 1892.]

[Footnote 103: EHRET, _Archiv f. Unfallheilkunde_, 1898, p. 32.]

[Footnote 104: RAYMOND AND JANET, "Note sur deux tics de pied," _Nouv.
icon. de la Salpêtrière_, 1899, p. 353.]

[Footnote 105: ODDO, "Tic de la génuflexion," _Marseille médical_, March
15 1902.]

[Footnote 106: RAYMOND AND JANET, _Névroses et idées fixes_, vol. ii. p.
391.]

[Footnote 107: HARTENBERG, "Tic de déglutition chez un hystérique,"
_Rev. de psychologie_, 1899, p. 175.]

[Footnote 108: ROSSOLIMO, "Ueber Dysphagia amyotactica," _Neurolog.
Centralb._ 1901, Nos. 4, 5, 6.]

[Footnote 109: BECHTEREW, "Ueber die psychischen Schluckstörungen,"
_Neurolog. Centralb._ 1901, p. 642.]

[Footnote 110: LERCH, "Convulsive Tics," _American Medicine_, Nov. 2,
1901.]

[Footnote 111: RAYMOND AND JANET, _loc. cit._ vol. ii. p. 35.]

[Footnote 112: _Ibid._ p. 357.]

[Footnote 113: SÉGLAS, "Paralysie générale et tic aérophagique,"
_Semaine médicale_, 1899, p. 9.]

[Footnote 114: NOGUÈS AND SIROL, _Arch. méd. de Toulouse_, June 1,
1898.]

[Footnote 115: SAENGER, _Monatsch. f. Pysch. u. Neur._ 1900, p. 77.]

[Footnote 116: TISSIÉ, "Tic oculaire," etc., _Journ. de méd. de
Bordeaux_, July 9, 1899.]

[Footnote 117: CHARCOT, _Leçons du mardi_, January 24, 1888.]

[Footnote 118: LETULLE, "Un cas de bégaiement compliqué de tics
coordinés multiples," _Gazette méd. de Paris_, 1883, p. 536.]

[Footnote 119: OLIVIER, "Le bégaiement dans la littérature médicale,"
_La parole_, No. 10, 1899.]

[Footnote 120: BIAGGI, _Arch. ital. di otologia_, 1897.]

[Footnote 121: DEREVOGE, _Thèse de Bordeaux_, 1898.]

[Footnote 122: Janke, IIIe _Congrès des médecins tchèques à Prague_,
1901.]

[Footnote 123: HASSLAUER, "Ueber spastischen Stimmritzen Krampf,"
_Militäraertz Zeitschrift_, 1900, p. 417.]

[Footnote 124: PICK, _Société des médecins allemands à Prague_, March
10, 1893.]

[Footnote 125: AIMÉ, "Un cas de tic élocutoire," _Revue médicale de
l'est_, January 1, 1901.]

[Footnote 126: UCHERMANN, _Arch. f. Laryngologie_, 1898, p. 326.]

[Footnote 127: GEYER, "Étude médico-psychologique sur le théâtre
d'Ibsen," _Thèse de Paris_, 1902.]

[Footnote 128: GRASSET, _Clinique médicale_, 1891.]

[Footnote 129: CHARCOT, _Leçons du mardi_, October 23, 1888.]

[Footnote 130: SÉGLAS, _Leçons sur let maladies mentales et nerveuses_,
1895, p. 83.]

[Footnote 131: GILLES DE LA TOURETTE, _Archives de neurologie_, No. 25,
1885, p. 19.]

[Footnote 132: GILLES DE LA TOURETTE, _Semaine médicale_, 1899, p. 153.]

[Footnote 133: CHABBERT, "De la maladie des tics," _Arch. de
neurologie_, 1893, p. 10.]

[Footnote 134: SCIAMANNA, _Accademia medica di Roma_, 1893.]

