ECHOLALIA

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 punctuatedby 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.

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:

A young girl, various members of whose family are stammerers, occasionally suffers from an extraordinary sensation of anguish in the course of conversation; she flushes and then becomes suddenly immobile, finding it impossible to articulate or even to utter a sound. Her glottis contracts forcibly; her efforts at expiration are ineffectual, or else the air escapes in little explosive puffs, and at the same time her lips twitch and her eyelids flicker. The whole seizure is over in a few seconds, whereupon the patient launches into conversation with volubility, until pulled up by a fresh attack. She shows remarkable acumen, moreover, in an analysis of her symptoms. "What happens is that I am suddenly overwhelmed with the fear of being unable to pronounce a given word, and at the thought my lips are sealed, I cannot make a sound, my throat is compressed, my tongue refuses to obey me, and my condition becomes one of abject misery." Curiously enough her phobia is not related to a particular word, and moreover her articulation is accurate and not embarrassed in presence of certain of the consonants. Phonation and respiration are implicated as well as articulation. The origin of this "cramp of speech" in psychical abnormalities is manifest.

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 treatmentand 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.

Whenever the patient tried to speak oral contortions and deviation of the tongue ensued, and hands and feet began to beat the air without his being able to utter a single word. The agitation was increased by emotion and diminished with volitional movement.

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.

Uchermann[126]has reported a case of recurrent attacks of mutism at intervals of five or ten minutes in a man of sixty-eight, examination of whose larynx during the seizure showed the glottis to be in spasm. Synchronously with these rhythmical clonic alternations of adduction andabduction occurred tonic contractions of the masseters and clonic contractions of the palate, tongue, and forearm. The phenomena had lasted for about a month when a right hemiplegia was superadded, and was followed by a fatal issue three weeks later. Unfortunately no autopsy was obtained to verify the observer's opinion of a lesion in the neighbourhood of the left precentral sulcus, involving the centres for mastication and phonation, for the tongue and for opening of the glottis.

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 repeatedad 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 ofHedda Gableris 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 wordcousisias 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 investigationhas been conducted by Guinon with great analytical skill.

At the upper end of the ladder among exclamations we meet words involuntarily and senselessly repeated, in a loud tone of voice, to the accompaniment of tics and grimaces. These expressions fall naturally into two groups that require to be rigorously differentiated.In the first of these the words uttered may be simply anything; each patient may have his own, and so their number is absolutely limitless. Occasionally one is in a position to discover in the antecedents of the case the reason for the choice of a particular word in preference to another, as in the instance of the man whose involuntary ejaculation, "Maria!" was the echo of a passion he had conceived years before for a young girl of that name.

In the first of these the words uttered may be simply anything; each patient may have his own, and so their number is absolutely limitless. Occasionally one is in a position to discover in the antecedents of the case the reason for the choice of a particular word in preference to another, as in the instance of the man whose involuntary ejaculation, "Maria!" was the echo of a passion he had conceived years before for a young girl of that name.

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:

Subsequently to his retirement from active business pursuits, the patient, a man fifty-nine years old, became depressed, morose, and irritable, till insomnia at length drove him in desperation to attempt suicide. By the merest chance he failed of his purpose. The development of involuntary sounds a few weeks later was followed at the end of a month by the equally involuntary ejaculation of his wife's and children's names—"Numa! Helen! Camille! Maria!" This habit persisted for as long as fourteen months, after which during three years he enjoyed excellent health. Owing to financial worries, however, a relapse occurred. Every few minutes he uttered various articulate cries in a loud, clear, and well-modulated voice, sometimes repeating the four names with great rapidity, at others calling out the same name with increasing violence. Severe convulsive twitches of arm and trunk musculature synchronised with his exclamations. The patient was incapable of either restraining or evenmodifying the cries; he was equally unable to replace one by another, to say Henry instead of Numa, or Jean instead of Helen.For hours at a stretch he would repeat the names of friends who had come to visit him; on the day before a consultation on his case his one cry was the name of the new physician who was going to examine him.A gradual improvement took place, and eighteen months after the onset of the condition the cure was complete.

For hours at a stretch he would repeat the names of friends who had come to visit him; on the day before a consultation on his case his one cry was the name of the new physician who was going to examine him.

