TREATMENT BY RE-EDUCATION
The author of the article "Tic" in the Dictionary in Sixty Volumes of
1822 urges the necessity of care and perseverance in the correction of
the involuntary movements characteristic of the disease. In 1830 Jolly
recommended different exercises in the treatment of convulsions, as a
means of interrupting the sequence of certain spasmodic phenomena.
Blache's[220] adoption, in 1851, of medical gymnastics in cases of
"abnormal chorea" was attended with excellent results; and Trousseau, as
we have seen, extolled the value of exercises systematically applied to
the muscles involved in non-dolorous tic. The principle of the treatment
consisted in the regular execution of given movements by the muscular
groups affected, to the rhythmical accompaniment of a metronome or the
pendulum of a clock.
In these instances we have a forecast of the modern methods of
re-education, so successfully employed to combat tic.
Letulle advises an appeal to the intelligence, good sense, and will of
the patient in the endeavour to provoke an inverse effort at the moment
when the tic begins, or even before. It is the prerogative of the
physician to indicate suitable exercises and to encourage and aid the
patient in his attempts. Even the most inveterate of tics may thus be
controlled and made to disappear. On the other hand, the _Traité de
médecine_ ignores the subject, while Lannois' paper in the _Traité de
thérapeutique_ contains the statement that in the treatment of
myoclonus--under which term various indefinite convulsive movements are
comprehended--no method has hitherto been of any avail. Yet in another
section of the same book we discover some sound advice anent tics and
choreas of hysterical origin, emanating from the pen of Pierre Janet.
It is well to study the influence of the attention on these
conditions; some tics are contingent on the direction of the
patient's attention to them, others appear solely during times of
distraction.... Education of movements by some form of drill may be
of the greatest utility.
These general therapeutic indications are applicable to all kinds of
tic, independently of their form and localisation. Moreover, they
conform to the procedures advocated by Brissaud since 1893.
So long as tic is regarded as a purely external phenomenon, treatment is
bound to be insufficient; but recognition of the relations between the
convulsion and the mental state of the subject has made possible a
rational therapeusis. There can be no doubt, thanks to the laborious
work of Bourneville, that systematised mental discipline has sometimes a
surprising effect on congenital psychical imperfections; and where the
patients have attained a higher level of mental development,
re-education has shown itself to be the method _par excellence_.
The credit of initiating treatment by forced immobility is due to
Brissaud, who in the year 1893 first utilised the method in cases of
mental torticollis. In the face of the risks of surgical intervention
and the unsatisfactory nature of existing therapeutic measures, Brissaud
emphasised the value of motor discipline in tic,[221] and it was not
long ere rules were formulated and precision introduced into the
application of the method.[222] The results were certainly encouraging,
so much so that improvement could be promised if treatment was
sufficiently protracted; cure, indeed, followed in various instances.
Brissaud's method is a combination of immobilisation of movements with
movements of immobilisation. Speaking generally, the patient is directed
to perform certain appropriate exercises under given conditions. Some of
these exercises are intended to teach him how to preserve immobility,
while the object of others is to replace an incorrect movement by a
normal one. In the case of the former, immobility is alike the goal in
view and the means of attaining it, while by recourse to suitable
movements, in the latter instance, the same end is sought.
It is essential to remember that the exercises must be graduated. To
begin with, the subject of tic is required to remain absolutely
motionless, as for a photograph, for one, two, three seconds--in fact,
as long as he can without fatigue. Very gradually the period is
increased, for patients have their good and their bad days, and too
great a demand on one day is apt to be succeeded by a relapse on the
next. One must rest content with even the most insignificant gain at
first, and soon the seconds will grow into minutes, and the minutes into
hours. It is desirable to specify on each occasion the duration of the
expected immobility. Place the patient at the outset in the position in
which his tic manifests itself least often, and do not cease to
encourage him by affirming that he can and must remain immobile. Once
the séance of immobilisation can be maintained for as much as five or
six minutes, begin to modify the patient's attitudes. If he has been
comfortably seated during the opening performances, try him when he is
standing, and as soon as he has accomplished this, vary the position of
his head, arms, trunk, and legs, repeating the séance in each case.
Eventually he will learn to maintain immobility of certain parts of his
body while he is walking, or while he is executing given movements with
his arms or legs. In all these performances direction must be specially
directed to the patient's tic. The method is obviously simple, so much
so that he may be inclined to question its utility and may fail to grasp
its import. One must not hesitate, however, to explain its purpose;
indeed, the rapid and intelligent appreciation of the method on the part
of the patient is a _sine qua non_ for success. Patient and doctor most
co-operate in defence and attack; and their union will culminate in
triumph. Simultaneously with this discipline of immobilisation the
subject must be taught the discipline of movements. The idea is to make
him perform slow, regular, and accurate movements to order, addressing
oneself to the muscles of the area in which the tic is localised. They
must be very simple at first, and the exercises must be very short. The
séance should never be prolonged beyond a few minutes, making, with the
immobilisation, not more than half an hour. This time will, of course,
soon be increased, but it is of prime importance to avoid fatigue. The
performances should be gone through three, four, or five times a day,
and always at the same hours. One of them at least ought to be under the
personal direction of the physician, whose duty it is to modify,
instruct, exhort, reprimand, as the case may be. In his absence the
supervision of the exercises must be left to some responsible
individual, who has an eye for faults as well as for progress.
Statements by the patients themselves are to be considered with reserve.
The repetition of the prescribed exercises should take place in front of
a looking-glass, whereby the patient may be exactly informed of any
mistakes in gesture or attitude. He cannot otherwise judge of the degree
of immobility attained, and may deceive himself, although he has the
best intentions in the world, as to the real state of affairs. He does
not know whether he is holding himself straight or not, as a general
rule, but a glance in the mirror will correct his fault. A careful
register must be kept of the progress he makes. Little by little the
jurisdiction of the physician will be reduced, provided the patient
maintains his interest in his own treatment. Indifference and
discouragement are fatal, and it must be the physician's aim to prevent
their occurrence.
Séglas has reported the history of a woman with mental torticollis, who
submitted to treatment by Brissaud's method, and a remarkably quick
alleviation was the result. At the end of three weeks, however, she
allowed her interest to slacken, and ere long the benefits obtained were
entirely frustrated.
It cannot be too often repeated that even though the tic disappear, the
patient must not be abandoned to himself, but must be persuaded to
continue his exercises. This is the price of success. As time goes on,
it is true, he encounters fewer difficulties in his way, and once he is
conversant with the method, he may be able to work out his own
salvation.
In the case of children, the efforts of the medical man may often be
seconded by parent or teacher, who has assisted at the first lessons and
is in a position to superintend their repetition. On the other hand,
treatment may be nullified by deplorable weakness on the part of father
or mother. One of the reasons for the existence or at least the
persistence of tics in children is that there has been no attempt at
their correction when they were still "bad habits." Neglect or
indulgence is an etiological factor of the first importance, as we have
already seen. Many a time we have had occasion to note this,
notwithstanding the protestations of the family. Fear of aggravating the
mischief is sometimes advanced as a reason for non-interference. Nothing
could be more misleading.
The method which seeks to check the youthful _tiqueur_ by the
multiplication of threats and penalties is not to be countenanced; it
produces the opposite effect to what is intended. Clearly the
educational therapeutic measures we have been advocating demand a
patience and an ingenuity on the part of both doctor and patient which
we have no desire to minimise, but it is along these lines that success
is to be reached.
A noteworthy adjunct to treatment is to sketch out a daily routine for
the patient to follow regularly and punctually. His mental disarray is
patent not merely from his disorders of motility, but in the
unmethodical and changeable habits of his everyday life. To introduce
discipline into his manner of living is a most wholesome step. To find
something with which to employ his leisure time, to direct his energies
into suitable channels, will prove to be eminently beneficial, not
merely for the child but also for the adult. Those who tic ought to be
able to contract good habits as readily as bad, provided their
instructor be sufficiently persevering and inventive.
There is an infinity of occupations for the patient to put his hands to,
and this variety suits his unsettled mood and his wavering attention;
but longer efforts will be secured from him if his interest in his task
can be engaged and stimulated as well. It is a good plan to make him
write down each day what he does and how it is done, and to have him
rehearse from time to time. Such pedagogical details are far from being
superfluous; adults, moreover, are quick to gather their significance
and to demonstrate their advantages in practice. That their fickle will
must be reinforced they know well; how to achieve this end they are
unaware. This fact explains their eager acceptance of the support
furnished by these "moral crutches."
Generally speaking, there is no call to interrupt treatment once it is
commenced, although occasionally we have found this desirable. The
fatigue of the first few days, almost unavoidable as it is, and
accompanied by new sensations, need occasion no alarm. We should
acquaint our patient of its explanation, and so obviate the mental
depression which its existence is apt to engender. Its ephemeral nature
will soon become plain, for a rest of a few days suffices for its
disappearance.
In some instances resort to procedures reminiscent of antagonistic
gestures seems to have been of avail.
One of our patients,[223] suffering from facial tic, was directed to
perform, as far as practicable, the opposite movements to her grimaces.
If her mouth was drawn to the right, she forthwith made a corresponding
twitch to the left; if her mouth was shut spasmodically, she was
instructed to open it widely and quickly. By such simple methods,
applied to all her tics, speedy control was regained, and once she had
mastered the theory of the process, the practice of regular exercises
and the development of antagonistic movements soon effected a complete
cure.
Training of the antagonists has also been recommended by
Hartenberg,[224] in a case of scratching tic. The patient was urged to
approximate the hand to the affected cheek very slowly, and almost at
the moment of contact the order was given to extend the arm briskly;
this gesture of opposition, moreover, was stimulated by faradisation to
the extensors of the forearm. The method, of course, is practically
identical with that adopted by Frenkel,[225] of Heiden, who provoked
energetic contractions of antagonistic groups by teaching the patients
to overcome increasing resistances. Prudence, however, must be observed
in carrying out these ideas, otherwise we run the risk of replacing one
tic by another.
