Chapter XVI: Introduction (6)

It is not my purpose to undertake an exhaustive psychoanalytic study of Epilepsy. Neither is it my purpose to enter into a discussion of the problems of differential diagnosis. It has already been shown, in borderland cases, that one cannot tell the difference between epilepsy and hysteria, without a prolonged psychoanalysis, and even then one cannot be certain. This suggests that the whole thing is more or less a matter of definition. Into such questions I cannot enter. My aim is much more modest. The immediate purpose of my paper is to study some of the problems of therapy, from the psychoanalytic point of view, of that small class of patients on the borderline between hysteria and epilepsy, or patients with epileptiform attacks.

The first publication of studies of this general nature was made by Dr. James J. Putnam and Dr. George A. Waterman in the Boston Medical and Surgical Journal for May, 1905, under the title "Certain Aspects of the differential Diagnosis between Epilepsy and Hysteria." In this paper the authors say, "No one, so far as we are aware, has as yet studied with sufficient thoroughness the subconscious memories of epileptics, and for all we now can say, closer resemblances may be found between these and the subconscious states of the hysterics than we now imagine." p. 513.

In this paper, however, therapy is only hinted at.

A contribution to our insight as to the epileptic state of mind is made by Jung, under the title, "Analyse der Assoziationen eines Epileptikers," in his, "Diagnostische Assoziationsstudien. Beitrage zur experimentellen Psychopathologie." p. 175 (1906).

He found an extraordinary number of emotionally toned, egocentric relations. There were some signs to suggest that the emotional tone in the epileptic was unusually lasting.

The first thing published on epilepsy avowedly from the psychoanalytic view-point was by Maeder: "Sexualitat und Epilepsy." Jahrbuch BI HI, 1909.

Maeder goes into the subject rather exhaustively, after characteristic German fashion, but his conclusions are comparatively simple. He says, "The sexuality of the epileptic is characterized by the prominence of auto- and allo-erotism. It retains much of the infantile form, but has undergone, nevertheless, a certain development, which I designate as 'sexual polyvalence.' For some unknown reason the libido seems to have an abnormal intensity." p. 154.

This is an important contribution to our knowledge of the psychic state of epileptics but it is notable that not a word is said as to therapy.

Sadger published the same year, "Ein Fall von Pseudoepilepsia hysterica psychoanalytisch erklart." (Wiener klein. Rundschau, p. 212, 1909.) But neither does he have anything to say about therapy.

Dr. Wilhelm Stekel, however, treats the problem from the therapeutic point of view in, "Die psychische Behandlung der Epilepsie." (Zentralblatt fur psychoanalyse p. 220 No. 5-6, Vol. 1).

The essential kernel of Stekel's view is that the epileptic is a repressed criminal. The convulsion is a substitute for the criminal act. He announces categorically that pseudoepilepsy is curable by psychoanalytic procedures. Of three cases which he completely analysed, two were cured. His final conclusion is fourfold: (1) Epilepsy, more often than we have hitherto thought, is of psychogenic origin. (2) In all cases there is a strong tendency to criminality which is unbearable to consciousness. (3) The attack is a substitute for an offense, hence, eventually a sexual offense. (4) Pseudo-epilepsy is curable by psychoanalysis.

Spratling calls attention "to the value of an occasional convulsion in certain cases. In some patients the fit acts as a safety valve that unquestionably permits escape from insanity. . . In many cases the convulsion seems t o come as the termination of an obscure (auto-toxic) cycle which varies in duration in different individuals and bears some relationship to the ascending period of the folie circulaire of the French. It seems that the specific cause of the fit in these cases is something that permeates the entire organism; something that comes and goes; that grows rapidly in intensity, exerting a pernicious influence on the patient by making him act out of harmony with his normal state, until the limit is reached and the mind loses its direction and control. The power of inhibition being finally destroyed, the nervous storm breaks with great force and violence." p. 361.

Although Spratling had in mind a toxic agent, one cannot but be struck with how completely his terms describe an emotional outburst.

In a paper read in Boston last winter, Dr. L. Pierce Clark advanced the view that the epilpetic seizure was the symbolical expression of the desire of the patient to return to the mutterleib. The convulsive moments were such reflect and random acts as one sees in infants or infers in the embryo. Regard for social sanctions is lost. This, of course, suggests the first step in criminality. Clark found that favorable cases were amenable to psychic treatment and said that some cases had been very much helped by psychoanalysis. I am not certain whether he claims to have cured any particular case of pseudo-epilepsy or epileptiform attacks, by psychoanalysis. In presenting some of my own cases let me begin with one that certainly was not a complete success, but nevertheless was much helped by psychoanalysis.

This case is that of a young girl, aged 14, without known inherited tendency. Her first attacks had occurred about a year previous in the form of fainting spells. These were afterwards followed by convulsions. In convulsions the patient thrashed about, kicking her legs and clawing at her chest. These convulsive movements stopped after a while and were followed by a deep sleep, after which the patient awoke without any memory of what had happened.

It was found that during the convulsion the patient imagined she was being pursued by a black-faced figure with claw-like hands, of a peculiar shape like her father's.

