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.