Part 32 (1/2)
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 inst.i.tution 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 Gra.s.set 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 a.r.s.enic 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 a.s.sociation 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. Gra.s.set 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 princ.i.p.al 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. .h.i.therto 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.
Ma.s.sAGE--MECHANOTHERAPY
In every case of tic the physician ought to a.s.sure 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 ma.s.sage, of special value in tonic tics as a prelude to pa.s.sive 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 ma.s.sage, 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 Salpetriere 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 att.i.tude.
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.