Further investigation showed that her father got drunk and did chase her, sometimes kicking her out of the house. She would undress her father sometimes and put him to bed. Once when taking off his shoes he kicked her, as she was bending over him, in the lower part of the abdomen. This was just before the convulsions developed. The fainting spells occurred soon after she had first seen her father naked. The image of his nakedness so distressed her by continually coming before her mind that she made the most desperate efforts to repress it, finally partially succeeding. Speaking of her father she said, "Every time I think of him I feel like taking a fit. Oh! It makes me feel terrible."

Her father had kicked her in the chest, too, which perhaps partially accounts for the clawing.

In the light of this knowledge the convulsive movements become a little more comprehensible. They are futile attempts to run away. They are the partial movements of flight.

The cries that sometimes initiated and accompanied the convulsions at first, afterwards became sufficiently articulate to be understood as calls "Mama, Mama, Mama."

It was found that when her father would chase her about the house, in drunken fury, she would call for her mother in frantic fear. Here, apparently, is a meaning of the call preceding the convulsions.

Under a very short psychoanalytic treatment the patient showed marked improvement. Her attacks became much less violent and much farther apart. She became able to control them to a great extent. Finally she became so well that one might say she had practically recovered.

Apparently there is no hint here of a repressed criminal complex. But a little deeper analysis suggests it, however. The first attack, which was in the form of a faint, occurred under the following circumstances. The patient was at the funeral of the father of her best girl friend. As she looked at the dead body of her friend's father the thought flashed through her mind, "He was so good, and now he is dead, while my father who is so bad, still lives. I wish he were dead." Shortly after she fainted.

There were a number of reasons, seemingly adequate, for incomplete success in this case. In the first place, the patient had been in this country only a few years and spoke very broken English. She is a Russian Jew. Obviously this was a very great barrier to understanding. In the next place it was almost impossible to change conditions of home, although Social Service worked wonders in this case. The father continued to get drunk, and one of the last of her now infrequent attacks occurred on his return from jail. The patient was dreadfully afraid lest her father find out that the knowledge of his delinquency had been discovered through her.

Not the least of the reasons militating against complete success was the short time possible for psychoanalytic treatment. The patient was seen only three weeks. As the time needed for a psychoanalysis is variable depending on the particular patient, it is clear that this would be too short a time to enable a young girl, only recently here from Russia, to understand, or to overcome resistances. That the treatment was as nearly successful as it was is perhaps encouraging to the hope that suitable cases under favorable conditions might be cured.

The next case is one where the diagnosis lay between hysteria and epilepsy. The symptoms were as follows: The patient had attacks in which she became unconscious, gasped, and spittle ran from her mouth. She also bit her tongue. She becomes stiff, eyes stark, and is left tired and weak. These attacks were first noticed about five years ago. Since then she has had about five similar attacks, the last three coming within five months. The last two were within a day of each other and frightened her so she came to the hospital. At the age of eight or nine she said that she had flashes of speechlessness, and a thought which she cannot define, as of a horse or a man. She never became unconscious or bit her tongue. After her first catamenial these flashes of speechlessness and thought came only at this time. At the age of two the patient said that she had fallen down stairs and hit her head. She said she was unconscious twenty-four hours.

As a result of a psychoanalysis the following facts were learned. The patient was a very sensitive child, exceedingly responsive to her environment. She was also stubborn and self-willed, at times. She was reserved and capable of great repression. When she was about three or four she remembers seeing in the Bible a picture of the Devil on a white horse. This used to make her shudder, but it also had a sort of irresistible fascination. Later, when she was seven or eight, it would come into her mind in school even and make her feel so badly she would lay her head on her arms. But she never told anybody what it was that troubled her and she would put it out of her mind. She thoroughly believed her mother when she told her that the Devil would come and get her if she did wrong.

At about the age of ten or eleven she began going with a girl much older than herself. She used to visit this girl and spend the night with her, and in turn have her at her own home. In this way they spent the night together quite frequently. Soon the girl wanted to masturbate her and although she repelled her advances at first she finally allowed it because she was told she would be regarded as queer if she didn't as other girls did it and liked it. She, however, never did get any pleasure out of the practice, and remained perfectly passive. She thought if her friend enjoyed it and it didn't hurt her she should let her have her pleasure. She never told of this.

The patient now began having what she called staring spells. These never lasted more than a second or so and they were never observed. She carefully concealed them. Just before the patient began to menstruate which was when she was about fourteen, she noticed that the day after she had been with the girl who masturbated her she had a terrific headache. Then she remembered that for a long time it had been so though she had never connected the headaches before with the masturbation. She stopped the practice immediately and never allowed it to be resumed.

