STRETCHING OF THE FACIAL NERVE. 
REPORT OF A 
NEW CASE, WITH REMARKS, AND A SUMMARY OF 
PREVIOUSLY REPORTED CASES. 
BY 
WILLIAM W. KEEN, M.D., 
OF PHILADELPHIA 
PROFESSOR OF SURGERY IN THE WOMAN'S MEDICAL COLLEGE OF PENNSYLVANIA ; 
SURGEON TO ST. MARY'S HOSPITAL. 
REPRINTED FROM THE 
TRANSACTIONS OF THE AMERICAN SURGICAL ASSOCIATION, 
MAY I, l886. 
PHILADELPHIA: 
WM. J. DORNAN, PRINTER. 
1886. STRETCHING OF THE FACIAL NERVE. 
Report of a New Case, with Remarks, and a Summary of 
Previously Reported Cases. 
I desire to report the following case of right facial spasm, which 
existed for five and a half years; and in which resection of the right 
infraorbital nerve was performed with temporary relief; after which 
stretching of the facial nerve was done, followed by cure, with lessen- 
ing paralysis of the face up to date of report. 
Mrs. A. S., native of England, aged forty-eight years, four feet 
seven and a quarter inches in height, weighing 138^ pounds, and by 
occupation a housekeeper, was sent to the surgical clinic at the 
Woman's Hospital, April 1, 1886, by Dr. Wharton Sinkler, for opera- 
tion, with the following history: 
Family : Mother died of dropsy at the climacteric. Father died of 
inflammation of the stomach. Two brothers were killed in the war. 
One brother living, but not in good health. 
Personal: Had nervous trouble when she was a child. Was para- 
lyzed, and unable to walk until she was six years old, when she was 
brought to this country, and the sea voyage seemed to restore the tone 
of her nervous system. When twelve years old was again troubled 
with loss of nerve power: could not hold anything in her right hand. 
This condition yielded to remedies in a short time. 
The menstrual function was established at sixteen years of age. The 
periods have always been accompanied by a profuse discharge, and a 
good deal of pain ; they were always regular until about five years ago, 
when her present nervous trouble began, since which time they recur 
every two or three weeks, accompanied by an exaggeration of the 
nervous twitching and pain in the head and arm. 
From the age of sixteen until five years ago she had no recurrence of 
nervous trouble, was always healthy, except an occasional sick head- 
ache, and twice an attack of chills and fever. 4 
KEEN, 
She was married at eighteen years of age, and has had ten children, 
nine of whom are living. Six months after the birth of the youngest, 
now nearly six years old, she noticed a drooping of the right upper eye- 
lid, and soon after a twitching of the under eyelid, and the eyeball was 
quite bloodshot. Was under treatment for some time without relief. 
In less than six months the entire right side of the face and the right 
platysma-myoid twitched constantly ; the angle of the mouth was drawn 
down and there was constant pain in the head. Talking, eating, and 
indeed any physical or mental effort increased the spasms. The twitch- 
ing of the cheek against the teeth made it sore, and the cheek was often 
caught between the teeth in mastication, so that long since she had all 
the teeth in the right half of the mouth removed, without any effect on 
the spasms. She has been under Dr. Sinkler's care from July 23, 1883. 
Galvanism has been faithfully used, as also other remedies such as 
conium, gelsemium, cannabis Indica, eserine, nitro-glycerine, iodide 
of potassium, etc., with no permanent effect. Conium had marked 
influence on the tic when pushed to full doses, but soon lost its effect. 
Quinine would relieve the pain in the head when severe. April 25, 
1884, Pain in the right leg began, and at times there was pain in the 
back of the neck and arms. February 2, 1885, she complained of 
twitching in the right leg. 
In June, 1884, the right infraorbital nerve was resected by Dr. T. 
G. Morton. About half an inch was cut out. This was followed by a 
cessation of all the twitching of the muscles, and the pain in the head 
was relieved. This relief continued a few days, but by the end of six 
weeks all the twitching returned, and, in addition later, a twitching 
of the right side and leg. Dr. Sinkler now sent her to Prof. Keen to 
have the nerve stretched, as had been agreed would be proper. 
Physical Examination. Lungs-vesicular murmur good. Heart- 
mitral regurgitation-murmur heard at the apex and in the axillary 
space. 