A gradual improvement took place, and eighteen months after the onset of the condition the cure was complete.

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

A miner who had gone through the experience of incipient suffocation found himself two months later irresistibly impelled to exuberant speech. The rapidity and indistinctness of his enunciation of words were very much in evidence, as well as a tendency to stammering and to tautology. A further symptom consisted in rotatory spasms of the head; but after five months a satisfactory cure resulted.

We may cite a last instance from Ball:

A young girl was in the habit of kneeling down, making the sign of the cross, and repeating "Jesus, Mary, Joseph." The performance was limited to this order of events, but its practice in drawing-rooms and still more in thoroughfares led to her being certified as insane.

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.

The patient (says Guinon) repeats echo-like the sounds he hears around him, and like the echo his reproduction of them is more or less lengthy. In its mildest form the symptom may consist in the repetition of a simple involuntary "ah!" which some one near by has ejaculated, or the last word or two of some one's talk is mimicked, or in a more advanced stage the whole of a phrase is reproduced.As a general rule the "echo" is rather obtrusive, but its commencement at least may be very different, the patient being astonished to find himself repeating in a subdued tone of voice what he hears others saying; and, struggling in fear to rid himself of the habit, he ends by sinking into a state of actual anguish. It is at this moment that he failsto inhibit his impulses and gives vent to the word he has been endeavouring to check, which he may repeat loudly and violently in a sort of fury. The fidelity and clearness with which the utterances of others are imitated are remarkable.Sometimes by an effort of the will the patient is able to suppress, it may be imperfectly, the impulse to echo, so that while his tongue is under his control, his will gives rein to his other tics, and a regular muscular debauch takes place. In the mildest cases he can replace a word by a movement, by a little cough or an insignificant "ahem!" but not beyond a certain point, for he will thus restrain himself only when he is forewarned; a sudden and unexpected ejaculation in his neighbourhood will catch him off his guard.

As a general rule the "echo" is rather obtrusive, but its commencement at least may be very different, the patient being astonished to find himself repeating in a subdued tone of voice what he hears others saying; and, struggling in fear to rid himself of the habit, he ends by sinking into a state of actual anguish. It is at this moment that he failsto inhibit his impulses and gives vent to the word he has been endeavouring to check, which he may repeat loudly and violently in a sort of fury. The fidelity and clearness with which the utterances of others are imitated are remarkable.

Sometimes by an effort of the will the patient is able to suppress, it may be imperfectly, the impulse to echo, so that while his tongue is under his control, his will gives rein to his other tics, and a regular muscular debauch takes place. In the mildest cases he can replace a word by a movement, by a little cough or an insignificant "ahem!" but not beyond a certain point, for he will thus restrain himself only when he is forewarned; a sudden and unexpected ejaculation in his neighbourhood will catch him off his guard.

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.

The echolalic repeats abruptly and rapidly what is said by others in his presence. That he does not stop to reflect is attested by his mimicry of bizarre words, technical terms, even of idioms in a foreign language.It is an interesting fact that of twelve cases of echolalia that have come under our observation, fifty per cent. occurred among the blind. The coincidence is a rational one; blindness and echolalia are united as cause and effect. In the case of the person born blind the auditory memory is in such an advanced state of development that, if he be not very intelligent, he will seek to fix the sound of an auditory impression in his defectively organised mind as soon as he hears it, and being unable to whisper it mentally, he stimulates his auditory centres by a less delicate process, and forthwith repeats aloud the word he has just heard. This is why we meet with instances of the echolalic blind repeating a sentencebefore replying to it. It is instructive to note in this connection that the choicest example of echokinesis we have seen was in a deaf mute, in whom no doubt the visual phenomena were analogous to the auditory phenomena of the echolalic.

It is an interesting fact that of twelve cases of echolalia that have come under our observation, fifty per cent. occurred among the blind. The coincidence is a rational one; blindness and echolalia are united as cause and effect. In the case of the person born blind the auditory memory is in such an advanced state of development that, if he be not very intelligent, he will seek to fix the sound of an auditory impression in his defectively organised mind as soon as he hears it, and being unable to whisper it mentally, he stimulates his auditory centres by a less delicate process, and forthwith repeats aloud the word he has just heard. This is why we meet with instances of the echolalic blind repeating a sentencebefore replying to it. It is instructive to note in this connection that the choicest example of echokinesis we have seen was in a deaf mute, in whom no doubt the visual phenomena were analogous to the auditory phenomena of the echolalic.

