Part 34 (1/2)
There is an infinity of occupations for the patient to put his hands to, and this variety suits his unsettled mood and his wavering attention; but longer efforts will be secured from him if his interest in his task can be engaged and stimulated as well. It is a good plan to make him write down each day what he does and how it is done, and to have him rehea.r.s.e from time to time. Such pedagogical details are far from being superfluous; adults, moreover, are quick to gather their significance and to demonstrate their advantages in practice. That their fickle will must be reinforced they know well; how to achieve this end they are unaware. This fact explains their eager acceptance of the support furnished by these ”moral crutches.”
Generally speaking, there is no call to interrupt treatment once it is commenced, although occasionally we have found this desirable. The fatigue of the first few days, almost unavoidable as it is, and accompanied by new sensations, need occasion no alarm. We should acquaint our patient of its explanation, and so obviate the mental depression which its existence is apt to engender. Its ephemeral nature will soon become plain, for a rest of a few days suffices for its disappearance.
In some instances resort to procedures reminiscent of antagonistic gestures seems to have been of avail.
One of our patients,[223] suffering from facial tic, was directed to perform, as far as practicable, the opposite movements to her grimaces.
If her mouth was drawn to the right, she forthwith made a corresponding twitch to the left; if her mouth was shut spasmodically, she was instructed to open it widely and quickly. By such simple methods, applied to all her tics, speedy control was regained, and once she had mastered the theory of the process, the practice of regular exercises and the development of antagonistic movements soon effected a complete cure.
Training of the antagonists has also been recommended by Hartenberg,[224] in a case of scratching tic. The patient was urged to approximate the hand to the affected cheek very slowly, and almost at the moment of contact the order was given to extend the arm briskly; this gesture of opposition, moreover, was stimulated by faradisation to the extensors of the forearm. The method, of course, is practically identical with that adopted by Frenkel,[225] of Heiden, who provoked energetic contractions of antagonistic groups by teaching the patients to overcome increasing resistances. Prudence, however, must be observed in carrying out these ideas, otherwise we run the risk of replacing one tic by another.
After the above general sketch of the essentials of the method, we may give examples of its application to particular instances.
For a tic of the eyelids, in especial for blinking tics, we make the patient open and shut the eyes to order, keep them closed or apart for a s.p.a.ce, shut one eye and then the other, and repeat the same sequence in different positions of the head. It is a good plan to enjoin simultaneous action of the oral musculature. The cessation of tonic contractions of the eyelids with opening of the mouth has been remarked several times, and Oppenheim finds an a.n.a.logy in the observations of Gunn and Helfreich, who have seen ptosis disappear as the mouth is opened.
If the eyeb.a.l.l.s are involved in a tic, insist on dissociating the movements of head and eyes; make the patient follow an object slowly with his eyes while the head is stationary; or let the head deviate to right or left, up or down, while the eyes remain fixed on some particular point.
When the lips are the seat of involuntary muscular action, have the patient show his teeth, open and shut his mouth, purse his lips; make him speak and conform his expression to his speech; let him read aloud slowly, and fix his attention on his subject.
As a specimen of treatment for a facial tic, we may cite the subjoined programme:
Every day, and three times a day, at the same hours--nine, one, and six--the patient is to look at himself for two minutes in a mirror, preserving absolute immobility the while; to read aloud for two minutes, to speak in front of the gla.s.s for two minutes, to walk backwards and forwards in front of the mirror for two minutes.
During the ten minutes of these exercises he will endeavour to keep his facial musculature under control. If the tic a.s.sert itself in the course of one of the exercises, he will recommence the latter, if necessary twice; the third time he will leave it till the next seance.
For tics of the head and neck, such as tossing tics and mental torticollis, inclination and rotation movements are indicated, of which an instance may be quoted:
Mademoiselle R. is quick in learning how to correct her muscular faults. Her actions are gradually becoming more complete and ample, and if she performs her allotted task with little animation, at the least there is no question of her indefatigable willingness. In less than a month she has been able to fix her regard, open her eyes widely, turn her head, uninterrupted either by halts or twitches; she can remain motionless in front of a looking-gla.s.s for as long as a minute. Equally satisfactory progress hat been made in the art of reading aloud; she breathes more regularly, and articulates more distinctly.
Thus the patient has come to realise that she need but give her attention to the involuntary movements for them to cease, and there has been a synchronous advance in her mental activity and power of concentration. Her nonchalance and timidity have diminished; she is no longer indifferent to her surroundings, nor furtive in her glances; she enters into conversation with zest, and her movements are characterised by decision.
Take another example of treatment, for a case of mental torticollis:
Stand or sit in front of a mirror and endeavour to maintain an absolutely correct position of trunk and shoulders.
Lift the arms vertically and turn the head to the right, then lower the arms while the head remains as it is.
Bend the body forward, and stretch the arms out till they touch the ground, the head meantime being rotated to the right. Then rise up again with the head in the same att.i.tude. After two or three efforts it will be found that the head can be kept straight for a few seconds.
In tics of the limbs, shoulders, hands, feet, innumerable movements will suggest themselves for practice. The young girl with a tic of genuflexion, under the care of Oddo, supplies an excellent proof of the value of Brissaud's method:
The immobilisation of movements was realised by the mother forcing the child to remain motionless in a fixed position for augmented periods. As for movements of immobilisation, the patient made peregrinations of increasing length under the mother's eye, the order being repeatedly given to suppress the genuflexions. At the same time, ma.s.sage and pa.s.sive movements to the limbs and joints were prescribed, with a view to diminis.h.i.+ng the articular cracks--the exciting cause of the bizarre tic from which the girl suffered.
In the course of ten or twelve days the genuflexions had entirely vanished, and a return of the pain in the c.o.xo-femoral articulation aided materially in consolidating the effects of the treatment.
Tics of speech should be handled in the same way as stammering. ”We do not treat stammerers, we educate them,” says Moutard-Martin. There can be no gainsaying the convincing results obtained by Chervin's technique.
For years there has been unanimity of opinion on the value of respiratory gymnastics in the treatment of stammering. The plan is to make the patient inspire deeply and quickly, and follow this with a prolonged expiration. Difficulties of articulation and phonation may be overcome by recitation, by declaiming, by scanning utterance, by dwelling on the vowels, etc. Various authors have laid stress on the advisability of concomitant therapeutic treatment.
In cases of stammering (says Olivier), all surgical interference is to be deprecated. Operations on the nose or throat are directed toward the removal of obstructions in the air-ways, but they are merely a preparatory step to the adoption of the education method.