E. Feindel

“ My tics upset my pince-nez, and I have to invent another tic to get it back into place. The absurdity of this vicious circle does not escape my observation, and I know I am its author, yet that cannot prevent my becoming its victim.
When the pince-nez is not in use I toy with the spring or with the cord, and a day seldom passes without my breaking the one or the other. As I wear spectacles at home one might suppose their relative stability would check my tricks; but their pressure on my temples and ears only serves to provoke fresh movements in a search for comfort. ”

“ Every evening before the return of her father she repeatedly looks into the corridor to see that no one is there; as soon as her parent arrives, she locks the door behind him hurriedly to prevent any one else appearing; every now and then in her fear of a footstep she listens at the door, and it is this gesture, this attitude of listening, that has degenerated into a tic which no amount of remonstrance or derision seems to affect. ”

“ 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. ”

“ This little matter has developed into an obsession. His loathing of cold water is so pronounced that his morning toilet is rather a stormy proceeding, and as he is too old to be washed by his mother, the inevitable result is that his face and hands are never clean. At school he is both attentive and docile, finding pleasure in his study of the classics, but evincing a perfect passion for German. Anything German is a source of ineffable joy, so much so that he hugs his dictionary with childish exuberance. ”

“ Yet here, again, peril lurks in too hasty a generalisation. To give the disease a name is not equivalent to pronouncing a diagnosis. The denominations "myoclonus," "muscular dystrophy," "degenerate," are alike inconvenient. Their scope is at once too inclusive and too exclusive. They may be indispensable; they are assuredly not sufficient.
The possibilities of misapprehension do not end here.
The manifestation of each and every tic—be it a flicker of the eyelid, a turn of the head, a cry, a cough—is through the medium of a muscular contraction. ”

“ As he grows up he passes by easy transitions from the voluntary to the automatic stage. He is taught to swim, and swimming soon rivals walking in the unconcern with which the movements are executed; he learns to write, and no less rapidly does the act become one of unconscious familiarity; his games, his exercises, the labour of his hands—be it digging or typewriting—all reach the level of regular automatism; in short, they are functional acts as truly as locomotion or even respiration, with the qualification of being neither essential nor general. ”

“ Results that steadfast and patient nurses and teachers are obtaining in an institution like Bicêtre may surely be obtained by the physician in his private practice, if the parents of a youthful candidate for tic would appreciate the importance of discipline and unite, intelligently and assiduously, in the task of education. How common it is to find them solicitous only of loading his tender brain with learning, instead of endeavouring, with all their mind and heart, to restrain deplorable bad habits that may one day blossom into tics, to the distress of all concerned! ”

“ If we are normally constituted, we betray a pleasant idea by a smile, we express our conviction by an appropriate gesture of affirmation; if we smile or gesticulate with no motive for doing either, we have begun to tic. It is not sufficient that the act be untimely at the moment of execution; we must be persuaded that it no longer stands in any relation to the idea which called it forth at the first, and that its repetition is excessive, its inappositeness constant, its performance urgent, and its inhibition transient, before we can say it is a tic. ”

“ It is as arduous a task to define the term "stability of the will," as it is to explain what is meant by physical or mental health. But as it is not essential to preface descriptions of disease with a disquisition on the signs of good health, so anomalies of voluntary activity may surely be noted without a preliminary excursus on normal volition.
Will power may deviate from the normal in either of two directions—in the direction of excess or of insufficiency. To both of these two forms of volitional disturbance the subjects of tic have become slaves. ”

“ 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. ”

“ A gesture which seems meaningless and useless to-day becomes intelligible and logical to-morrow, when we learn the reason for it. In the course of an attack of conjunctivitis a patient acquires the habit of winking his eye, and though the inflammation subsides, the habit persists. If we are ignorant of its cause, are we to call the tic convulsive since it appears to us needless? And if we do know its origin; can we say it is co-ordinated when one muscle only is involved in the contraction? ”

“ At first, cortical intervention is inharmonious and unequal: the child is vacillating and volatile; he is a creature of sudden desire and transient caprice; he turns lightly from one interest to another, and is incapable of sustained effort; at once timid and rash, artless and obstinate, he laughs or cries on the least provocation; his loves and his hates are alike unbounded. ”

“ The physician's earliest duty is to warn the parents of the dangers of indifference, and thereafter to install himself as teacher, if the disease should manifest itself in spite of his precautions. He has no choice in the matter, and he should have the frankness to say so, indicating at the same time on what his convictions rest. He need have no fear of damaging his professional prestige by the simplicity of his methods. Let him not promise what he may not be able to perform; encouragement, not deception, must be his watchword. ”

“ At the other pole from these silly fears and dislikes we meet with various absurd predilections and meaningless attractions: one can sit only on a certain seat, sleep only in a certain bed; another cannot enter a room except by a particular door; a third will make a long detour to pass along a certain street; in this street he will always walk on the same side, and lengthen or shorten his stride to step always on the same flagstones. ”

“ An obsession ought to be called an obsession, and there ought to be a similar understanding in the case of phobias and fixed ideas, for each and all may exist independently of any motor reaction whatever, and therefore can never be classed with tic. It is only when the obsession or the fixed idea entails the automatic repetition of some motor phenomenon that a syndrome can be constituted to which the name of tic may be applied. As a matter of fact, a tic can no more be exclusively mental than exclusively muscular. ”

“ After what has been said of the rôle played by psychical disorders in the genesis of tic, we can readily comprehend the reason for this. The intensity and tenacity of any tic are determined by the degree of volitional imperfection to which its subject has sunk. He who can will can effect a cure; be it a simple tic, or be it a case of Gilles de la Tourette's disease, if he can struggle long and energetically, the tic's doom is sealed. Permanent cures have undoubtedly been obtained, but they are the exception. Left to himself, the victim to tic can seldom escape from it. ”

“ I have had an opportunity (says Séglas) of observing an instance of aerophagia in a woman of fifty-four years, who for the last fifteen years has been suffering from hypochondriasis in a delusional form. She believes she has a hole in her head, and that her brain is gangrenous; she is no longer conscious of her body, nor of her food as it passes through. "It is like a cupboard empty of everything but air." Grafted on this delusion is an aerophagic tic, upon which the patient relies in support of her contentions. ”

“ The execution of a functional act at an inopportune moment constitutes another variety of functional disorder. A smile with no pleasant thought to correspond; a cry, a word, that betoken no precise idea; a gesture to relieve an irritation that does not exist; a chewing movement when the mouth is empty—all are examples of untimely, inappropriate functional acts, which merit the name of tics if in addition they are anomalous as regards rhythm, amplitude, and intensity. ”

“ Before isolation is resorted to, it is important to familiarise oneself with the patient's mode of life, to ascertain whether it is capable of modification in accordance with one's ideas for treatment, and to determine the exact influence of his environment on him. We have frequently had occasion to remark how potent is this environment as an etiological factor; with young people, in particular, negligence on the part of parent or guardian places the child in jeopardy. ”

“ If, when asked what a rattle is, we make a turning movement with our hand, or if when asked to explain the word brandebourg we indicate an imaginary arrangement of braid on our coat—these two experiments always succeed—we are attempting to express an idea by mimicry at the actual moment of its arising in the mind; but the subject of a tic—which may primarily have been the representation by mimicry of an idea—continues the gesture long after the idea which provoked it has vanished. ”

“ 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. ”

“ Concentration of the attention may diminish the intensity or even inhibit the occurrence of a tic; inversely, a simple bad habit is manifested preferably during this very concentration. In the heat of physical or intellectual labour, we have all our favourite and characteristic tricks: we curl our moustache, we twist our beard, we scratch our forehead, we rub our chin, we nod our head, we fidget with our fingers in reading, speaking, reciting—in any mental or physical exercise requiring our attention we reveal innumerable little oddities of movement ”

“ A man will learn the habit of perpetually smoothing his hair, and will not desist from his favourite trick though he become absolutely bald.
But such automatic habits and mannerisms are not genuine tics so long as the movement executed conserves in form the characters of a normal gesture. Be it never so inopportune or absurd, it is not a tic. It comes rather under the heading of stereotyped acts, whose kinship with, and difference from, the tics, have been well demonstrated by Séglas. ”

“ I have often stood on the edge of the pavement waiting for a vehicle to pass, and at the moment of its approach darted across just under the horse's nose. On each occasion I have been conscious equally of the absurdity and yet of the irresistibility of the idea; each time the attempt to withstand it has been labour lost. ”

“ If we define a habit, in the words of Littré, as a "disposition acquired by the repetition of the same acts," we can easily conceive how intimate is the relation between habit and automatism, and how constant rehearsal of the same movement in the same manner will create a mode of motor reaction independent of the function of the will. It has been made clear already that the phenomena of tic, regarded from the motor standpoint, reveal an identical process at work ”

“ Any one who can use a pen with his right hand is not long in acquiring the faculty of mirror writing with his left. In this way the simultaneous execution of a normal movement with right hand and left is facilitated, and the sound limb imposes regularity on the other. Whatever be the localisation of the tic or tics, this is the technique to adopt. It presents this advantage, that its combinations and permutations serve to stimulate the patient's interest, and he, at the same time, is required to keep a watchful eye on his involuntary actions ”

“ Mademoiselle R. cannot stand upright. She rests on either one leg or the other. Her left foot is never flat on the ground, but sometimes on the inner border, sometimes on the outer. The faulty attitude is readily enough corrected, though she declares she is ignorant of it. It is a sort of half clonic, half tonic, tic of the foot, whose slowness is on a par with that of all her other acts.
It is because clonic tics are so easily recognised that they are the most familiar, but we must not ignore another variety—viz. the tonic tics, corresponding to the tonic form of convulsion. ”

“ A radical cure is not without the bounds of possibility, but it depends greatly on the patient himself; his success is contingent on his faithful repetition of exercises long after the tic is gone; for while a cure results whenever the tic ceases to incommode its subject, fatigue or emotion on some future occasion may reawaken the tendency to involuntary movements, and only a methodically trained will can triumph over the temptation to relapse. ”