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.

If I say to an echolalic, "Are you hungry?" he will instantly answer, "Are you hungry?" Under the influence of re-education the reply will eventually change to "Are you hungry? are you ...? Yes, sir, I'm hungry," then to "Yes, sir, I'm hungry," and finally to "Yes, sir."

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, themanie blasphématoireof 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.

The victims of this disease (says Guinon) have an extraordinary propensity for choosing the foulest and most indecent words, however elevated their position and correct their breeding. Reference may be made to the classic instance of the Marquise de Dampierre, who all her long life was in the habit of repeating certain immodest sayings even on the most solemn occasions.

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 withfolie 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.

TICis, from its nature, highly variable in its evolution; each tic has a development peculiar to itself. Mental differences among individuals have their counterpart in physical differences, in health as well as in disease, and a comprehensive sketch of the evolution of tic is therefore impracticable. We shall restrict ourselves accordingly to a few general remarks.

In the great proportion of cases of tic the onset is an insidious one. We have already made a sufficiently detailed examination into the pathogenic mechanism to obviate any repetition in this place, but we may note how unsettled the earliest manifestations are, how a tic may pass from one muscle or group of muscles to another, and even when its exciting cause is patent an apprentice stage always precedes its final establishment. Of the truth of this the history of J. provides an excellent instance. Another one is from Pitres:

A nine-year-old boy received a severe shock one day through being pounced on by some companions who were in hiding behind a wood pile, and though the emotion was of short duration, he commenced a few days later to exhibit involuntary muscular twitches of the upper part of his body, and to utter suppressed cries. The phenomena increased in violence and in frequency, and, in spite of treatment, a year later he was not freed of them entirely. For an unknown reason the tics renewed their activity when he was seventeen and continued so for the next three years, until a spell of Pitres' respiratory exercises effected a complete cure.

An evolution such as the above may be considered more or less typical of the great majority of tics.

We have seen that the tic may be localised indefinitely in one and the same muscle or muscular group, but its site may also vary from day to day. Two tics may co-exist and coincide, or a third may appear with the disappearance of the others. Unexpected resurrections may succeed periods of complete repose.

Tic always shows a tendency to invade; regarded as a functional act, it moves in the direction of greater complexity.

After involving the orbicularis, for instance, a tic will spread to neighbouring groups, in particular to those muscles whose synergic contractions form a special expression of countenance. That is why tics of the eyelids are associated with movements of the pyramidales, frontales, and corrugators. Tics of the lips or of the alae nasi very commonly extend to the corresponding elevators. It is not surprising that muscular groups accustomed to act in physiological unison should also be affected together (Noir).

Moreover, the fecund imagination of the victim to tic is calculated to facilitate the invention of all sorts of modifications, complications, parodies, and caricatures of the functional acts on which his tics are grafted.

Tics are constantly varying in amplitude, degree, and frequency; as O. remarked spontaneously, "We have our good days, and we have ourmauvais quarts d'heure." The sedative effect of rest, solitude, silence, and obscurity may be contrasted with the detrimental results of fatigue, noise, fear of ridicule, etc.

However incapable S. is of rotating his head to the right when requested to do so, the movement is executed with the utmost readiness should his attention be drawn in that direction. But if he hesitates, even momentarily, before looking round, he cannot then do so without the preliminary performance of all sorts of contortions, ending in a twist of his body through a half circle to the right. Sometimes he actuallyturns round two or three times, after the fashion of a dog chasing its tail. Let him have a pleasant visit, on the other hand, let him engage in a discussion, or be engrossed in a play, let him administer a rebuke to some one, and immediately his trouble is forgotten, his speech is accompanied with animated gestures, the vicious position of his head vanishes—in short, he becomes normal.

