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.