Tics and Their Treatment Part 36

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 a.s.sociation 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 circ.u.mstances 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 inst.i.tution; 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 const.i.tute 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 const.i.tute 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 Bicetre:

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 p.u.b.erty 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 inst.i.tution like Bicetre 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 a.s.siduously, in the task of education. How common it is to find them solicitous only of loading his tender brain with learning, instead of endeavouring, with all their mind and heart, to restrain deplorable bad habits that may one day blossom into tics, to the distress of all concerned! The physician's earliest duty is to warn the parents of the dangers of indifference, and thereafter to install himself as teacher, if the disease should manifest itself in spite of his precautions. He has no choice in the matter, and he should have the frankness to say so, indicating at the same time on what his convictions rest. He need have no fear of damaging his professional prestige by the simplicity of his methods. Let him not promise what he may not be able to perform; encouragement, not deception, must be his watchword. Along these lines lies his duty as a physician; there, too, will he find that his treatment will be fraught with success.

APPENDIX

_Les tics et leur traitement_, of which an English translation is here presented to the medical profession, was published at the close of the year 1902. In it our knowledge of the vexed subject of tics and spasms has been summarised and reviewed, and its reception in France, together with the fact of its having been translated into German without delay, prove that it has been regarded as the standard work on a topic the importance of which is being daily emphasised. At all the recent Congresses on the Continent the tics in one or other of their aspects have provided fruitful matter for discussion, whereas in England they have hitherto been greatly neglected. In the brief s.p.a.ce of time that has elapsed since the book was produced there have been many and varying contributions to the subject, as a reference to the Bibliography herewith appended will show. Without doubt the reawakening of interest is in considerable measure due to the stimulus provided by the labours of MM. Meige and Feindel, yet it cannot be maintained that they have said the last word. In order that English readers may have before them the latest available information on the tics, various paragraphs from Meige's monograph (1905) have been incorporated, as has already been remarked in the Prefatory Note.

It is desirable, however, to indicate briefly certain points on which opinion is still divided, points on which the results of the most recent observations help to shed some light. Probably it has not escaped the reader's attention that the authors have with commendable wisdom refrained from dogmatising on some of these, although they are always able to give reasons for their adherence to one or other view. But in one respect at least the att.i.tude which they have adopted has been unmistakable, and that is in regard to the fundamental importance of agreement in the matter of terminology.

The amount of misconception that exists about what const.i.tutes a tic is almost beyond credence; indeed, only those who have had occasion to examine the literature can have any adequate idea of it. Discussions at neurological and other societies not infrequently reveal how vague are the notions of many who must have more than a pa.s.sing acquaintance with the disease clinically. Now, a great deal of this misconception would disappear if the distinction between a tic and a spasm elaborated by Brissaud were adhered to, as the authors so strenuously advocate. It is quite unnecessary to insist further on this point, but, on the other hand, it is only fair to state that even in France the views of Brissaud, Meige, and Feindel do not command universal acceptance.

M. Cruchet, of Bordeaux, to whom frequent reference is made in this volume, has in several communications on tic expressed himself at some length, and some of these have made their appearance since the publication of _Les tics et leur traitement_. According to him, the original meaning of the word "tic" is a movement arising in a "bad habit," and there would never have been any confusion had the term "tic douloureux" not been introduced. We know well enough the exact significance of this term, but its use led to, the adoption of the cognate term "tic non-douloureux," and in the latter group two absolutely different conditions have been confused--viz. true tics, and spasms in Brissaud's sense. The difference between the two is now recognised everywhere in France; but in England and America, as Risien Russell points out in his article in Clifford Allb.u.t.t's _System of Medicine_, tic is still applied to such conditions as facial spasm and the involuntary movements of trigeminal neuralgia, whereas it should be reserved for what we usually call "habit spasm" and "habit ch.o.r.ea." The advantage of the word "tic" over these rather c.u.mbrous terms must be patent to the unbia.s.sed mind.

It is, however, in his persistent affirmation that a tic, to be a tic, must be clonic, that Cruchet disagrees with the tenets of Meige and Feindel. He has abandoned the use of the term "organic tic" in favour of spasm; and he maintains that "tonic tic" and "tic of att.i.tude" should give place to "habit att.i.tude" and "convulsive att.i.tude," as the case may be. His definition of tic is in the following terms:

Tic consists in the execution--short, abrupt, sudden, irresistible, involuntary, inapposite, and repeated at irregular but frequent intervals--of a simple isolated or complex movement, which represents objectively an act intended for a particular purpose.

Curiously enough, however much this definition emphasises the clonic element in tic, Cruchet makes a subdivision into habit tics and convulsive tics, of which the former "are exactly comparable to normal movements, except that they are involuntary at the moment of their execution, are performed for no reason or purpose, and their frequency is unusual." Their difference from convulsive tics is merely one of degree; a habit tic may become a convulsive tic, and some are convulsive from the beginning. A habit tic, if the movement be a slow one, is closely allied to the "att.i.tude"; and it is not always practicable to draw a distinction between them.

Thus Cruchet himself admits that the clonic element in tic may be minimal, so that the differences between him and our authors are by no means so insuperable as might be imagined. What he calls a habit tic is equivalent to the stereotyped act of the others, who hold, it will be remembered, that the movement of tic differs from the normal movement not merely by being involuntary, irresistible, inapposite, and so on, but also by being exaggerated.