An intercurrent affection may act either as a deterrent or as a stimulus; with convalescence, however, there is usually a re-establishment of the mischief. The most potent influence over the phenomena of tic is wielded by a sense of well-being, to employ Janet's discriminating expression. Well-being is a panacea for thetiqueurno less than for the hysteric. The tic of the worried financier disappears, as we have had occasion to note, under the magic of a rise in stocks or a knowledge of solvency. The child's happiness is bound up in his freedom, which explains the cessation, in Tissié's little patient, of all convulsive movements during the holidays.

Much evidence is forthcoming to support these points, but we must admit that the why and wherefore of a tic's amelioration or aggravation often escape us, nor must we forget that both in the child and the adult spontaneous cure is not unknown.

As has been remarked, the evolution of tic does not lend itself to systematic description, but there are cases that form an exception, their course being regularly progressive. Strictly speaking, they are instances of Gilles de la Tourette's disease.

Under the title, "Study of a nervous affection characterised by motor inco-ordination, and accompanied with echolalia and coprolalia," Tourette[131]grouped together,in 1885, a certain number of cases presenting features in common and so enabling him to describe a morbid entity, specially remarkable for its progressive evolution. He was followed in the same line by Guinon, who supplied an account in nosographical form, and since then the disease has figured in all the text-books.

To obtain a schematic picture of the condition we shall borrow from Tourette's[132]last communication on the subject:

About the age of seven or eight a little boy or girl—for the sexes are affected equally—commonly with a wretched family history, begins to exhibit a series of tics. The attention of the parents is soon drawn to the fact, but they seldom give much heed at first, since the twitches are limited preferably to the facial musculature. At this stage, too, expiratory laryngeal noises are occasionally superadded.The movements may be confined for a long time to the face, but under the influence of causes very difficult to determine they gradually invade the shoulders and the arms. First one shoulder is shrugged and then the other, then the trunk is inclineden masseto right or left; then the patient waves his hands or his arms, or bends backwards and forwards, or jumps up and down, flexing the knees alternately and tapping with his feet. The muscles of the larynx sometimes participate in the abnormal functioning, whence it is that many sufferers from tic give vent to quick expiratory "hems" and "ahs," which coincide often with the twitches of trunk and limbs.The disease may be limited to this stage, but it is not uncommon to find, a few months or years after the beginning of the facial movements, that the inarticulate laryngeal sound becomes organised and develops in a particular direction, thus, in a sense, showing a pathognomonic value. Under the influence of causes whose action we are, in the majority of cases, powerless to appreciate, the patient gives vent one day to a word or short phrase of a quite special character, inasmuch as its meaning is always obscene. These words and phrases are exclaimed in a loud voice, without any attempt at restraint. There must be a complete absence of the moral sense where there is coprolalia such as this; at the moment of the ejaculation some irresistible psychical impulse must drive the patient to utter filthy words unreservedly and with no consideration for other people.Another psychical stigma—echolalia—is occasionally, though less frequently, observed in these cases.

The movements may be confined for a long time to the face, but under the influence of causes very difficult to determine they gradually invade the shoulders and the arms. First one shoulder is shrugged and then the other, then the trunk is inclineden masseto right or left; then the patient waves his hands or his arms, or bends backwards and forwards, or jumps up and down, flexing the knees alternately and tapping with his feet. The muscles of the larynx sometimes participate in the abnormal functioning, whence it is that many sufferers from tic give vent to quick expiratory "hems" and "ahs," which coincide often with the twitches of trunk and limbs.

The disease may be limited to this stage, but it is not uncommon to find, a few months or years after the beginning of the facial movements, that the inarticulate laryngeal sound becomes organised and develops in a particular direction, thus, in a sense, showing a pathognomonic value. Under the influence of causes whose action we are, in the majority of cases, powerless to appreciate, the patient gives vent one day to a word or short phrase of a quite special character, inasmuch as its meaning is always obscene. These words and phrases are exclaimed in a loud voice, without any attempt at restraint. There must be a complete absence of the moral sense where there is coprolalia such as this; at the moment of the ejaculation some irresistible psychical impulse must drive the patient to utter filthy words unreservedly and with no consideration for other people.

Another psychical stigma—echolalia—is occasionally, though less frequently, observed in these cases.

Such, then, is Gilles de la Tourette's disease, a clinical type of which many examples have been recorded. We do not think, however, that all tics can be brought under the same category; we lose sight of its distinguishing features if we make the attempt. Of coursefrusteand atypical cases are encountered, but even in them it is rare not to find a certain degree of mental instability in dependence on which echolalia and coprolalia rest, so completing the morbid syndrome, and it is important to recognise the successive development of these various constituents.

