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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 manOEuvre, 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_.