After menstruation began the staring spells became grouped and came only during her periods. But they were more numerous. She would have a number in one day. They were not yet sufficiently observable to be noticed. At about this time she had a terrible fright. She was kneeling at her mother's side listening to a story when she thought she saw a woman's face looking at her over her mother's shoulder. She was speechless with terror. This was not noticed and she did not tell. Around this time too she had another fright. She was studying one evening at the dining-room table when she saw a face looking in at the window. She screamed, and kept on screaming, but finally was able to tell that she had seen someone looking in at the window. Her father took her out and showed that it couldn't be so because there were no tracks in the snow which was on the ground. She wouldn't or couldn't stop crying, however, and kept it up all night, she said. Just before menstruation she did some sleep-walking. She got up one night and went to her mother and said she had something to tell her. Her mother tried to get her to say what it was but could not, and saw that her daughter was asleep. She kept saying, "you know what it is." The mother did not dare to waken her and finally got her quietly back into bed. The next morning she remembered nothing of what had happened.

When the patient was about sixteen she married. Her husband did not want any children and practiced coitus interruptus, but she became pregnant nevertheless and had an abortion performed. Although c.i. continued to be practiced she became pregnant again and this time she had a daughter. Four more years of c. i. followed. During all this time the patient had the staring spells, but they were never noticed and she never told, not even her mother. Then, like a thunder bolt out of a clear sky, came a tragedy.

She was pregnant again, and visiting her mother, expecting her husband for over Sunday, when she received a letter saying he had left her and had gone off with another woman. When she read the letter she lost consciousness.

Then followed a terrible time. In hate of her husband and on account of fear lest she be unable to care for her baby she had another abortion performed. This time she nearly died through not having proper medical attendance afterwards, but she finally recovered and lived a life of feverish activity and hate.

During her marriage she had been entirely frigid with respect to the sexual act. A friend told her she had been missing an essential experience of marriage. About a year after her husband left her she met a man who thrilled her through and through, and thought, "this is what my friend meant." This man showed her some attention and she set out consciously to seduce him. She soon succeeded and though he was wildly in love with her and wanted to marry her, she steadfastly refused on the score of not loving him, but was his mistress for two or three years. During this time her staring spells seem to have been at a minimum, but I cannot assert that they disappeared.

Then she met the man who became her second husband. She had refused to marry her lover because she did not "love" him. She now dropped him completely, and getting a divorce from her husband on the ground of desertion, married.

She was happy about a year and a half when her husband moved to a country cross-road near a "hotel" (bar-room). Here he began drinking badly, and consorting with prostitutes. For three years she fought her husband off, in fear of infection. During this time she had no intercourse. At this time began the attacks of unconsciousness. She was alone one night, while her husband was off carousing, when she had a terrible fright on seeing a man trying to get in at the window. This was probably hallucinatory as nothing came of it. But from this time forth she was subject to attacks, in which she lost consciousness, had convulsions, frothed at the mouth, and bit her tongue badly.

At the end of about three years, however, her patience broke, and she told her husband that if he did not stop she should leave him. This threat brought him to his senses apparently, and he completely reformed. But her love for him was dead. And though she now permitted marital relations to be resumed, she remained from this time on absolutely frigid. Her husband too, now suffered from premature ejaculation. Thus from the point of view both of "passion" and of "love" the patient was not satisfied. Her attacks increased in number and violence, coming now at any time, not being confined to the menstrual period as at first, and coming days as well as nights.

In this patient we have represented the points of view both of Stekel and of Clark. The patient showed conclusively her capacity for criminal action. She also illustrates the craving for a return to the mother. The morning of the day on which she had the first attack in which she bit her tongue, she passed through the town where her mother was living and thought, "Oh, if I could only go to my mother." But remembering she had promised her lawyer to live a year with her husband, she went on. Of the sexual character of her conflicts no further comment is necessary.

Here then we have the natural history of what? Hysteria? or Epilepsy? This question I shall not attempt to answer. But what has been the therapeutic result of psychoanalysis? This question I can answer.

In the six months during which the analysis has been in progress the patient has had no attacks in which she has had convulsions, frothed at the mouth, or bitten her tongue. She has had only three spells in which consciousness was lost and these were mild. The last one was described by the daughter. She said it was like a faint; that her mother was in it only a short time; that she had none of the symptoms she used to have; and was all right soon afterwards with no bad after-effects. She added that since her mother had been coming to the hospital she had improved so much they never thought of her now as being sick. The bad feelings have diminished so much in number and intensity as to be almost negligible. Family relations have so improved husband and wife are practically at one in their purposes. Social relations have also improved to such an extent that the patient has been able to prevent the wreck of the home of a friend, and in her church is an active worker on a number of committees. She is now doing her best to get her daughter started right in life. The patient regards herself as having practically recovered.

The next case I wish to present for your consideration is that of a young man twenty-six years old. He was brought into the accident-room of the hospital one night last Summer suffering from convulsions. He continued to have convulsions throughout the night, and as many as five interns were required to hold him quiet. These convulsions seemed to have enough purpose in them to warrant the diagnosis of hysteria, so the next morning he was referred to me.