It is, indeed, this evolution of symptoms which is so characteristic of Gilles de la Tourette's disease. A careful scrutiny of recorded cases of tic, however, makes it abundantly clear that they do not all belong to the disease of convulsive tics; their localisation, form, and progress are so different that the effort to assimilate them to Tourette's disease would abolish the nosographical value of the latter. One patient may have an ocular tic all his life, and nothing else; the affection of another may be limited to a tic of the shoulder and arm; a third blinks and makes a facial grimace; a fourth is a coprolalic who has never suffered from tic. Are they all to be considered incomplete cases of the disease of convulsive tics? To answer in the affirmative is equivalent to a failure to appreciate the distinctive characters of a judiciously isolated syndrome, and a refusal to describe tics as they are met with in everyday life. One questions, in fact, whether some of the cases allotted to Tourette's disease really conform to it. Take an instance from Chabbert[133]:

A woman, aged forty-two, had had an injury to the left side of her face at the age of nine, as a result of which appeared a convulsivefacial tic, accompanied at times by hysterical attacks which continued for eight years. The tic itself, an abrupt contraction of the inferior portion of the left orbicularis palpebrarum, underwent no subsequent change, in degree or extent. At a later stage a fairly definite tendency to coprolalia became manifest.

An unvarying post-traumatic palpebral tic in an hysterical subject cannot be said to constitute the syndrome of Gilles de la Tourette, in spite of the coprolalia.

In another of his cases the diagnosis is no less open to doubt:

The son of the previous patient was a youth of nineteen, with a bad heredity on the father's side. In boyhood he had been a somnambulist. Some months previously to his coming under observation he developed a convulsive tic limited to the frontalis. Stigmata of hysteria were present in dyschromatopsia, restriction of the visual fields, and left hemihyperæsthesia.

A third case reported by the same author does probably belong to the disease of convulsive tics:

A woman aged forty-four, of a strumous diathesis, exhibited tics of face and limbs, occurring in the form of attacks sufficiently violent to cause bruises, attacks which were invariably associated with coprolalia. In addition, she suffered from echolalia, echokinesis, andfolie du doute.

We can only repeat, of course, that each type of tic passes by insensible gradations into others that precede it or succeed it in the hierarchy of tics; but we must, provisionally at least, neglect the links that unite neighbouring groups if we are to avoid losing sight of admittedly distinctive characters in too comprehensive summaries. It is desirable to retain the term "disease of convulsive tics" for those cases whose progressive evolution ends in the generalisation of the convulsive movements, to the accompaniment of coprolalia and sometimes of echolalia. This clinical form represents the most advanced degree attained bythe disease; it might be called the tic's apogee. From its psychical aspect, moreover, the development it undergoes may culminate in actual insanity.

According to the teaching of Magnan, the disease of convulsive tics does not constitute an entity, since each and all of its symptoms may occur separately as episodic syndromes of degeneration. The general considerations with which we introduced our study are applicable in this connection, and we shall be content to say with Noir:

We cannot deny the validity of the objections raised by Magnan and his school; but the fact that these various symptoms may and do most frequently occur singly is no reason for expunging the disease of Gilles de la Tourette from the text-books. The combination of these symptoms constitutes a clinical entity which has a specific evolution, and while its subjects are degenerates in the sense of Magnan and of Charcot, they may be ranged by themselves in a very definite group.

In some cases which apparently come under this category, psychical disturbance has not been a prominent feature.

Sciamanna[134]is the reporter of a case where a young man with neuropathic antecedents was afflicted with tics involving various muscular groups; his intellect, however, was normal, and the only psychical change was an insignificant disorder of affectivity.

In such a case it would be instructive to know the mental condition after the lapse of some years.

Two typical examples of Tourette's disease have been described by Köster[135]as "disease of impulsive tics"; a third case—in which widespread muscular twitches, the muscles of respiration and the cremastersincluded, were coupled with sometimes a monotonous intonation and sometimes a jerky speech, though psychical functions were unimpaired—is considered by Kopczynski[136]to be a case of convulsive tic, which he distinguishes from the "disease of convulsive tics."

