E. Feindel

IN movements of inspiration or of expiration the passage of air through a more or less contracted glottis gives rise to all sorts of sounds, some of which, under certain conditions, must be included in the category of tics.

The most elementary of these, and at the same time the most common (says Guinon), is the involuntary exclamation. In the midst of his tics and grimaces, a cry—ah!—escapes the patient's lips at intervals, a shrill, sudden, and momentary cry which interrupts his talk, or breaks in on a period of silence, and which he repeats only once or perhaps several times in succession. The thread of his conversation, nevertheless, is seldom if ever discontinuous, and his audience is witness of its rationality and accuracy of expression. Rather more complicated is the ejaculation "ouah!" Sometimes one meets with noises that are faithful reproductions of the sounds emitted by various animals.

Guinon is disposed to exclude such simple involuntary explosions as "ahem! ahem!" from the tics, though he admits the analogy to them. He says the sound exactly resembles the trifling little clearance of the throat which is repeated a thousand times a day by people suffering from chronic angina. We, however, are inclined to look upon it as an ordinary spasmodic reaction evoked by some laryngeal or pharyngeal irritation, which in spite of the removal of the latter continues to take place, and because of its meaningless repetition is fairly to be classed as a tic. All that we have said of blinking, for instance, is applicable in this connection.

Of course the embellishment of one's discourse with more or less audible expirations is of frequent occurrence: the hesitating eh ... eh ... to which children give vent in the recitation of their lessons is not confined to them alone. It can scarcely be maintained that these laryngeal noises are tics, since their production is coincident with the exercise of the faculty of speech; hence they are not unlike "functional cramps." On the other hand, the unexpected bark or gurgle that breaks the silence is a pure tic of phonation.[117] Those who suffer in this way reveal characteristic stigmata in the immediateness of the compelling idea and the exaggerated nature of the subsequent satisfaction. To unravel the intricacies of the origin of these tics is a matter of considerable difficulty, though probably imitation is not without influence in their genesis. Reference will be made later to a tic of this kind attributed by Charcot to imitation.

Among the insane similar cries are often the outcome of delusions. At the Congress of Limoges a case was reported by Briand of an old man who imagined himself transformed into a clock and swung his arms with pendulum-like regularity, indicating the hours by uttering raucous sounds at the proper intervals. However curious these sounds were, the fact of their being appropriate is decisive against their classification as tics.

Unmistakable tics of speech, however, do occur.

Speech is a complex of different muscular acts, and, being so, is liable to be disarranged in various ways, by defect in respiration, phonation, articulation, even in ideation. Organic affections aside, it is inadmissible to describe as tics each and all of the functional disturbances of speech that are not based on any discoverable material lesion of nerve centres. One must in fact distinguish between troubles of speech confined to occasions when the faculty is in operation and those that consist in not merely useless but inopportune utterance. However arduous it may occasionally be to draw this distinction, however common the occurrence of transitional forms, it has the advantage of limiting the scope of the term "tic of language." To the latter category only can the description be applied.

For this reason we think it preferable to exclude stammering, stuttering, and all defects of phonation or articulation whose existence is revealed only in the act of speaking. At the same time reference must be made to facts linking these functional anomalies to the tics, and to instances of the latter existing with or succeeding the former.

Such is the case with stammering.

According to Letulle,[118] stammering is a tic of speech whose beginning is a functional disturbance of nervous centres, as is that of tics in general. Holding as we do, however, that one of the features of tic is its appearance in season and out of season, we cannot class stammering as a tic, since its exhibition is restricted to the exercise of a certain function, viz. speech. It is therefore comparable to a "professional cramp," and we may briefly note the analogies it offers to the tics.