"Last Wednesday night," he said, "I was having dinner with a customer at the Hotel Thorndike. I began to feel sick and went to the toilet and vomited. Then I went back and got my friend and started for a drug store in Park Square to get some quinine. But before I got very far I began to shiver and shake and I knew that it took quinine two or three hours to work so I started back to the hotel to get a room. No rooms were to be had, so I said 'get a taxi and take me to the hospital.' I lost the use of my legs on the steps and they had to carry me. In this attack I was more or less conscious all through it." What were you thinking of in the taxi, I asked. "I don't know. I felt as if I wanted to jump at something and grab something." Can you not remember what was in your mind, I continued. "Only what I've told you," he answered. Will you lie down and close your eyes and imagine yourself back in the taxi, I asked. Now tell me what you see. After a moment he said, "I see flames." What else do you see? "Nothing, only flames. I feel as if I wanted to jump into the fire." Did you see flames in the taxi, I asked. "Yes, that was what I wanted to jump at." At this moment the patient gave a start. What did you see then, I asked. "There is something in the flames, an object, I don't know what it is. It might be a thing or a person. I feel as if I wanted to grab the object." At this instant the patient gave a violent jump into the air and then sank back relaxed. What did you see, I asked. "This object. It seemed to be attracting me." Can't you tell what it is, I said. "No. But it seems almost like a person. It seems as if I could see an arm." What else do you see? "The arms seem beckoning me." It is a person then? Is it a man or a woman? "I don't know. I can't make out." Look. "It is a woman. I can see now." Is it anybody you know? "No, I can't see any face." What do you see? "Just a woman, standing in the flames, with outstretched arms, as if imploring me to come. I feel a yearning, as if I must jump and grab her." The patient stiffened slightly and gave a sort of spring up from the couch and then sank back, breathing a little heavier. What did you see, I asked. "I thought she beckoned me to come." Can you see who it is now? "No The face is blank." Look again and see if you can't tell who it is. What do you see? "I can't tell. I see several faces come and go." Do you recognize them? "Yes. The first is my little girl's; then I see a former sweetheart of mine; then I see my wife's face."

Gradually the following story was elicited from the patient. His mother died when he was seven and his father married again in less than a year. The former sweetheart was his step-mother's half-sister who came to live at their house because the schools were better. He became infatuated with this girl and his step-mother did everything she could to encourage his feeling as she thought it would be a good match. The vision of his sweetheart in the flames was based on an actual occurrence. She was sitting in front of a fireplace once when a log of burning wood fell out and he jumped to pull her away and held her close in his arms for a moment.

Finally, however, he broke off absolutely all relations with the girl. The reason seems quite adequate. Why didn't you marry, I asked. He answered, "we quarrelled and I left her. I didn't like her morals. She went with other men and had connection with them. I saw her go into the woods one night with another fellow, and once at Salisbury Beach I saw her go into a hotel with a man and register as his wife."

About a year after this the patient began going with another girl more in an attempt to crowd the image of his former first love out of his mind than because he had fallen in love again. A year later they married. From the first his married life was not entirely happy. More or less unconsciously he began to regret lost opportunities. He was a travelling man and soon after marriage his route was enlarged necessitating his being away from home a month at a time. On these trips he used to get exceedingly lonesome especially as he steadily refused going with other travelling men and making a night of it as they often did. One of his routes took him to Virginia and he said that he had returned from New York on the way there just for the sake of spending a night with his wife. Once, in New York, he was unfaithful to his wife and on that occasion contracted gonorrhea. This, however, was the only time he has ever had extra-marital sexual relations, he said.

Just before his attacks began, which was about four years ago, he was told by his wife's doctor that it would be impossible for her to have any more children as she was suffering from heart disease. To his mind this meant giving up coitus. Then, unconsciously, he began to dream of Anna, his first love. He regretted more than ever not taking advantage of his former opportunities, and unconsciously dallied with the thought of deserting his wife. Just at this time his attacks began.

As the analysis progressed his attacks diminished and shortly disappeared. Gradually the image of his wife took full possession of his mind and the image of Anna disappeared. Towards the end of the analysis as he was lying on the couch with his eyes shut, he saw Anna in the flames and felt the yearning but not so strongly as to lead to any impulsive movements. What do you think all this might mean, I asked. "I don't know," he answered, "it might mean I still cared for Anna and that if I let myself go it would break up my home." With his full realization of the meaning of this symbolization, it was assumed that he was cured.

Seven months later, in company with a colleague, I visited my former patient and he told me that he had not had a moment's illness since I last saw him. He told me that while occasionally the thought of Anna would come to his mind, it never disturbed him, and never distracted his attention from other things. He has prospered in his business, and I saw every evidence of a happy home.

This case merits consideration for a number of reasons. In the first place the attacks were cured by psychoanalysis. No one who saw the association of the symbolical imagery and the convulsive movements could fail to see that there was a causal connection between them. The subsidence in violence and frequency of the convulsive movements as the conscious grasp of the meaning of the mental symbolical imagery increased was also completely convincing of the therapeutic value of the analysis. The question of the permanence of the recovery is of course open, because seven months is far too short a time to carry complete conviction.

