Tics and Their Treatment. Feindel Eugène

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