* * * * *
After the above general sketch of the essentials of the method, we may
give examples of its application to particular instances.
For a tic of the eyelids, in especial for blinking tics, we make the
patient open and shut the eyes to order, keep them closed or apart for a
space, shut one eye and then the other, and repeat the same sequence in
different positions of the head. It is a good plan to enjoin
simultaneous action of the oral musculature. The cessation of tonic
contractions of the eyelids with opening of the mouth has been remarked
several times, and Oppenheim finds an analogy in the observations of
Gunn and Helfreich, who have seen ptosis disappear as the mouth is
opened.
If the eyeballs are involved in a tic, insist on dissociating the
movements of head and eyes; make the patient follow an object slowly
with his eyes while the head is stationary; or let the head deviate to
right or left, up or down, while the eyes remain fixed on some
particular point.
When the lips are the seat of involuntary muscular action, have the
patient show his teeth, open and shut his mouth, purse his lips; make
him speak and conform his expression to his speech; let him read aloud
slowly, and fix his attention on his subject.
As a specimen of treatment for a facial tic, we may cite the subjoined
programme:
Every day, and three times a day, at the same hours--nine, one, and
six--the patient is to look at himself for two minutes in a mirror,
preserving absolute immobility the while; to read aloud for two
minutes, to speak in front of the glass for two minutes, to walk
backwards and forwards in front of the mirror for two minutes.
During the ten minutes of these exercises he will endeavour to keep
his facial musculature under control. If the tic assert itself in
the course of one of the exercises, he will recommence the latter,
if necessary twice; the third time he will leave it till the next
séance.
For tics of the head and neck, such as tossing tics and mental
torticollis, inclination and rotation movements are indicated, of which
an instance may be quoted:
Mademoiselle R. is quick in learning how to correct her muscular
faults. Her actions are gradually becoming more complete and ample,
and if she performs her allotted task with little animation, at the
least there is no question of her indefatigable willingness. In
less than a month she has been able to fix her regard, open her
eyes widely, turn her head, uninterrupted either by halts or
twitches; she can remain motionless in front of a looking-glass for
as long as a minute. Equally satisfactory progress hat been made
in the art of reading aloud; she breathes more regularly, and
articulates more distinctly.
Thus the patient has come to realise that she need but give her
attention to the involuntary movements for them to cease, and there
has been a synchronous advance in her mental activity and power of
concentration. Her nonchalance and timidity have diminished; she is
no longer indifferent to her surroundings, nor furtive in her
glances; she enters into conversation with zest, and her movements
are characterised by decision.
Take another example of treatment, for a case of mental torticollis:
Stand or sit in front of a mirror and endeavour to maintain an
absolutely correct position of trunk and shoulders.
Lift the arms vertically and turn the head to the right, then lower
the arms while the head remains as it is.
Bend the body forward, and stretch the arms out till they touch the
ground, the head meantime being rotated to the right. Then rise up
again with the head in the same attitude. After two or three
efforts it will be found that the head can be kept straight for a
few seconds.
In tics of the limbs, shoulders, hands, feet, innumerable movements will
suggest themselves for practice. The young girl with a tic of
genuflexion, under the care of Oddo, supplies an excellent proof of the
value of Brissaud's method:
The immobilisation of movements was realised by the mother forcing
the child to remain motionless in a fixed position for augmented
periods. As for movements of immobilisation, the patient made
peregrinations of increasing length under the mother's eye, the
order being repeatedly given to suppress the genuflexions. At the
same time, massage and passive movements to the limbs and joints
were prescribed, with a view to diminishing the articular
cracks--the exciting cause of the bizarre tic from which the girl
suffered.
In the course of ten or twelve days the genuflexions had entirely
vanished, and a return of the pain in the coxo-femoral articulation
aided materially in consolidating the effects of the treatment.
Tics of speech should be handled in the same way as stammering. "We do
not treat stammerers, we educate them," says Moutard-Martin. There can
be no gainsaying the convincing results obtained by Chervin's technique.
For years there has been unanimity of opinion on the value of
respiratory gymnastics in the treatment of stammering. The plan is to
make the patient inspire deeply and quickly, and follow this with a
prolonged expiration. Difficulties of articulation and phonation may be
overcome by recitation, by declaiming, by scanning utterance, by
dwelling on the vowels, etc. Various authors have laid stress on the
advisability of concomitant therapeutic treatment.
In cases of stammering (says Olivier), all surgical interference is
to be deprecated. Operations on the nose or throat are directed
toward the removal of obstructions in the air-ways, but they are
merely a preparatory step to the adoption of the education method.
No one of the vaunted "cures" for stammering is infallible, since
all depend in the last resort on the will power of the patient, nor
is there anything mysterious about them. Isolation is not always
indicated; what is indispensable is reinforcement of the will.
The intimate relation between tics of speech and various kinds of
stammering has led to the application to both of the same re-education
methods. Pitres,[226] in particular, bases his line of treatment for
tics in general on regulation of respiratory activity, as he has
observed that tics diminish or die away with a deep and regular
respiratory rhythm. His plan is as follows:
Supported against a wall, with shoulders braced back, the patient
is instructed to take slow and deep inspirations, raising his arms
the while, and letting them fall with expiration. This performance
is repeated three times a day, for ten minutes at a time.
The method has been elaborated by Tissié, and Cruchet also has thereby
obtained excellent results, which he has put on record in his thesis.
The patient is placed upright against some support, his heels
together and his arms by his side. For the first three minutes he
recites aloud, drawing a slow deep breath at frequent and regular
intervals. Then he proceeds to make similar long inspirations and
expirations, elevating his arms synchronously with the former, and
depressing them with the latter. The exercises may advantageously
be repeated every three hours to begin with, then their duration
may be increased and the intervals lengthened, until the séances
are extended to fifteen minutes three times a day. Their
continuance will vary with the individual, but the ultimate aim is
to reduce the period and to spin out the interval still more, until
eventually their object has been attained and they may cease.
A concrete example may be given:
A young man had suffered for eleven years from generalised tics of
peculiar intensity. Every few seconds violent twitches of an
electric-like rapidity seized the muscles of his head, trunk, and
limbs, to the accompaniment of abrupt cries and inarticulate
growls. A sojourn of a few weeks in hospital, and the acquisition
of the most elementary technique in athmotherapy, resulted in a
complete cure ere many months had passed.
Tissié explains the action of this method on tics by a special action of
regular respiration on psychomotor centres. Raymond and Janet incline to
the opinion that attention depends on respiratory activity, but
Tissié[227] argues there is antagonism between deep respiration and
maintenance of attention, and Cruchet supports this hypothesis.
If we prescribe respiratory exercises, we are temporarily
suppressing the attention, and reducing psychical activity to a
minimum. Thus tic, which is a reflex of thought, does not occur,
and if the exercises are renewed often enough, the habit will
gradually be lost.
In our opinion, it is precisely the bestowal of the attention on the
allotted task that has such a salutary effect. Whatever be the
movements, they demand of the patient a momentary halt, a momentary
interruption of those ill-timed motor reactions that make concerted
action impossible. Observation shows that the degree of successful
control is in proportion to the degree of concentration of the
attention. The novelty of the exercise in itself acts as a stimulus, but
when this novelty wears off, faults are prone to reappear. Hence the
necessity of varying the procedures, and of rendering them always
interesting; in the end the habit of supervision is contracted, and the
patient feels increasing satisfaction in watching his physical
infirmities daily diminish and the resources of his will daily widen.
Respiratory drill is an admirable method of procuring this result; it
acts in the same way as any of the other exercises. Its use is not
confined to tics of speech or of respiration, for thoracic muscles are
involved in tic much more frequently than is commonly supposed. By
resort to this technique Madet cured an expiratory hiccough[228] in a
man of forty-six, who was afflicted in addition with twitches of head,
trunk, and hands.
Systematized exercises have of course the advantages of exercise in
general; motor, sensory, and psychical functions alike are stimulated
and regulated, and tend to become normal. In particular, muscular
exercise is a striking way of disciplining volition. Accordingly, we
never fail to prescribe such pastimes as gymnastics, in any of its
forms, rowing, fencing, cycling, lawn tennis, etc.; games which demand
attention, skill, and decision are useful auxiliaries, and manual
occupations of a more delicate nature ought not to be forgotten,
provided they require of the patient a certain amount of immobility.
Every case, needless to say, must be treated on its merits, but the
general indications we have supplied can easily be modified to suit the
individual.
The various procedures directed, under different names, to the
suppression of tic by re-education, are all modelled on the same plan.
Köster attributes the disease to exhaustion of higher co-ordinating
centres, and counsels their reinforcement by appropriate exercise.
Oppenheim, in his _Lehrbuch der Nervenkrankheiten_, adduces evidence of
the value of what he calls _Hemmungstherapie_, which is merely an
application of the principles and therapeutic rules laid down by
Brissaud in 1893, and described by one of us in 1897, apropos of mental
torticollis. The same may be said of the line of treatment pursued by
Dubois, which appears to be based on the pathogenic interpretation given
by Oettinger,[229] according to whom the brain of tic patients is
incapable of conserving the image of sustained immobility, and thereby
loses the habit of voluntary immobilisation. The essence of treatment,
therefore, consists in habituating the subject to rest motionless like a
statue in a position conducive to repose, and for a given time.
As has been already remarked, the polymorphism of tics is such that the
plan of treatment selected must be necessarily elastic if it is to be
altered to suit individual cases. What is the point in enjoining
absolute immobility on a patient whose blepharotic is never in evidence
unless he is walking about?
* * * * *
We may now proceed to narrate the details of various cases of tic
treated by the combined method of disciplinary movements and immobility,
taking the history of O. as our first example.
_October 15, 1901._--Séance of absolute immobility in the upright
position, with the head straight, for five seconds; to be repeated
in front of a mirror for five minutes, with intervals for rest of
fifteen seconds. Movements of rotation of the head to left and
right, with progressively lengthening pauses in each of the extreme
positions. Respiratory exercises with elevation and depression of
the arms eight times a minute, decreasing steadily to four a
minute. These exercises are to occupy a quarter of an hour morning
and evening. Explain to the patient the action of the
sternomastoids and how they combine to fix the head. Make the
patient lie on his back and move his head antero-posteriorly.
