Tics and Their Treatment Part 31

A sudden twitch of the whole body Letulle particularises as a "tic of starting," and Noir too thinks that a start of this nature may const.i.tute a tic, but we are inclined to consider it a generalised reflex.

TICS AND PROFESSIONAL CRAMPS

We have already had occasion to enlarge on the distinguis.h.i.+ng features of professional or occupation cramps, spasms, or neuroses. Writers, pianists, violinists, flutists, dressmakers, telegraphists, watchmakers, milkers, knackers, blacksmiths, shoemakers, tailors, dancers, embroiderers, barbers, etc., etc., are all liable to suffer from occupation cramps. In every case the condition is one of inability to perform the professional movement, and that alone.

Gra.s.set proposes to separate intra-professional from post-professional spasm, the former consisting in the impossibility of making the necessary professional movements, the latter in the involuntary over-reproduction of the familiar act. Properly speaking, the post-professional spasm is a tic.

We need not do more than remind the reader of the close affinities we have already seen to exist between tics and professional cramps, and of the mental instability which both cla.s.ses of patient present.

L. supplies an instance of variable hemich.o.r.ea followed by writers'

cramp and later by mental torticollis.

When L. was eight years old ch.o.r.eiform movements of the right arm began to appear, and soon rendered writing an impossibility. The disease continued for so long a time that one might not unreasonably expect to find considerable actual impairment of her caligraphy. As a matter of fact, it is scarcely affected: the patient can make her letters correctly, but after each letter she lifts her pen to allow her fingers to perform an abrupt movement, then she proceeds.

It cannot therefore be considered a true writers' cramp, but when she had learnt to write with the other hand it was not long ere that became the seat of a genuine cramp. The moment she attempted to make the pen move over the paper her grasp of it tightened and her fingers stiffened; her wrist would no longer answer her. To obviate the trouble she used a pencil, at first with complete success; but the cramp occurred afresh, and she gave up writing altogether. Prolonged holidaying, however, and respite from the exercise, had a salutary effect, and to-day there is no trace of former mischief.

CHAPTER XVII

PROGNOSIS

The prognosis in a case of tic depends solely on the mental state of the patient. After what has been said of the role played by psychical disorders in the genesis of tic, we can readily comprehend the reason for this. The intensity and tenacity of any tic are determined by the degree of volitional imperfection to which its subject has sunk. He who can will can effect a cure; be it a simple tic, or be it a case of Gilles de la Tourette's disease, if he can struggle long and energetically, the tic's doom is sealed. Permanent cures have undoubtedly been obtained, but they are the exception. Left to himself, the victim to tic can seldom escape from it.

As far as life is concerned, tics are harmless, yet, according to Gilles de la Tourette, the prognosis is by no means always unchanging.

The establishment of a tic is never followed by its ultimate disappearance; it may be modified in all sorts of ways, yet the expert observer will not fail to mark its presence. A complete cure is not to be expected, for however much paroxysms may be alleviated and their frequency reduced, the morbid condition has become a sort of function, a product of the patient's mental const.i.tution.

The statement may be taken to imply that no tic abandoned to itself ever vanishes completely, but the generalisation is inaccurate. Systematic treatment may lead not only to amelioration, but also to cure. Certain tics of children are by nature ephemeral, and disappear spontaneously, never to return. It is easy to understand how that may be. Psychical evolution and physical evolution alike are liable to singular variations. Hence the development of a tic in early life is no reason for despair, seeing that we are not justified in the a.s.sumption that the volitional debility which it proclaims is to persist. We must believe that volition may be reinforced, and we must further the attainment of this end by every means at our disposal. Negligence on our part is highly culpable.

Tics of childhood are curable: we draw attention to the fact afresh.

Their spontaneous dissolution is not unknown, but parents must not consider the question merely one of time. They must impress on their children the sobering effect of good behaviour and decorum. Discipline of this kind may be a long and delicate task, but to condone indulgence in untimely movements, on the pretext that they are merely quaint, is a mistake fraught with the gravest consequences.

