In some cases spasmodic torticollis may be of the nature of a true tic, the movement being a purposive act, the result of a mental action, which by frequent repetition becomes habitual and involuntary, as in the so-called mental torticollis of Brissaud. In this form of disease, if proper treatment is commenced early, the condition may be effectually removed. Such treatment will consist in re-educational exercises on the principles carried out in the respiratory gymnastics employed in the management of stammering. The exercises suitable for the treatment of the tic type of torticollis should embrace efforts at immobilisation. The patient seated in front of a mirror attempts to correct .the deformed position of the head and shoulders by a strong voluntary effort, which after repeated trials he soon is enabled to accomplish and maintain for a few seconds at a time, whilst during rhythmical movements of the arms and body in various directions he steadily learns to replace the faulty movement of the head by the normal one. Such exercises to be of any lasting benefit must he performed at stated periods of the day with great deliberation and pro longed patience till his volition becomes schooled and strengthened by a careful exercise of his will power under the supervision and suggestion of his medical attendant.
Drug treatment is usually disappointing. Bromides have been given in large doses, and occasionally relief may he obtained from the severe spasms. Hyoseine has been employed, and a combination of both agents gr. hyoscine hydrobromide with 20 grs. sodium bromide) adminis tered thrice daily often diminishes the severity of the spasms in a marked manner. Weir Mitchell's plan consists in the administration of Gelsemium in doses sufficient to produce very pronounced symptoms of the physio logical action of the drug. Hypodermic injections of Atropine are less satisfactory than Hyoseinc. Gowers finds that Morphia hypodermically, when persisted in daily for months in amounts of z to i gr., is often curative. He points out the obvious objection to the establishment of the opium habit, and recommends that the patient should not pass out of the physician's hands till he has been treated for the morphinisni induced by the use of the remedy.
Electricity is seldom of any real service if used alone, unless in one type of spasmodic torticollis where the malady is really of paralytic origin. In the ordinary clonic and tonic forms electricity when employed with massage and after surgical procedure is always of use, and should have a trial. The best way to apply electricity is in the form of a weak galvanic
or continuous current to the muscles which are the site of the tonic or clonic spasms. If the interrupted current is used it should only be applied to the opposing weak muscles, and sometimes marked benefit has been thus obtained by causing lively contractions in the weakened antag onists whilst the spasms are modified in the sterno-mastoid and trapezius by the continuous current.
Injection of strong alcohol into the spinal accessory trunk and other nerves or into the tissues immediately surrounding them has been ad vocated, lint the method is an impracticable one without exposing the nerves, which then can be more easily excised than injected.
The plan of fixing the head and neck in an immovable apparatus has been abandoned, since this nearly aiwa s aggravates the patient's suffering and does no permanent good; it is found impracticable by this means to tire out thw opposing muscles.
Surgical procedures usually afford a very considerable degree of relief, and sometimes complete disappearance of all the symptoms speedily follows, but relapses are so frequent that operation should only be resorted to as a last resource.
Stretching the spinal accessory is the least serious of the operations recommended, but almost invariably the spasms, both tonic and clunk, return after a brief interval. Better results are obtainable by excising a considerable portion of this nerve trunk, and when the splenius is not affected permanent relief may follow. Some surgeons practice the operation of avulsion, or tearing out the nerve by its roots. Should the spasms return, the more radical operation should be resorted to of cutting down upon the posterior primary divisions of the first five cervical nerves, and excising a portion of each. Section of the muscles by the open method without division of their nerves has been performed by some surgeons, hut as a rule this is 2111 operation only suitable for the congenital type of fixed torticollis. Kocher has, however, successfully removed the entire sterno-mastoid. Chiene, recognising that the seat of the functional mischief was in the cortex of the brain, recommended trephining and the removal of a superficial slice of the cerebral surface.