_October 19._--O. has still his tics, but he can already remain
motionless on command, and is conscious of satisfaction in so
doing. Just as his exercises come to an end there is always a
momentary recrudescence of the tics, but a very appreciable calm
follows.
_October 21._--Immobility is maintained well for half a minute. The
patient is to resume his cycling and fencing, physical exercises
which he has abandoned for more than a year.
_October 25._--O. considers himself greatly improved. He has gained
insight into the way of combating his tics, and his self-confidence
is on the up grade. For several days he has devoted his attention
to his tic of blinking, with the result that he can open his eyes
longer and more easily.
_October 28._--He evinces a preference for certain of the
exercises: if they please him, he performs them accurately; if they
do not, they are neglected.
_November 20._--The head tics are still rather violent at times. A
period of intellectual and bodily fatigue has supervened, but he
tries his fencing again, and to his profound satisfaction he has
managed to keep free of tics during the bouts. He is recommended to
avoid all possible causes of cerebral and physical exhaustion.
_December 3._--He continues to make satisfactory progress. His
habit of supporting his chin on his cane is abandoned, though an
attempt to dispense with the latter entirely, when he is out in the
street, has ended disastrously. He is content to hold it in his
hand and strike his leg with it from time to time.
_December 13._--Whenever O. is tempted to tic again, he stands in
front of a mirror and commences to sing, and while the song lasts
his tics remain in abeyance. His trick of sitting crossways on a
chair and rubbing his chin against the back is also discarded, with
the result that the callosities have vanished. As far as his
walking is concerned, he has adopted the plan of endeavouring to
get from one point to another without allowing his tics to assert
themselves, and his efforts have been crowned with success.
_February 3._--The patient has recovered his self-confidence, and
the compliments of his friends prove an additional restorative. It
is true the tics still recur, but their number is less, their
duration shorter, their severity considerably diminished. What O.
is best able to appreciate is the disappearance of the state of
_mal obsédant_ that accompanied them.
Take another example in the person of young J.:
In his case our object was to discipline him by successive
modifications of his caprices. The first important result achieved
was the suppression of his precious mattress--a result not obtained
without difficulty, for the mere mention of it sufficed to provoke
floods of tears and ebullitions of anger. He was then sent into the
country for a few days to forget his heart's desire, but the labour
was lost. No sooner had he arrived than he discovered another
mattress in a barn, and transferred his affections to it.
Eventually the day came when he was finally convinced of the
absurdity and inconvenience of his practice, and when the tender
yet firm remonstrances of his parents prevailed. The prospect of
congratulations awaiting him, and his own keenness to get better,
stimulated him to fresh efforts, and the reward was success.
Not long after, however, he began to complain of mental suffering
from the restraint laid on him, and the distress was undoubtedly
genuine. We accordingly gave him permission to stretch himself on
his bed at certain fixed times and for a fixed period, which was to
be reduced each day by some minutes. He entered into the spirit of
the regulations so happily that in less than a month the period
spent in the horizontal position had sunk from two hours and three
quarters to an hour and a half daily, and at last it was dispensed
with altogether.
On his "nervous movements" re-education by immobility and
methodical exercises had a beneficial influence, and he acquired
the faculty of controlling his variable and attitude tics.
Repetition of the séances under the eye of the physician, drill in
front of a looking-glass, symmetrical and synchronous exercises for
the arms, as well as ordinary practice in dressing and undressing,
buttoning and unbuttoning clothes, eating, drinking, etc, with the
left hand--all contributed materially to his progress. Many other
re-educative prescriptions were enjoined on the patient; suffice it
to say that in three months he was able to dress and feed himself,
to behave properly at table, and to restrain himself generally, in
spite of the obstacles provided by his babyish tricks and natural
weakness.
Further, the advance he has made has reacted profitably on his
mental condition, and if his fickleness and vacillation persist, at
the least the trend of the educative exercises has been in the
direction of reinforcement of the will. Hence is it that he is now
more attentive, less introspective, less capricious; he is no
longer overwhelmed at the gravity of his condition; he is
conscious of having taken its measure, and of his power to master
it.
We have also applied Brissaud's method to the treatment of variable
chorea, with no less encouraging results. Its worth in cases of mental
torticollis has been noted by several authors as well as by ourselves. A
cure resulted in a peculiarly difficult instance recorded by
Martin[230]:
A young man of twenty-six suffered from melancholia and
hypochondriasis. He used to complain that his limbs were hopelessly
rotten, that his hands, feet, legs, were gone, vanished; his head
and neck had ceased to exist. So easily was he irritated that to
most questions he vouchsafed no answer. His sentiments of affection
were much blunted; a visit from his mother evoked no pleasurable
sensation. All day long he used to lounge on a couch, his head sunk
on his breast, and inclined somewhat to the right. The attitude was
exaggerated if he was addressed, but while he could raise his head,
by the help of his hand, to regard his interlocutor, it resumed its
position of flexion as soon as he withdrew the support. Confined to
the left side of his face was a tic which consisted in abrupt and
jerky elevation of the corner of the mouth. On request, he would
gain his feet laboriously and walk with abdomen protuberant, back
arched, and legs apart. From time to time the neck musculature on
the left side was the seat of convulsive movements. The left
sternomastoid and trapezius were in a state of tonic contraction,
and on any attempt being made to correct this vicious attitude,
spasm occurred, and the patient resisted to his utmost.
On March 10, 1900, treatment was begun; an effort was made to gain
the patient's confidence by explaining that a cure was within the
bounds of possibility, and by demonstrating to him that his limbs,
which were in a state of slight contracture, could be moved by his
hand. The procedure was renewed three times a day, and followed by
baths and massage.
By April 15 the contractures had disappeared, and he could perform
any movement of relaxation himself. His attention was now drawn
more particularly to his head, which was still in a faulty
position, and annoyed him considerably. Advantage was taken of an
improvement in his tractability to make him perform some movements
of his neck. At first the mere effort produced a spasmodic
contraction, but he was able to move his head very slightly up and
down. After five months of such treatment, occupying on an average
three hours a day, his mental torticollis was finally reduced to
subjection, an interesting feature of the case being the
parallelism between the physical and the psychical improvement.
On three occasions since we have noted a recurrence of the
torticollis, but each time it has been both brief and easily
overcome. The cure has been maintained now for upwards of a year,
and four months ago the patient resumed his work.
We must impress ourselves with the importance of recognising the
proneness of tics to relapse. Any triviality which may have a
prejudicial effect on the patient's will-power is calculated to
facilitate the reawakening of a bad habit. Such relapses are commonly
transient, and are instructive in so far as their manifestation
sometimes differs from the original tic and entails alterations in
treatment.
L., for instance, whose condition was one of permanent rotation of
the head to the right, had a fit of depression after eight days of
treatment and noteworthy improvement, a depression so severe that
she questioned the practicability of a cure, and forthwith her head
began to turn to the right again. On this occasion, however, the
tic was an intermittent one, consisting of clonic contractions of
the cervical muscles chiefly, without antagonistic gesture. For
five days the fit persisted, and was sufficiently acute to render
omission of the exercises advisable.
After some days' rest a beginning was made with the treatment
again, under the direction of one of us and in the presence of her
father. We took care to place ourselves always in front and to the
left of the patient, on the side opposed to her torticollis. The
position allotted her at table was such that in order to converse
with her parents she had to turn to the left.
Not long thereafter a second fit of depression occurred, but on
this occasion her head began to rotate to the left. She had been
under treatment for six weeks, when she made the remark one day
that her head seemed once more to be drawn to the right. She
hastened to add, moreover, that she had discovered a means of
remedying the mischief--viz. by putting her left hand to her left
cheek--a corrective proceeding nothing short of paradoxical.
It was about this time that the pains and dragging sensations in
the muscles of the neck subsided. On the other hand, for days on
end, then for gradually diminishing periods, there existed a
slight trembling of the head, due to muscular exertion, and
explicable by the contraction of small cervical muscles on one side
and their antagonists on the other.
On more than one occasion we have remarked this trembling as the
forerunner of a cure. It vanishes spontaneously as the amelioration of
the patient's condition becomes more definite.
Several months may intervene between relapses. Descroizilles cites a
case of convulsive movements of the head and shoulder of three years'
duration, which yielded to exercises in a few weeks. The tic reappeared
six months later, and, resisting treatment by gymnastic discipline, was
cured by suspension. Three months later it returned once more.
Facts of this description emphasise the desirability of considering
rapid cures with reserve; where the improvement, on the contrary, is
insensible, the results are much more likely to be permanent. Unforeseen
complications, again, may arise once a cure is affected.
One of our patients[231] had been rather quickly relieved of a
mental torticollis by the usual therapeutic measures, and we had
allowed him to resume his avocation, when he suddenly appeared in a
depressed and despairing mood a month later to say that he was
worse than ever. The rotatory tic had not returned, it is true, but
its place was taken by another phenomenon. If, as he walked along
with head straight, his attention was suddenly directed to the
right, he seemed at once to become "crystallised"; he halted, and
could not deviate his head as he wanted, and at the same moment
something appeared to choke him; in three or four seconds all was
over, and his action unimpeded. As a result of these attacks he
sank into a wretched state of more or less permanent anguish. A
visit to his country home was of little avail; no sooner had he
arrived than his head began to twist about in every direction,
although, try as he would, he could not move it backwards. We
accordingly prescribed absolute rest in bed, a strict regime,
hydrotherapy, and unfailing regularity in the performance of
gymnastic exercises. Not long after a fresh torticollis developed,
by which the chin was deviated to the left and the head tilted to
the right. Once more we initiated a scheme of regular drill, and in
the course of a short time a satisfactory cure ensued. During the
last three years we have had frequent opportunities of seeing our
patient, and can certify that he remains mentally and physically
normal.