[Footnote 135: KÖSTER, "Ueber die Maladie des Tics impulsifs," _Deutsche
Zeitschr. f. Nervenheilk_. 1899, p. 147.]

[Footnote 136: KOPCZYNSKI, "Ein Fall von Bewegungsneurose in Form von
Tic convulsif," _Gazeta Lekarska_, 1900.]

[Footnote 137: INNFELD, "Ein chronische, progressive Fall von
Muskelkrämpfen," _Wien. klin. Wochenschr._, 1898, p. 17.]

[Footnote 138: PATRY, "De la chorée variable ou polymorphe," _Thèse de
Paris_, 1897.]

[Footnote 139: GILLES DE LA TOURETTE, _Semaine médicale_, 1899, p. 153.]

[Footnote 140: FÉRÉ, "Note sur un cas de chorée variable," _Nouv. icon.
de la Salpêtrière_, 1898, p. 454.]

[Footnote 141: SGOBBO, "Un caso di torcicollo mentale," _Il manicomio
moderno_, 1898, p. 424.]

[Footnote 142: FEINDEL AND MEIGE, "Quatre cas de torticolis mental,"
_Arch. gén. de médecine_, January, 1901, p. 61.]

[Footnote 143: RAYMOND AND JANET, _Névroses et idées fixes_, vol. ii. p.
377.]

[Footnote 144: FOURNIER, "Tic rotatoire," _Thèse de Strasbourg_, 1870.]

[Footnote 145: FEINDEL AND MEIGE, "Quatre cas de torticolis mental,"
_Arch. gén. de médecine_, 1901, p. 61.]

[Footnote 146: GRASSET, "Tic du colporteur," etc., _Nouv. icon. de la
Salpêtrière_, 1897, p. 217.]

[Footnote 147: NOGUÈS AND SIROL, "Un cas de torticolis mental," _Nouv.
icon. de la Salpêtrière_, 1899, p. 82.]

[Footnote 148: RAYMOND AND JANET, _Névroses et idées fixes_, vol. ii. p.
381.]

[Footnote 149: CHATIN, "Note sur un cas de trismus mental," _Rev.
neurologique_, 1900, p. 310.]

[Footnote 150: MEIGE, "Histoire d'un tiqueur: tics variables, tics
d'attitude," _Journ. de méd. et de chir. pratiques_, August 25, 1901.]

[Footnote 151: RAYMOND AND JANET, _Névroses et idées fixes_, vol. ii. p.
385.]

[Footnote 152: GAUPP, _Centralb. f. Nervenheilk._, February, 1900.]

[Footnote 153: GRASSET, _Clinique médicale_, 1891.]

[Footnote 154: FÉRÉ, "L'épilepsie et les tics," _Journ. de neurologie_,
1900, p. 309.]

[Footnote 155: PITRES, _Leçons sur l'hystérie_, vol. i. p. 317.]

[Footnote 156: CHARCOT, _Leçons du mardi_, October 23, 1888.]

[Footnote 157: RAYMOND AND JANET, _Névroses et idées fixes_, vol. i. p.
397.]

[Footnote 158: SCHERB, "Hémispasme tonique du côté droit constituant un
tic mental professionnel: tic de la mendiante," _Soc. de neur. de
Paris_, May 3, 1900.]

[Footnote 159: BABINSKI, "Definition de l'hystérie," _Soc. de neur. de
Paris_, November 7, 1901.]

[Footnote 160: DIDE, "La myoclonie dans l'epilepsie," _Annales
médico-psychol._, September--October, 1899.]

[Footnote 161: MANNINI, "Policlonia ed epilessia," _Gas. degli osped. e
delle clin._, September 30, 1900, p. 1220.]

[Footnote 162: ROSSI AND GONZALES, _Annali di neurologia_, 1900, fasc.
4.]

[Footnote 163: SCHUPFER, "Sulle mioclonie," _Il policlinico_, 1901, vol.
viii. p. 1.]