It cannot be denied that in many cases of tic this exaggeration of the normal movement is anything but obvious; many conform absolutely to the definition of Meige and Feindel, except that the movements are not violent, or grotesque, or "caricatures." To withhold the term "tic" on this account would be rather unfortunate, especially since no standard exists whereby to estimate exaggeration. Enough has been said, however, to demonstrate how insignificant are the discrepancies between the rival definitions.

Another question recently raised by Cruchet is the possibility of the persistence of tic during sleep.

The evidence he has adduced in favour of this has now been accepted, as far as tics of the neck are concerned, by Meige. They are leas abrupt and less frequent, it is true; otherwise, they are identical with the movements of the waking hours. A case of a hiccoughing tic persisting in sleep has come under my own observation within the last few months. Now, it is not difficult to understand that a movement such as tic, which occurs during the conscious state in spite of the will of the subject, may arise when consciousness is diminished. In fact, one wonders why they are not more frequently remarked, seeing that they are habitual movements, and habit movements are by no means uncommon in sleep. It is highly probable, of course, that the observation of the watcher is not minute enough, but there is another reason. The peculiarity of all, or almost all, of these habitual movements in sleep is that they are rhythmical--we may instance the head nodding and head rolling of children; but it is a noteworthy fact that they are often regulated by respiration. When it is recalled how respiratory drill is eminently calculated to diminish the frequency and lessen the severity of very many tics, it will be admitted that the regularity of the respiratory movement in sleep is the most likely explanation of the infrequency of tic during that period.

One other matter may be shortly alluded to. In Cruchet's terminology, a tic is an anomalous gesture, and cannot be applied to an anomalous att.i.tude, since the latter is tonic rather than clonic. For an anomaly of att.i.tude he suggests the use of the word "deformity." Hence "habit deformity" is comparable to habit tic, and "convulsive deformity" to convulsive tic. As a habit tic may develop into a convulsive tic, so a habit torticollis may degenerate into a convulsive torticollis. There is no reason why the operation of habit as a factor should not effect the latter transformation exactly as it does the former; and as habit is held to be a psychical phenomenon, it is easy to conceive why the term "mental torticollis" should have arisen, and been so widely accepted.

But it will be readily understood that while Cruchet affirms that no mental torticollis can ever be a tic, in his sense of the word, this is due solely to his refusal to consider any movement which is tonic as partaking of the nature of tic. In all other respects, the description which he gives of mental torticollis shows that it is nought else than a tic in Meige's sense.

In an article on convulsive torticollis which has been contributed by Meige to the _Pratique medico-chirurgicale_ (1907) he emphasises afresh the distinction between torticollis-spasm and torticollis-tic. The former is provoked by an irritative lesion in the motor nerves supplying the muscles of the neck, or in their nuclei of origin, and the character of the contractions ("contracture fremissante" [Meige], "contractions parcellaires," "contractions paradoxales" [Babinski]) in a definite peripheral nerve area is not likely to be mistaken. In other cases the objective phenomena distinctive of spasm are awanting: the characteristics of tic, on the contrary, are conspicuously present, and among these cases, where psychical disturbance plays a preponderant role, are to be found those described by Brissaud as mental torticollis.

It is to be noted that these writers alike decry the surgical treatment of torticollis, and perhaps not without good reason. Nevertheless the method must not be condemned on theoretical grounds merely, and it is permissible to believe that their experience may have been unfortunate.

The records of the National Hospital provide many instances of surgical interference in torticollis and allied conditions of the neck, the results of which make one hesitate in expressing a dogmatic opinion. It is, however, impossible to enlarge further on the subject in this place.

S. A. K. WILSON.

BIBLIOGRAPHY

[In one or two instances, where the original paper has been inaccessible, its t.i.tle is reproduced as given in the French edition, but in brackets. Through the kindness of M. Cruchet, of Bordeaux, I have seen the proofs of his new volume of 800 pages on _Les torticolis spasmodiques_, which is at present in the press (Ma.s.son: Paris). It is a splendid monograph on the subject, and contains many references to the literature.--S. A. K. W.]

ABADIE AND DUPUY-DUTEMPS, "Hemispasme facial gueri par une injection profonde d'alcool," _Societe de neurologie de Paris_, February 1, 1906.

ABT, "Spasmus Nutans," _Journal of the American Medical a.s.sociation_, February 3, 1900, p. 269.

ACHARD AND SOUPAULT, "Tremblement hereditaire et tremblement senile," _Gazette hebdomadaire_, April 22, 1897, p. 373.

AIMe, "Un cas de tic elocutoire gueri par la methode de reeducation et d'entrainement," _Revue medicale de l'Est_, January 1, 1901, p.

25.

---- "Traitement de certains tics consideres comme des syndromes emotionnels," _Revue de psychologie clinique et therapeutique_, September, 1901.

ALDRICH, "Tic," _Medical Record_, July 30, 1904, p. 169.

ALLARD, "Tics chez les alienes," _These de Lyon_, 1886.

D'ALLOCCO, "Parecchi casi di mioclonia, la maggior parte familiari," _Riforma medica_, 1897, p. 223.

ALTHAUS, "Two Cases of Wryneck successfully treated by Electricity," _Medical Times and Gazette_, May 25, 1861, p. 544.

AMUSSAT, "Torticolis datant de six ans; section du muscle sternomastodien; guerison," _Gazette medicale_, 1834, p. 829.

ANDERSON, "Sternomastoid Torticollis," _Lancet_, January 7, 1893, p. 9.