THE TREATMENT OF TICS
THE CURABILITY OF TICS
Tics are commonly held to be trivial affections of but passing 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definition of tic, a little out of date perhaps, but affording a glimpse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 attitudes, 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 constitution
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 Duchenne 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
Encyclopædic 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 constitutional treatment cannot do much more than
retard its evolution."
In Guinon's article on convulsive tic in the Encyclopædic 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]:
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 institution 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 Grasset 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 arsenic 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 association 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. Grasset 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
principal 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 hitherto 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.
MASSAGE--MECHANOTHERAPY
In every case of tic the physician ought to assure 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 massage, of
special value in tonic tics as a prelude to passive 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 massage, 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 Salpêtrière 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 attitude.
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 séances 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 Maréchal'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 chorea, 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 assure 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, principally 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 incumbent 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 obsédant_.
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 pass 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 class 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 assure 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
analogy, 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.
The surgeon had not been behindhand, however. Gardner in 1888 was
convinced of the necessity of dealing with the posterior branches of the
second and third cervical pairs, a method practised a few months later
by Smith and by Keen. One or two cases recorded by Ballance, according
to whom division of the posterior roots was performed as far back as
1882 or 1883, are highly instructive:
A woman, thirty-two years old, had suffered for seventeen months
from convulsive movements inclining the head to the right shoulder
and turning the face to the left, the muscles affected being the
sternomastoids, right trapezius, and complexus. On May 30, 1887,
half an inch of the left spinal accessory was resected before its
entry into the muscle, whereupon the spasm diminished in intensity
and the sternomastoids ceased to contract. On June 6 two-thirds of
an inch of the right accessory was removed, the patient being able
four days later to keep her head straight by the application of her
hand to the right side; but on July 4 violent spasms of the
trapezius recommenced, demanding section of the posterior branch of
the second pair. By the 21st there was a little stiffness of the
neck on the right which speedily disappeared, and in March, 1891,
recovery was still complete.
The second case concerned a woman, aged twenty-nine, with
convulsive movements of the trapezii dating back seven years.
Resection of both spinal accessory nerves at the posterior border
of the sternomastoid was practised on November 21, 1892;
consecutive double trapezius paralysis revealed the fact that the
deep rotators of the head on either side were similarly in a state
of spasm; on December 13, 1892, the posterior branches of the
first, second, and third left cervical roots were divided by Keen's
method, the contractions being now confined to the deep rotators of
the right side, which were to be treated in their turn in the same
manner.
Comment is needless.
In a case of spasm of the left sternomastoid and certain muscles of the
neck reported by Chipault,[207] bilateral removal of the superior
cervical sympathetic ganglion was followed by instantaneous relief,
succeeded by a relapse and a second cure; a degree of retrocollic spasm
persisted.
Kocher's plan of cutting successively all the muscles affected has given
varying results, according to de Quervain. This procedure has been
adopted by others, notably by Nové-Josserand[208] in a case where
treatment by suggestion had proved of no avail. For some days after the
operation the spasm was exaggerated, although it eventually disappeared.
It is permissible, however, to doubt the definite and radical nature of
these cures if we look at the long catalogue of admitted operative
failures.
Linz's two cases[209] of resection were unsatisfactory. In Popoff's
experience[210] tonic muscular spasm returned in spite of repeated
neurectomies, in contradistinction to the notable improvement he
accomplished by simple re-education. Tichoff[211] found the torticollis
reappear four days after division of the spinal accessory, and though,
in his opinion, relapse supervenes after this operation in more than
fifty per cent. of cases, he expresses himself in favour of further
operative interference.
Two of Dalwig's patients developed a functional torticollis to avoid the
diplopia caused by a superior strabismus. Ocular tenotomy, as might have
been foreseen, was quite ineffectual in checking the tic; indeed, the
author himself seems to have been well aware of the necessity, in curing
such vicious habits, of influencing the attention. He proceeds to
emphasise the hopefulness of orthopædic, as opposed to surgical,
treatment, and recommends the use of a cardboard collar, though any
benefit thus derived is, in our experience, purely ephemeral.
A case of Oppenheim's underwent first tenotomy, then elongation, and
finally resection of the spinal accessory, with the result that, in
spite of complete atrophy of the sternomastoid and partial atrophy of
the trapezius, spasm settled with renewed intensity on the splenius,
omohyoid, and remaining fibres of the trapezius. Application of a seton
was equally negative, but the patient soon after made astonishing
improvement by a mineral water "cure"!
