Part 35 (1/2)
_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 diminis.h.i.+ng 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.