Stammering,[119] which in more than fifty per cent. of cases is hereditary, and associated with a neuropathic diathesis, usually betrays itself in childhood and becomes aggravated at puberty. The old idea which credited stammerers with exceptional intellectual powers, in whom, however, rapidity of thought surpassed rapidity of action on the part of the muscles of articulation, is exploded, and to-day those thus afflicted are assigned their true place among the volitionally infirm. In a few rare cases stammering has been due to organic disease of the centres for articulate speech, or of bulbo-pontine nuclei; it has been supposed also to result from genuine spasm on a reflex arc, and this is a possible explanation; as a general rule, however, the pathogeny of stammering is identical with that of tic. Its dependence on such affections of nose, larynx, and pharynx as hypertrophic rhinitis and adenoids has been emphasised by Biaggi[120]; and Derevoge,[121] in directing attention to the association of volitional enfeeblement with respiratory troubles, remarks that stammerers sometimes have a phobia for certain words. Many observers have been convinced of the psychical nature of the affection from the fact of its disappearance during singing, as well as from the effect anger, elation, and other stimuli have in momentarily inhibiting it. The same is of course true of the tics.

Further, little attempt is made either by the tiqueur or the stammerer to correct his failing, so that prognosis improves with the adoption of systematic treatment. Stammering is a functional anomaly; it is a derangement of respiration, phonation, and articulation. However normal be the movements of lips and throat in the execution of certain acts, they are far from being normal in the exercise of speech. As a preliminary to speaking the stammerer clenches his teeth and approximates his lips, thus effectually preventing the inrush of air except by the nares; simultaneously he contracts his tongue and obstructs the isthmus of the pharynx, while the glottis also may close spasmodically. Then he abruptly expands his thorax and inhales a considerable quantity of air, yet is he ever on the verge of breathlessness, for he cannot voluntarily arrest himself, or make a break between two respirations. He seeks to continue speaking though his lungs are empty of air; he cannot control expiration by antagonistic contraction of inspiratory muscles; often he finds himself unable to commence speaking at all.

The glottis is either open, allowing the silent escape of air, or it is completely occluded. In the midst of syllables or words the voice is frequently "cut" by a sudden halt indicative of spasmodic closure of the glottis. A contrast to the ease with which vowels are pronounced is provided by the difficulty experienced in the enunciation of various consonants. Convulsive movements of the lips frustrate the endeavour to form the series of successive positions which the consonants demand.

An association of stammering with convulsive phenomena of a different nature has often been remarked. Instances of this have been given by Janke.[122] One patient takes a few paces backward, limping with his left leg till he finds something to give him support, and knocking his shoulder several times against wall or furniture, as soon as he encounters it; if he is seated he rises slowly from the chair, holding it with his hands the while, and forthwith falls back into his seat in order to begin. Another taps his fingers on his thigh whenever the word he is about to utter commences with "g" or "k."

In Brissaud's clinique we have met with a couple of instructive cases:

The first concerned a showman who used to exhibit a series of dissolving objects by means of mirrors, and who found one day that he could not speak without scanning his syllables and explosively ejaculating his words; at the same time his conversation was punctuated by sudden and exaggerated shutting of the eyes and by facial contortions. After a pause the inauguration of a phrase was ushered by still more energetic and widespread spasms of the head and even of all the body.

The other was an eighteen-year-old Jewish boy, who before beginning to speak gave vent to a hard sound like "kh" four or five times in succession, each being accompanied by a violent rotation of the head to the right, wrinkling of the face, and a little jump. The patient then addressed himself to speak with the utmost assurance, there being no sign of tic or stammer unless he stopped for a moment and endeavoured to recommence. On the other hand, he could sing to perfection.

There may also be troubles of speech of a tonic kind, whereby a more or less complete and sustained mutism is produced, an excellent example of which has recently come under our notice:

To a similar affection characterised by total inability to speak in a high or a low voice, whispering only being practicable, the term "spastic aphonia" has been applied. It is at the moment when the patient wishes to speak that the spasm occurs, as in a case reported by Hasslauer,[123] which resisted all treatment and was considered by him to have features in common with hysteria and occupation neuroses.