Urinalysis. Specific gravity 1.028. Color, yellow-white-white de- 
posit. Reaction strongly alkaline, no albumen, no sugar. 
April 1, 1886. Present State. Entered the hospital in condition 
before described. The nervous twitching increased when she was ad- 
dressed or when she tried to speak. Whether her face twitched during 
sleep could not be determined, as she awakened on the slightest noise. 
Given an oil injection in the afternoon in preparation for the operation. 
2d. Bowels loose, did not sleep very well through the night. 
Operation. Began etherizing at 1 o'clock, April 2, Dr. Sinkler present 
and assisting. At 1.10 an angular incision wasjmade two and a half STRETCHING OF THE FACIAL NERVE. 
5 
inches long. The angle of the incision was at the apex of the mastoid 
process, the two lines passing upward behind the ear, and downward 
in a line parallel with the border of the sterno-cleido-mastoid muscle. 
Ligated the posterior auricular artery. The parotid gland was dissected 
and pushed forward till the prevertebral muscles and their aponeurosis 
were reached. A very weak current of electricity was then applied by a 
wet sponge to the cheek and a fine wire to various points in the wound 
until the nerve was found. Immediately a spasm of the facial muscles 
followed the application. The nerve was then laid bare. A hook was 
next passed under it and the nerve stretched several times from the 
face outward, pulling the head over to the right side. When the nerve 
was stretched, marked contraction of the facial muscles was seen. The 
force used was estimated at between four and five pounds. No more 
force was used because a few fibres were felt giving away when an at- 
tempt was made to lift the head. Horsehair drainage was used and 
four silver sutures were introduced. Complete paralysis of the facial 
muscles was noted after the stretching and before she had recovered 
from the ether. Upon recovering consciousness the patient remarked 
the absence of pain in the head. 
Before the operation: pulse 90, temp. 98.8°. After the operation: 
pulse 82, temp. 98.6°. 
A carbolized gauze dressing was applied and the operation was com- 
pleted at 1.50 p. m. On coming out of ether she had four nervous 
chills. Was given a five grain assafoetida suppository, which quieted 
her. Took a dessertspoonful of milk or beef-tea every twenty min- 
utes or half hour through the afternoon. At 6 p. m. complained of 
severe pain in the ear, which soon passed away. At 7 p. m. vomited, 
otherwise retained all nourishment. Took short naps through the 
afternoon and evening. After the operation there was complete paral- 
ysis of the facial muscles. The right eyelid did not close of itself. 
Slept very well through the night, snoring loudly. 
3d (1st day after operation). 6 a. m. pulse 77, temp. 99.40. 
Paralysis of facial muscles not so marked as immediately after the 
operation. No pain in the head, but she complains of a soreness in the 
right side of leg, which was rubbed with liniment. Took from half an 
ounce to an ounce of milk every hour, with some coffee. At 1 p. m. 
pulse 86, temp. 100.40. Gave four grains of quinine. The wound was 
dressed at 2.30 p. m., slight oozing was found on the dressing. At 
4 p. m. pulse 96, temp. 100.40. Felt very comfortable all day and 
slept soundly all night. 
4th (2d day). 6 a. m. pulse 85, temp. 98.6°. Took more nourish- 6 
KEEN, 
ment at longer intervals. Had no pain in the ear. 4.30 p. m. pulse 
81, temp. 990. Leg and side still painful, rubbed with liniment. 
3th (3d day). 6 a. m. pulse 85, temp. 98.7°. Slept very well through 
the night, did not snore as on previous nights. Eyelid nearly closed, 
and facial muscles seem a little less relaxed than before. There has 
been no twitching of the facial muscles of platysma or leg since the 
operation. Sat up with bed-rest for an hour in the morning and for 
twenty-five minutes sat in rocking-chair in the afternoon. 4.30 p. M. 
pulse 80, temp. 98.6°. 
6th (4th day). Temp. 98.4°, pulse 76. Hunyadi water for slight 
constipation. Out of bed. All the stitches removed this afternoon 
and the horsehair drainage-a few drops of sanious discharge followed. 
Bandage removed and adhesive plaster applied. Evening temp. 99.6°, 
pulse 74. 
7 th (5th day). Temp. 98.8°, pulse 73. Complained of pain behind 
her ear. There was a little discharge through the night. Applied a 
compress of absorbent cotton with iodoform sprinkled upon it. 
