Tics and Their Treatment

by Henry Meige; E. Feindel

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.