TORTICOLLIS, OR WRY-NECK.
Several different diseased conditions are included under these titles, which call for treatment based on totally different principles.
Rheumatic Tcrticollis, or " stiff neck," is an acute transient condition allied to lumbago and other forms of fibrositis which come on after exposure to cold. The pain, tenderness, and stiffness of the sterno mastoid and trapezius muscles are best relieved by the application of a rubber bottle partially filled with hot water, or by enveloping the neck with warm cotton-wool covered over with thin mackintosh sheeting, or by the use of a hot poultice or thick laver of .1ntiphlogistine or Cataplasma Kaolini. Gentle massage hastens the resolution of the fibrositis, hut this should not be commenced till after the expiration of a few days.
Constitutional remedies of the antirheumatic type as Salicylates, Aspirin, etc., should be given as in acute lumbago.
Congenital or Fixed Torticollis is either due to some developmental error in the sterno-mastoid muscle or to its rupture during labour. In these latter cases, after the local treatment of the hmmatoma by heat, mild friction with Lin. Pot. Iod. cum Sapone and the envelopment of the neck in cotton-wool, the deformity generally entirely disappears.
In the congenital cases due to arrested development of the muscle and those instances of permanent wry-neck which return after the resolution of the ruptured muscle, surgical treatment is usually necessary. When the affection is due to the presence of a gumma, which is rarely the case, iodides should be administered.
Before resorting to operation, however, if the case be seen early the muscles may be stretched under general anaesthesia, and the head fixed in its normal position by a poroplastic or other form of unyielding splint. This method, when assiduously followed up by massage, douching, electricity, and passive movements, occasionally effects a cure.
The best procedure in all intractable cases is to make a free horizontal incision above the line of the clavicle, so as thoroughly to expose both heads of origin of the sterno-mastoid. The heads arc then identified, the sternal head divided about LI inches above its insertion, and the clavicular head close to the bone. The face is then rotated into the corrected position, and the lower end of the clavicular portion sutured to the upper end of the sternal portion still attached to the sternum, all bands of fascia, especially the posterior sheath of the sterno-mastoid, being care fully divided before the suture. Sometimes it is necessary that the
scalenus anticus should be divided at the same time. Some surgeons operate through an incision made along the anterior border of the sterno mastoid. The subcutaneous operation is now universally abandoned for these open methods. After suturing the wound the head should be placed in an over-corrected position between sand-bags, and when healing has taken place a plaster of Paris, poroplastic or stout leather splint should be applied, or an apparatus with elastic cords adjusted so as to keep up mild traction on the head.
The after-treatment will consist in persevering passive movements, massage, electricity and douching. At night a cap, with strings to bind the head towards the unaffected side, should be worn.
In cases of the so-called False Torticollis which supervenes upon caries of the cervical vertelme, the above operative procedure seldom affords a satisfactory result.
Spasmodic Torticollis is a most intractable affection. The disease must be recognised as a " neurosis " arising independently of any morbid con dition of the muscles, and often shows itself in neurotic subjects after some profound mental or psychic disturbance. The site of the functional mischief is supposed to be in the motor cortex, and the muscles' involved arc those supplied by the spinal accessory and upper cervical nerves. The sterno-mastoid and trapezius are often affected at the sante time, and the splenius is not infrequently also at fault, though the sterno-mastoid may alone be involved. The condition may he due in some cas,g.tr) reflex irri tation, and the exciting cause should in every case be carefully sought for, though in advanced cases the original excitant may have disappeared after the tonic and clonic spasms have become established. If the disease originates in an occupation neurosis, or is the result of a faulty position of the head due to astigmatism or other error of refraction, by correcting these in the very early stage of the affection the patient may be saved from the advent of the established neurosis.