Tics and Their Treatment Part 32

We cannot say that cure is certain, but we may count on longer or shorter intervals of arrest, either spontaneous or as a sequel to the employment of serviceable measures such as hydrotherapy or rational gymnastics.

It should be said that the cases which Charcot, Tourette, and Guinon had more especially in mind were of a graver nature, such as the disease of generalised convulsive tics with echolalia and coprolalia, and peculiarly resistant to treatment. Patients suffering from these forms of tic present in the most advanced degree psychical instability and volitional fickleness, and betray an irresistible tendency to impulsion and obsession, calculated to render the inst.i.tution of any methodical treatment futile. In their case patience and perseverance may be rewarded, but they never consent to undergo for a sufficiently long period the discipline indispensable for their cure.

Fortunately, these severer varieties are exceptional. The vast majority of cases are certainly more amenable to modern therapeutic measures, and the results obtained so far place the disease in a much more favourable light. Letulle had already remarked, in 1883, that the most tenacious of co-ordinated tics might be amended, mitigated, and even wholly inhibited.

MEDICINAL TREATMENT

All the ordinary medicinal agents in vogue in nervous and mental diseases have at one time or other been applied to the cure of tics; all have proved equally inefficacious.

Sedatives and hypnotics, such as the bromides, chloral, or the preparations of opium, sometimes effect a transient improvement, but they cannot permanently modify the psychasthenia which is the key to the situation. According to Gra.s.set and Rauzier, the injection of morphia, atropine, curare, and the inhalation of chloroform or ether have been of some avail, as has the employment of zinc valerianate, and of gelsemium in large doses. Quinine, cannabis indica, and a.r.s.enic have also been tried.

Unexpected success has followed the administration of the bromides in some instances, and for the treatment of various neuroses, convulsive tics in particular, Flechsig's opium and bromide cure for epilepsy has been adopted by Dornbluth, with encouraging results. It is true some of the symptoms of epilepsy may be manifested in the guise of tics, while, on the other hand, the a.s.sociation of tic and epilepsy is not unknown; but however that may be, there is sufficient and reliable evidence to justify at least the empirical use of bromide as a last resource.

Every conceivable sedative and derivative have had their advocates, while local and counter-irritant medication has not been without support. Gra.s.set and Rauzier obtained transitory improvement by means of strong mustard plasters; Busch applied the actual cautery to the vertebral column.

Cold, hot, and tepid douches, warm fomentations, simple, medicinal, and vapour baths, have all been prescribed. Resort has been made to rhythmic traction of the tongue, to thoracic compression, to phrenic electrisation, in all of which procedures, as Oppenheim observes, the princ.i.p.al effect must be a psychical one.

The predisposition of the subjects of tic to mental disturbance renders the administration of ether, morphia, or cocaine in their case inadvisable. For a similar reason it is better to avoid antipyrine, sulphonal, hypnotics generally, and above all opium in the form of laudanum or thebaic extract.

If a sedative be really indicated, we prefer the preparations of valerian, as their disagreeable odour is scarcely likely to encourage abuse of the drug. Stimulants such as kola, coca, caffeine, etc., are rather to be avoided. Hartemberg recommends the preliminary use of lecithin to improve the patient's general condition.

The inconstancy of the therapeutic results. .h.i.therto obtained must not be allowed to act as a deterrent. Success achieved by medicinal means may not always be attributable merely to suggestion.

DIET--HYGIENE--HYDROTHERAPY

The details of the patient's diet are not to be neglected; he may be the victim of some caprice which is injuring his general health. In the case of children supervision is desirable, to obviate their eating either too much or too quickly.

General hygiene must be made the subject of special attention. We have often been convinced of the salutary effects of alteration in a patient's mode of life, or of modification of his environment, such as is ensured by holidaying, or by sea voyages, or by "cures" at watering-places and seaside resorts.

Hydrotherapy in one or other of its forms may also be utilised. Except in cases of hysteria, the tepid douche is preferable to the cold one. A morning and evening tub, followed by energetic friction of the skin, is a favourite prescription.