There can be little doubt that the arrest of movement in these cases is comparable to what obtains in writers' cramp, and therefore, rigorously speaking, a tonic tic.

A case has been recorded by F. Pick[124] of a man of thirty-eight years of age afflicted with convulsive movements of the face and troubles of speech.

Another instance is referred to by AimÉ[125] under the name of tic of elocution, where the combination of convulsive movements of neck, shoulder, and arm with spasm of articulation of eight years' standing disappeared under the influence of methodical re-education.

Kopczynski cites the case of a man with facial and other tics who used often to utter a long string of words or even a whole sentence in an extremely monotonous voice, resuming his natural tone thereafter; occasionally, too, he used to pause in the middle of a remark for as long as forty seconds.

Mention must be made here of true spasms of phonation or laryngospasms, the result of local irritation, which disappear with its removal. Central lesions, of course, might conceivably produce the same effect.

If now we direct our attention to the content of speech, we shall see how it too may reveal anomalies not unlike tics.

Letulle quotes the case of a man who could not utter four consecutive words without sandwiching a "sir" between them. Similarly, the "don't you know," "do you see," "you know," of so many people are repeated ad infinitum. One of us has an acquaintance who interlards his talk with "you understand," and this formula is reiterated without modification though he may be addressing his friend in the second person singular.

There used to be a poor creature driven by destitution to sell papers in the streets, or to figure as a negro in the corridors of the Hippodrome, who was wont to garnish his speech with a "Well, my boy! all right, by Jove!" repeated at intervals, whoever it was he happened to be speaking to, and even though it was their first time of meeting.

In Ibsen's play of Hedda Gabler is a character George Tesman, a weak being who begins every sentence with "I say, Hedda," and ends with a no less invariable "eh!"[127]

These habitual words and phrases—and many more instances may be cited—are analogous to the mannerisms exhibited during concentration of the attention on the performance of certain acts. They cannot be considered tics unless reproduced at other times as well. Moreover, while the use of such terms may be overdone, it can hardly be said to be unreasonable. However irritating their effect, they indicate simply an exuberance of style and a degree of inattention, not a grave mental shortcoming.

Of a less trivial nature is a curious anomaly that consists in the complication of speech by the introduction of meaningless expressions uncontrolled by the will. This is a functional defect very much akin to the tics.

A distinguished medical colleague was in the habit of muttering the word cousisi as he talked.[128] SÉglas described similar occurrences as "stereotyped acts of speech." One of the SalpÊtriÈre patients used to close every sentence with the phrase "in all and for all." Another's opening remark was always "Araken-Doken-Zoken." It is permissible to regard many of the neologisms imagined by the insane as examples of stereotyped speech. A patient, for instance, who suffered from delusions of persecution, said he was being pursued by the Evil Eye ("reluquets"—reluquer, to leer at). With the eventual disappearance of the association linking the original idea to the neologism, the patient may no longer be capable of explaining the meaning of the phraseology he has invented, but in the case of those whose mental level is more nearly normal the coining of new words need not be more than a sort of eccentricity, which is generally accompanied, however, by other indications of instability. We may remind ourselves of O., with his "vertigos" and "para-tics."

But if, finally, words or phrases escape the subject's lips at moments of silence, with whose imperious and unexpected emission he is powerless to cope, then we are dealing with true tics of speech. Their investigation has been conducted by Guinon with great analytical skill.

Such troubles are unmistakable tics. The mechanism of their production is identical, be the actual localisation brachial, facial, or laryngeal, and this applies in particular to the motor verbal hallucinations so excellently studied by SÉglas. As a matter of fact, tics of speech are often nothing more than the mode of exteriorisation of these hallucinations. The same is the case with verbal impulsions.

In this rubric of tics of speech we may class various cases recorded under differing titles, among which an interesting one due to Pitres may be quoted:

In the same connection Pitres refers to a case reported by Calvert Holland.

We may cite a last instance from Ball:

ECHOLALIA

In his description of the disease which bears his name, Gilles de la Tourette used the expression echolalia to denote a certain phenomenon of occasional occurrence among those who tic.