Facts such as these teach us two things: the task of the physician is
not ended with the disappearance of the tic, for it is the pathological
mental state of the patient which renders him so easy a prey, and if we
can modify that state by re-education, we may count on the cure being
permanent. For a long time, however, we shall be well advised to talk
simply of improvement. In the second place, relapse or slowness of
progress is no reason for despair; treatment may have to be persevered
with for a year or years, till the patient learns how his muscles act,
how to maintain immobility, and how to effect a voluntary
movement--notions which his fickle mind has hitherto neglected to grasp.
Education of the will in the direction of control is calculated to bring
him into line with normal individuals.
A radical cure is not without the bounds of possibility, but it depends
greatly on the patient himself; his success is contingent on his
faithful repetition of exercises long after the tic is gone; for while a
cure results whenever the tic ceases to incommode its subject, fatigue
or emotion on some future occasion may reawaken the tendency to
involuntary movements, and only a methodically trained will can triumph
over the temptation to relapse.
With this reservation, one may expect permanence in the cure, provided
the affection is of recent date and the patient gives evidence of his
assiduity and desire for relief.
MIRROR DRILL
Among various re-educational procedures which are worth mentioning for
their practical value, a place must be given to what has been called
mirror drill by one of us.
We all know that the term mirror writing is in use to specify that mode
of caligraphy which looks exactly like ordinary writing when it is
reflected in a mirror or if the paper is held to the light and seen from
the reverse side. Mirror handwriting may be done with either hand. If
the right hand be employed, the characters are traced from right to left
and are centripetal in relation to the axis of the body. If, on the
contrary, it is the left hand that we use, the letters go from right to
left, but they are centrifugal.
Innumerable examples of this condition have been described and various
theories elaborated. Apart from such cases, it is a matter of common
observation that if any one be asked to write synchronously with the two
hands, his left hand will tend spontaneously to adopt the mirror
form.[232] The experiment may be tried on some one who has never made
the attempt to write with the left hand, and has never heard of mirror
writing. Ask him to abandon his left hand completely to the movements it
may be constrained to fashion while the right hand is tracing the
required words, and let his eyes be closed; in practically every case
the left will make mirror characters. It may therefore be contended that
mirror writing is the natural writing of the left hand, an opinion
supported by Vogt, Durand, etc., and more recently by Ballet,[233] who
remarks that this variety of writing for the left hand is natural in
left-handed people who have not been influenced by education.
The actual form of the characters is of little significance. We have
often repeated the experiment and substituted Greek, German, typographic
and stenographic letters, but always with the same result. It is perhaps
worthy of note that in simultaneous writing considerable modification of
the letters traced by the right hand occurs; they become hesitating and
childish; the lines are sinuous and irregular, and the characters
themselves ill distinguished. The same holds good for drawings.
On the other hand, the first attempt of the left to make mirror writing
to order is frequently laborious. Mingled with true mirror characters
will be found ordinary letters automatically traced, for automatism of
left-hand movements is not the inevitable sequel of automatism of
right-hand movements. From time to time the visual image of a normal
letter rises in the mind, an image which does not correspond to that
which the hand is endeavouring to express, whence doubt, reflection,
arrest, and, usually, error. If, however, the subject allows his left
hand to write, without preoccupying himself with the shape of the
letters it is making, or with his eyes shut, automatism reasserts its
sway and mirror writing results.
Of course a person who is asked for the first time to use his left hand
in writing may force himself to trace ordinary characters, but to do so
he must evoke the visual image of each letter and seek to reproduce the
contours of this image slowly, yet often inaccurately. There is nothing
automatic in this. Hence it is that ordinary writing with the left hand
demands prolonged education and patient effort, and may never attain any
rapidity, whereas mirror writing with the same hand is acquired with
facility in a more or less automatic manner.
It may well be that the natural left-hand mirror writing of which we are
speaking is a purely motor phenomenon, since the calling up of the
visual images of letters, so far from proving of assistance, is
calculated rather to obscure and hamper it.
It has been pointed out by Ballet that variations in the aptitude for
left-hand mirror writing exist, especially in the case of those who
cannot write without the aid of the visual image of letters. Since they
copy this image in using the right hand for caligraphical purposes, they
are tempted to do the same when the left is in use. In fact, the
facility with which one learns mirror writing seems to depend on one's
power of writing without recourse to these images. The explanation of
the ease with which the left hand reproduces, in the guise of mirror
writing, the movements of the other, is to be sought in the symmetrical
arrangement of the muscles in relation round the body axis.
Physiologists tell us, further, that the simultaneous contraction of two
symmetrical muscles is more readily attained than that of two
asymmetrical muscles. The law of symmetry and the law of least effort
correspond.
What is true of writing is no less true of all other forms of motor
activity. In physical exercises the surest results are achieved by the
synchronous contractions of symmetrical muscles, whereas education is
much more arduous should this lesson from experience be ignored. For
instance, nothing is easier than to make the arms describe circles in
the same direction, but rotation in opposite directions is very
difficult. Few people can revolve their thumbs in opposite ways. This is
a matter of common observation among teachers of physical culture. The
rapidity with which the action of swimming can be learned is in
striking contrast to the slowness with which the art of fencing is
apprehended. Little effort is required of the music beginner if his
pianoforte exercises demand the activity of symmetrical muscles for
their execution; on the other hand, the playing of a scale by the two
hands in unison comes only with long practice, since it entails the
simultaneous use of asymmetrical muscles.
Facts such as these are of more than passing interest. One cannot afford
to neglect their import where muscular education is concerned, whatever
be its nature, whatever be its object. Yet there is an unfortunate
tendency to concentrate attention on the development of the skill of one
arm only, and that the right. Sometimes the use of the left arm for
certain purposes is criticised adversely, and of course most people are
congenitally less able to work with it. But habit, example, and even
fashion, combine to render the right arm preponderant in everything, to
the detriment of the other. It is a common occurrence to attribute
awkwardness to this left arm, when its inferiority is really nothing
else than a sign of faulty education. In many cases the left is as good
as the right; its apparent _gaucherie_ is because of its attempt at
executing movements which are similar to those of the right, instead of
those which are correspondingly opposite.
Thus experience shows that the education of the right upper limb is
reflected on the left upper limb, although the subject may be sublimely
ignorant of the fact. But though this influence be latent, it is none
the less real, and may prove of service if occasion arise. Weber,
Fechner, and Féré[234] have all devoted attention to this subject.
From the therapeutic point of view, considerable significance attaches
to these facts. Temporary disablement of the right arm, such as follows
fracture or arthritis or writers' cramp, need not be disconcerting, for
the patient can proceed to utilise the faculty for mirror writing which
his left hand has unconsciously acquired. In all affections which are
accompanied by troubles of motility it is an excellent plan to apply the
prescribed muscular exercises to both sides of the body, and the
regularity with which they are performed on the sound side will have a
corrective influence on the mirror movements of the affected side. We
assume, of course, that there is no irremediable destructive lesion
which interferes with the continuity of paths joining functional
centres, otherwise the education of the normal limbs could not be
expected to produce any beneficial effect on the other. It is especially
in motor disorders of functional origin that mirror movements prove
useful, and the frequent unilaterality of these disorders readily allows
of the institution of a re-educative mirror drill. Speaking generally,
the faculty of writing supplies us with the best means of attaining our
end, for the variety of exercises it offers is likely to rivet the
patient's attention, and he has proofs of his progress under his eyes.
The goal in view is not, of course, the attainment of caligraphical
perfection--the subjects of tic are seldom guilty of bad penmanship; but
the execution of the required movements demands a voluntary constraint
that cannot but be profitable.
After the séances of absolute immobility, then, our custom is to set
daily exercises in writing, drawing, painting, tracing, ornamentation,
etc., varying the indications in accordance with individual tastes and
aptitudes. At the same time, we insist on the patient's devoting both
hands simultaneously to his task. It will be found advantageous to
devise movements for the fingers, then for the hand, the forearm, and so
on, and to instruct him in each successively. Thus, one may begin by
having him make the movements in space, then with chalk on a blackboard
placed vertically, then on the same placed horizontally, or on the
ground; or he can be asked to trace symmetrical designs and ornaments on
a wall. The essential points are that he use both arms simultaneously,
symmetrically, and accurately, and that all inopportune gestures be
inhibited.
In several of our cases procedures such as these have been adopted. O.
was not long in acquiring the faculty of writing with both hands, the
left tracing mirror characters. The object of the exercise was to oblige
him to maintain tranquillity and a correct position of his head and
neck, while his hands were simultaneously employed. By this means, as
well as by synchronous drawing exercises, he soon became so deft that he
learned to conserve almost complete immobility during the performance,
to his great satisfaction. No less creditable results were attained with
L. and with young J.
The method appears to us to be indicated above all in cases where the
left arm is the seat of tic. Any one who can use a pen with his right
hand is not long in acquiring the faculty of mirror writing with his
left. In this way the simultaneous execution of a normal movement with
right hand and left is facilitated, and the sound limb imposes
regularity on the other. Whatever be the localisation of the tic or
tics, this is the technique to adopt. It presents this advantage, that
its combinations and permutations serve to stimulate the patient's
interest, and he, at the same time, is required to keep a watchful eye
on his involuntary actions; so is his will disciplined.
REST IN BED
In the majority of cases absolute rest in bed is not desirable, but a
youthful patient should always be sent to bed early, and be allowed to
lie long; twelve hours in bed is not excessive. This rule is one which
must not permit of exceptions; whatever be the excuses invented by the
parents, we should see that it is rigorously obeyed. Two or three hours'
rest some time in the course of the day may be enjoined, provided the
period be fixed and uninterrupted. To break in on frequent siestas with
little promenades or with times of unrest is not productive of any good.
If it is impossible to maintain discipline during the day, absolute rest
in bed for a longer or a shorter period may be counselled; the sedative
effect of this measure cannot be gainsaid, especially when, for no
apparent reason, exacerbations develop, with increase of emotional,
obsessional, or other psychical phenomena.
