Tics and Their Treatment. Feindel Eugène

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. Dupré13 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

13

DUPRÉ, Soc. de neur. de Paris, April 18, 1901.

14

DUPRÉ, loc. cit.