The comparison of this case with the one immediately preceding raises a very interesting question. Why is this patient apparently completely cured and the other one not? Several reasons may be noted. The patient is much younger. He had never been through anything like the same mental strains. His trouble was of short duration. But above all as he was successful in his business he was successful in his sublimation. Here is a sine qua non of a successful psychoanalysis: the capacity and the opportunity for successful sublimation. If these are present the prognosis is good.

It is interesting also to compare this case in its results with the contentions of Clark and of Stekel. It is hard to see any signs of a definite criminal tendency. Inasmuch as the temptation to go back to his early love is a sign of a tendency towards regression and erotism generally the patient shows what Clark has spoken of as a desire to return to the mother-body. This case is not very important, however, to the views of either Clark or Stekel as the analysis is relatively superficial, and there is no knowing what a more thorough analysis might reveal. From the point of view of superficiality, however, the case is important as it emphasizes Taylor's view of the value of a modified analysis. The patient was seen only five times.

On the basis of these, and a number of other similar cases, I should like to suggest, from a descriptive point of view, that the epileptiform seizure is of the nature of an orgasm. An orgasm is a sudden, explosive, discharge of nervous energy, raised to the breaking point of nervous tension. I should like to generalize the idea of orgasm. Ordinarily, of course, it is confined to the sexual sphere. In the last case I reported it seems to me fairly clear that the explosive actions, convulsive-like impulses, were closely associated in the mind of the patient with sexual ideas. That they were substitutes for the normal relief of sexual tension, seems to me also clear. This idea is perhaps more convincing if I add the fact, as stated by the patient, that his last attack started when he saw an attractive girl sitting at a nearby table in the Thorndike Hotel, and who started him dreaming about Anna, because she looked so much like her.

The second case I reported seems also easily brought under this conception. Here we know more about the earliest childhood of the patient and we can easily imagine that there was an especial predisposition for the form the symptoms took. This, however, does not militate against the descriptive value of the above conception. That the epileptiform attacks did not take place until after actual sexual orgasms had been experienced, lends weight to the conception I am presenting here. The first case is not so clear. This is partly due to the fact that it was impossible to make anything like a complete analysis. But it shows nothing contradictory to the conception, and indeed has some slight value as added evidence in favor of the conception, in as much as the original trauma consisted of a kick in the genitals, by her father.

This conception does not contradict either Stekel's or Clark's ideas, but rather supplements them. The essence of the criminal act lies in its unrestrained aggressive character. From this point of view anything getting in the way of the libido discharge has to take the consequences. This also agrees with Clark, only his idea seems to me perhaps a little too passive to describe fully the dynamic quality of the attack.

Here, as in Hysteria, the therapeutic effect of an analysis depends on the possibility of sublimation. The three cases I have given in some detail may easily be arranged in order. The last case having the best chances for sublimation shows the best results.

ON THE GENESIS AND THE MEANING OF TICS

BY MEYER SOLOMON, M. D.

Associate in Neurology, Maimonides Hospital, Chicago

THE problem of the genesis and meaning of the strange manifestations which we find in that peculiar disorder which goes by the accepted name of tics is indeed difficult of solution. The analytic and genetic standpoint only comparatively recently assumed in the domain of neurology and psychiatry is having an ever wider and wider application. The problems in neurology and psychiatry which still cry loudly for solution and rational explanation are indeed numerous. Some of these questions are so baffling that at times they seem almost beyond the ken of the human mind. Nevertheless, with persistence and the "Don't give up the ship" spirit keenly imbued into us, and with that irrepressible spirit of investigation and of research born of optimism and of curiosity, we may expect to see many of these problems which now seem to us so hopelessly unsolvable gradually rescued from the uncertain waters of speculation and theorization and brought to the more sound shores and land of the knowable and the known. If our theories be but tinctured with due admixture of that sound self-criticism that comes of prolonged and serious reflection and deliberation, and if the results of observation and investigation be brought forth in support of these theories, then we need have no hesitancy in permitting freedom in theorization and speculation. Let us also remember that unsound theories or standpoints do not come to stay, but, after surviving for a certain time, give way before that which is more sound, more tangible, more near the truth, which, to be sure, is always but approximately attained. If, therefore, the theory which I intend to set before you for consideration may seem on first thought far-fetched and unsupported, I beg you to remember that in a field where but comparatively little is known with absolute certainty, it behooves us to take notice of all theories or conclusions which may be propounded, since, even though they may not contain the whole truth, they may, perhaps, contain certain germs of truth, which may contribute, in some measure, however slight, toward the ultimate solution of the problem under consideration.

With these brief prefatory remarks, I shall forthwith enter into the discussion of the genesis and meaning of the tics.

I may say at once that this is not merely a theoretical and purely academic proposition which has no practical bearings in the way of prognosis and treatment. On the other hand, a real understanding of the nature, origin, and significance of the tics is of decided value in giving us proper standpoints and orientation with respect to the prevention, prognosis and cure of the condition.