In face of such facts, it is truly surprising to see the increasing
support given to surgical intervention. Walton,[212] for an instance,
admits the central origin and progressive nature of the disease, and
recognises the futility of surgical procedures, yet constitutes himself
their advocate. Would it not be more in accordance with the dictates of
reason and wisdom to refrain?
We must not omit to mention the extraordinary method devised by
Corning[213] of injecting into the muscles a warm mixture of tallow and
oil which will solidify at 37° C., to which proceeding he proposes to
give the fantastic name of _elOEomyenchisis_. The idea is to fix
previously relaxed muscles. He does not seem to have had many imitators.
* * * * *
Torticollis apart, few tics invite treatment at the hands of the
surgeon, with the exception of facial tics or spasms.
Here, too, the results have usually been anything but encouraging.
Stewens[214] reports three cases of facial tic cured by the correction
of errors of refraction, while elongation of the facial nerve failed of
its object. Resection of a branch of the trigeminal is valueless; facial
elongation only causes a corresponding paralysis, and should this latter
accident be transient, as in a case of Bernhardt's, so is the relief
from the tic.
To obviate the much more frequent inconvenience of a permanent facial
paralysis, J. L. Faure[215] suggests spino-facial anastomosis. In a
woman suffering from contracture and spasmodic twitchings in the region
of the facial, Kennedy, of Glasgow, divided the nerve and immediately
anastomosed the cut end laterally with the spinal accessory. At the end
of fifteen months the spasm had vanished and the paralysed facial nerve
had recovered its functions.[216]
Strictly speaking, then, in certain cases of genuine facial spasm the
possibility of some such treatment may be entertained if all other means
have failed, but persistence of the facial palsy and the grave
consequences it may entail are always to be dreaded. In facial tics,
however, under no pretext whatever is the surgeon justified in
attempting to interfere.
In the case of spasms properly so called, efforts directed to the
removal of the exciting cause--should it be known--are often crowned
with success. Conjunctivitis, rhinitis, odontalgia, may occasion
grimaces and contortions which cease with the disappearance of the
irritation. In 1884 Fraenkel showed to the Medical Society of Berlin a
woman, forty-five years old, with mimic convulsions of four years'
duration, attributable to a rhinitis. Every time the mucous membrane of
the left nasal fossa was touched a violent spasm ensued; but a few
applications of the galvano-cautery brought the phenomena to an end.
Oppenheim has seen facial and masseter spasm checked by the extraction
of a carious tooth, and in another case by an operation on the ear.
Emphasis must once more be laid on the fact that any success achieved
has been in reference to spasms; as much cannot be said of tics and
analogous affections. The surgical treatment of stammering has long
since received its quietus.
* * * * *
We may bring this discussion to a close by applying to tics in general
certain considerations of Brissaud[217] anent mental torticollis:
"Instead of proceeding to operate at once and being content thereafter
to enjoin on the patient, whenever the wound is healed, a course of
exercises to be persevered with over long months or even years, better
give the same good advice long months or even years before inflicting
him with the operation."
ORTHOPÆDIC TREATMENT
The use which has in some instances been made of various forms of
apparatus for temporary fixation or for gymnastic purposes is, as a
rule, rather hurtful than otherwise. The patient is disconcerted by
their withdrawal, and prone to recommence his inopportune movements. It
is preferable to allow him to adopt his own attitudes independently of
the physician. An accessory not always at hand must not be allowed to
become indispensable to the control of his tic, else he may make its
absence a pretext for the discontinuation of his exercises.
Excellent results, it is true, have been obtained in chorea by recourse
to apparatus of restraint. According to the recent descriptions of
Huyghe[218] and of Verlaine,[219] after the administration of a few
whiffs of chloroform to the patient, the affected limbs are massaged
vigorously enough to enable him to have some conception of what is being
done. Light anæsthesia is continued while they are immobilised in duly
padded splints and covered closely with bandages. At the end of five or
six days the dressings are removed, when all choreic twitching will be
found, as a general rule, to be gone; should it persist, the treatment
must be repeated. In numerous instances the method has been eminently
successful.
So favourable an issue is scarcely to be looked for in the case of tics.
Rather are these forms of apparatus liable to do harm in the direction
of fresh outbursts.