When a child holds its knife or fork incorrectly, or puts its elbows on the table, or its finger in its nose, we feel that the habit is displeasing; but how much more serious the outlook if the trick consists in biting the lips, or tossing the head, or blinking the eyes! The former is an offence against good taste; the latter is a tic in embryo.

It may be said, as a general rule, that the chances of spontaneous cure are in inverse proportion to the age of the patient and the duration of his tic.

Tics of adult life may also be cured, less often, it is true, than in the case of children. Oppenheim gives the history of a woman with a rebellious facial tic of twelve years' duration, which ceased on the occasion of a certain happy event in the family life. Of course one wants to know whether it ever returned, for many so-called cures are simply remissions.

T. had suffered from torticollis for a whole year, but on the eve of her son's marriage it stopped entirely for three days, and she deemed the cure permanent; it was not long, unfortunately, ere she underwent a relapse.

Brissaud[192] quotes an instructive case of temporary cessation of tic.

A patient afflicted with mental torticollis of three years' standing learned that his son had been injured and had been removed to hospital to undergo an operation. In an instant his torticollis disappeared, but a rea.s.suring report from the surgeon a few days later was followed by a recrudescence of the condition.

It is true a hardened _tiqueur_ may be relieved of his tic, but the potentiality remains. He is still at the mercy of the impulse to tic, should it arise. Cruchet gives the history of a young man who suffered in succession from convulsive movements of negation, facial tic, blinking of the eyes, abrupt yawning, and twitches of the shoulder--all in the s.p.a.ce of two years. Each disappeared in its turn, independently of treatment, without leaving any trace behind. In cases of this description a new tic is ever imminent. The facility with which one tic replaces another is a matter of common observation. We have often had occasion to observe relapses, or partial relapses, in which an altogether new tic suddenly makes its appearance on the top of one which has either been improving or has actually been checked.

Apart, however, from obdurate forms of long standing, especially such as are accompanied by signs of grave mental defect, we maintain that the subjection of patients to appropriate treatment for an adequate period has a favourable influence on prognosis. The curability of tic was denied by Oddo, but he has recently seen fit to change his opinion, and to confine his pessimistic views to Gilles de la Tourette's disease.

The prognosis of the mental state of victims to tic is outwith our province: it is a topic long since handled by psychiatrists. We may ask, however, whether any particular prognostic import is to be attached to the tics themselves.

In cases of Gilles de la Tourette's disease the progressive unfolding of motor disorders suggests a corresponding evolution of psychical derangements which may end in dementia. Brissaud warns us that in cases of mental torticollis we must be on our guard against the apparition of some much more redoubtable affection than the torticollis, for that, sometimes, is an incident in the prodromal stage of general paralysis of the insane. Seglas has had a case of aerophagic tic which eventually became one of general paralysis, and a similar instance occurred in the practice of one of us.

Not long ago Dufour[193] advanced the opinion that the occurrence of a motor syndrome consisting of the automatic movements of tic, in a case of delusional insanity, heightens the gravity of the prognosis as regards chronicity. It had been already remarked by Morel that such of the insane as contract tics usually degenerate into dements. Most of the contributors to the study of idiocy have noted the relation between the degree of intellectual debility and the extent of the automatic and rhythmical movements.

In this connection Joffroy has made some interesting statements.

Sometimes there is not merely co-existence, but an actual parallelism between the motor and the psychical disturbance. I have under observation at present a young woman suffering from attacks of agitation, with delusions and hallucinations, who has developed a facial tic in the course of her psychosis, and increase in the violence of the tic is a.s.sociated with abrupt utterance of imperfectly formed syllables. During the last two months she has been having attacks in the evening, when the psychical troubles have become more intense, and simultaneously there has been aggravation of the tic and incessant emission of laryngeal sounds and syllables. Here then is a parallelism between the two groups of symptoms.