I need not enter into a description of the characteristics of tics in this place. I may merely mention that tics have two aspects--a psychic and a physical. It is, in other words, a psychoneurosis. The characteristic mental state is one of doubt, of indecision, of inadequacy, of restlessness, of tension, of discomfort and of dissatisfaction, which is more or less unappeasable and irrepressible and uncontrollable until it finds vent in a rather explosive series of motor expressions which, as it were, are the safety valve for the peculiar feeling of tension and discomfort which the individual has been experiencing and which is accompanied by a sense of relief, satisfaction and a relative degree of comfort and mental rest. The mental imperfection (Charcot) of the ticquer is a polymorphic psychic defect (Brissaud, Meige and Feindel) characterized by mental infantilism; for ticquers, like other psychoneurotics, are like big children. They have the mind of children, in respect to the emotional make-up.

The mental condition of ticquers is especially characterized by the imperfection or weakness of volition, by a certain degree of mental instability and lack of inhibitory control of the desires, tendencies, activities and motor expressions of the individual, this defect laying the groundwork for the impulsions and obsessions, as also for hysterical, so-called neurasthenic, hypochondriacal, depressive and so-called dementia praecox reactions. The tic movement is the symbol of the psychic defect or degeneration or instability.

The earlier investigators were responsible for the differentiation of the tics from such other conditions as Sydenham's chorea, Huntington's chorea, the spasms, the stereotypies, the habit movements, the myoclonias, and other allied conditions. It is due to their pioneer work that tics were recognized as a definite and distinct clinical entity. The process of disintegration of these various movements and their differentiation one from the other cannot be overvalued. Among those who have contributed most to this subject may be mentioned Magnan and his pupils, especially Saury and Legrain, Gilles de la Tourette, Letulle, Guinon Noir, Pitres, Cruchet, Grasset, Trousseau, Charcot, Brissaud Meige and Feindel. Although Trousseau recognized the the ticquer was mentally abnormal, it was Charcot who first called definite attention to the psychic origin of the condition and to the fact that tic was indeed a mental disorder, a psychoneurosis, a psychomotor reaction. His lead was subsequently followed up by Brissaud, and by the latter's pupils Meige and Feindel, the latter two authors giving us a comprehensive discussion of the subject in their well-known classic. [1]More recently the Freudian school has attempted to dig down into the roots of the tree which ultimately sends forth its branches in the guise of tics.

[1] Tics and their treatment. English translation by S. A. K. Wilson. New York, 1907. This book contains an extended bibliography.

VIEWS OF THE FRENCH SCHOOL

The usual conception of tics, as laid down by Brissaud, Meige and Feindel,[1] may be stated as follows: Tic movements are physiological acts which were originally functional and purposeful in character, but which have become habits, apparently purposeless and meaningless. The motor reaction is the result of some external stimulus or idea (normal or abnormal) or both, which originally was necessary for the production of the tic movement, which latter eventually became habitual and automatic, and, owing to repetition, was executed, even in the absence of the external stimulus or idea, without apparent purpose or meaning. At first but little more than purposive habit movements, they finally became irrepressible acts which sought for expression, which were but little under the control of the will, which occurred in attacks varying in frequency, duration and severity, which decreased under distraction and generally ceased during sleep, which were increased in frequency and duration and severity by fatigue, emotional upset, mental unrest, conflict and strain, while the lack of inhibition and will power, the lack of self-control was the dominant mental state, leading to feelings of insufficiency, doubt, indecision and incapacity, and making the ground work for the psychasthenic reactions in the form of morbid impulses and obsessions, and for the hysterical, so-called neurasthenic and other morbid psychic trends.

The inherent or acquired neuropathic and psychopathic state is the basic condition which prepares the subsoil.

From a consideration of the motor symptom we may say that it is but a pathological habit, which, however, is apt to lead to the tendency toward or generation of an increasing number of such pathological habits.

Characteristic of tics we may mention their being conscious before and after but not during their execution, their being disordered functional acts, their impetuous, irresistible demand for execution, the antecedent desire, and the subsequent satisfaction.

The etiology of tics, as laid down by Meige and Feindel, may be summed up by stating that they occur most frequently in young subjects, less frequently in savages and animals than in the civilized, there is a psychic predisposition based on heredity (of a similar or dissimilar neuropathy or psychopathy) upon which Charcot laid great stress, imitation (especially in the young) plays a role, as also brain fatigue (emotion, mental upset and worry) and indolence, with the frequent exciting cause of an external or internal stimulus or an idea, which is the explanation of the origin, source, situation and form of the tic or tics present in any particular case.

Scattered references to emotional shock acting as a possible exciting cause of tics, as at times of obsessions, can be found in the literature. Dupre[2] has made such reference. Meige and. Feindel[3] themselves make the statement that "Fear may elicit a movement of defense, to persist as a tic after the exciting cause has vanished." They also state that "in ticquers the impulse to seek a sensation is common and also to repeat to excess a functional act."

[2] Soc. de Neur. de Paris, April 18, 1901, quoted by Meige and Feindel, page 54, of the English translation (reference 1).

[3] Loc. cit., p. 62.

Bresler[4] has called attention to the fact that the movements are in the nature of defensive and protective movements of expression and mimicry and originally in reaction to some external irritant or as the result of some idea, and he proposed the name "mimische Krampfneurose" for them. This is somewhat allied to Breuer and Freud's theory of hysteria.

