Tics and Their Treatment

by Henry Meige; E. Feindel

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 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. 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."