8th (6th day), a. m. temp. 98.4°, p. m. 98.4°. Very little dis- 
charge. 
9th (7th day), a. m. temp. 99.90, pulse 73. Able to masticate. 
Given an enema. Bowels moved. Evening temp. 99°. 
Was taken unwell. At this period previously the twitching of the 
face and also of the right side and leg, as well as the pain, were always 
much worse. All of these are now entirely gone. Neither twitching 
nor pain is present anywhere. 
10th (8th day). Discharged well. 
27th (25th day). No twitching or pain. Still complete paralysis, 
though the eye can be nearly closed. 
September 10, 1886, five months after the operation, the patient 
remains well. The facial palsy has almost entirely disappeared, and 
the face has nearly regained its normal expression. 
I append the following electrical examination made with great 
care by Dr. G. Betton Massey : 
" The under-mentioned muscles of expression of the right side of the 
face were examined on the tenth day after you had operated-that is, 
on the 12th of April, and also on the seventeenth and twenty-fourth 
days after operation. A control examination was at the same time 
made of the sound side for comparison, and the figures found are placed 
in the table as the normal formula of each muscle. STRETCHING OF THE FACIAL NERVE. 
7 
" Farado-contractility was found greatly weakened on the tenth day, 
and totally abolished on the seventeenth. The galvanic responses 
tabulated below were noted with great care, all errors from changes in 
resistance being eliminated by the use of a milliampere meter (Bar- 
rett's). They were those produced by the minimal current strength at 
closure of the circuit. 
" It will be noted by a reference to the table that the frontalis showed 
the serial change indicative of reaction of degeneration in a slight 
degree on the seventeenth day. This remained the same on the twenty- 
fourth, when slight modal change, consisting of a slow wave-like con- 
traction instead of a sharp, quick one, was noted. The orbicularis 
palpebrarum showed quantitative diminution of excitability on the 
tenth day, and serial change on the seventeenth. The levator labii 
superioris showed slight serial change on the tenth day, which has 
increased since, amounting on the twenty-fourth day to more than a 
complete reversal of the normal figures. This was true also of the 
zygomaticus major, orbicularis oris, and levator menti, in all of which 
increasing serial change has been found, together with great modal 
alteration of contraction. The lower muscles of the face show greater 
change than the upper." 
Minimal. 
Contraction at 
Remarks. 
Kathodic 
closure. 
Anodic 
closure. 
f Normal 
I 
1% 
Frontalis .... J Iot£ 
17th day 
1/2 
I 
L 24th day 
I 
Slight modal change. 
f Normal 
% 
I 
Orbicularis palpebrarum 4 
2/2 
2 
3 
[ 24th day 
2% 
Slight modal change. 
J- Normal 
2^ 
3 
Levator labii superioris -j day 
4 
2% 
2 
L 24th day 
3 
Modal change. 
[ Normal 
2^ 
3 
Zygomaticus major . ■ day 
2^ 
5 
3K 
Modal change. 
L 24th day 
2% 
Great modal change. 
f Normal 
2% 
3 
Orbicularis oris J loth d^ 
3 
Slight modal change. 
1% 
' Yz 
Great modal change. 
L 24th day 
1% 
Great modal change. 
f Normal 
2% 
Levator menti . . - Iotfj ja^ 
1 17th day 
2% 
3 
Great modal change. 
L 24th day 
I 
% 
Great modal change. 
The subsequent history, with the later electrical changes, I shall report 
at future meetings of the Association. 8 
KEEN, 
No. 
Reporter 
and 
method. 
Reference. 
Date. 
Sex, age, 
and side. 
Dura- 
tion of 
disease. 
Supposed 
cause. 
Temporary result. 
Final result 
Remarks. 
I 
Baum. 
(Baum's me- 
thod.) 
Berliner klin. 
Woch., 1878, 
No. 40, p. 595. 
July 20, 
1878. 
F. 35 L. 
6 years. 
Epileptic 
fit. 
Paralysis disappeared in half an 
hour; cure for 8-9 mos. Slight 
return after 8-9 months, another 
later. After two years so nearly 
well as not to need a second 
operation. 
Great im- 
provement two 
years after 
operation. 
Right side occasionally twitched. 
2 
Bernhardt. 
.Hahn oper- 
ated. 
