Chapter IX: The Different Tics (2)

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

TICS OF THE TRUNK

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

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

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

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

TICS OF THE ARM AND OF THE SHOULDER

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

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

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

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

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

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

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

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

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

TICS OF THE HANDS--SCRATCHING TICS

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

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

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

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

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

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

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

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

TICS AND WRITING

Are writing tics to be recognised?

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

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

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

Another would write after almost every sentence:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

TICS OF THE LOWER EXTREMITIES--WALKING AND LEAPING TICS

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

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

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

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

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

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

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

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

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

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

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

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

Leaping tics are met with also.

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

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

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

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

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