Fig. 272.—Congenital Wry-neck seen from behind to show scoliosis.
There is also asymmetry of the head and face, the affected side being the smaller. The eye on this side lies on a lower level, and is more oblique than its neighbour, the cheek is flattened, and the mouth asymmetrical. Instead of the eyebrows and the lips forming parallel lines, their axes converge towards the side of the contracted muscles and fasciæ.
Treatment.—While it may be possible when the condition is recognised during infancy to counteract the tendency to contraction and deformity by manipulations, massage, and exercises alone, it is usually necessary to divide the shortened structures as a preliminary to orthopædic measures.
Subcutaneous tenotomy—at one time the favourite method of treatment—has been entirely replaced by the open operation, which admits of all the structures at fault, including the cervical fascia, being thoroughly divided, without risk of injuring other structures in the neck. The result of division of the shortened tissues is seen at once in a marked increase in the interval between the sterno-clavicular joint and the mastoid process. As in other deformities, the operation is only a preliminary, although an essential one, to the treatment by massage, movement, and exercises which must be persevered with for months, and it may be for years. When the torticollis attitude has been corrected in childhood, the asymmetry of the skull disappears.
Spasmodic wry-neck is the term applied to a condition in which clonic contractions of certain muscles produce jerkings of the head. The muscles most frequently at fault are the sterno-mastoid and trapezius of one side, and the posterior rotators of the opposite side. By these muscles the head is pulled into the wry-neck position, and is at the same time retracted, and there is more or less constant nodding or jerking of the head.
The condition is usually met with in adults of a neurotic disposition who are in a depressed state of health, and is due to some lesion, as yet undiscovered, in the nerve mechanism of the affected muscles—most probably in their cortical centres. It would appear that in some cases the spasmodic jerkings are originated by certain movements habitually made by the patient in the course of his work. In others, as a result of astigmatism and other errors of refraction, the patient has acquired the habit of repeatedly tilting his head to enable him to see clearly, and these movements have become continuous and uncontrollable.
The affection tends to become progressively worse until the patient is incapacitated for work or enjoyment. Sleep even may be interfered with.
Treatment.—In well-marked cases the use of drugs, electricity, or restraining apparatus is never curative, but these measures combined with massage have been temporarily beneficial in milder cases.
Of the operative procedures, resection of portions of the accessory nerve on one side, and of the posterior primary divisions of the first five cervical nerves on the opposite side, seems to offer the best prospect of recovery. Simple division of these nerves or resection of the accessory alone has not proved permanently curative. Open division of the offending muscles without interfering with the nerves has given good results, and is a much simpler operation (Kocher).