Baum's 
method). 
Zeitschr. fiir 
klin. Med., 
1881, p. 96. 
Nov.i5(?), 
1878. 
M. 36 R. 
5 years 
No paralysis resulted ; twitching 
returned next day. After two 
years, all in all, some improve- 
ment ; often free for hours, at 
which times active movements 
do not arouse the spasms. Im- 
provement not sufficient to en- 
couragehim to undergo a second 
operation. 
Some im- 
provement two 
years after 
operation. 
Pain preceded the spasms for two 
years. No electrical difference 
on two sides. 
3 
Schtissler. 
(Baum's me- 
thod.) 
Berliner klin. 
Woch., 1879, 
No. 46, p. 684, 
and Godlee's 
table in Trans. 
Clin. Soc. xvi. 
p. 227. 
Jan. 23, 
1879. 
F. 39 L. 
8 years. 
9 
Paralysis for six weeks, disap- 
pearing at twelve weeks. Slight 
return after six months, and 
growing worse, but in nothing 
like the previous severity. 
Some im- 
provement six 
months after 
operation. 
4 
Eulenberg. 
(Hueter 
operated, 
Hueter's 
method.) 
Centralbl. fiir 
Nervenheilk., 
1880, No. 7. 
and Godlee's 
table. 
Dec. 2, 
1879. 
F. 27 L. 
2 years. 
2 
Paralysis for three months, then 
slowly disappeared, and as. it 
disappeared the twitchings re- 
turned, but never so violent as 
before 
Some improve- 
ment three 
months after 
operation. 
• 
Chiefly sudden and severe bleph- 
arospasm extending to left side 
of face, and slightly to right 
side; also to some spinal acces- 
sory muscles and flexors of hand 
and fingers. Schirmer had 
stretched and divided leftsupra- 
orbital nerve without result. 
Posterior auricular nerve not 
paralyzed by Hueter's opera- 
tion. Reaction of degeneration 
followed the operation. Loss of 
taste in left anterior half of 
tongue for fifteen weeks. 
Table of the Recorded Cases of Stretching of the Facial Nerve. STRETCHING OF THE FACIAL NERVE. 
9 
5 
Putnam. 
(Baum's 
method.) 
Archives of 
Med.,N. Y., 
Feb. 1881. 
April 24, 
1880. 
M. 
25 
R. 
3 years. 
9 
Paralysis disappeared after three 
months. Spasms returned after 
nearly a year. 
Unrelieved 
nearly a year 
after the 
operation. 
Reaction of degeneration had be- 
gun on fourth day when first 
examined electrically, but this 
disappeared after nine months 
6 
Bernhart. 
(Langen- 
beck oper- 
ated 
Hueter's 
method.) 
Zeitschr. klin. 
Med., 1881, 
p. 99. 
June 18, 
1880. 
M. 
21 
L 
4 years. 
Cold 
Complete paralysis three days. 
Nearly gone in three months. 
Gradual return of spasm there- 
after, but not so severe as be- 
fore. 
Somewhat re- 
lieved four 
months after 
operation. 
Patient would willingly submit to 
a second operation as the par- 
alysis was the lesser evil. Re- 
action of degeneration. Only 
branches to eye and upper face 
stretched. 
7 
Sturge and 
Godlee. 
(Godlee 
operated 
Baum's 
method.) 
Trans. Clin. 
Soc., London, 
1881, xiv. p. 
44, and 1883, 
xvi. 229. 
July 20, 
1880. 
F. 
72 
R. 
6 years. 
Mental 
shock. 
Paralysis nearly disappearing af- 
ter three months Slight uncon- 
scious twitching after three 
months. At end of nine months, 
following severe emotional dis- 
turbance, entire return. 
Unrelieved 
three years 
after opera- 
tion. 
8 
Southam. 
(Baum's 
method.) 
Lancet, Aug. 
27, 1881, and 
April 10, 1886. 
March 28, 
i88r. 
F. 
59 
L. 
2 years. 
Fright. 
Paralysis disappeared at sixteen 
weeks. 
Cure after five 
years. 
9 
Hoffmann. 
Bernhardt, 
Deutsch, med. 
Woch., 1882, 
No. 9, and 
Godlee's table. 
March 28, 
1881. 
F. 
35 
R. 
9 
Paralysis lasted to some extent 
till the fall of 1881. At this time, 
while she was pregnant, and af- 
ter delivery, spasms were worse, 
but then subsided (entirely?). 
Cure or great 
improvement 
twenty-five 
months after 
operation. 
Under lip and platysma branches 
too deep, and were not stretched. 
IO 
Godlee. 
(Bau m's 
method.) 
Trans. Clin. 
Soc., London, 
1883, xvi. 
p. 220. 
Nov. TO, 
1880, left 
nerve; 
March 24, 
1881, right 
nerve. 
M. 
36 
R. 
L. 
3 years. 
Paralysis of both sides; began to 
disappear, after twelve weeks, 
on each side. As control re- 
turned, spasms recurred. 
Unrelieved 
two years after 
operation. 
Left supraorbital nerve was di- 
vided Sept. 13,1881, for tender- 
ness, but without good result. 
II 
Navratil. 
Chir. Beit- 
rage, S. 10. 
Quoted by 
Zesas; vide 
infra. 
May 15, 
1881. 
F. 
? 
R. 
7 years. 
Slight twitching for three days, 
then disappeared. 
Unknown. 
Not seen later. 
Slight attack of erysipelas. 
12 
Putnam. 
Godlee's 
table. 
June 1, 
1881. 
F. 
45 
L. 
9 years. 
Entire paralysis for two months 
or more. After several months 
spasms reappeared. 
Unrelieved 
after some 
months. 
Supraorbital nerve had been di- 
vided fruitlessly. 10 
KEEN, 
No. 
Reporter 
and 
method. 
Reference. 
Date. 
Sex, age, 
and side. 
Dura- 
tion of 
disease. 
Supposed 
cause. 
Temporary result. 
Final result. 
Remarks. 
13 
Southam. 
(Baum's 
method.) 
Lancet, Oct. 8, 
1881, and God 
lee's table. 
Aug. 1, 
i88r. 
F. 32 R. 
4 years. 
Paralysis present after three 
months, but fading. 
Cure three 
months after 
operation. 
14 
Benedikt. 
Wien. med. 
Presse, 1882, 
Nos. 13 and 14. 
July 2, 
1881. 
Old. 
An old paralysis was followed by 
secondary tic convulsif for 
which the operation was done. 
The lagophthalmia vanished in 
the eight days of healing. 
Faradic contractility which had 
been absentreappeared, and the 
galvanic approached normal. 
Improvement 
about three 
weeks after 
operation. 
Operation was difficult, as it was 
through the scar of old glandu- 
lar inflammation; nerve was 
found thin and gray, and de- 
generated. 
15 
Bernhardt. 
(Hahn oper- 
ated.) 
Berliner klin. 
Woch., 1882, 
No. 14, and 
Deutsche med. 
Woch., 1882, 
Nos. 9 and 29. 
Aug. 
1881. 
F. 35 L. 
3% years. 
Persistent 
drawing 
with a 
lens. See 
remarks. 
Paralysis disappeared entirely in 
five months ; twitching began 
after seven months; after ten 
months considerable twitching, 
but not so bad as before. 
Improvement 
ten months 
after 
operation. 
Posterior auricular nerve not par- 
alyzed ; reaction of degenerat'n 
[Godlee says it "followed lupus 
which caused contraction of 
eyelids.'' Bernhardt says it 
followed " nach anhaltendem 
Zeichnen mit der Loupe wobei 
das linke Ange besonders ange- 
strengt wurde," An amusing 
error of translation.] 
16 
Gray. 
(Baum's 
method.) 
Proc. Med. 
Soc. King's 
Co., N. Y., 
1882, vii. 
p. T27. 
May 8, 
1882. 
M. 36 R. 
16 years. 
This was a case of tic douloureux 
preceded by tic convulsif; pain 
relieved for four days, then 
worse than ever; twitching less- 
ened ; paralysis. 
Unrelieved as 
to pain; 
twitchings im- 
proved after 
three months. 
Reaction of degeneration. 
'7 
Gray. 
(Baum's 
method.) 
do. 
June 16, 
1882. 
M. 22 R. 
(L.) 
10 years. 
Only right side stretched; paral- 
ysis. 
Cure three 
months after 
operation. 
Both hands also choreic. Re- 
action of degeneration. 
18 
Zesas. 
Wien. med. 
