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of difficulties. Suddenly she was ticcing, jammed, and blocked; the beautiful smooth flow which had borne her along seemed to break up, and dam, and crash back on itself. Her walking and talking are gravely affected. She is impelled to rush forward for five or six steps, and then suddenly freezes or jams without warning; she continually gets more excited and frustrated, and with increasing excitement the jamming grows worse. If she can moderate her excitement or her impulsion to run, she can still walk the corridor without freezing or jamming. Analogous problems are affecting her speech: she can only speak softly, if she is to speak at all, for with increased vocal impetus she stutters and stops. I have the feeling that Miss R.’s “motor space” is becoming confined, so that she rebounds internally if she moves with too much speed or force. Reducing her L-DOPA to 3 gm. a day reduced the dangerous hurry and block, but led to an intensely severe oculogyric crisis—the worst Miss R. has had since starting L-DOPA. Moreover, her “wiping” tic—which reappeared on the 28th—has grown more severe and more
complex
with each passing hour. From a harmless feather-light brush of the chin, the movement has become a deep circular gouging, her right index finger scratching incessantly in tight little circles, abrading the skin and making it bleed. Miss R. has been quite unable to stop this compulsion
directly,
but she can override it by thrusting her tic-hand deep in her pocket and clutching its lining with all of her force. The moment she forgets to do this, the hand flies up and scratches her face.
    AUGUST 1969
    During the first week of August, 13 Miss R. continued to have oculogyric crises every day of extreme severity, during which she would be intensely rigid and opisthotonic, anguished, whimpering, and bathed in sweat. Her tics of the right hand became almost too fast for the eye to follow, their rate having increased to almost three hundred per minute (an estimate confirmed by a slow-motion film). On August 6, Miss R. showed very obvious palilalia, repeating entire sentences and strings of words again and again: “I’m going round like a record,” she said, “which gets stuck in the groove. . . .” During the second week of August, her tics became more complex, and were conflated with defensive maneuvers, counter-tics, and elaborate rituals. Thus Miss R. would clutch someone’s hand, release her grip, touch something nearby, put her hand in her pocket, withdraw it, slap the pocket
three
times, put it back in the pocket, wipe her chin
five
times, clutch someone’s hand . . . and move again and again through this stereotyped sequence.
    The evening of August 15 provided the only pleasant interlude in a month otherwise full of disability and suffering. On this evening, quite unexpectedly, Miss R. emerged from her crises and blocking and ticcing, and had a brief return of joyous salacity, accompanied with free-flowing singing and movement. For an hour this evening, she improvised a variety of coprolalic limericks to the tune of “The Sheikh of Araby,” accompanying herself on the piano with her uncontractured right hand.
    Later this week, her motor and vocal block became absolute. She would suddenly call out to Miss Kohl: “Margie, I . . . Margie, I want . . . Margie! . . . ,” completely unable to proceed beyond the first word or two of what she so desperately wanted to say. When she tried to write, similarly, her hand (and thoughts) suddenly stopped after a couple of words. If one asked her to try and say what she wanted, softly and slowly, her face would go blank, and her eyes would shift in a tantalized manner, indicating, perhaps, her frantic inner search for the dislimning thought. Walking became impossible at this time, for Miss R. would find her feet completely stuck to the ground, but the impulse to move would throw her flat on her face. During the last