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.