Woch., 1884, 
No. 2; and 
1885, No. 27. 
Nov. 16, 
1882. 
M. 37 R. 
8 years. 
Cold. 
No paralysis followed; spasm 
lessened, and ceased Jan 4, 
1883 [seven weeks], July, 1885, 
still cured. 
Cure two years 
and eight 
months after 
operation. 
No electrical change. 
Tab le- Concluded. STRETCHING OF THE FACIAL NERVE. 
11 
'9 
Bernhardt. 
(Levy oper- 
ated.) 
Archiv fiir 
Psychiatric 
und Nerven- 
krank., 1884, 
xv. p. 777. 
Jan. 16, 
1884. 
M. 25 
R. 
4% years. 
Cold. 
Had paralysis of right face when 
first seen ; after operation par- 
alysis much diminished by 
April 1, 1884. By May 8, 
spasms returned almost as bad 
Unrelieved of 
spasms four 
months after 
operation; 
previous par- 
alysis some- 
what im- 
proved. 
Reaction of degeneration. 
as ever. Voluntary power o 
some muscles had returned. 
ver 
20 
Kaufmann. 
(Hueter's 
method.) 
Centralbl. fiir 
Chirurg., 1885, 
No. 3. 
Sept. 16, 
1884. 
M. 61 
R. 
7 years. 
Anger. 
Incomplete paralysis ; improve- 
ment for four days ; on fifth day 
returned as bad as ever. 
Unrelieved 
four months 
after operation 
Only part of nerve stretched. On 
fifth day same nerve divided 
without result. 
21 
Keen. 
(Baum's 
method.) 
Trans. Amer. 
Surg. Assoc., 
iv. p. 275. 
April 2, 
1886. 
F. 48 
R 
5% years. 
Nervous 
trouble 
coincident 
with clim- 
acteric 
Paralysis ; not lessened when 
ported (25 days), and with 
return of spasms. 
re- 
no 
Uncertain; 
too early to re- 
port (25 days); 
[five months 
after operation 
still cured; 
paralysis 
n early 
disappeared.] 
Reaction of degeneration on tenth 
day. Infraorbital nerve had 
previously been stretched with- 
out permanent relief. 
The most accurate tables heretofore compiled, though not free from errors, 
are those of Godlee and Zesas. That of Chandler (New York Medical Record, 
Sept. 9, 1882) is exceedingly inaccurate. Eulenberg has reported only one 
case, and there is no such case as that of "Germon," while the rose-colored 
views of the results are not justified by the facts. Dr. Harte, in Agnew's Sur- 
gery (vol. iii.) has used the tables of Chandler without verification (in that of 
mimic spasm at least), and has repeated its errors. Moreover, Harte's last four 
cases should be of the facial, and not the inferior dental nerve. 
Of these 21 cases there are males, 9; females, ix; unstated, 1. The right 
nerve was involved it times, the left 7, both 2, and side not stated I. The age 
is from 21 to 72. Four of them had undergone previous operations (4, 10,12, 21), 
the first three section or resection of the supraorbital, and the last of the infra- 
orbital nerve, with no permanent effect. 
Davidson (Lancet, 28, 1882) stretched the infraorbital nerve in a woman, set. 
fifty-three, for muscular spasms limited to the muscles of the region supplied by 
this nerve. The spasms ceased in a fortnight. The case was reported about 
two months after the operation. 12 
KEEN, 
Remarks.-The operation of nerve stretching was first intro- 
duced by Billroth and Nussbaum in 1872. It has been done 
only twenty-one times upon the facial nerve so far as I have 
been able to ascertain. Five of these cases have been done in 
America (Putman two, Gray two. My own is the fifth). These 
twenty-one cases are summarized in the preceding tables. 