[Footnote 164: MALM, "Tic rotatoire," _Allg. med. Centralzeit._, 1899,
No. 64.]

[Footnote 165: FÉRÉ, "L'épilepsie et les tics," _Journ. de neurologie_,
1900, p. 309.]

[Footnote 166: LUZENBERGER, "'Absences' psichiche in isterici," _Riv.
speriment. di fren._, 1900, p. 822.]

[Footnote 167: MEIGE, _Les tics_, July, 1905 (Masson).]

[Footnote 168: CAHEN, "Contribution à l'étude des stéréotypies,"
_Archives de neurologie_, 1901, p. 474.]

[Footnote 169: MEIGE, "Spasme facial franc," _Soc. de neur. de Paris_,
April 17, 1902.]

[Footnote 170: HALLION, "Convulsions localisées," _Traité de médecine_,
vol. vi. p. 897.]

[Footnote 171: MAYER, _Alienist and Neurologist_, July, 1897.]

[Footnote 172: BRUANDET, "Un cas d'hémispasme facial," _Rev.
neurologique_, 1900, p. 658.]

[Footnote 173: FORNACA, _Clinica medica italiana_, No. 11, 1901.]

[Footnote 174: DESTERAC, "Syndrome du torticolis spasmodique," VIe
_Congrès français de médecine_, Toulouse, April, 1902.]

[Footnote 175: MARIE AND GUILLAIN, "Mouvements athétoïdesde nature
indéterminée," _Soc. de neur. de Paris_, April, 1902.]

[Footnote 176: CHAUFFARD, "Maladie de Friedreich avec attitudes
athétoïdes," _Semaine médicale_, 1893, p. 409.]

[Footnote 177: ODDO, "Le diagnostic différentiel de la maladie des tics
et de la chorée de Sydenham," _Presse médicale_, September 30, 1899.]

[Footnote 178: BRISSAUD, "La chorée variable des degénérés," _Rev.
neur._, 1896, p. 417.]

[Footnote 179: SINKLER, "Habit Chorea," _Amer. Journ. of the Med.
Sciences_, May, 1897, p. 559.]

[Footnote 180: NONNE, "Zwei Fälle von 'Maladie des Tics,'" _Neurolog.
Centralbl._, 1898, p. 327.]

[Footnote 181: LEMOINE, "Note sur un cas de paramyoclonus multiplex
suivi des troubles psychiques et de l'écholalie," _Rev. de médecine_,
1892, p. 882.]

[Footnote 182: D'ALLOCCO, "Parecchi casi di mioclonia, la maggior parte
familiari," _Riforma medica_, vol. i. 1897, p. 223.]

[Footnote 183: HERMANN, "Myoklonische Zuckungen bei progressiver
Paralyse," _Neurolog. Centralbl._, June 1, 1901, p. 498.]

[Footnote 184: SCHULTZE, "Ueber Chorea, Poly-und Monoklonie," _Neurolog.
Centralbl._, 1897, p. 611.]

[Footnote 185: HELDENBERG, "Myoclonus fonctionnel intermittent,"
_Semaine médicale_, 1899, p. 194.]

[Footnote 186: HAJOS, "Ein Fall von Myospasmia Spinalis," _Ungar. med.
Presse_, 1898, No. 34.]

[Footnote 187: BECHTEREW, "Myotonie eine Krankheit des Stoffwechsels,"
_Neurolog. Centralbl._, 1900, p. 98.]

[Footnote 188: KAISER, "Myotonische Störungen bei Athetose," _Neurolog.
Centralbl._, 1897, p. 674.]

[Footnote 189: MARINA, "Delle miospasie in generale e della miospasia
atetosica in particolare," _Il policlinico_, 1902, p. 577.]

[Footnote 190: LABBÉ, _Presse médicale_, 1897, p. 185; MILLS, _Journ. of
Nervous and Mental Disease_, 1879, p. 504.]