[4] Quoted by Meige and Feindel, Loc. cit., p. 267.

The object of tic is some imaginary end, the influence of the will always being present in the beginning, although later it may be absent. Tics are of cortical origin, being coordinated and synergic, clonic or at times tonic[*] muscular movements, physiologically and not anatomically grouped, premeditated, purposive, of abnormal intensity, apparently causeless and inopportune.

[*] Cruchet objects to calling these tonic reactions tics.

Insufficiency of inhibition is the cause of the beginning and of the persistence of bad habits and of tics.

Tic is a sign of degeneration, in the biological and evolutionary sense, a degenerative neuropathic and psychopathic basis, as mentioned previously, being present, although often latent.

The maladie des tics is but the extreme form.

The onset is as a rule insidious, with a tendency to spread.

Spontaneous cures may occur, while Gilles de la Tourette's disease is but the extreme form of a condition in which antagonistic gestures are frequently adopted by the patient to adapt himself and to get to a state of rest.

This, as I see the situation, is as far as the French students of this subject (including Brissaud, Meige and Feindel, and even Janet) have permitted themselves to go. And, in my opinion, their observations and conclusions seem to be quite accurate.

VIEWS OF THE FREUDIAN SCHOOL

Recently the Freudian school has endeavored to penetrate more deeply to the nucleus of the problem and to solve it. Freud has delimited what he calls obsessional or compulsion neurosis (Zwangsneurosis), which is classed under psychasthenia by the French and under neurasthenia by others. The Freudians regard this as a distinct neurosis, sometimes complicated by neurasthenic or hysterical symptoms. The characteristic symptom is a feeling of compulsion. The symptoms may be motor (obsessional acts, impulsions), sensory (obsessional hallucinations or sensations), ideational (obsessions), and affective (obsessive emotions, particularly doubt and fear). In this condition we find that there is an excessive psychical significance attached to certain thoughts. Obsessions are characterized by dissociations from the main personality. They thus exist in the unconsciousness. The original unconscious mental processes have brought about, by displacement, an excess of psychical significance to these thoughts. Ernest Jones[5] states that Freud found, by his work in psychoanalysis, that obsessions represented, symbolically, the return of self-reproaches of ancient, infantile and early childhood origin, which had been repressed and buried until the obsession made its appearance. "They always refer to active sexual performances or tendencies;" and, as Jones further explains, "there occurs early in life an exaggerated divorce between the instincts of hate and love, and the conflict and antagonism between the two dominate the most important reactions of the person. A fundamental state of doubt, an incapacity for decision, results from this paralyzing doubt. The patient oscillates between the two conditions of not being able to act (when he wants to), and of being obliged to act (when he doesn't want to). The symptom symbolizes the conflicting forces. These are not, as in hysteria, fused into a compromise-formation, but come to separate and alternating expression; one set of manifestations, therefore, symbolizes the repressed forces, another the repressing."

[5] See his article on "The Treatment of the Psychoneuroses," White and Jelliffe's Modern Treatment of Nervous and Mental Diseases, Vol I, pp. 408-409.

To put the matter plainly, the Freudians contend that obsessions are symbolical representations of the repressed sexual activities and tendencies of infantile and early childhood origin. It must be remembered that the Freudians employ the term sexual in a very broad sense, including under it the most indirect and distant physical, mental and moral reverbations. conscious or "unconscious," of the relations between the sexes. The sexual impulse is here conceived of as having incestuous, bisexual and polymorphous perverse sexual tendencies. The word sexual is not only used as synonymous with love, but practically all emotional surgings, all feelings, all affectivity, all sense-cravings and bodily heavings are classed by certain members of the Freudian school as sexual. This latter interpretation and extension of the connotation generally accorded by us to the term sexual we surely have no right to give it.

Clark, of New York City, is the author who has carried out the Freudian idea to its ultimate conclusion. I refer to his series of three papers[6] in the Medical Record, and call particular attention to his last (third) paper in which he has fully elaborated his theory of the meaning of tics.[*]

[6] His three papers, which appeared in the Medical Record, New York, in the issues of February 7 and 8, and March 8 1914, are entitled: (1) "Some Observations upon the Etiology of Mental Torticollis," (2) "A Further Study upon Mental Torticollis as a Psychoneurosis," and (3) "Remarks upon Mental Infantilism in the Tic Neurosis." A fourth paper by Clark on tics appeared in the Medical Record of January 30, 1915.

[*] J. Sadger has also come to similar conclusions.

Clark's conception of the meaning of tic movements and of the mental state characteristic of ticquers must be here given. Although not denying the basic neurotic constitution present in ticquers, Clark sums up by giving the following definite and fully developed theory:

"The ticquer has a strong sexual attachment; this is so strong that the love instinct ineffectually sublimates the hate instinct and in the warring conflict doubt and physical and psychic inadequacy arise. The situation continues and generates mental, and physical infantilism, which in turn make for increased feelings of tension. Motor and psychic restlessness succeed. The motor expression manifests itself most often in habit movements of disguised sexual significance (autoerogenous pleasures) a form of physical stereotypy, in its broadest psychophysical meaning. The mental state often pari passu takes up obsessive thinking and various physical acts and thoughts are formed as defense mechanisms, born of conscious guilt. The motor habits are usually inhibited or displaced in part, and the tic remains as a motor symbol, usually in itself non-sexual, as a fragment of the former complete habit movement. The mechanism of the completely evolved tic is either a conversion (hysteric) or substitution (obsessive) mechanism or both."