Ma.s.sAGE--MECHANOTHERAPY

In every case of tic the physician ought to a.s.sure himself of the integrity of the muscles involved by examining for developmental anomalies, atrophies, hypertrophies, etc., the presence of which might lead him to reconsider his diagnosis. He may then order ma.s.sage, of special value in tonic tics as a prelude to pa.s.sive movements, or counsel the employment of some form of instrument or apparatus to correct muscular insufficiency or to gauge the extent and rapidity of motor reaction.

As a general rule we deprecate these devices. They are open to the same objections that have been raised to all the mechanical arrangements ever invented to counteract stammering, from the pebbles of Demosthenes to the fork of Itard, or Colombat's interdental plate, or Wutzer's glossonachon, or Morin's marbles: the patient is relieved of his infirmity only to become the slave of his instrument.

ELECTROTHERAPY

Electricity in all forms has been requisitioned, but it does not appear to have justified its trial. In our opinion, moreover, it is contraindicated in convulsive affections.

In cases of functional spasm of the neck, Charcot[195] was wont to extol the combined use of electricity and ma.s.sage, citing instances of a very protracted and aggravated nature where relief or even cure followed the application of the induced current to the muscles not involved in the spasm.

A case in point was a man who entered the Salpetriere in 1888 with clonic spasm of the sternomastoid and trapezius, originating in depression caused by financial losses. The symptoms were not unlike what has been described more recently as mental torticollis. The condition had resisted all treatment during nine months, but vanished with singular rapidity after a few applications of the battery, during which the unaffected sternomastoid was faradised for fifteen minutes so as to produce the inverse of the pathological att.i.tude.

Equally satisfactory results are frequently obtained in mental torticollis from the maintenance of the antagonistic position by the hand or campimeter, or simply by order given. It ought not to be forgotten, however, that Charcot himself was astonished at these unlooked-for successes, since he closes his lesson with the sceptical injunction not to hail the victory complete nor ignore in such histories the chapter of relapses.

Several of our own patients, similarly affected, have found electrotherapy an egregious failure. Most sufferers from tic have essayed it at one time or another, and if they do not accuse it of having intensified their symptoms, the memory they retain of it is usually anything but pleasant. All that is permissible in suitable cases is to employ electricity "in psychotherapeutic doses." Let the patient see the coil, or hear the interrupter, or feel the damp electrodes, and even though the current be infinitesimal, in the sequel the suggestion may prove efficacious. Generally speaking, however, such subterfuges ought to be avoided.

SUGGESTION

Hypnotic suggestion has sometimes given tangible results, but it is strictly applicable only to hysteria, which is, as we have seen, a comparatively rare accompaniment of tic.

Reference may be made to some cases of Raymond and Janet, where the method was successful in curing a constant giggle of four months'

duration; hiccough also, and spasms of the limbs, were combated by these means.

One of the cases recorded by Welterstrand[196] was a child of ten years who had stammered ever since he could speak at all, and who in addition had for some time suffered from facial contortions--elevation of the eyelids and eyebrows, and twitching of the lips. Six seances sufficed to banish the symptoms, which at the end of several months had not recurred. Another of his patients was a young woman, twenty years old, with incessant spasmodic movements of mouth and eyebrows. The disfiguring grimaces of years disappeared completely by the tenth sitting.

Van Renterghem[197] has recorded a case of rotatory tic also cured by hypnotism. Feron[198] and Vlavianos[199] report similar successes, but one may legitimately ask whether the phenomena were not really hysterical manifestations, and if the results attained any degree of permanence. Treatment by suggestion is, as a general rule, ineffectual.

In Marechal's[200] case of mental torticollis with symptoms of two years' duration, recourse was made to this measure but without avail, and our experience has been identical.

Raymond and Janet[201] have noted favourable results by the adoption of suggestion during waking hours, without going the length of hypnotic sleep; in one case of tic simulating ch.o.r.ea, a cure followed the threat of surgical intervention.

The same objection may be raised to ordinary as to hypnotic suggestion, that it is not of universal applicability. Besides, it is very difficult to know exactly what meaning the term is intended to convey. To encourage the patient and a.s.sure him of progress, to reproach or reprimand him on occasion, is to employ an integral and invaluable factor in all re-educational treatment of tics; but is this truly suggestion?