Reason for the Operation. All of the cases have been for 
more or less extensive tic non-douloureux of the face, lasting 
from two to ten years. In two cases paralysis of the face pre- 
ceded the convulsive tic, and in one case tic douloureux fol- 
lowed the tic convulsif. As Sturge has pointed out, the lesion 
in tic convulsif is probably central and not peripheral, though 
Kaufmann's curious case (see p. 286) would seem to show other- 
wise. In my own case the previous history points almost con- 
clusively in this direction from the repeated and extensive 
paralyses. It might be objected, therefore, in limine, that the 
operation should not be done since it cannot reach the actual 
seat of the disease, and any interference with the nerve, the 
mere conductor of motor impulses, would have to paralyze the 
muscles permanently in order to effect the desired relief. The 
experiment of Godlee, in which he dissected out the spinal acces- 
sory and the facial and found that a slight pull on the former was 
immediately evident on the central side of the short, wide, and 
straight jugular foramen, while traction on the facial even to 
rupture of the nerve was not perceptible at the central end of the 
long, narrow, and curved aquaeductus Fallopii, proves that no 
central alteration can be urged in favor of the operation on the 
seventh nerve, although in one case (4) taste was lost for fifteen 
weeks. But, per contra, while the expected paralysis nearly 
always follows, it always disappears in time, as I shall show, and 
the relief of the tic that has followed in a good proportion of 
the cases, gives a reasonable ground for the operation. 
Method of Operating. Two methods have been proposed, that 
of Baum and that of Hueter. In the former the incision is 
made behind the ear by an angular incision two and a half 
inches long, the apex being at the apex of the mastoid process. 
The parotid gland is the first landmark. Its posterior border is STRETCHING OF THE FACIAL NERVE. 
13 
dissected and pushed forward by a grooved director and forceps 
till the shining aponeurosis of origin of the sterno-cleido is seen 
as the second landmark. The interspace between these two is 
cleared to the depth of one or one and a half inches, when the 
prevertebral muscles and their anterior fascial covering are the 
next landmark. The nerve lies in front of this fascia. Some- 
times the posterior belly of the digastric is seen. The transverse 
processes of the vertebrae and the styloid process can both be 
felt and are valuable as additional guides. This space between 
the mastoid process and the vertical ramus of the jaw is quite 
narrow and deep. It will barely admit the finger. Hence a 
good side light is essential, and I found great help from a 
student lamp and a forehead mirror held by Dr. Sinkler, which 
illuminated the deeper parts admirably. The chief trouble is to 
find the exact spot at which the nerve crosses this space on its 
way from the stylo-mastoid foramen to enter the parotid. Dis- 
section will always reveal it, but in order to avoid needless 
injury and abridge the search, I found the use of a weak faradaic 
current very useful. A strong current at any point in the moist 
state of the wound will produce muscular spasm at once, but a 
very weak current will only do so when the nerve is touched. 
A wet sponge was held on the cheek and the wire end of the 
other cord was touched at successive points till the nerve was 
easily detected, when its white trunk was quickly laid bare. 
While being stretched the extent of twitching produced by it 
should be noted to see whether the trunk has been stretched on 
the central side of all the branches. If any branches have 
escaped, the muscles supplied by them will not twitch when 
the nerve is stretched, and also, even during etherization, spon- 
taneous convulsive movements will sometimes recur in the 
muscles the nerve branches to which have not been stretched, 
and so point out what branches have escaped. 
The other method is that of Hueter by an incision in front of 
the ear two inches long, its middle at the level of the upper 
part of the lobule. The parotid is at once disclosed. The 
incision is carried more and more deeply till, at about three- 
quarters of an inch, one of the two main branches of the nerve 14 
KEEN, 
is reached. Further dissection will soon reveal the second 
branch and at their junction the main trunk. If it is desired to 
dissect back to the foramen, a second short incision at right 
angles to the first must be made posteriorly. 
Of the two methods, that of Baum is by far the better. In 
the first place, its scar is hidden by the ear, and especially in a 
woman this is very desirable. Secondly, it is far less bloody: 
usually only the posterior auricular artery is cut, and possibly 
one or two other small vessels; whereas, in Hueter's, there 
are, usually, a number of glandular branches requiring ligature. 
Thirdly, much less damage to the gland and other tissues is 
inflicted. Fourthly, and chiefly, the nerve is reached directly at 
its emergence from the stylo-mastoid foramen before it has 
given off any branches except, possibly, the posterior auricular, 
an unimportant branch. How important this advantage is, is 
best shown by Kaufmann's case, in which he operated by 
Hueter's method. His first stretching disclosed the fact that he 
had not gone far enough back, for the frontalis and orbicularis 
palpebrarum were not paralyzed. Enlarging the wound upward 
and downward (it should have been backward) a second stretch- 
ing gave the same result. On the fifth day the twitching was 
as bad as ever, and he wished to do Baum's operation, but the 
patient would not consent to a second scar, so he opened the 
original wound, found the injected nerve and divided it. The 
wound promptly healed, but no benefit resulted, and the patient 
went home worse than he came, for he not only had the twitch- 
ing but his cheek and mouth were also paralyzed. 