[Footnote 191: ACHARD AND SOUPAULT, "Tremblement héréditaire et
tremblement sénil," _Gazette hebdomadaire_, 1897, p. 373.]

[Footnote 192: BRISSAUD, "Contre le traitement chirurgical du torticolis
mental," _Rev. neurologique_, 1897, p. 34.]

[Footnote 193: DUFOUR, "A propos des tics et troubles moteurs chez les
délirants chroniques," _Soc. de neur. de Paris_, November 7, 1901.]

[Footnote 194: CHARCOT, _Leçons du mardi_, 1888-9, p. 469.]

[Footnote 195: CHARCOT, _Leçons du mardi_, June 26 and July 10, 1888.]

[Footnote 196: WELTERSTRAND, _L'hypnotisme et ses applications à la
médecine pratique_, Paris, 1899, pp. 74-6.]

[Footnote 197: VAN RENTERGHEM, "Un cas de tic rotatoire," _Journ. de
neurologie_, May 20, 1898.]

[Footnote 198: FERON, "Un cas de tic traité par la suggestion," _Journ.
de neurologie_, No. 13, 1899.]

[Footnote 199: VLAVIANOS, "Tic nerveux traité avec succès par la
suggestion hypnotique," _Journ. de neurologie_, 1899, p. 318.]

[Footnote 200: MARÉCHAL, "Un cas de torticolis spasmodique," _Journ. de
neurologie_, May 20, 1899.]

[Footnote 201: RAYMOND AND JANET, _Névroses et idées fixes_, vol. ii.]

[Footnote 202: ELIOT, "The Surgical Treatment of Torticollis, with
Special Reference to the Spinal Accessory Nerve," _Annals of Surgery_,
1895, p. 493.]

[Footnote 203: COUDRAY, "Torticolis spasmodique, résection du spinal,"
_Association française de chirurgie_, October, 1898.]

[Footnote 204: PAULY, "Spasmes fonctionnels du cou," _Congrès français
de médecine interne_, Lyon, October, 1894.]

[Footnote 205: PAULY, "Théorie réflexe du torticolis spasmodique,"
_Revue de médecine_, 1897, p. 130.]

[Footnote 206: RISIEN RUSSELL, _Brain_, 1897, p. 35.]

[Footnote 207: CHIPAULT, _Travaux de neurologie chirurgicale_, 1901, p.
220.]

[Footnote 208: NOVÉ-JOSSERAND, "Sur un cas de torticolis spasmodique,"
_Lyon médical_, September 4, 1898.]

[Footnote 209: LINZ, "Ueber spastische Torticollis," _Inaug. Dissert._,
Bonn, 1897.]

[Footnote 210: POPOFF, "Torticolis spastique, torticolis mental
(Brissaud), torticolis psychique ou polygonal," _Moniteur russe de
neurologie_, 1899, No. 4.]

[Footnote 211: TICHOFF, "Un cas de convulsions toniques et cloniques des
muscles du cou," _Soc. de neur. et de psychiat. de Kazan_, March 26 and
September 24, 1895.]

[Footnote 212: WALTON, "Nature and Treatment of Spasmodic Torticollis,"
_Amer. Journ. of the Med. Sc._, March, 1898, p. 295.]

[Footnote 213: CORNING, "Elœomyenchisis, or the Treatment of Chronic
Local Spasm by the Injection and Congelation of Oils in the Affected
Muscles," _New York Medical Journal_, 1894, p. 449.]

[Footnote 214: STEWENS, "Facial Spasm and its Relation to Errors of
Refraction," _Amer. Journ. of the Med. Sc._, 1900, p. 33.]

[Footnote 215: FAURE, "Traitement de la paralysie faciale d'origine
traumatique par l'anastomose spino-faciale," _Presse médicale_, 1901, p.
259.]

[Footnote 216: _See_ BREAVOINE, _Thèse de Paris_, 1901.]