A last instance, published by Innfeld[137]as a case of "chronic progressive muscular spasm," is an unmistakable example of tic, in spite of the author's declaration that it does not correspond to any known morbid type and his attempt to liken it to chronic chorea. A boy of fifteen exhibited convulsive movements which had begun in the facial musculature and thence spread to the head, shoulders, and hands, and were accompanied with respiratory noises and involuntary exclamations. There was no alteration in sensation or in reflectivity, or in electrical excitability. Sleep banished while emotion aggravated the movements.

If the disease of Gilles de la Tourette, by reason of the uniformity of its symptomatology and the regularity of its evolution, justifies its differentiation as a separate entity among the tics, a comparison of it with another type, of polymorphic manifestation, irregular evolution, and uncertain duration, may prove instructive. We refer to the affection described by Brissaud as variable chorea.

The form of the motor reactions in this condition warrants the application to it of the term chorea, but the analogies the disease presents to tic are very close,nevertheless, and sometimes the two occur in the same individual. Patients suffering from variable chorea reveal the same mental abnormalities as are found among those who tic, while the troubles of motility are sometimes so similar to what we meet with in the latter that Gilles de la Tourette regarded the condition simply as one form of convulsive tic, the more so that it is occasionally accompanied by explosive utterance and even coprolalia.

This view, however, is calculated to obliterate the distinctive characters of the two affections, and ought not to be entertained. We cannot do better than repeat Brissaud's original description:

The use of the word chorea need occasion no ambiguity: the chorea consists in the appearance of meaningless and apparently idiopathic involuntary movements, whose repetition during rest and action alike is proof of their irrationality and incongruity; the duration of the symptoms may be limited as in chorea minor or Sydenham's chorea, or unlimited as in chorea major or Huntington's chorea. "Variable" is the epithet we apply to the chorea because of the lack of uniformity in its exteriorisation, the irregularity of its development, and the inconstancy of its duration. It comes and goes, waxes and wanes, vanishes abruptly to reappear unexpectedly; it is a neurosis without a characteristic march.Notwithstanding the fact that we are dealing with a chorea—that is to say, with a disease which is almost as readily recognisable by the public as by any professional—the difficulty of fixing its onset is paralleled by the difficulty of knowing when it has ceased. This uncertainty is explained by the facile and changeable nature of the patient; until the condition is revealed by unmistakable signs it passes for an insignificant muscular caprice of no pathological importance, while its disappearance is not associated with any particular modification of the patient's ways.There is a natural tendency to identify all "nervous movements" with myoclonus, but the conception is a remarkably nebulous one, and means nothing more than "muscular twitch." On the other hand, it is well understood that "nervous movements" are more or less sudden movements of limbs, shoulders, face, always involuntary and generally increasing in force and frequency with the nervous state of the patient.Parents say, for instance, that their child has become more restless and irascible, and at the same time that he has had "more movements of the nerves." The coincidence is unfailing. Is the expression "nervousmovement" lacking in precision? Yet it signifies what it is intended to signify. We are concerned neither with tonic convulsions nor with clonic spasms, nor yet with tics of habit; what the term stands for is a complex contraction, brisk but not violent, closely allied to the simplest of automatic acts, such as a step in advance, a shrug of the shoulders, a frown, a sigh, a moan, a crack of the fingers, an exclamation—in any case usually a gesture of impatience. The whole thing, however, is so variable and fugitive, that it cannot be said to constitute a definite convulsive phenomenon. The contractions, further, in spite of their complexity, escape the notice of their originator, who is quite surprised at being asked the meaning of the movement he has just made, as he is almost entirely ignorant of it.Briefly, the "nervous movements" of which we have been speaking do not belong either to myoclonus or to tic, but owe their distinctiveness to their multiplicity and inconstancy. At the same time they are always grafted on a certain neuropathic diathesis akin to that of chorea; in fact, they are nought else than a form of chorea themselves.

Notwithstanding the fact that we are dealing with a chorea—that is to say, with a disease which is almost as readily recognisable by the public as by any professional—the difficulty of fixing its onset is paralleled by the difficulty of knowing when it has ceased. This uncertainty is explained by the facile and changeable nature of the patient; until the condition is revealed by unmistakable signs it passes for an insignificant muscular caprice of no pathological importance, while its disappearance is not associated with any particular modification of the patient's ways.