ISOLATION
Isolation is a rather severe proceeding, which, however, one must not
hesitate to utilise in rebellious cases, or if the patient's mental
state precludes the possibility of prolonged application of systematic
discipline. Wyemann[235] cites a successful case, where a youth of
seventeen, with a bad family history, suffered from convulsive movements
in association with coprolalia, and was cured of the latter by
isolation. Some would even recommend the removal of the patient to a
hospital for mental disease. Such a step, however, is rather premature,
for he may already have begun to improve where he happens to be, and it
is not always certain that a sojourn of this character will be
beneficial.
Before isolation is resorted to, it is important to familiarise oneself
with the patient's mode of life, to ascertain whether it is capable of
modification in accordance with one's ideas for treatment, and to
determine the exact influence of his environment on him. We have
frequently had occasion to remark how potent is this environment as an
etiological factor; with young people, in particular, negligence on the
part of parent or guardian places the child in jeopardy. To combat this
unfortunate tendency must be our aim, as soon as we are convinced of the
risk.
Sometimes it is sufficient to draw the attention of the parents to the
disastrous consequences of indulgence or indifference; but we shall show
our wisdom in not relying too much on promises, however sincere and
solemn. These parents may be perfectly honest in their protestations,
but they are often as changeable and weak as their offspring, and lack
that very firmness and perseverance which they imagine themselves
capable of exhibiting. Thus, in spite of their undoubted intelligence
and good will, their efforts at control are unsatisfactory, and under
such circumstances the withdrawal of the patient from his family circle
is urgently indicated.
We cannot think, nevertheless, that the asylum is the ideal--there is
risk in the contiguity of other neuropaths or psychopaths; and while the
value of rigorous isolation consists in its stimulating and quickening
effect on the patient's self-control, whereby the day of his return to
ordinary life is hastened, yet it too frequently happens that the old
temptations are as powerful as of yore, and that the same causes which
operated when his tics first made their appearance reawaken vicious
tendencies more or less imperfectly masked.
Most subjects learn to still their tic during the physician's brief
visit; further, most achieve a similar result while they remain inmates
of a special institution; but as soon as they find themselves in their
old quarters, so soon does the impulse to tic dominate them again. In
fact, their victory is incomplete; the ground they gain is not held. The
goal to strive after is the repression of their tic under all
conditions, apart from extraneous intervention and influence. Once he
has been instructed in the methods of inhibition, the _tiqueur_ has no
one but himself to fall back on when face to face with the allurements
of his daily life.
These reserves made, it is clear that removal of the patient from his
environment has its advantages, but it is better to maintain only a
degree of isolation, and to allow him to come into his own circle from
time to time, under a wise supervision. The ideal measure would be to
consign him to the care of an attentive and devoted teacher, whose
superintendence would be permanent. In this respect, unfortunately, all
that we can do at present is to indicate what we think a desideratum,
for while well-to-do families may have their tutor, we do not know of
any one who has held a corresponding office as an instructor of children
with tic. The realisation of this novel proceeding might present genuine
difficulties in practice, but we may hope that once parents, patients,
and physicians are acquainted with the nature of tics and the efficacy
of the re-education method, many prejudices against that fruitful
therapeutic contrivance will vanish.
PSYCHOTHERAPY
Immobilisation and regulation of exercise and occupation do not
constitute the whole of the treatment; they form merely its objective
side. Psychotherapy is another factor, of capital importance.
In the words of Brissaud, psychotherapy is an _ensemble_ of
agencies calculated to demonstrate to the patient where his will is
at fault, and how to exercise to the best advantage what of it is
left. To come to particulars, his defect lies in his inability to
check a cortical caprice. These are not rhetorical unrealities, nor
is there anything mysterious about the method; it demands no
special competence beyond the gentle and encouraging firmness of
the ideal teacher. The physician can constitute himself instructor
without having to borrow from the more or less occult practices of
hypnotic suggestion. In fact, we must make it clear to the patient
that the co-operation of the latter is indispensable, and that it
is his will which is to come into action. The personal influence of
the teacher will be exerted in sustaining his pupil's efforts, in
making him take note of the progress effected, in keeping him to
the allotted times for exercise and drill.
Thus, and thus only, is psychotherapy to be applied to tic. Lucid and
sincere explanations and kindly counsels are wanted, not ceremonies and
mysterious paraphernalia. Resoluteness, patience, clemency, and good
sense are the weapons in the physician's armamentarium; docility, faith,
and perseverance, on the patient's part, will enable him to emerge
victorious. As soon as the compact is made, the battle against bad
habits, where there is neither truce nor quarter, commences in earnest.
The victim to tic will speedily unlearn the habit of perpetuating bad
habits; he will, in addition, learn the habit of not contracting bad
habits. In this way a double benefit--physical as well as moral--will
accrue.
As a consequence, psychotherapeutical treatment directed specially to
the subject's mental condition is scarcely necessary. The plans adopted
to inhibit inopportune motor manifestations will prove of value for
psychical imperfections.
Education might almost be considered a species of prophylactic
treatment, intended to obviate the possible development of tics.
Bourneville has verified this statement in his experience at Bicêtre:
Gymnastic exercises, and other measures directed towards the
development of the child's faculties, ought to be conducted with
kindness and gentleness, and by the aid of boundless devotion and
patience the methods of the authorities are bearing unexpected
fruit every day. We are convinced that the infrequency of tic in
such as have reached puberty is attributable rather to the zealous
application of a sound pedagogical method than to anything
connected with the age and physical development of the child.
Results that steadfast and patient nurses and teachers are obtaining in
an institution like Bicêtre may surely be obtained by the physician in
his private practice, if the parents of a youthful candidate for tic
would appreciate the importance of discipline and unite, intelligently
and assiduously, in the task of education. How common it is to find them
solicitous only of loading his tender brain with learning, instead of
endeavouring, with all their mind and heart, to restrain deplorable bad
habits that may one day blossom into tics, to the distress of all
concerned! The physician's earliest duty is to warn the parents of the
dangers of indifference, and thereafter to install himself as teacher,
if the disease should manifest itself in spite of his precautions. He
has no choice in the matter, and he should have the frankness to say so,
indicating at the same time on what his convictions rest. He need have
no fear of damaging his professional prestige by the simplicity of his
methods. Let him not promise what he may not be able to perform;
encouragement, not deception, must be his watchword. Along these lines
lies his duty as a physician; there, too, will he find that his
treatment will be fraught with success.
APPENDIX
_Les tics et leur traitement_, of which an English translation is here
presented to the medical profession, was published at the close of the
year 1902. In it our knowledge of the vexed subject of tics and spasms
has been summarised and reviewed, and its reception in France, together
with the fact of its having been translated into German without delay,
prove that it has been regarded as the standard work on a topic the
importance of which is being daily emphasised. At all the recent
Congresses on the Continent the tics in one or other of their aspects
have provided fruitful matter for discussion, whereas in England they
have hitherto been greatly neglected. In the brief space of time that
has elapsed since the book was produced there have been many and varying
contributions to the subject, as a reference to the Bibliography
herewith appended will show. Without doubt the reawakening of interest
is in considerable measure due to the stimulus provided by the labours
of MM. Meige and Feindel, yet it cannot be maintained that they have
said the last word. In order that English readers may have before them
the latest available information on the tics, various paragraphs from
Meige's monograph (1905) have been incorporated, as has already been
remarked in the Prefatory Note.
It is desirable, however, to indicate briefly certain points on which
opinion is still divided, points on which the results of the most recent
observations help to shed some light. Probably it has not escaped the
reader's attention that the authors have with commendable wisdom
refrained from dogmatising on some of these, although they are always
able to give reasons for their adherence to one or other view. But in
one respect at least the attitude which they have adopted has been
unmistakable, and that is in regard to the fundamental importance of
agreement in the matter of terminology.
The amount of misconception that exists about what constitutes a tic is
almost beyond credence; indeed, only those who have had occasion to
examine the literature can have any adequate idea of it. Discussions at
neurological and other societies not infrequently reveal how vague are
the notions of many who must have more than a passing acquaintance with
the disease clinically. Now, a great deal of this misconception would
disappear if the distinction between a tic and a spasm elaborated by
Brissaud were adhered to, as the authors so strenuously advocate. It is
quite unnecessary to insist further on this point, but, on the other
hand, it is only fair to state that even in France the views of
Brissaud, Meige, and Feindel do not command universal acceptance.
M. Cruchet, of Bordeaux, to whom frequent reference is made in this
volume, has in several communications on tic expressed himself at some
length, and some of these have made their appearance since the
publication of _Les tics et leur traitement_. According to him, the
original meaning of the word "tic" is a movement arising in a "bad
habit," and there would never have been any confusion had the term "tic
douloureux" not been introduced. We know well enough the exact
significance of this term, but its use led to, the adoption of the
cognate term "tic non-douloureux," and in the latter group two
absolutely different conditions have been confused--viz. true tics, and
spasms in Brissaud's sense. The difference between the two is now
recognised everywhere in France; but in England and America, as Risien
Russell points out in his article in Clifford Allbutt's _System of
Medicine_, tic is still applied to such conditions as facial spasm and
the involuntary movements of trigeminal neuralgia, whereas it should be
reserved for what we usually call "habit spasm" and "habit chorea." The
advantage of the word "tic" over these rather cumbrous terms must be
patent to the unbiassed mind.
It is, however, in his persistent affirmation that a tic, to be a tic,
must be clonic, that Cruchet disagrees with the tenets of Meige and
Feindel. He has abandoned the use of the term "organic tic" in favour of
spasm; and he maintains that "tonic tic" and "tic of attitude" should
give place to "habit attitude" and "convulsive attitude," as the case
may be. His definition of tic is in the following terms:
Tic consists in the execution--short, abrupt, sudden, irresistible,
involuntary, inapposite, and repeated at irregular but frequent
intervals--of a simple isolated or complex movement, which
represents objectively an act intended for a particular purpose.
