Tics and Their Treatment

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, Charcot195 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 Welterstrand196 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 Renterghem197 has recorded a case of rotatory tic also cured by hypnotism. Feron198 and Vlavianos199 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's200 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 Janet201 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. Eliot202 was convinced of the value of this measure, and made a special study of the technique. Coudray203 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 Pauly204 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 Russell206 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-Josserand208 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 cases209 of resection were unsatisfactory. In Popoff's experience210 tonic muscular spasm returned in spite of repeated neurectomies, in contradistinction to the notable improvement he accomplished by simple re-education. Tichoff211 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 Corning213 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 elœomyenchisis. 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. Stewens214 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. Faure215 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 Brissaud217 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 Huyghe218 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.

CHAPTER XIX

TREATMENT BY RE-EDUCATION

THE author of the article "Tic" in the Dictionary in Sixty Volumes of 1822 urges the necessity of care and perseverance in the correction of the involuntary movements characteristic of the disease. In 1830 Jolly recommended different exercises in the treatment of convulsions, as a means of interrupting the sequence of certain spasmodic phenomena. Blache's220 adoption, in 1851, of medical gymnastics in cases of "abnormal chorea" was attended with excellent results; and Trousseau, as we have seen, extolled the value of exercises systematically applied to the muscles involved in non-dolorous tic. The principle of the treatment consisted in the regular execution of given movements by the muscular groups affected, to the rhythmical accompaniment of a metronome or the pendulum of a clock.

In these instances we have a forecast of the modern methods of re-education, so successfully employed to combat tic.

Letulle advises an appeal to the intelligence, good sense, and will of the patient in the endeavour to provoke an inverse effort at the moment when the tic begins, or even before. It is the prerogative of the physician to indicate suitable exercises and to encourage and aid the patient in his attempts. Even the most inveterate of tics may thus be controlled and made to disappear. On the other hand, the Traité de médecine ignores the subject, while Lannois' paper in the Traité de thérapeutique contains the statement that in the treatment of myoclonus – under which term various indefinite convulsive movements are comprehended – no method has hitherto been of any avail. Yet in another section of the same book we discover some sound advice anent tics and choreas of hysterical origin, emanating from the pen of Pierre Janet.

It is well to study the influence of the attention on these conditions; some tics are contingent on the direction of the patient's attention to them, others appear solely during times of distraction… Education of movements by some form of drill may be of the greatest utility.

These general therapeutic indications are applicable to all kinds of tic, independently of their form and localisation. Moreover, they conform to the procedures advocated by Brissaud since 1893.

So long as tic is regarded as a purely external phenomenon, treatment is bound to be insufficient; but recognition of the relations between the convulsion and the mental state of the subject has made possible a rational therapeusis. There can be no doubt, thanks to the laborious work of Bourneville, that systematised mental discipline has sometimes a surprising effect on congenital psychical imperfections; and where the patients have attained a higher level of mental development, re-education has shown itself to be the method par excellence.