There is a natural tendency to identify all "nervous movements" with myoclonus, but the conception is a remarkably nebulous one, and means nothing more than "muscular twitch." On the other hand, it is well understood that "nervous movements" are more or less sudden movements of limbs, shoulders, face, always involuntary and generally increasing in force and frequency with the nervous state of the patient.

Parents say, for instance, that their child has become more restless and irascible, and at the same time that he has had "more movements of the nerves." The coincidence is unfailing. Is the expression "nervousmovement" lacking in precision? Yet it signifies what it is intended to signify. We are concerned neither with tonic convulsions nor with clonic spasms, nor yet with tics of habit; what the term stands for is a complex contraction, brisk but not violent, closely allied to the simplest of automatic acts, such as a step in advance, a shrug of the shoulders, a frown, a sigh, a moan, a crack of the fingers, an exclamation—in any case usually a gesture of impatience. The whole thing, however, is so variable and fugitive, that it cannot be said to constitute a definite convulsive phenomenon. The contractions, further, in spite of their complexity, escape the notice of their originator, who is quite surprised at being asked the meaning of the movement he has just made, as he is almost entirely ignorant of it.

Briefly, the "nervous movements" of which we have been speaking do not belong either to myoclonus or to tic, but owe their distinctiveness to their multiplicity and inconstancy. At the same time they are always grafted on a certain neuropathic diathesis akin to that of chorea; in fact, they are nought else than a form of chorea themselves.

The psychical peculiarities of the patient with variable chorea may be summed up in instability of thought and action, combined with mental infantilism. Hence the terms "polymorphous chorea" and "chorea of degenerates" are used synonymously for variable chorea.[138]Sometimes the disorders of the mind include hallucinations, and various forms of phobia or mania.

One or two examples may be given:

A microcephalic youth of sixteen, a monorchid, developed what appeared at first to be an ordinary chorea subsequently to an orchidopexy. The movements, however, varied from day to day and from hour to hour. Sometimes they disappeared for days at a time, to reappear suddenly just when the neurosis seemed cured. The influence exerted on them by the will was both mild and transient. They constituted, in short, a particular kind of chorea, changing and changeable, and differing from intermittent chorea in that neither remissions nor relapses were ever wholly complete. Further, the condition was implanted on a basis of mental and physical degeneration, and seemed likely to become established as a permanent functional stigma.In another case a peculiar chorea gradually supervened, for no obvious reason, in an adult female of tardy and imperfect physical and intellectualdevelopment. It was difficult to decide whether the psychical or the somatic phenomena were preponderant; but to the material, tangible, and visible signs of constitutional inferiority was superadded a choreiform instability of the whole voluntary muscular system, consisting in agitation, gesticulation, and incorrigible motor restlessness, coupled with a conspicuous incapacity for rational action.The steps in the evolution of this functional defect were very slow, and coincided with final confirmation of the intellectual insufficiency. As for the chorea, its localisation and its intensity, its increase and its decrease, its extension and its limitation, seemed to vary, in a way that could not be foreseen, at the call of certain undetermined circumstances.

In another case a peculiar chorea gradually supervened, for no obvious reason, in an adult female of tardy and imperfect physical and intellectualdevelopment. It was difficult to decide whether the psychical or the somatic phenomena were preponderant; but to the material, tangible, and visible signs of constitutional inferiority was superadded a choreiform instability of the whole voluntary muscular system, consisting in agitation, gesticulation, and incorrigible motor restlessness, coupled with a conspicuous incapacity for rational action.

The steps in the evolution of this functional defect were very slow, and coincided with final confirmation of the intellectual insufficiency. As for the chorea, its localisation and its intensity, its increase and its decrease, its extension and its limitation, seemed to vary, in a way that could not be foreseen, at the call of certain undetermined circumstances.