I am disposed, however, to believe that the usual prognosis given where motor and mental defects co-exist is too guarded. I have seen the catatonia of dementia praec.o.x disappear spontaneously, in spite of its intensity and the unfavourable outlook prophesied by all who had seen the case.

In distinction, then, from the value of a knowledge of the patient's mental condition, we consider the motor reactions of tic of little prognostic significance.

CHAPTER XVIII

THE TREATMENT OF TICS

THE CURABILITY OF TICS

Tics are commonly held to be trivial affections of but pa.s.sing medical interest, while in addition they have gained the notoriety of being peculiarly rebellious to treatment. Such undeserved criticism is at once too superficial and too severe. As far as life is concerned, the prognosis is favourable, but they often contrive, quite as forcibly as many graver diseases, to render existence intolerable. To neglect them or to consider them _a priori_ incurable is entirely unwarranted. Some degree of amelioration is practically always attainable, and even complete cures may be effected.

It is an old doctrine this of the incurability of tic, but the sufferers have not always been left to their fate. Forecasts of methods of treatment likely to ensure success were made long ago. In the "Dictionary in Sixty Volumes" of the year 1821 will be found a definition of tic, a little out of date perhaps, but affording a glimpse of therapeutic possibilities: "The word tic is ordinarily employed to designate certain unnatural habits, bizarre att.i.tudes, peculiar gestures, etc., whose correction demands a painstaking perseverance that is not always sufficient to procure the desired result."

Trousseau later introduced an element of precision into current therapeutic measures by the application of a sort of gymnastic exercise to the muscles involved. He declared his opinion, however, that the arrest of one tic would soon be followed by the development of a second, which would in turn give place to a third, and so on; for the disease was essentially chronic, and in a sense formed part of the const.i.tution of its subject. Subsequent observation has frequently borne witness to the truth of this remark, though the expression is too absolute.

For the majority of the older writers, nevertheless, the incurability of tic was axiomatic.

Pujol held non-dolorous facial tic to be most intractable. In the hands of d.u.c.h.enne of Boulogne faradisation of the muscles was followed by only transient improvement. Axenfeld considered idiopathic facial convulsions hopeless from the point of view of treatment.

It has been remarked already that many of the earlier observers failed to discriminate between tic and spasm. In the article "Face" in the Encyclopaedic Dictionary, for instance, Troisier includes every sort of facial movement under the term "convulsive tic," among them reflex spasms from dental caries or buccal ulceration, and muscular contractions occasioned by peripheral or nuclear irritation. His opinions as to the curability or otherwise of these movements are sufficiently dogmatic: "Convulsive tic is not a serious condition, yet it is in a majority of cases incurable and as a consequence most distressing. One can hope for success only if the tic is of reflex origin, where extraction of a tooth, or local treatment of an ulcer, or resection of part of the trigeminal nerve may be indicated."

Here the confusion is obvious.

Gilles de la Tourette's description of the disease known as convulsive tic accompanied with echolalia and coprolalia is couched in equally pessimistic terms.

"It is no menace to existence, and the patient may well attain a ripe old age, but in revenge he stands very little chance of escaping from it. A radical cure is yet to be found. Isolation, hydrotherapeutics, electricity, and const.i.tutional treatment cannot do much more than r.e.t.a.r.d its evolution."

In Guinon's article on convulsive tic in the Encyclopaedic Dictionary of the Medical Sciences of 1887 thirty pages were devoted to description and the following few lines to treatment:

"This chapter will of necessity be brief.... In presence of this affection the physician is unfortunately helpless. During exacerbations any nerve sedative may be tried. In severe cases or if the symptoms become aggravated, the sole treatment likely to be accompanied by improvement, scarcely by success, is a combination of hydrotherapeutics with isolation."

Nor is Charcot much more encouraging[194]: