Psychotherapy

CHAPTER II

CHOREA

This twitching affection, so familiar that it need not be described particularly, is sometimes classed as a pure neurosis, sometimes as a nervous disease with perhaps some organic basis and sometimes is placed among the ailments related to rheumatism and attributed to some pathological condition of the circulation.

Etiology.—Two elements must be considered in the problem of the etiology of the disease—the predisposition and the direct occasion. The affection occurs particularly in nervous children who are made to occupy their intellects too much while their muscular systems are kept quiet for long hours. Often a preceding running down in weight is noticed, though sometimes the child only fails to increase in weight as it should in proportion to its growth. It occurs quite frequently among chlorotic girls just before or about the time of puberty. Anemia generally seems to predispose to it, but the affection may occur among children who seem to be in excellent physical health, though usually a distinct nervous heredity is found.

Immediate Causation .—Fright is one of the most frequent immediate causes or occasions of the development of chorea. Mental worry of any kind may have the same effect. Scolding has produced it; a sudden grief has seemed to be the occasion; a slight injury, and still more, a severe injury, or a surgical operation, even a slight one, may be the forerunner of it.

Pathology.—No definite lesions have been found to which the disease can be attributed, though a careful search has been made for them. Endocarditis is an extremely common accompaniment. It is probably present in three-fourths of the cases that have come to autopsy. Osler found it in sixty-two out of seventy-three cases in the literature. The association of the affection with rheumatism is insisted on by the French and English particularly, and certainly in a considerable number of cases there is a history of preceding or coincident rheumatism, that is, an acute rheumatic arthritis. Often these attacks are concealed under such names as "growing pains" or "colds in the joints" but it is not hard to elicit a history of a red and swollen joint with some fever. In children mild cases may occur of genuine acute rheumatism with the involvement of but a single joint and that not severely. These mild forms are often found in the history of cases of chorea.

It seems likely that the heart affection is often responsible for the symptoms and it is probably through the endocarditis that whatever connection there is between chorea and rheumatism exists.

All the elements in the disease point to the influence of the mind over it. The predisposition is caused by over-use of the mind at a time when many claims are being made on the nervous system because of the growth of muscles. There must, as a rule, be a pathological basis, natural or acquired, that is, something that tends to produce a defect in the circulation, but even without this certain children suffer from the affection. If the patient is an object of solicitude or of curiosity at home or at school, the symptoms rapidly become worse. At any time the consciousness of observation makes them worse. The symptoms do not occur during sleep, or at times when the patient's mind is much occupied with some absorbing interest. They lessen just to the degree that the patient's own attention is not called to them or the consciousness not allowed to be concentrated on them. Chorea often occurs in bright, intelligent children and always seems worse in them.

Treatment.—The story of the therapeutics of chorea in recent years strongly confirms the idea of the place of mental influence in the cure of the disease. We have had a whole series of remedies, introduced with a promise of cure by distinguished authorities, used for a time with apparent success by many physicians, and then gradually falling into innocuous desuetude. It was recognized that any remedy would have to be used over a rather prolonged period, at least from five to ten weeks. It was appreciated, also, that the patient must be kept quiet, both in mind and body, emotional disturbances especially being avoided, that all physical functions have to be set right and that the nutrition particularly must be corrected if in anything it is abnormal. Where all this is done patients recover without any remedy quite as promptly in most cases as with any of the supposed specifics. Expectant treatment, supplemented by symptomatic treatment, has proved in many institutions to give excellent results without the necessity of troubling the patients with more or less dubious drugs. It was important that the patient should be given certain medicine and impressed with the idea that this medicine was expected to do them good, a suggestion automatically emphasized at every dose, but it is probable that few men of considerable clinical experience now hold the notion that we have any genuinely curative remedy for chorea, though we have certain tonic, alterative remedies which, in conjunction with the setting of the mind at rest, help to put the patient in a condition where the affection is gradually overcome.

The most important object in the treatment of chorea must be its prevention or its early recognition, and its immediate treatment; then there is little likelihood of relapses and, above all, the condition does not last long. Children who have had an attack of acute articular rheumatism or who have suffered from growing pains or any other of the rheumatic simulants of childhood should be watched carefully during their growing period and at certain critical times in early life. They should be especially regarded immediately after being sent to school. The first sign of involuntary twitchings should be taken to mean that the children are overborne and a period of rest from anxiety and study and over-exercise should be afforded them. Of course, all this watchful care must be exercised without attracting the little patient's attention, or the very purpose of the care will be defeated and the mind disturbed.

Rest does not mean that patients should be kept absolutely in bed even after chorea has frankly developed, but that there should be hygienic rest. Long hours of sleep, interesting occupations without much exercise, a period of lying down in the afternoon, but, above all, such occupation of mind with simple pleasant things as keeps their attention from themselves. Visitors should not be allowed to see them; above all, they should not be conscious objects of over-solicitous care on the part of father and mother or the relief of symptoms will be delayed and the condition will be made worse. As a rule, children do not worry about themselves nor their physical ailments, but they can be made to do so by seeing the over-anxiety of others. A good nurse of sympathetic nature with power to interest the child, is better than its mother for a constant companion, though family life, the playing with brothers and sisters and the regular routine of home is the best possible mental solace and occupation. Grandmothers are useful adjuvants in the treatment late in the affection. At the beginning their over-solicitude nearly always does harm.

Habit Following Chorea.—In certain nervous children after the chorea itself has subsided there remains a habit of twitching that often is almost more intractable than the chorea itself. This is particularly likely to be manifest in children who have an unfortunate nervous heredity or in those whose nervous systems have been impaired by preceding infections disease as anterior polio-myelitis, syphilis or one of the forms of meningitis. Occasionally it is seen in children without nervous heredity, but they are usually children surrounded by solicitous relatives, made the centre of pathological interest and constantly fussed about. The habit is not surprising and would remind the observant physician of the whoop that by habit sometimes clings to children in any cough that they may have for months after they have had whooping cough. Often it will be found that these children are capricious eaters, that they take tea and coffee, that their diet instead of being the simple nutritious food that they should have consists of many things that their mothers obtain to tempt their appetites and that the children can really have anything they crave for and get it much oftener than is good for them. To continue any form of presumedly specific treatment in these cases does no good. If arsenic is used over long periods, or any of the salicylates because of the supposed connection of chorea and an underlying rheumatic diathesis they will certainly do harm. The patients' diet can be regulated, nerve stimulants of all kinds must be denied them, and their appetites must be brought into order by the proper care of a nurse who will not yield too readily to their caprices, and then the solicitous environment must be changed. These cases represent a good many of the so-called prolonged choreas and are really habits or tics due to concentration of mind and a certain hysterical tendency to continue to attract attention which may be noted.

CHAPTER III

TICS

Without any good reason in the etymology or the history of the word, the term "tics" has now been generally accepted to signify certain involuntary movements, frequently recurrent, of which, by habit, certain persons usually of diminished nervous control, become the victims. For the psychotherapeutist, however, they have an interest quite beyond that which they have for the ordinary student of nervous diseases. They represent the possibility of the formation of habits in the nervous system, originally quite under the control of the will, but which eventually become tyrannously powerful and quite beyond management by the individual. They deserve to be studied with particular care because it is probable that they represent objectively what occurs also on the sensory side of the system, but which not being manifest externally, is spoken of as entirely subjective. If nerve explosions of motor character can, through habit, get beyond the control of the patient, it is not unlikely that sensations, primarily of little significance, may, in persons of low nervous control, become by habit so likely to be repeated as to make the patient miserable. Hence the study of tics as here presented.

As a result of the studies of Gilles de la Tourette, we realize that there is an essential distinction between involuntary movements of various kinds, and that spasms and tics must be separated from one another. Tics consist of various movements of the voluntary muscles. Probably the most familiar is that of winking. Everybody winks both eyes a number of times a minute quite unconsciously, though the unconscious movement accomplishes the definite and necessary purpose of keeping the conjunctiva free from irritant particles. When this same movement is done more frequently than is necessary, or is limited more to one eye than to the other, or is repeated exaggeratedly in both eyes, then it is a tic. There are many other facial tics. Most of them represent movements of the lips or of the nose or of the skin of the forehead and all of them are identical with movements that are occasionally performed quite voluntarily. There are movements of the lips as in sucking, or smacking sounds may be made, or such movements of the features as are associated with sensations of taste or smell. Sometimes changes of facial expression may be tics and without any reason there may be recurring expressions of emotion, of joy, or grief, or fright, or even pain. Sometimes the tics affect structures that are internal, as various motions of the larynx accompanied by the production of grunting or sighing sounds or sometimes even of particular words. In children the tendency is prone to manifest itself in the utterance of forbidden words, usually vulgar, sometimes indecent.

Besides these facial and throat tics any of the voluntary muscles of the body may be affected. There may be the gestures that accompany certain mental states, or there may be twisting or turning movements as if the patient were in an awkward position and wanted to get out of it, or as if the clothes were hampering movement and there was an effort to relieve some discomfort. The head may be lifted and lowered, or may be twisted from one side to the other and, indeed, various nodding tics are extremely common. Almost any ordinary movement may, in nervous people, come to be repeated so frequently as to be a tic.

Practically all of the convulsive or quasi-convulsive movements associated with respiration are likely to become the subject of tics. Yawning, for instance, involuntary to some degree, usually a reflex with a physical cause, but so readily the subject of imitation, may become so frequent as to be repeated a couple of times a minute and this repetition kept up for many days. Sneezing may also become a tic, though it is usually a definite reflex due to palpable physical causes. Hiccoughs may easily become the subject of a tic. The occurrence of a persistent hiccough is in popular medicine a sign of unfavorable prognosis in serious diseases, especially such as involve the abdominal region. In connection with neurotic affections of the abdomen, however, hiccoughs are not uncommon and are of no serious significance.

Varieties of Tics.—There are many more tics than are ordinarily supposed. Indeed, there are few of us who escape them entirely. Nearly all the curious phrases that people interlard so frequently into their conversation, usually quite unconscious of them, or of the ridiculous significance they often have, must be placed under the tics. Some men cannot say a dozen words without interpolating "don't you know." Others use some such expression as "in that way." I once knew a distinguished professor of elocution who by actual count used this phrase forty times in an hour. Some say "hum" or "hem" every sentence or so. Whenever there is a bit of obscurity in their thought these voluntary but unconscious expressions are sure to pop out. No one who has had much experience in public speaking ever succeeds in keeping entirely out of such bad habits. It is curious how phrases will insist on repeating themselves. One year one set of words, or a pet phrase, or mode of expression, creeps unconsciously here and there into an address. Then either because the speaker has been reading dictated copy, or because some good friend has the courage to tell him of it, he finds out the bad habit and suppresses it.

Word formulas senselessly repeated are only one of many forms of tics that public speakers are prone to indulge in. Gesture which begins as an artificial adornment of speech, very appropriate in itself, after a while may settle down into certain forms that not only often lack elegance but that are really disturbing to an audience. Of these gestures and movements men are often quite unconscious. They have become habitual and in the absorption of mind with the thought and the words, they are reproduced quite involuntarily though they are all originally voluntary movements. Nearly every public speaker needs a mentor to correct him of such faults. It is rather difficult to break some of these habits and it requires no little concentration of effort and attention to be successful in eradicating them. It can be done, however, provided the habit is not too inveterate, and this is the best evidence that tics of other kinds can also be eradicated if the patient really takes the matter in hand and is not of a weakened will.

Teachers' Habits .—Indeed it is almost impossible for public speakers and teachers not to acquire certain habits irritating to their auditors at first but amusing as they grow used to them, and students particularly learn to look kindly at the ridiculous side of many of them. I remember an old professor of literature who used to lecture at some length on each of the important contributors to English prose and poetry. We soon observed that whenever he came to their deaths he took out his handkerchief and blew his nose. This was as inevitable and as invariable a rule as the laws of the Medes and the Persians. It was, as it were, his tribute of sympathetic condolence with humanity for the loss of a brilliant contributor to English literature.

Occasionally the effort to break up these habits will seriously interfere with modes of thought and habits of expression, for the time being at least. A professor at a certain university had a habit every now and then of plucking at a button on his coat. His students could tell when his hand was going to find this object of its occupation and knew from experience that he would twist it a certain number of times. He was not what would ordinarily be called a nervous person. One day he happened to take off his coat shortly before a lecture and one of the students surreptitiously removed the button. At the end of the first few minutes of his lecture his hand went up to find the button as usual but failed. For the moment there was a hesitancy in his speech; then he tried again. A little later his hand went up unconsciously and was disappointed; then he stammered and lost the thread of his discourse. The last half hour of that lecture was seriously impaired because of the absence of that button.

Tricks of Speech .—There are many other curious tricks of speech that are really tics. Women often indulge in them and sometimes even pretty women spoil their appearance by bad habits. All of us know the pretty woman who talks very fast, but who every now and then projects her tongue a little beyond her teeth. Occasionally there is a tendency to wrinkle the nose or the forehead. Most of us have seen the woman who sets her face into a definite smile of a particular kind whenever her company manners are in use, though there is a vacancy behind the smile that is rather disturbing. Some people have habitual movements of the fingers that are really tics, and even positions assumed on sitting down that are very ungraceful, or that are very noticeable, sometimes partake of this character.