By these who have studied Freudism this will, in a way, be understood. For these who have not it may be more difficult of understanding without somewhat further elaboration or explanation. In this connection I must again mention that the Freudians include tics under their obsessive (obsessional) neuroses. The theory of the mental mechanisms and evolution of these states is given in the attached quotation, which is taken verbatim from Clark's paper.

"The affect of the painful idea does not become transformed into physical symptoms, as in the conversion mechanism of hysteria, but affixes itself to other ideas not in themselves unbearable, thus producing by this false relationship a substitutive symptom or obsession.

" . . . In all such obsessive neurotics the transformed reproaches which have escaped repressions are always connected with some pleasurably accomplished sexual act of childhood but may be almost entirely lost. The obsessive acts really represent the conflict between impulses of opposite instincts, love and hate, which are usually of equal value. The warring conflict engendered makes for a curiosity to discover the meaning of life forces (sexual largely) and the desire to know the end thereof. The nuclear-complex of all this is a precociousness of emotional life and an intensive fixation on one or the other parent or brother or sister. The intensive love fixation waxes the stronger as the unconscious hate requires increased barriers against its breaking through into the main or everyday personality. As a result of these conflicts the will is partially weakened, there is an incapacity for resolution, first in the realm of love alone; then later succeeds a diffusion or displacement of the mechanism all over the field of activity. A series of secondary defense mechanisms are now brought in and these may enable the obsessive person to get square in a limited way (as religious practices enable many to do). Some special adaptation is required sooner or later, and the individual, having used up all the helps, then falls back upon the different forms of obsessive acts and thinking. Thus the obsessive neurosis is generated."

Clark then proceeds to explain:

"If one is not permitted to draw deductions from a few data as to the further genesis of the tic disorders, we may still hold out a tentative hypothesis, pieced together from many sources that a certain type of nervous make-up is inherited. In such the emotional life is precocious much beyond the intellectual faculties. The ticquer in infancy has the emotional feelings of love and hate of an adult. Their very precociousness aids the parental fixation and adhesion, and makes it the more difficult for the libido to detach itself at the proper age. One should bear in mind that the parental fixation in itself does not directly produce the mishaps of adult life but this small fault in infancy generates wider and wider maladaptations as development progresses. It is these latter glaring faults and trends that make for the character defects, and these really break down the final effort at adaptations and adjustments producing the tic or obsessive disorder. But the essential nucleus of the defect is lack of balance, precocious parental fixation, and continued attachment to the parent-stem, that makes the adult defect possible. The very infantile precociousness of the emotions argues for the hereditary transmission of destructive temperamental qualities. Here, as elsewhere in tracing hereditariness in so-called functional nervosities, one should take as the unit character for study the mental traits or trends and exclude definite disease entities applied to ancestral disorders. I believe it is not too suppositious to think that many of these variant individuals are really atavistic in makeup and have continued from one generation to another special defective traits of emotional makeup which are fortunately denied the average individual."

The writer cannot understand how the theory which he has taken the trouble to so fully present in the above quotations can be maintained. Jones and Clark both assert that the tics or habit spasms as probably of the same nature as the obsessions in general. Moreover, Jones agrees that "familiar examples of compulsion in a slight degree are the obsessive impulses to touch every other rail of an iron fence as one walks past, to step on the cracks between the flagstones of the pavement, or not to step on them, and so on." A little reflection will show us the impossibility and illogicality of viewing all these conditions as being fundamentally of sexual origin. Let us follow the argument. If tics are of sexual derivation, as the Freudians here openly maintain, then it must follow that those familiar examples of compulsion, such as the obsessive impulse to touch every other post, etc., are likewise of sexual origin. This conclusion is forced upon us, since, even according to Jones, the only difference between the marked tics and the lesser manifestations is one of degree.[*] Now, these slighter impulsive tendencies to which we have here referred are very frequent in all children and by no means infrequent in grown-ups. They are habitual movements, which may be of transient duration only or may, by repeated performance, develop into more or less fixed habits. If, then, these habits are of sexual significance, it must follow that all other habits, especially if associated with a certain degree of consciousness or awareness, are in like manner symbolical of the past infantile and early childhood sexual activities and tendencies. This conclusion is, as is seen, inevitable, if we believe in the Freudian theory of the pathogenesis of the tics. However, since this leads us to a reductio ad absurdum, we must, of course, reject the explanation which has been offered by the Freudian school.

[*] The accompanying mental state characteristic of ticquers is absent in habits. We can stop doing the latter when our attention is directed to them; not so in tics Meige and Feindel have discussed these and other differences.