our profession.

Even in the hands of the skilled adjustor, the pessary will cause trouble.

As I stated in my paper, I have followed a systematic plan of treatment for these cases, that is, secure for them certain mental habits by making them learn or memorize certain lines of prose; this is especially good plan in the beginning of these morbid mental neuroses. This plan of treatment I believe to be most important. I wish to emphasize the fact that we do not discover one reflex which is to be removed but two, three, four or even five. Any such reflexes should be removed and then this intelligent plan of treatment should be employed; there may be used mental, physical, dietetic, or combined forms. of treatment, as may suggest themselves to you. A point I also wish to emphasize in particular, that physicians are too prone to attacks and remove one causative factor and think then that all has been done that can be done and send such a patient away. I have frequently known of patients who had been treated from the surgical standpoint for the removal of the cause of the morbid reflex and had finally turned to the eye specialist, the internist, or the stomach man to have the condition improved. In dealing with these morbid reflex neuroses anything which acts as an accessory cause should be removed.

Dr. E. Bates Block, closing: With regard to the treatment of this class of cases, this depends upon the indidividual case; it depends upon the physician's opinion as to the best plan of treatment to pursue in each individual case. A system of education should be employed, teaching certain principles; also the system should be built up, their general health should be improved and strengthened, and the condition of the nervous system should be improved by the use of tonics, and so forth; all this is very effective in the treatment of these patients. We find in many cases that the moral treatment is better than the physical; also the use of drugs which tend to lessen the

sexual desire. There is the use of bromides and other agents which is so valuable in lessening this desire. The cases are so very different, and depend upon so many different causes that it is impossible to lay down any one plan of treatment for every case.

TICS IN CHILDREN AND THEIR TREATMENT.

Henry C. Whelchel, M.D., Douglas, Ga.

In presenting this subject today, it is not for the purpose of giving you something new, but to call attention to a condition that we general practitioners, too often treat lightly, by telling the mother that it is a habit, and the child will out grow it.

It has been said, that the frequency of ties, is in direct proportion to the civilization of a people. Considering the frequency of this condition, and the discomfort which it causes the patient, and his family, it must be said that the subject has not received the attention which it deserves.

Many of the tics, which are so annoying, and obstinate in adult life, give as their outward manifestation a tie in early life. Often such a tie was neglected, looked upon as a bad habit, to be out grown, or treated with drugs without relief, and the patient and his family discouraged. It cannot be too strongly emphasized that a tie is simply a motor manifestation of a peculiar mental state, and should be looked upon as a warning, a danger signal of possible trouble to come.

Tic, some times called mimic spasm, habit spasm, etc., has been defined by Gowers as: "A spasmodic movement, half voluntary in aspect, which the patient is unable to control."

By Guinon as: "An habitual, and conscious movement resulting in the contraction of one or more of the muscles of the body; reproducing most frequently in an abrupt manner; some reflex or automatic action of common life.

By Meigs and Feindel: "A tie is a psychomotor affection in which two elements are essential: First, an

abnormal state, a lack of control of the will; Second, a motor manifestation due to some stimulus from without, or from the brain."

When the stimulus acts from without, the movement is executed with a definite purpose.

By repetition this movement becomes habitual or automatic; continuing without cause or purpose, the will being too weak to inhibit it.

The original purpose of the movement, or posture, is usually apparent; it is a co-ordinate act, adapted to some definite object; as for example, a gesture of defense, or an expression of some emotion, as of grief, pain, fright or joy. These movements are repeated in response to an irresistable desire, and are followed by a feeling of satisfaction. These ties of which blepharospasm is a type, are more or less under the control of the patient, who can by an effort of the will do considerable to repress them, but such repression is followed by a vague feeling of discomfort.

The contractions follow each other at irregular intervals, and are rapidly executed, and may be repeated at great rapidity from two, to many times, when a lull occurs for an indefinite time. Any excitement or embarrassment promptly recalls, and intensifies the morbid motions.

On the other hand, any decided interest fixing the patient's attention, interrupts the twitchings. They also disappear in sleep. There are no sensory disturbances.

This affection is by no means rare. In the physical examination of a large number of children in the New York Public Schools, it was found that about one in eighty was affected with muscular tic.

In the etiology of this affection, as in all the neuroses of children, there are two important factors: First, the inherited predisposition, the favorable soil; Second, the environment, including the method of training. sexes are about equally affected. In this it differs from chorea, in which more than twice as many cases occur

in females. Ties rarely manifest themselves before the fourth year, most commonly observed about the seventh or eight year.

In predisposed individuals, slight things may act as exciting causes, such as physical or mental shock, traumatism or fright, infections diseases, by lowering the vitality.

Frequently the movement or gesture was originally performed for a definite purpose, for example; a child has a granular conjunctivitis,, or a foreign body in the eye, blinking is done with an endeavor to remove the cause of irritation, as the neck is scratched by the collar, and the finger is run around the neck to separate it. In the normal child as soon as the source of irritation is removed the act is unnecessary, but not so with the future victim of a tic. Here the act continues in response to that irresistable impulse those cases becoming more wide-spread involve the neck and upper extremities, so that attitudes and gestures are produced in conformity with the underlying mental idea. I will mention only a few of the more common forms of ties. One is the blinking of the eyelids or blepharospasm, which may occur with other movements of the face, hands or shoulders. Another is the licking of the lips, and another which is often met with, is the long drawn inspiration, with or without a sigh. Such children will some times complain of a heaviness on the chest, and can't catch their breath. On examination no true dyspnea is found, and the chest shows no pathological changes. The quick nod so frequently seen in girls, perhaps originated from a desire to adjust their hats.

Another form which is very important, on account of the proper treatment is the so-called "Mental Torticollis", in which some deviation of the head is customary, and is spasmodically maintained. Ordinarily it ceases when the patient lies down, or it can be controlled by a slight amount of manual pressure upon the head or face.