It is when we are required to keep quiet that we are tempted to restlessness; it is when silence is compulsory that we feel we must talk. Now, when one is learning his lessons, conversation is prohibited, the natural consequence being that he seeks to evade the galling interdict by giving vent to some inarticulate sound. In this fashion did my "cluck" come into being. Moreover, we abhor a vacuum, and fill it as we may. Various are the artifices we might employ – such, for instance, as speaking aloud; but that is much too obvious, and does not satisfy: to make a little grunt or cluck, on the other hand – what a comfort in a tic like that!
We need not smile at these explanations, for they are corroborated by the facts of clinical observation. Fear of silence is nothing else than a form of phobia, comparable to the fear of open spaces.
O.'s account of the origin of his tics supplies further evidence of the mental infantilism of those with whom we are at present concerned. It is the prerogative of "spoilt children" to wish to do exactly what they are forbidden to do. They seem to be animated by a spirit of contrariness and of resistance; and if in normal individuals reason and reflection prevail with the approach of maturity, in these "big babies" many traces of childhood persist, in spite of the march of years.
In the strict sense of the words there never has been any echolalia or coprolalia in O.'s case, though it has happened that expressions lacking in refinement have escaped him; but he never has been consciously yet irresistibly urged to utter a gross word. The sole vestige of anything of the kind is a sort of fruste coprolalia that consists in an impulse to use slang – an impulse which he cannot withstand and which he finds consolation in obeying.
Some additional details may be submitted to illustrate the intimate analogies between tics and obsessions.
O. is a great cigarette smoker, and with him the call to smoke is inexorable. It is not so much, however, the effects of the narcotic for which he seeks as the sum of the sensations derived from the act – the rustling of the tobacco in the paper, the crackle of the match, the sight of the cloud of smoke, the fragrance of it, the tickling of nose and throat, the touch of the cigarette in the fingers, or between the lips – in a word, a whole series of stimuli, visual, auditory, olfactory, and tactile, whose habitual repetition gradually introduces into the act of smoking an automatic element that brings it into line with the tics. The suppression of this parasitic function commonly produces a feeling of the utmost discomfort; inability to indulge in it causes the keenest anguish. More agonising than the actual impossibility of smoking is the idea of its being impossible. Hence it is that O. lights cigarette after cigarette, taking a few whiffs at each and throwing them aside scarce touched, or leaving them here, there, and everywhere. The dose is immaterial; it is the rehearsal of the act he finds so soothing.
In regard to his taste for liquor a similar description might be given. The intoxicating effect of any beverage had little attraction for him; it was the drinker's gesture and the numerous accompanying sensations that he sought to renew. Any form of drink, therefore, served to gratify his desire; in other words, his behaviour revealed a phase of dipsomania rather than a stage of alcoholism. For that matter, the development of symptoms of alcoholic poisoning proved a blessing in disguise, since they reinforced the inhibitory power of the will, and enabled it to abort a sensori-motor habit that had wellnigh become established.
No objective alteration in cutaneous sensibility in any of its forms is discoverable on examination of O., but he bewails a long array of subjective sensations, painful or disagreeable as the case may be. Certain abdominal pains in particular occupy his thoughts: after being in bed about an hour he begins to suffer from pain in the abdomen and across the kidneys, so acute that he is forced to rise and walk about his room, or sit on one chair after another; at length it moderates enough to allow return to bed and permit of sleep. During these crises there is no sign of any local pathological condition, no distention or tenderness or evacuation of the bowel. They usually last for some days at a time and disappear suddenly, as when, after several nights' and days' uninterrupted suffering, his pains vanished as by an enchanter's wand once he set foot on the boat that was to take him to England.
We have had the opportunity of observing our patient in the throes of one of these attacks, and while we did not doubt the genuineness of his sufferings, we could not but be struck with the dramatic exuberance of his gestures. He wriggled on his chair, unbuttoned his clothes, undid his necktie and his collar, pressed his abdomen with his hands, sobbed and sighed and pretended to swoon away. Such excessive reaction to pain is characteristic of a nervous and badly trained child, not of a man of his years. Notwithstanding his humiliation at these exhibitions of weakness, he can no more control them than he can his ordinary tics; in fact, the tics run riot during the crises of pain.
On several occasions the reflexes have been the object of examination. The pupillary reactions are normal, as are the tendon reflexes of the upper extremity; but the knee jerks are much diminished, and one day we failed to elicit them at all, though we noted their return a week later. A careful search for further signs of possible cerebro-spinal mischief proved negative, if we except a slight flexion of the knees when walking and a tendency to a shuffling gait.
Notwithstanding this absence, in O.'s case, of any definite indication of organic disease, we cannot afford, in our examination of patients, to overlook any symptom, however fleeting or trivial it may appear, since it is only by painstaking investigation both on the physical and the mental side that we can ever hope to determine the characters and fathom the nature of the affection, apart from the value of such an investigation as an aid to diagnosis, prognosis, and treatment.
With charming spontaneity and frankness, but critically withal, O. has furnished us with a picture of his mental state. Nothing could be truer or more instructive than this piece of self-observation, even though his obvious pleasure in hearing himself talk is a little weakness of which, to tell the truth, he is the first to accuse himself:
In childhood and at school my accomplishments were ever on the same dead level of mediocrity. I was neither brilliant nor backward; in the drawing-room or in the playground, I was good at everything without excelling in anything; the astonishing facility with which I learned to sing, play, draw, and paint, was linked with inability to distinguish myself at these pursuits.
Each new study, each new game, attract and captivate me at first, but I soon tire of them, and once a fresh enterprise has taken their place, indifference to them changes to disgust. If I am amused with a thing, I do it well; if bored, I throw it aside. I suppose it is characteristic of people who tic to be fickle and vacillating.
The versatility which is so fundamental an element in O.'s nature has not been prejudicial to his business career. He has managed and still manages important commercial undertakings, demanding initiative and decision, and, so far from sparing himself in any way, he has exhibited a combination of caution and audacity that has stood him in good stead. It is more especially in the conduct of urgent operations that his alertness is displayed. His comprehensive grasp of the situation enables him to put his machinery at once into action, with eminently satisfactory results, if we judge by his prosperous and assured position.
His mobile and impulsive temperament is revealed in his every deed, but he shows at the same time a curious disposition to alternate between the pros and the cons of a question. It is the outcome of his extremely analytical and introspective mind.
I find myself seeking a knot in every bulrush. I experience a sensation of pleasure only to tax my ingenuity in discovering some danger or blame therein. If a person produces an agreeable impression on me, I cudgel my brains in the attempt to detect faults in him. I take it into my head to ascertain how anything from which I derive enjoyment might become an aversion instead. The absurdity of these inconsistencies is perfectly patent to me, and my reflections occasion me pain; but the attainment of my ends is accompanied with a feeling of pleasure.
In regard to my tics, what I find most insupportable is the thought that I am making myself ridiculous and that every one is laughing at me. I seem to notice in each person I pass in the street a curious look of scorn or of pity that is either humiliating or irritating. No doubt my statement is a little exaggerated, but my fellows and I have an overweening self-conceit. We wish to be ignored, and yet we wish to be considered; it is annoying to be the object of sympathy, but we cannot bear to become a laughing-stock. Accordingly our goal is the dissimulation of our