Curiously enough, however much this definition emphasises the clonic
element in tic, Cruchet makes a subdivision into habit tics and
convulsive tics, of which the former "are exactly comparable to normal
movements, except that they are involuntary at the moment of their
execution, are performed for no reason or purpose, and their frequency
is unusual." Their difference from convulsive tics is merely one of
degree; a habit tic may become a convulsive tic, and some are convulsive
from the beginning. A habit tic, if the movement be a slow one, is
closely allied to the "attitude"; and it is not always practicable to
draw a distinction between them.
Thus Cruchet himself admits that the clonic element in tic may be
minimal, so that the differences between him and our authors are by no
means so insuperable as might be imagined. What he calls a habit tic is
equivalent to the stereotyped act of the others, who hold, it will be
remembered, that the movement of tic differs from the normal movement
not merely by being involuntary, irresistible, inapposite, and so on,
but also by being exaggerated.
It cannot be denied that in many cases of tic this exaggeration of the
normal movement is anything but obvious; many conform absolutely to the
definition of Meige and Feindel, except that the movements are not
violent, or grotesque, or "caricatures." To withhold the term "tic" on
this account would be rather unfortunate, especially since no standard
exists whereby to estimate exaggeration. Enough has been said, however,
to demonstrate how insignificant are the discrepancies between the rival
definitions.
Another question recently raised by Cruchet is the possibility of the
persistence of tic during sleep.
The evidence he has adduced in favour of this has now been accepted, as
far as tics of the neck are concerned, by Meige. They are leas abrupt
and less frequent, it is true; otherwise, they are identical with the
movements of the waking hours. A case of a hiccoughing tic persisting in
sleep has come under my own observation within the last few months. Now,
it is not difficult to understand that a movement such as tic, which
occurs during the conscious state in spite of the will of the subject,
may arise when consciousness is diminished. In fact, one wonders why
they are not more frequently remarked, seeing that they are habitual
movements, and habit movements are by no means uncommon in sleep. It is
highly probable, of course, that the observation of the watcher is not
minute enough, but there is another reason. The peculiarity of all, or
almost all, of these habitual movements in sleep is that they are
rhythmical--we may instance the head nodding and head rolling of
children; but it is a noteworthy fact that they are often regulated by
respiration. When it is recalled how respiratory drill is eminently
calculated to diminish the frequency and lessen the severity of very
many tics, it will be admitted that the regularity of the respiratory
movement in sleep is the most likely explanation of the infrequency of
tic during that period.
One other matter may be shortly alluded to. In Cruchet's terminology, a
tic is an anomalous gesture, and cannot be applied to an anomalous
attitude, since the latter is tonic rather than clonic. For an anomaly
of attitude he suggests the use of the word "deformity." Hence "habit
deformity" is comparable to habit tic, and "convulsive deformity" to
convulsive tic. As a habit tic may develop into a convulsive tic, so a
habit torticollis may degenerate into a convulsive torticollis. There is
no reason why the operation of habit as a factor should not effect the
latter transformation exactly as it does the former; and as habit is
held to be a psychical phenomenon, it is easy to conceive why the term
"mental torticollis" should have arisen, and been so widely accepted.
But it will be readily understood that while Cruchet affirms that no
mental torticollis can ever be a tic, in his sense of the word, this is
due solely to his refusal to consider any movement which is tonic as
partaking of the nature of tic. In all other respects, the description
which he gives of mental torticollis shows that it is nought else than a
tic in Meige's sense.
In an article on convulsive torticollis which has been contributed by
Meige to the _Pratique medico-chirurgicale_ (1907) he emphasises afresh
the distinction between torticollis-spasm and torticollis-tic. The
former is provoked by an irritative lesion in the motor nerves supplying
the muscles of the neck, or in their nuclei of origin, and the character
of the contractions ("contracture frémissante" [Meige], "contractions
parcellaires," "contractions paradoxales" [Babinski]) in a definite
peripheral nerve area is not likely to be mistaken. In other cases the
objective phenomena distinctive of spasm are awanting: the
characteristics of tic, on the contrary, are conspicuously present, and
among these cases, where psychical disturbance plays a preponderant
rôle, are to be found those described by Brissaud as mental torticollis.
It is to be noted that these writers alike decry the surgical treatment
of torticollis, and perhaps not without good reason. Nevertheless the
method must not be condemned on theoretical grounds merely, and it is
permissible to believe that their experience may have been unfortunate.
The records of the National Hospital provide many instances of surgical
interference in torticollis and allied conditions of the neck, the
results of which make one hesitate in expressing a dogmatic opinion. It
is, however, impossible to enlarge further on the subject in this place.
S. A. K. WILSON.
BIBLIOGRAPHY
[In one or two instances, where the original paper has been
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Bordeaux, I have seen the proofs of his new volume of 800 pages on
_Les torticolis spasmodiques_, which is at present in the press
(Masson: Paris). It is a splendid monograph on the subject, and
contains many references to the literature.--S. A. K. W.]
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---- "Crampe des écrivains et torticolis d'origine mentale,"
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---- "Tics et spasmes cloniques de la face," _Leçons sur les
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---- "Contribution à l'étude des rythmies d'habitude du sommeil,"
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---- "Sur un cas de maladie des tics convulsifs," _Archives
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DALEY, "Primary Myokymia, with Report of a Case," _Medical News_,
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DAMAIN. _See_ TOURETTE.
DANA, "Myoclonus Multiplex and the Myoclonias; Report of Cases and
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DEBOUT, "Torticolis par contracture des muscles splenius droit et
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DELVART, "Le paramyoclonus multiplex chez l'enfant," _Thèse de
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DERCUM, "Spasmodic Torticollis and its Medical Relations," _Medical
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DERSCHEID-DELCOURT, "Un torticolis d'origine oculaire," _La
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DESCROIZILLES, "De quelques cas de tics convulsifs," _Revue
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DESNOS, "Spasme du sternomastoïdien gauche," _Union médicale_,
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DESTERAC, "Torticolis spasmodique et spasmes fonctionnels," _Revue
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---- "Syndrome du torticolis spasmodique," _Congrès de Toulouse_,
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---- "Le syndrome du torticolis spasmodique," _Nouvelle iconographie
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DIDE, "La myoclonie dans l'épilepsie," _Annales
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DONATH, "Beitrag zu den Clavier-u. Violinspielerneurosen," _Wiener
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DORNBLUTH, "Zur Behandlung gewissen spastischer Neurosen,"
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DREHER, "Tics im Kindesalter und ihre Behandlung," _Jahrbuch f.
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DROMARD, "Psychologie comparée de quelques manifestations motrices
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---- "Du trouble de l'attention chez les tiqueurs," _Bulletin de
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1901, p. 259.
FEINDEL, "Le traitement médical de torticolis mental," _Nouvelle
iconographie de la Salpêtrière_, Nov.-Dec. 1897, p. 404.
FEINDEL, "Le torticolis mental, et son traitement," _Gazette
hebdomadaire_, February 20, 1898, p. 169.
---- "Spasmes grimaçants de la face datant de trois mois; traitement
et guérison en quatre jours," _Revue de psychologie clinique et
thérapeutique_, April, 1899.
---- "Le torticolis mental," _Gazette hebdomadaire_, August 28,
1903, p. 805.
---- _See_ BRISSAUD.
---- _See_ MEIGE.
FEINDEL AND MEIGE, "Tic ou spasme de la face," _Revue
neurologique_, March 15, 1898, p. 125.
---- "Revision iconographique du torticolis mental; trois cas
nouveaux; traitement," _XIIIe Congrès international de médecine,
section de neurologie, Paris_, August, 1900.
---- "Quatre cas de torticolis mental," _Archives générales de
médecine_, January, 1901, p. 60.
---- "Torticolis mental surajouté à des mouvements hémichoréiformes;
guérison du torticolis; amélioration générale," _Société de
neurologie de Paris_, November 7, 1901.
FÉRÉ, "Tic non douloureux de le face du côté gauche," _Archives de
physiologie_, 1876, p. 267.
---- "Tic de la face du côté gauche," _Comptes rendus de la société
de biologie de Paris_, 1876, p. 62.
---- "Le tic de salaam; les salutations névropathiques," _Progrès
médical_, December, 1883, p. 970.
(References to early literature.)
---- "Crampe fonctionnelle du cou," _Revue de médecine_, 1883, p.
769.
---- "Contribution à la pathologie des spasmes fonctionnels du cou,"
_Revue de médecine_, September, 1894, p. 755.
---- "Note sur un cas de chorée variable, avec contractions
fasciculaires des deltoïdes," _Nouvelle iconographie de la
Salpêtrière_, Nov.-Dec. 1898, p. 454.
---- "L'épilepsie choréique," _La médecine moderne_, 1899, p. 209.
---- "L'épilepsie et les tics," _Journal de neurologie_, September
5, 1900.
---- "L'influence sur le travail volontaire d'un muscle de
l'activité d'autres muscles," _Nouvelle iconographie de la
Salpêtrière_, Sept.-Oct. 1901, p. 432.
FÉRON, "Tic guéri par suggestion," _Journal de neurologie_, 1899,
p. 246.
FIERSINGER. _See_ HUCHARD.
FILIPPO, "Mioclono multiplex in un lattante," _Gazzetta degli
ospedali e delle cliniche_, March 12, 1905, p. 329.
FISCHER, "Les chorées électriques; paramyoclonus; myoclonie,"
_Gazette des hôpitaux_, May 2, 1903, p. 513.
FOLLET. _See_ RÉNON.
FORCHHEIMER, "Torticollis intermittens," _Archives of Pediatrics_,
1887, p. 96.
FORNACA ["Observations cliniques sur le torticolis mental"],
_Clinica medica italiana_, November, 1901, No. 15.
FOURNIER, "Quelques considérations sur le tic rotatoire," _Thèse de
Strasbourg_, 1870.
FRANCIS, "Case of spasmodic torticollis; section of spinal
accessory nerve; recovery," _Lancet_, November 11, 1893, p. 1184.
