Tics and Their Treatment Part 33

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 Nove-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 orthopaedic, 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 astonis.h.i.+ng 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 const.i.tutes 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 _elomyenchisis_. 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 ma.s.seter 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 a.n.a.logous 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."

ORTHOPaeDIC 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 p.r.o.ne to recommence his inopportune movements. It is preferable to allow him to adopt his own att.i.tudes 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 ch.o.r.ea 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 ma.s.saged vigorously enough to enable him to have some conception of what is being done. Light anaesthesia 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 ch.o.r.eic 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's[220] adoption, in 1851, of medical gymnastics in cases of "abnormal ch.o.r.ea" 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 _Traite de medecine_ ignores the subject, while Lannois' paper in the _Traite de therapeutique_ contains the statement that in the treatment of myoclonus--under which term various indefinite convulsive movements are comprehended--no method has. .h.i.therto been of any avail. Yet in another section of the same book we discover some sound advice anent tics and ch.o.r.eas 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_.

The credit of initiating treatment by forced immobility is due to Brissaud, who in the year 1893 first utilised the method in cases of mental torticollis. In the face of the risks of surgical intervention and the unsatisfactory nature of existing therapeutic measures, Brissaud emphasised the value of motor discipline in tic,[221] and it was not long ere rules were formulated and precision introduced into the application of the method.[222] The results were certainly encouraging, so much so that improvement could be promised if treatment was sufficiently protracted; cure, indeed, followed in various instances.

Brissaud's method is a combination of immobilisation of movements with movements of immobilisation. Speaking generally, the patient is directed to perform certain appropriate exercises under given conditions. Some of these exercises are intended to teach him how to preserve immobility, while the object of others is to replace an incorrect movement by a normal one. In the case of the former, immobility is alike the goal in view and the means of attaining it, while by recourse to suitable movements, in the latter instance, the same end is sought.

It is essential to remember that the exercises must be graduated. To begin with, the subject of tic is required to remain absolutely motionless, as for a photograph, for one, two, three seconds--in fact, as long as he can without fatigue. Very gradually the period is increased, for patients have their good and their bad days, and too great a demand on one day is apt to be succeeded by a relapse on the next. One must rest content with even the most insignificant gain at first, and soon the seconds will grow into minutes, and the minutes into hours. It is desirable to specify on each occasion the duration of the expected immobility. Place the patient at the outset in the position in which his tic manifests itself least often, and do not cease to encourage him by affirming that he can and must remain immobile. Once the seance of immobilisation can be maintained for as much as five or six minutes, begin to modify the patient's att.i.tudes. If he has been comfortably seated during the opening performances, try him when he is standing, and as soon as he has accomplished this, vary the position of his head, arms, trunk, and legs, repeating the seance in each case.

Eventually he will learn to maintain immobility of certain parts of his body while he is walking, or while he is executing given movements with his arms or legs. In all these performances direction must be specially directed to the patient's tic. The method is obviously simple, so much so that he may be inclined to question its utility and may fail to grasp its import. One must not hesitate, however, to explain its purpose; indeed, the rapid and intelligent appreciation of the method on the part of the patient is a _sine qua non_ for success. Patient and doctor most co-operate in defence and attack; and their union will culminate in triumph. Simultaneously with this discipline of immobilisation the subject must be taught the discipline of movements. The idea is to make him perform slow, regular, and accurate movements to order, addressing oneself to the muscles of the area in which the tic is localised. They must be very simple at first, and the exercises must be very short. The seance should never be prolonged beyond a few minutes, making, with the immobilisation, not more than half an hour. This time will, of course, soon be increased, but it is of prime importance to avoid fatigue. The performances should be gone through three, four, or five times a day, and always at the same hours. One of them at least ought to be under the personal direction of the physician, whose duty it is to modify, instruct, exhort, reprimand, as the case may be. In his absence the supervision of the exercises must be left to some responsible individual, who has an eye for faults as well as for progress.

Statements by the patients themselves are to be considered with reserve.

The repet.i.tion of the prescribed exercises should take place in front of a looking-gla.s.s, whereby the patient may be exactly informed of any mistakes in gesture or att.i.tude. He cannot otherwise judge of the degree of immobility attained, and may deceive himself, although he has the best intentions in the world, as to the real state of affairs. He does not know whether he is holding himself straight or not, as a general rule, but a glance in the mirror will correct his fault. A careful register must be kept of the progress he makes. Little by little the jurisdiction of the physician will be reduced, provided the patient maintains his interest in his own treatment. Indifference and discouragement are fatal, and it must be the physician's aim to prevent their occurrence.

Seglas has reported the history of a woman with mental torticollis, who submitted to treatment by Brissaud's method, and a remarkably quick alleviation was the result. At the end of three weeks, however, she allowed her interest to slacken, and ere long the benefits obtained were entirely frustrated.

It cannot be too often repeated that even though the tic disappear, the patient must not be abandoned to himself, but must be persuaded to continue his exercises. This is the price of success. As time goes on, it is true, he encounters fewer difficulties in his way, and once he is conversant with the method, he may be able to work out his own salvation.

In the case of children, the efforts of the medical man may often be seconded by parent or teacher, who has a.s.sisted at the first lessons and is in a position to superintend their repet.i.tion. On the other hand, treatment may be nullified by deplorable weakness on the part of father or mother. One of the reasons for the existence or at least the persistence of tics in children is that there has been no attempt at their correction when they were still "bad habits." Neglect or indulgence is an etiological factor of the first importance, as we have already seen. Many a time we have had occasion to note this, notwithstanding the protestations of the family. Fear of aggravating the mischief is sometimes advanced as a reason for non-interference. Nothing could be more misleading.

The method which seeks to check the youthful _tiqueur_ by the multiplication of threats and penalties is not to be countenanced; it produces the opposite effect to what is intended. Clearly the educational therapeutic measures we have been advocating demand a patience and an ingenuity on the part of both doctor and patient which we have no desire to minimise, but it is along these lines that success is to be reached.

A noteworthy adjunct to treatment is to sketch out a daily routine for the patient to follow regularly and punctually. His mental disarray is patent not merely from his disorders of motility, but in the unmethodical and changeable habits of his everyday life. To introduce discipline into his manner of living is a most wholesome step. To find something with which to employ his leisure time, to direct his energies into suitable channels, will prove to be eminently beneficial, not merely for the child but also for the adult. Those who tic ought to be able to contract good habits as readily as bad, provided their instructor be sufficiently persevering and inventive.