[Footnote 217: BRISSAUD, _Revue neurologique_, 1897, p. 34.]

[Footnote 218: HUYGHE, "Du traitement de la chorée hystérique par
l'immobilisation," _Le nord médical_, August 1, 1901.]

[Footnote 219: VERLAINE, "Traitement de la chorée arythmique hystérique
par l'immobilisation sous chloroforme," _Thèse de Lille_, 1901.]

[Footnote 220: BLACHE, "Traitement de la chorée infantile," _Gazette
hebdomadaire_, 1864, p. 787.]

[Footnote 221: BRISSAUD, "Tics et spasmes cloniques de la face," _Journ.
de médecine et de chirurgie pratiques_, January 25, 1894. BRISSAUD AND
MEIGE, "Trois nouveaux cas de torticolis mental," _Rev. neur._, December
10, 1894, p. 697. BOMPAIRE, "Du torticolis mental," _Thèse de Paris_,
1894. FEINDEL, "Le traitement médical du torticolis mental," _Nouv.
icon. de la Salpêtrière_, 1894, p. 404. _Id._, "Le torticolis mental et
son traitement," _Gazette hebdomadaire_, February 20, 1898, p. 169.
FEINDEL AND MEIGE, "Revision iconographique du torticolis mental; cas
anciens et cas nouveaux; traitement," _Congrès de Paris, 1900, volume de
la section de neurologie_, p. 513. _Id._, "Quatre cas de torticolis
mental," _Arch. gén. de médecine_, January, 1901, p. 61.]

[Footnote 222: BRISSAUD AND FEINDEL, "Sur le traitement du torticolis
mental et des tics similaires," _Journal de neurologie_, April 15,
1899.]

[Footnote 223: FEINDEL, "Spasmes grimaçants de la face, datant de trois
mois," _Revue de psychologie clinique et thérapeutique_, April, 1899.]

[Footnote 224: HARTENBERG, "Traitement et guérison d'un cas de tic sans
angoisse," _Revue de psychologie clinique et thérapeutique_, January,
1899, p. 17.]

[Footnote 225: FRENKEL, "De l'exercice cérébral appliqué au traitement
de certains troubles moteurs," _Semaine médicale_, 1896, p. 124.]

[Footnote 226: PITRES, "Tics convulsifs généralisés traités et guéris
par la gymnastique respiratoire," _Journ. de médecine de Bordeaux_,
February 17, 1901, p. 106.]

[Footnote 227: TISSIÉ, "Tic oculaire et facial accompagné de toux
spasmodique, traité et guéri par la gymnastique médicale respiratoire,"
_Journ. de médecine de Bordeaux_, July 9 and 16, 1899.]

[Footnote 228: MADET, "Myoklonie in der Art eines expiratorischen
Singultus," _Wiener medic. Blätter_, No. 30, 1899.]

[Footnote 229: OETTINGER, "The Disease of Convulsive Tic," _Amer. Journ.
of the Med. Sc._, September, 1899, p. 303.]

[Footnote 230: MARTIN, _Congrès de Limoges_, 1901.]

[Footnote 231: BRISSAUD AND FEINDEL, "Sur le traitement du torticolis
mental et des tics similaires," _Journ. de neurologie_, April 15, 1899.]

[Footnote 232: MEIGE, _Congrès du Limoges_, 1901.]

[Footnote 233: BALLET, "L'écriture de Léonard de Vinci: contribution à
l'étude de l'écriture en miroir," _Nouv. icon. de la Salpêtrière_, 1900,
p. 597.]

[Footnote 234: FÉRÉ, "L'influence sur le travail volontaire d'un muscle
de l'activité d'autres muscles," _Nouv. icon. de la Salpétrière_, 1901,
p. 432.]

[Footnote 235: WYEMANN, "Ueber ein Fall von Tic de Guinon," _Göttinger
Dissertation_, 1900.]





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