FRANÇOIS, "Essai sur les convulsions idiopathiques de la face,"
_Mémoire présenté à l'Académie royale de Belgique_, 1843.
FRENKEL, "De l'exercice cérébral appliqué au traitement de certains
troubles moteurs," _Semaine médicale_, 1896, p. 123.
---- "Spasme primitif du facial avec mouvements fibrillaires
continus ('myokymie')," _Revue neurologique_, 1903, p. 609.
FRIEDREICH, "Ueber coordinirte Erinnerungskrämpfe," _Virchow's
Archiv_, 1881, p. 430.
FUR (LE). _See_ CHIPAULT.
GALLAVARDIN AND SAVY, "Sur un cas de torticolis congénital avec
autopsie et examen histologique du système nerveux," _Lyon
médical_, November 22, 1903, p. 767.
GARDNER AND GILES, "Neurectomy in Spasmodic Torticollis and in
Retrocollic Spasm, or 'torticolis postérieur,'" _Australian Medical
Journal_, December 15, 1892, p. 613.
GAUSSEL, "Spasme bilatéral des muscles du cou et de la face,"
_Nouvelle iconographie de la Salpêtrière_, Sept.-Oct. 1904, p. 337.
GAUTHIER, "Des mouvements automatiques rythmiques," _Thèse de
Paris_, 1898.
GAUTIEZ, "Contribution a l'étude des spasmes du cou," _Thèse de
Paris_, 1884.
GEHUCHTEN (VAN), "Mouvements spasmodiques du membre supérieur droit
propagés au sterno-cléido-mastoïdien du même côté," _Société belge
de neurologie_, October 29, 1898.
---- "Un curieux cas de tic," _Journal de neurologie_, 1899, No. 3.
GELLÉ, "Du torticolis ab aure laesa," _Tribune médicale_, 1894,
Nos. 50 and 51.
GERHARDT, "Accessoriuskrampf mit Stimmbandbeteiligung," _Münchener
medicinische Wochenschrift_, 1894, p. 181.
GIGLIOLI, "Del torcicolle mentale," _Rivista critica di clinica
medicina_, February 13, 1904, p. 104.
GILBERT. _See_ CADIOT.
GILES. _See_ GARDNER.
GILLET, "Tic douloureux de la face," _Thèse de Paris_, 1903.
GILMOUR, "'Latah' among South African Natives," _Scottish Medical
and Surgical Journal_, January, 1902, p. 18.
GONZALES. See ROSSI.
GOWERS, "On Saltatoric Spasm," _Lancet_, July 14, 1877, p. 42.
GRAFF, "Ein Fall von spastischen Krampfen der Halsmuskulatur,"
_Deutsche medicinische Wochenschrift_, March 22, 1900, p. 66.
GRASSET, "Un cas de maladie des tics et un cas de tremblement
singulier de la tête et des membres gauches," _Leçons de clinique
médicale_, 1891, p. 466.
---- "Tic du colporteur (spasme polygonal post-professionnel),"
_Nouvelle iconographie de la Salpêtrière_, July-August, 1897, p.
217.
---- "Pathogénie du tic" (Congrès de Grenoble), _Revue
neurologique_, 1902, p. 782.
GROLHOUX, "Le spasme facial," _Thèse de Paris_, 1904.
GUERTIN, "D'une névrose convulsive et rythmique déjà nommée; forme
de chorée dite électrique," _Thèse de Paris_, 1881.
GUIBERT, "Crampe fonctionnelle du cou," _Revue de médecine_, 1892,
p. 317.
GUILLAIN. _See_ MARIE.
GUINON, "Maladie des tics convulsifs," _Revue de médecine_, 1886,
p. 50.
---- "Tics convulsifs et hystérie," _Revue de médecine_, 1887, p.
509.
HABEL, "Ueber Fortbestehen von Tic convulsif bei gleichseitiger
Hemiplegie," _Deutsche medicinische Wochenschrift_, March 24, 1898,
p. 189.
HADDEN, "On Head-nodding and Head-jerking in Children, commonly
associated with Nystagmus," _Lancet_, June 14, 1890, p. 1293.
HAJOS, "Ein Fall von Myospasmia Spinalis," _Ungarische medicinische
Presse_, 1898, No. 34.
HALLION. _See_ BRISSAUD.
HAMMOND, "Myriachit, nova malattia del sistema nervoso," _La
medicina contemporanea_, March, 1884.
HANKE, "Ein Beitrag zur Aetiologie des Caput obstipum musculare,"
_Inaugural Dissertation, Kiel_, 1900.
HARTENBERG, "Traitement et guérison d'un cas de tic sans angoisse,"
_Revue de psychologie clinique et thérapeutique_, January, 1899, p.
17.
---- "Tic de déglutition chez un hystérique; traitement et guérison;
considérations," _Revue de psychologie clinique et thérapeutique_,
June, 1899, p. 175.
---- "La psycho-thérapie nouvelle," _Revue de psychologie clinique
et thérapeutique_, February, 1901.
HASSLAUER, "Ueber phonischen Stimmritzenkrampf," _Deutsche
militär-ärtzliche Zeitschrift_, 1900, p. 417.
HAUSER AND LORTAT-JACOB, "Contribution à l'étude des paralysies
psychiques," _Revue de médecine_, November, 1901, p. 995.
HEATON, "Involuntary Rotation of the Head cured by continued
Pressure on the Neck," _British Medical Journal_, February 17,
1879, p. 228.
HELDENBERGH, "Myoclonus fonctionnel intermittent et paradoxal,"
_Semaine médicale_, June 7, 1899, p. 194.
---- "Un cas de tremblement fonctionnel de la main droite," _Journal
de neurologie_, November 5, 1901.
---- "Spasme tonique involontaire et intermittent du cou," _Belgique
médicale_, 1902, No. 23.
HELMICH, _Ueber Wesen u. Behandlung des Schreibkrampfes u.
verwandter Krankheiten_, Bielefeld, 1902.
HENOCH, "Ueber Chorea," _Berliner klinische Wochenschrift_,
December 24, 1883, p. 801.
HERMANN, "Myoclonische Zuckungen bei progressiver Paralyse,"
_Neurologisches Centralblatt_, 1901, p. 498.
HEVEROCH, "Paramyoclonie de Friedreich, combinée avec l'épilepsie,"
_Revue neurologique_, 1902, p. 198 (reference).
HIRSCHFELD, _Ueber die Maladie des Tics convulsifs_, Berlin, 1891.
HUCHARD AND FIERSINGER, "Le syndrome myoclonique," _Revue de
médecine_, October, 1905, p. 741.
(Thirty-four references to the literature of myoclonus.)
HUYGHE, "Du traitement de la chorée hystérique par
l'immobilisation," _Nord médical_, August 1, 1901, p. 173.
---- "Chorée arythmique hystérique unilatérale droite; torticolis
mental," _Nord médical_, December 15, 1903, p. 283.
INGELRANS, "Les spasmes de la face," _Écho médical du nord_, June
11, 1905, p. 277.
INNFELD, "Ein chronische, progressive Fall von Muskelkrämpfen,"
_Wiener klinische Wochenschrift_, 1898, p. 17.
IOTEYKO, "Un cas de tics de la face guéri par suggestion," _Journal
de neurologie_, January, 1906, p. 1.
ISCOVESCO. _See_ ROUILLARD.
ISIDOR, "Étude du torticolis spasmodique, et son traitement
chirurgical," _Thèse de Paris_, 1895.
ITARD, "Mémoire sur quelques fonctions involontaires des appareils
de la locomotion, de la préhension, et de la voix," _Archives
générales de médecine_, July, 1825, p. 385.
JACCOUD, "Des impulsions locomotrices systematisées; spasmes
rythmiques," _Gazette des hôpitaux_, 1886, p. 1185.
JACQUET, "Le tic de salaam," _Thèse de Paris_, 1903.
JANET. _See_ RAYMOND.
JANKE, "Sur les mouvements musculaires conscients et inconscients
dans le bégaiement," _IIIe Congrès des médecins tchèques à
Prague_, 1901.
JANOWITZ, "Tic convulsif, paramyoclonus multiplex, et chorée
électrique," _Thèse de Paris_, 1891.
JANTZEN, "Tonisch-klonische Krämpfe in Gefolge einer
Zahnextraktion," _Deutsche zahnärtz. Wochenschrift_, 1900, p. 1399.
JAROCHEVSKY, "Sur l'étiologie et la thérapie de la chorée
rythmique," _Revue (russe) de psychiatrie_, 1902, p. 736.
JOFFROY, "Des myopsychies," _Revue neurologique_, April 15, 1902,
p. 289.
JOLLY, "Ueber die sogenannte Maladie des Tics convulsifs," _Charité
Annalen_, vol. xii. 1892, p. 740.
KEEN, "A New Operation for Spasmodic Wryneck," _Annals of Surgery_,
January, 1891, p. 44.
KENNEDY, "On the Restoration of Co-ordinated Movements after
Nerve-crossing, with Interchange of Function of the Cerebral
Cortical Centres," _Proceedings of the Royal Society_, 1900, p.
431.
KNAPP, "Functionelle Contractur der Halsmuskeln," _Archiv f.
Psychiatrie u. Nervenkrankheiten_, 1905, p. 1263.
KNY, "Ueber ein dem Paramyoclonus Multiplex (Friedreich)
nahestehendes Krankheitsbild," _Archiv f. Psychiatrie u.
Nervenkrankheiten_, 1888, p. 577.
KODYM, "Une nouvelle espèce de spasme fonctionnel," _Revue
neurologique_, 1895, p. 155 (reference).
KOPCZINSKI, "Un cas de névrose motrice sous forme du tic
convulsif," _Revue neurologique_, 1902, p. 582 (reference).
KOPPEN, _Ueber das psychische Moment bei der
Beschäftigungsneurosen, im besonderen beim Schreibekrampf_,
Göttingen, 1903.
KÖSTER, "Ueber die Maladie des Tics impulsifs," _Deutsche
Zeitschrift f. Nervenkeilkunde_, 1899, Hft. 3-4, p. 147.