SURGICAL TREATMENT

Surgical procedures are and can be applicable only to a small minority of tics, princ.i.p.ally those of the neck, and in particular mental torticollis.

Now, while we question the necessity of emphasising afresh the uselessness of surgical interference, we believe it inc.u.mbent on us to indicate more precisely the extreme, inefficacious, and sometimes perilous nature of the measures to which patients are exposed in the vain hope of putting an end to their _mal obsedant_.

In the vast majority of cases the upshot of operative intervention is the creation of transient or permanent muscular paralyses and pareses.

Of two infirmities patients voluntarily choose the one whose evils have not yet been brought home to them. To enlighten them, to warn them against their own rashness, to impress on them repeatedly the truth of the fact that so-called radical operations do not exclude the possibility of recurrence--this we conceive to be our bounden duty.

Spasmodic torticollis more particularly has tested the surgeon's sagacity and talent. Yet in the ever-increasing number of recorded cases there is usually a curious indefiniteness of statement on a point of primary importance: was surgical aid sought for the treatment of a tic, or of a spasm?

Torticollis tic--mental torticollis--is a psychical disease pure and simple, which does not enter the province of surgery, while torticollis spasm--spasmodic wryneck--may come within the scope of the surgeon's knife, though only on condition that the irritative lesion be sharply localised. Now, not only is this information generally missing, but even more frequently perhaps a hard and fast line between the two cannot be drawn. The wisest course would be to delay the adoption of a plan of treatment whose results are so problematical, but these considerations have unfortunately been outweighed by the operator's laudable desire and expectation of ensuring respite from a most painful affliction.

It is purposely to demonstrate how invalid this plea must henceforth remain that we shall now pa.s.s rapidly in review the various surgical devices imagined for the relief of torticollis tics and spasms.

The first methods to be practised were elongation, ligature (Collier), section (Gardner and Giles), or resection, of the spinal accessory. The last of these was performed for the first time by Campbell in 1866, then by Southam, Mayor, Collier, Pearce Gould, Edmond Oxen, Appleyard, Atkins, etc. Eliot[202] was convinced of the value of this measure, and made a special study of the technique. Coudray[203] recognised the insufficiency of section or resection of the accessory, yet decided in its favour.

In the present state of our knowledge (he says), the treatment to be preferred for spasmodic torticollis is resection of the external branch of the accessory. Its superiority over the multiple and successive divisions of the neck muscles vaunted by Kocher--apart from the absence of proof that the latter is more efficacious than the simpler operation--is based on the view that, as the dependence of the condition on cerebral lesions and its occurrence in nervous individuals render uncertain the accomplishment of a complete cure in every instance, with such a cla.s.s of patient it is essential to have recourse to an operative minimum. In nearly every case, nevertheless, marked amelioration ensues on this procedure, the benefit derived from it forming its thorough justification.

If the advantages of such an operation are not more appreciable, we must take up a position of much greater reserve regarding its suitability, particularly in view of the fact that the prosecution of a line of treatment absolutely devoid of risk may a.s.sure equally, if not more, satisfactory results.

The next step was to devote attention to the cervical nerves.

The co-existence of goitre and functional spasm of the neck suggested to Pauly[204] that pressure on the recurrent laryngeal nerve might occasion a reflex spasm via the muscular branch of the spinal accessory. By a.n.a.logy, in some cases of spasmodic torticollis a point of irritation on one of the sensory nerves of the cervical plexus might generate a reflex motor reaction in the area of the accessory, with possible diffusion to neighbouring trunks.[205] It might then be a good plan to divide the branches of the superficial cervical plexus, just as the trigeminal is divided for tic douloureux of the face.

It soon became obvious that resection of the spinal accessory was insufficient. Risien Russell[206] adduced physiological evidence to show that some of the muscular groups involved in the condition are not innervated by the spinal accessory, but by the second, third, and fourth cervical roots, section of which is imperative to obtain positive results.