In spite of their frequency among those who are addicted to tic, echolalia and echokinesis cannot be enumerated with the tics, seeing that their exhibition is dependent on the actions of others, whereas once a tic is established it requires no stimulus from without for its manifestation. Of course their affinity to the tics is very close: they spring from the same soil; they represent in the adult the persistence and amplification of the child's propensity for imitation, and therefore in their own way postulate a degree of mental infantilism.

Echolalia in the blind has been made the subject of an interesting study by Noir.

Noir is inclined to apply this mechanism to the case of echolalics who are not actually blind. He quotes instances which go to show that their visual memory is awanting, that as far as it is concerned they are "blind."

The hypothesis is attractive. It may be further remarked that the echolalia is a "motor," in the same way as the patient afflicted with hallucinations of sight or hearing is an "auditory" or a "visual."

Echolalia is amenable to treatment, and is even capable of cure. Noir gives an interesting example of the evolution of the process.

Echolalia, however, is not an exclusive appurtenance of those who tic. We can remember a case of general paralysis in the clinique of Brissaud at the HÔtel Dieu, who had the regular habit of repeating the question that was addressed to him; if it were a little long, only the last ten or fifteen words were echoed. A case is quoted by Cantilena of a woman with right hemiplegia and partial epilepsy who invariably reiterated the closing phrase of anything said to her. Several cerebral tumours were discovered at the autopsy.

It is conceivable of course that an actual lesion, as well as a congenital developmental defect, may interfere with the will's inhibitory powers, in which case auditory or visual stimuli are transmitted to motor centres unmodified, the result being the production of sounds or of other movements.

COPROLALIA

Coprolalia, the manie blasphÉmatoire of Verga, is, according to Gilles de la Tourette, one of the most frequent affections of speech in the disease of convulsive tics.

There is no necessary connection, as a matter of fact, between tic and coprolalia, though of course they may co-exist, sometimes in association with other syndromes; they are in reality only episodic syndromes of hereditary insanity.

A distinction ought to be drawn between coprolalia and the use of trivial or inconvenient terms, words with which even some well-educated persons are wont to garnish their conversation. Guinon had a case of a man who in the presence of his mother resorted to language of a kind absolutely disallowed in polite society. In the etymological sense of the word, no doubt, he was a coprolalic, but it cannot be said that he was suffering from tic.

On the other hand, the abrupt and impetuous utterance of oaths or obscene expressions, to the ejaculation of which an irresistible impulse seems to drive the patient independently of time and place, amounts to a coprolalic tic of speech, and reveals a deplorable volitional debility on his part; for he is incapable of checking an act to the impropriety of which he is fully alive.

According to Guinon the reason of this bizarre preference for obscene remarks is absolutely unknown, although Charcot's view[129] that coprolalia is frequently nothing more than echolalia is one of some plausibility. He refers to one of his patients who alternated her coprolalic utterances with a sort of barking noise that was an exact imitation of her favourite dog.

We ourselves have had for a long time under observation a youth in the service of Professor Brissaud whom some instinct seemed to prompt to repeat any lewd expression he happened to hear, or indeed any which might be so interpreted. It might then be said of him that his coprolalia varied with his surroundings and with his own ideas; it was accompanied by inconstant and irregular convulsive movements of the limbs.

After all, there is not so very much to choose between the coprolalic and the individual whom impatience or anger forces to blaspheme or at any rate to utter words that do not form part of his ordinary vocabulary. And though the ejaculation be not audible, the first degree of coprolalia consists in the mental presentation of the objectionable phrase. Among those who suffer from obsessions mental coprolalia is far from uncommon. A patient with folie du doute, mentioned by SÉglas,[130] was afraid to pronounce indelicate words because he felt himself articulating them mentally, and sometimes he used to ask whether they had not really escaped him. One step more, and these verbal hallucinations assume the characters of a genuine tic.