Chapter XIX: 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.