In a third instance we meet with many of the symptoms already noted among those who tic:

X. is a well-developed boy of fifteen, but there is something peculiar about his physiognomy which defies analysis. If his mother's statements can be trusted, he is intelligent, quick, witty, sound in judgment, and blessed with an excellent memory. From the very first he has been eccentric, timid, and hypersensitive, and is to-day as tender-hearted and affectionate to his people as ever. He has various little "manias" of his own; he must have a knife, fork, and spoon for himself, and cannot take his food in comfort if they have been set before some one else. Each morning he dresses himself with extreme deliberation, then comes down to breakfast, of which, however, he will not partake unless he has touched all the door handles on his way. 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. He listens deferentially to his teachers, but takes no note of what he hears. In German, Greek, and Latin he is at the head of his class, whereas in history and mathematics he is at the foot.The "nervous movements" for which he has been brought to the consulting-room consist of a series of gesticulations akin both to tic and to chorea. Some are much more frequent than others, meaningless gestures executed spontaneously, one might almost say unconsciously. As he walks to school with his books under his left arm, his right hand roams over his person; and in the class-room the movements arerepeated. At table he rubs his back against the chair, and alternately flexes and extends his right leg. Apart from these "habit tics," he exhibits actual twitches of his muscles generally, and evidence of the consequent disturbance of his movements is furnished by a glance at his untidy bedroom, his disarranged books, his blotted papers, his slovenly clothes. When he goes out with his parents, he is never at their side, but lounges along in his own way, then suddenly hurries to regain his place by them, falling back again and occupying himself by crossing his legs, knocking his ankles together, shrugging his shoulders, grimacing, etc. All the movements can be arrested for a time by an effort of the will. At any one's behest he can maintain tranquillity for a minute, but the strain is too severe, and the muscular dance recommences sooner or later.The movements are highly variable in type and degree, nor can the mother specify the date of their appearance. It is only during the last three years that her attention has been more particularly drawn to them, and their increasing gravity occasions her some anxiety. The boy has become the laughing-stock of his companions at school, hence he limits his stay there to the actual hours of his classes.Three years later the choreic symptoms vanished. X. is to-day a stalwart youth, though still timid and eccentric. It is evident that in his case the variable chorea has been but an episode in adolescence, to be added to the numerous stigmata of degeneration enumerated above.Notwithstanding its slow evolution (says Brissaud), the neurosis, in so far as it was a disorder of motility, seems to have completely disappeared. The importance of this for prognosis is fundamental, but from the point of view of diagnosis it is no less significant, seeing that the nature and form of the movements suggested chronic or Huntington's chorea.

The "nervous movements" for which he has been brought to the consulting-room consist of a series of gesticulations akin both to tic and to chorea. Some are much more frequent than others, meaningless gestures executed spontaneously, one might almost say unconsciously. As he walks to school with his books under his left arm, his right hand roams over his person; and in the class-room the movements arerepeated. At table he rubs his back against the chair, and alternately flexes and extends his right leg. Apart from these "habit tics," he exhibits actual twitches of his muscles generally, and evidence of the consequent disturbance of his movements is furnished by a glance at his untidy bedroom, his disarranged books, his blotted papers, his slovenly clothes. When he goes out with his parents, he is never at their side, but lounges along in his own way, then suddenly hurries to regain his place by them, falling back again and occupying himself by crossing his legs, knocking his ankles together, shrugging his shoulders, grimacing, etc. All the movements can be arrested for a time by an effort of the will. At any one's behest he can maintain tranquillity for a minute, but the strain is too severe, and the muscular dance recommences sooner or later.

The movements are highly variable in type and degree, nor can the mother specify the date of their appearance. It is only during the last three years that her attention has been more particularly drawn to them, and their increasing gravity occasions her some anxiety. The boy has become the laughing-stock of his companions at school, hence he limits his stay there to the actual hours of his classes.

Three years later the choreic symptoms vanished. X. is to-day a stalwart youth, though still timid and eccentric. It is evident that in his case the variable chorea has been but an episode in adolescence, to be added to the numerous stigmata of degeneration enumerated above.

Notwithstanding its slow evolution (says Brissaud), the neurosis, in so far as it was a disorder of motility, seems to have completely disappeared. The importance of this for prognosis is fundamental, but from the point of view of diagnosis it is no less significant, seeing that the nature and form of the movements suggested chronic or Huntington's chorea.

A case described by Gilles de la Tourette[139]as disease of the tics seems really to have been one of variable chorea.

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