Tics and Their Treatment Part 34

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 rehea.r.s.e 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 s.p.a.ce, 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 a.n.a.logy in the observations of Gunn and Helfreich, who have seen ptosis disappear as the mouth is opened.

If the eyeb.a.l.l.s 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 gla.s.s 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 a.s.sert 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 seance.

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-gla.s.s 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 att.i.tude. 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, ma.s.sage and pa.s.sive 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 c.o.xo-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 Tissie, 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 seances 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 pa.s.sed.

Tissie explains the action of this method on tics by a special action of regular respiration on psych.o.m.otor centres. Raymond and Janet incline to the opinion that attention depends on respiratory activity, but Tissie[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 p.r.o.ne 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.

Koster 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._--Seance 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.