Part 33 (1/2)

The surgeon had not been behindhand, however. Gardner in 1888 was convinced of the necessity of dealing with the posterior branches of the second and third cervical pairs, a method practised a few months later by Smith and by Keen. One or two cases recorded by Ballance, according to whom division of the posterior roots was performed as far back as 1882 or 1883, are highly instructive:

A woman, thirty-two years old, had suffered for seventeen months from convulsive movements inclining the head to the right shoulder and turning the face to the left, the muscles affected being the sternomastoids, right trapezius, and complexus. On May 30, 1887, half an inch of the left spinal accessory was resected before its entry into the muscle, whereupon the spasm diminished in intensity and the sternomastoids ceased to contract. On June 6 two-thirds of an inch of the right accessory was removed, the patient being able four days later to keep her head straight by the application of her hand to the right side; but on July 4 violent spasms of the trapezius recommenced, demanding section of the posterior branch of the second pair. By the 21st there was a little stiffness of the neck on the right which speedily disappeared, and in March, 1891, recovery was still complete.

The second case concerned a woman, aged twenty-nine, with convulsive movements of the trapezii dating back seven years.

Resection of both spinal accessory nerves at the posterior border of the sternomastoid was practised on November 21, 1892; consecutive double trapezius paralysis revealed the fact that the deep rotators of the head on either side were similarly in a state of spasm; on December 13, 1892, the posterior branches of the first, second, and third left cervical roots were divided by Keen's method, the contractions being now confined to the deep rotators of the right side, which were to be treated in their turn in the same manner.

Comment is needless.

In a case of spasm of the left sternomastoid and certain muscles of the neck reported by Chipault,[207] bilateral removal of the superior cervical sympathetic ganglion was followed by instantaneous relief, succeeded by a relapse and a second cure; a degree of retrocollic spasm persisted.

Kocher's plan of cutting successively all the muscles affected has given varying results, according to de Quervain. This procedure has been adopted by others, notably by Nove-Josserand[208] in a case where treatment by suggestion had proved of no avail. For some days after the operation the spasm was exaggerated, although it eventually disappeared.

It is permissible, however, to doubt the definite and radical nature of these cures if we look at the long catalogue of admitted operative failures.

Linz's two cases[209] of resection were unsatisfactory. In Popoff's experience[210] tonic muscular spasm returned in spite of repeated neurectomies, in contradistinction to the notable improvement he accomplished by simple re-education. Tichoff[211] found the torticollis reappear four days after division of the spinal accessory, and though, in his opinion, relapse supervenes after this operation in more than fifty per cent. of cases, he expresses himself in favour of further operative interference.

Two of Dalwig's patients developed a functional torticollis to avoid the diplopia caused by a superior strabismus. Ocular tenotomy, as might have been foreseen, was quite ineffectual in checking the tic; indeed, the author himself seems to have been well aware of the necessity, in curing such vicious habits, of influencing the attention. He proceeds to emphasise the hopefulness of orthopaedic, as opposed to surgical, treatment, and recommends the use of a cardboard collar, though any benefit thus derived is, in our experience, purely ephemeral.

A case of Oppenheim's underwent first tenotomy, then elongation, and finally resection of the spinal accessory, with the result that, in spite of complete atrophy of the sternomastoid and partial atrophy of the trapezius, spasm settled with renewed intensity on the splenius, omohyoid, and remaining fibres of the trapezius. Application of a seton was equally negative, but the patient soon after made astonis.h.i.+ng improvement by a mineral water ”cure”!

In face of such facts, it is truly surprising to see the increasing support given to surgical intervention. Walton,[212] for an instance, admits the central origin and progressive nature of the disease, and recognises the futility of surgical procedures, yet const.i.tutes himself their advocate. Would it not be more in accordance with the dictates of reason and wisdom to refrain?

We must not omit to mention the extraordinary method devised by Corning[213] of injecting into the muscles a warm mixture of tallow and oil which will solidify at 37 C., to which proceeding he proposes to give the fantastic name of _elomyenchisis_. The idea is to fix previously relaxed muscles. He does not seem to have had many imitators.

Torticollis apart, few tics invite treatment at the hands of the surgeon, with the exception of facial tics or spasms.

Here, too, the results have usually been anything but encouraging.

Stewens[214] reports three cases of facial tic cured by the correction of errors of refraction, while elongation of the facial nerve failed of its object. Resection of a branch of the trigeminal is valueless; facial elongation only causes a corresponding paralysis, and should this latter accident be transient, as in a case of Bernhardt's, so is the relief from the tic.

To obviate the much more frequent inconvenience of a permanent facial paralysis, J. L. Faure[215] suggests spino-facial anastomosis. In a woman suffering from contracture and spasmodic twitchings in the region of the facial, Kennedy, of Glasgow, divided the nerve and immediately anastomosed the cut end laterally with the spinal accessory. At the end of fifteen months the spasm had vanished and the paralysed facial nerve had recovered its functions.[216]

Strictly speaking, then, in certain cases of genuine facial spasm the possibility of some such treatment may be entertained if all other means have failed, but persistence of the facial palsy and the grave consequences it may entail are always to be dreaded. In facial tics, however, under no pretext whatever is the surgeon justified in attempting to interfere.

In the case of spasms properly so called, efforts directed to the removal of the exciting cause--should it be known--are often crowned with success. Conjunctivitis, rhinitis, odontalgia, may occasion grimaces and contortions which cease with the disappearance of the irritation. In 1884 Fraenkel showed to the Medical Society of Berlin a woman, forty-five years old, with mimic convulsions of four years'

duration, attributable to a rhinitis. Every time the mucous membrane of the left nasal fossa was touched a violent spasm ensued; but a few applications of the galvano-cautery brought the phenomena to an end.

Oppenheim has seen facial and ma.s.seter spasm checked by the extraction of a carious tooth, and in another case by an operation on the ear.

Emphasis must once more be laid on the fact that any success achieved has been in reference to spasms; as much cannot be said of tics and a.n.a.logous affections. The surgical treatment of stammering has long since received its quietus.

We may bring this discussion to a close by applying to tics in general certain considerations of Brissaud[217] anent mental torticollis:

”Instead of proceeding to operate at once and being content thereafter to enjoin on the patient, whenever the wound is healed, a course of exercises to be persevered with over long months or even years, better give the same good advice long months or even years before inflicting him with the operation.”

ORTHOPaeDIC TREATMENT