Tics and Their Treatment Part 35

_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 a.s.sert 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 obsedant_ 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 att.i.tude tics.

Repet.i.tion of the seances under the eye of the physician, drill in front of a looking-gla.s.s, symmetrical and synchronous exercises for the arms, as well as ordinary practice in dressing and undressing, b.u.t.toning and unb.u.t.toning 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 ch.o.r.ea, 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 att.i.tude 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 att.i.tude, 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 ma.s.sage.

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 p.r.o.neness 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. .h.i.therto 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 repet.i.tion 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 a.s.siduity 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 subst.i.tuted 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 rea.s.serts 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 a.s.sistance, is calculated rather to obscure and hamper it.

It has been pointed out by Ballet that variations in the apt.i.tude 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 pa.s.sing 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 Fere[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 a.s.sume, 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 inst.i.tution 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 seances 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 apt.i.tudes. 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 s.p.a.ce, 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