LABBÉ, "Débilité mentale et tremblement," _Presse médicale_, 1897,
p. 185.
LAGRANGE, _La médication par l'exercice_, Paris, 1894.
---- _Les mouvements méthodiques et la mécanothérapie_, Paris,
1899.
LAMBRANZI, "Due casi di policlonie nella demenza precoce," _Rivista
di patologia nervosa e mentale_, 1901, p. 241.
---- "Su le policlonie nella demenza paralitica," _Rivista di
patologia nervosa e mentale_, August, 1902, p. 360.
LAMY, "Myoclonie avec hémianesthésie sensitivo-sensorielle chez un
sujet atteint de monoplégie infantile du membre inférieur,"
_Société de neurologie de Paris_, May 5, 1904.
---- "Hémispasme clonique facial; spasmes cloniques chez l'homme et
chez le chien," _Société de neurologie de Paris_, July 6, 1905.
LANDOLT, "Torticolis oculaire," _Bulletin médical_, 1890, p. 573.
LANNOIS AND POROT, "Sur les hémispasmes de la face; hémispasme
facial vrai, hémispasme hystérique," _Lyon médical_, February 7,
1904, p. 234.
LASÈGUE, "De la toux hystérique," _Société médicale des hôpitaux de
Paris_, 1855, p. 269.
LEGRAIN, "Du délire des dégénérés," _Thèse de Paris_, 1885.
LEMAIRE. _See_ LEMOINE.
LEMBO, "Paramyoclonus multiplex di Friedreich," _Giornale di
neuropatologia_, 1887, p. 261.
LEMOINE, "Note sur un cas de paramyoclonus multiplex suivi de
troubles psychiques et de l'écholalie," _Revue de médecine_,
November, 1892, p. 882.
LEMOINE AND LEMAIRE, "Étude clinique et séméiologique du
paramyoclonus multiplex," _Revue de médecine_, December, 1889, p.
1018.
(Thirty-nine references to the literature of paramyoclonus
multiplex.)
LENTZ, "Rotation permanente de la tête à droite," _Journal de
neurologie_, 1897, p. 502.
LERCH ["Tics convulsifs"], _American Medicine_, November 2, 1901.
LEROUX, "Du tic post-choréique," _Revue mensuelle des maladies de
l'enfance_, June, 1891, p. 251.
LESZYNSKY, "Spasmodic Wryneck and its Treatment; Report of two
Cases with Recovery," _Journal of Nervous and Mental Disease_,
February, 1901, p. 103.
LETULLE, "Note à propos d'un cas de bégaiement compliqué de tics
coordinés multiples," _Gazette médicale de Paris_, 1883, p. 536.
LEVI AND BONNIOT, "Un cas de myospasme clonique et tonique
(myoclonotonie acquise)," _Société de neurologie de Paris_, May 11,
1905.
---- "Myoclonotonie acquise," _Revue d'hygiène et de médecine
infantile_, 1905, p. 569.
LEVY, "Ererbte Mitbewegungen," _Neurologisches Centralblatt_, July,
1901, p. 605.
---- "Angeborenen Mitbewegungen bei willkürlichen Bewegungen,"
_Archiv f. Psychiatrie u. Nervenkrankheiten_, 1903, p. 927.
LEWIN, "Phosphaturie mit Tic convulsif bei einem 3-1/2-jahrigen
Kinde," _Archiv f. phys.-diat. Therapie_, 1900, p. 281.
LINZ, "Ueber spastische Torticollis," _Inaugural Dissertation_,
Bonn, 1897.
LONDE. _See_ ROBIN.
LORENZETTI, "A proposito di alcuni casi di tic convulsivo,"
_Gazzetta degli ospedali e delle cliniche_, November 22, 1903, p.
1478.
LORTAT-JACOB. _See_ HAUSER.
LUGARO, "Sulla mioclonia," _Rivista di patologia nervosa e
mentale_, 1896, p. 389.
LUNDBORG, _Die progressive Myoklonus-Epilepsie (Unverricht's
Myoklonie)_, Upsala, 1903.
---- "Ist Unverricht's sogenannte familiäre Myoklonie eine klinische
Entität?" _Neurologisches Centralblatt_, February 15, 1904, p. 162.
LUZENBERGER, _Tic muscolari simplici, tic emotivi, e malattia di
Gilles de la Tourette_, Naples, 1897.
---- "'Absences' psichichi in isterici," _Rivista sperimentale di
freniatria_, December, 1900, p. 822.
LYMAN, "Torticollis and Nodding Spasm," _International Medical
Magazine_, vol. ii. 1894, p. 741.
MADER, "Myoklonie in der Art eines expiratorischen Singultus,"
_Wiener med. Blätter_, 1899, No. 30.
MALM ["Tic rotatoire"], _Allgemeine medicinische Centralzeitung_,
1899, No. 64.
MANNINI, "Policlonia ed epilessia," _Gazzetta degli ospedali e
delle cliniche_, September 30, 1900, p. 1220.
---- "Coree, policlonie, tic e malattia dei tic," _Riforma medica_,
July, 1902, p. 137.
MARÉCHAL, "Un cas de torticolis spasmodique," _Journal de
neurologie_, May 20, 1899, p. 206.
MARIE (PIERRE), "Spasme névropathique d'élévation des yeux,"
_Société de neurologie de Paris_, April 18, 1901.
MARIE AND GUILLAIN, "Mouvements athetoïdes de nature indéterminée,"
_Société de neurologie de Paris_, April 17, 1902.
MARINA, "Delle miospasie in generale e della miospasia atetosica in
particolare," _Il policlinico, sezione pratica_, 1902, p. 577.
MARROTTE, "Tic non douloureux de nature hystérique reparaissant
sous le type quotidien," _Société médicale des hôpitaux de Paris_,
1851.
MARTAUD, "Étude sur le tic convulsif simple," _Thèse de Bordeaux_,
1897.
MARTIN (CLAUDE), "Tic congénital associé à du bégaiement," _Journal
de médecine de Bordeaux_, 1900, p. 172.
---- _See_ DAVESAC.
---- (ÉTIENNE), "Deux cas de torticolis mental chez les aliénés:
observations relatives au traitement de cette affection," _Écho
médical de Lyon_, September 15, 1901.
MASSALONGO, "Corea elettrica o mioclonia elettroide di origine
gastrica," _Riforma medica_, vol. iii. 1892, p. 471.
(References to the literature of electric chorea.)
---- "Contribution à l'origine corticale des tremblements," _Revue
neurologique_, 1903, p. 455.
MASSARO ["Vingt-six cas de géniospasme en cinq générations"], _Il
pisani_, 1894, fasc. I.
MASSARY AND TESSIER, "Torticolis mental ou torticolis spasmodique
(torticolis-tic ou torticolis-spasme)," _Revue neurologique_,
December 30, 1904, p. 1204.
MAYER ["Tic convulsif remplaçant une névralgie sus-orbitaire"],
_Alienist and Neurologist_, July, 1897.
MEIGE, "Tics variables; tics d'attitude," _Société de neurologie de
Paris_, July 4, 1901.
MEIGE, "Les mouvements en miroir; leurs applications pratiques et
thérapeutiques," _Revue neurologique_, 1901, p. 280.
---- "Histoire d'un tiqueur; tics variables; tics d'attitude,"
_Journal de médecine et de chirurgie pratiques_, August 25, 1901,
p. 609.
---- "Sur les tics," _Gazette hebdomadaire_, May 1, 1902.
---- "Spasme facial franc," _Société de neurologie de Paris_, April
17, 1902.
---- "Tic et fonction," _Revue neurologique_, 1902, p. 383.
---- "Tic et écriture," _Gazette hebdomadaire_, June 12, 1902, p.
541.
---- "La genèse des tics," _Journal de neurologie_, June 5, 1902.
---- "La correction des tics par le contrôle du miroir," _Journal de
médecine et de chirurgie pratiques_, October 25, 1903, p. 769.
---- "Micropsie chez un tiqueur bègue," _Société de neurologie de
Paris_, January 15, 1903.
---- "L'aptitude catatonique et l'aptitude échopraxique des
tiqueurs; les exercices thérapeutiques de détente," _Congrès de
Madrid_, April, 1903.
---- "Tics des yeux," _Annales d'oculistique_, 1903, p 167.
---- "Neue Beiträge zur Prognose und Behandlung des Tic; die
psycho-motorische Selbsterziehung unter Spiegelkontrolle," _Journal
f. Psychologie u. Neurologie_, 1903, p. 53.
---- "Le phénomène de la chute du bras," _Revue neurologique_,
August 30, 1903.
---- "Tics des lèvres; cheilophagie, cheilophobie," _Journal de
neurologie_, October 20, 1903, p. 481.
---- "Le spasme facial; ses caractères cliniques distinctifs,"
_Revue neurologique_, October 30, 1903.
---- "Les tics," _Revue scientifique_, May 15, 1904.
---- "Migraine ophtalmique; hémianopsie et aphasie transitoires;
hémiface succulente; photophobie et tic de clignement," _Revue
neurologique_, September 30, 1904, p. 961.
---- "Génio-tics et génio-spasmes," _Société de neurologie de
Paris_, April 6, 1905.
---- "Tics de sphincters," _Congrès de Rennes_, August, 1905.
---- _See_ BRISSAUD.
---- _See_ FEINDEL.
MEIGE AND FEINDEL, "Traitement des tics; traitement par
l'immobilisation des mouvements et les mouvements
d'immobilisation," _Presse médicale_, March 16, 1901, p. 125.
MEIGE AND FEINDEL, "Les causes provocatrices et la pathogénie des
tics de la face et du cou," _Société de neurologie de Paris_, April
18, 1901.
---- ---- "Sur la curabilité des tics," _Gazette des hôpitaux_, June
20, 1901, p. 673.
---- ---- "L'état mental des tiqueurs," _Progrès medical_, September
7, 1901, p. 146.
---- ---- "Les associations du torticolis mental," _Archives
générales de médecine_, February, 1902, p. 168.