Lorenz recommends the application of an overcorrecting apparatus after operation to force the head over to the opposite side. Considering that the neck is an exceedingly important organ, this manipulation would require the greatest care.
I prefer the excellent absorbent cotton correction bandage of Schanz. The neck is enveloped in an thick layer of absorbent cotton, which is fixed by bandages; then follow more cotton layers and bandages until the head, owing to the power of expansion of the cotton wool, will not only become fixed, but even assume a position of extension. By applying cushions of uneven thickness any desired oblique position or overcorrection can be attained and retained. The bandage may remain undisturbed for several weeks.
The consists in the treatment of the scoliosis of the cervical vertebra. which may already have developed in older cases. In this treatment all the apparatus and methods formerly used for the bloodless treatment may be applied.
Among other methods ID: operation T.ange's section of the upper end of the muscle may be mentioned. In this operation the cicatrix, being at the hair border, can be easily concealed.
Wullstcin's method of plastic shortening of the muscle of the oppo site side will hardly become necessary in children.
The bloodless methods are limited to equalization or overcorrection of the pathological position either by forcing the head to hang clown obliquely in Glisson's sling, or bo manual overcorrection, or to wearing a portable apparatus for fixing the head in a position of overcorrection. This can be achieved by plaster of Paris, celluloid or hard leather collars, etc., or by traction devices which comprise a band attached to the head and shoulder, to the pelvis, or to a special corset (Sayre, Lorenz, Hes sing, Hoffa, and others).
Recamier originated and Lorenz revived the subcutaneous tearing of the muscle to avoid the external scar. Codivilla added a pinching forceps to facilitate the severing of the muscle.
I prefer the open section as being less dangerous, observing the necessary care as to cosmetic results, since the operation is easy and asepsis attainable in so small a wound.
The success of the operation depends upon the secondary results which the deformity had already occasioned. The consecutive curving of the vertebral column is an unpleasant complication which favors relapses, and we know also that torticollis results from the faulty posi tion in pronounced scoliosis. Thus we can easily enter upon a vicious circle.
Facial asymmetry and the resulting habitual attitude of the head and the axis of the eye render correction difficult, especially if corn p]icated by stunted growth of the other muscles on the affected side.
All these factors demand early operation in congenital torticollis. As early as the first few weeks a bloodless corrective treatment should be instituted by t he insertion of cushions on the affected side. If the hama toma is still palpable it should be treated by massage, heat, and resorb ents (iodine). Portable apparatus (collars) are not applicable in the newborn owing to the tenderness of their skin. By the treatment out lined above 1 have been able in various instances to prevent the develop ment of torticollis in spite of an cniginally present hwmatoma. If the symptoms, however, should become more pronounced in the first few months in spite of the corrective treatment, I advise immediate operation.
The operation is slight and almost bloodless, and can be carried out in infants without anaesthesia, and as children at that age are always in the recumbent position the after-treatment will meet with no diffi culty whatever. (Overcorrecting plaster-bed; see "Spondylitis" for instructions how to make it.) Fixed scoliosis is not yet present, while the facial asymmetry which certainly occurs even in the first few months corrects itself after removal of the causative affection by reason of the intensity of growth during that period. (I have obtained the best possible results in twenty operative cases of this kind.) The treatment of the other forms of torticollis has already been described. If torticollis is merely an accompanying symptom of some other affection, the treatment of the two conditions will be combined, always taking into due consideration the topographico-anatomical conditions of the neck.
Rheumatic torticollis is very rare in children and I have only observed it a few times in later childhood where an arthritic tendency existed. As a rule it yields in a short time to energetic massage and antirheumatic treatment.
Neurogenic, spastic or clonic torticollis is likewise a rare affection in children. I have seen it only once in a girl thirteen years of age with a neuropathic tendency. A plaster collar for fixing and considerably overcorrecting the deformity made it disappear in four weeks. Other wise section of the nerve supplying the muscle (spinal accessory) has been recommended (Kocher), and in very pronounced cases the section of the posterior branches of the first four cervical nerves (Kennedy).