Fussiness .—A very common form of tic that is quite difficult to control is that tendency to be doing something with some of their muscles which characterizes many men. They must handle a pencil or a knife, or they must swing on their chair or tilt back on it, or keep one of their limbs swinging over the other, or twirl their moustaches or stroke their beards, or rumple their hair, and they cannot find it quite possible to sit still. The difference between men and women in this regard is remarkable. Women are conceded to be much more nervous than men, but men are ever so much more fidgety than women. The author of "The Life of a Prig" in his book "The Platitudes of a Pessimist" has some striking paragraphs with regard to this subject. He says:

To look nearer home, the British bar affords splendid examples of nervous fidget. Observe barristers pleading a cause. How they torture a piece of red-tape, how they twirl their eye-glasses or spectacles, and how they hitch at their garments, as if they momentarily expected them to desert their finely proportioned figures. But worse than the Queen's Counsellors, and even worse than the domestic peripatetic, is the villain who is abandoned to a performance vulgarly known as "the devil's tattoo"—drumming with the fingers.

Writers' Tics .—Writers, and above all writers for the daily press and such as have to do their writing in a rush and therefore get nervous and anxious about it, are especially prone to develop tics, though others who write leisurely may do so. Some of these are curious and others are only expressions of nervousness common to all people. Many of them chew their nails, some of them bite at their fingers round the nails and make them sore, many of them chew the ends of their pens and find it practically impossible to keep a pen with a long handle to it. Some of them run their hands through their hair until it is in a greatly rumpled condition, some of them pluck at their eyebrows. I have one patient who when he is going through a particular nervous strain plucks out the middle portion of his right eyebrow so that he has a distinct bald spot at this point.

The tradition in newspaper offices is that these curious expressions of the tendency of the body to occupy itself with something while the mind is occupied are more or less inevitable in nervous people. They continue for many, many years. They are only habits, however, that it would have been rather easy to break in the beginning, though they become extremely difficult to modify after they have once secured a firm hold. Occasionally I have fastened a piece of adhesive plaster over a much battered eyebrow, but that made it difficult for the man to go on with his work. His hand would go up involuntarily time after time and while plucking at his eyebrow would not disturb in the slightest his train of thought, just as soon as his fingers touched the unusual object a serious distraction occurred and work was not only slower, but much more difficult.

In Games .—The tendency to the formation of curious habits of associated movements can be seen very well in most games where skill is combined to a certain degree with chance. It is most noticeable, perhaps, in bowling. Few men are able to restrain themselves from making some special movement just as the ball strikes the pin. This is sometimes a motion of the head, oftener it is a jerk of the trunk, sometimes it is an associated movement of the arms, occasionally it is a kick or a stamp. In billiards the same movements are noticeable if a man is much interested in making a difficult shot. Usually there is some movement of the body or of the hands or of the head that would indicate his desire to move the ball in a particular direction. Women who play these games do not usually have these associated movements to such a marked degree and this may be due either to their better restraint to movement in general, for as we have said men do not acquire the habit of self-restraint in small matters of deportment as women do, or to the fact that such associated movements might disarrange their clothes. Perhaps, also, they are not as much interested in the games as a rule as are the men. Of course, similar associated movements may be seen in outdoor sports that require skill yet have an element of chance in them. For it is, as it were, to overcome this that the additional movement is made.

Children's Tics .—Some tics consist of some very curious habits. Occasionally children hear some obscene or vulgar expression and repeat it. The repetition of it produces such a look of shock to propriety on the part of some of the other little ones who happen to be present that they repeat it in the spirit of bravado and then continue to utter it until it becomes a habit that is hard for them to break. After all, the use of blasphemy later on in life is really a tic, a habit of uttering words no longer expressive of any particular feeling, as a rule, unless in exceptional circumstances but just the result of a tendency for the speech organs to repeat certain words. They tell a good story of the Rev. Sydney Smith who, wishing to break an acquaintance of the habit of indulging in expletives, interlarded his speech with "fire tongs and sugar tongs" every ten words or so and when his auditor protested that that added nothing to the significance of what he said the Rev. Sidney suggested that that was also true of various blasphemous expressions that his acquaintance was accustomed to use.