What light this case may throw upon the pathology of the 
disease I am hardly able to say. It certainly would seem to 
point to a peripheral cause for the spasms. 
In Hoffmann's case also the muscles of the under lip and the 
platysma were not paralyzed, and in Eulenberg's and Hahn's 
cases the posterior auricular branch was not affected. 
I have only had opportunity to compare the two methods 
upon the cadaver. The result of a score of trials is decidedly 
in favor of Baum's method, except in the ease of performance 
from the less room and greater depth, in which particulars STRETCHING OF THE FACIAL NERVE. 
15 
Hueter's is the better operation. But these should not weigh 
in view of the reasons before stated. 
The nerve being found, how shall it be stretched, in what direc- 
tion, and with what force? 
I have found an ordinary blunt hook an excellent means, and 
no other instrument seems necessary. 
As to direction, I stretched it chiefly from the periphery toward 
the centre as well as the hook would allow, both because no 
stretching on the central end would affect the medulla, and 
because, as Marcus has shown, traction on the central end of a 
mixed nerve abolished sensibility while traction on the periph- 
eral end abolished both motion and sensation, and the motor 
effect was here desired. 
The amount of force to be used is as yet undetermined. Gray 
estimated it in his case at six to seven pounds; Southam at four 
to five pounds; and in my own case it was estimated at four to 
five pounds. It was not enough to lift the head of the patient 
(which would probably weigh six to seven pounds), for on care- 
fully attempting to do this, before the head could be lifted I felt 
a few fibres giving way and I at once desisted. The head, 
however, was rolled from left to right quite forcibly. 
Putnam records an interesting experiment on a dog. The 
facial has two branches, each about equal in size to the main 
trunk in man. One of these broke at forty pounds. A much 
less weight would have broken the nerve in my patient, and in 
several cadavera injected and condensed by the chloride of zinc 
the attempt to lift the head caused rupture of the nerve. The 
dog above alluded to was then allowed to come partially out of 
the ansesthesia and the other branch was stretched. At seven 
pounds the motion of the eyelid was impaired, a second pull of 
eight pounds produced complete palsy, which disappeared on 
the second day. Putnam recommends that the patient should 
be allowed partially to recover from the ether to judge of the 
effects of the pull, and that two pulls of about six and seven 
pounds be the limit imposed, unless symptoms be so severe that 
prolonged palsy be desired. My own impression is that this is 16 
KEEN, 
too great a force and that it can be best achieved empirically, 
the attempt being made to lift the head (six to seven pounds) 
and being abandoned the moment any fibres give way. 
In Eulenberg's case the nerve was physically disorganized by 
the stretching, yet the paralysis disappeared in three months 
and the spasms returned, though with abated force. Schiissler 
states that in his case, after three or four pulls, the nerve lay 
in a small loop in the cavity of the wound, yet the palsy disap- 
peared in twelve weeks and the spasms partially returned after 
six months. 
The effects of slight and of severe stretching differ materially. 
As has been shown by Haber, Ranke, Cornet, and others, slight 
stretching either has no influence on the irritability of the nerve 
or even increases it, whereas greater stretching diminishes it 
or destroys it. Hence, in cases of facial spasm the stretching 
should be as severe as the integrity of the nerve will allow. 
And again the fact that the motor function of a mixed nerve is 
last lost is an additional reason for the maximum stretching 
that the nerve will bear. As Weir Mitchell also has shown that 
a nerve stretched to one-fifth of its length lost its mechanical 
irritability but not its electrical, but that this last was lost 
when the stretching reached one-quarter of its length, this is 
also another reason for the greater degree of stretching. But 
this stretching should be gradual and not sudden. 
The fact noted by Billroth that in crutch palsy, which is 
caused by direct pressure, the motor function is lost while sen- 
sibility remains, naturally raises the question as to whether 
pressure might not be advantageously substituted for stretching 
or, as in Baum's case, combined with it. Stretching first abol- 
ishes the sensory function, and the motor function last; while 
pressure reverses this and abolishes the motor function first. 
Zederbaum's careful experiments {Archiv Physiol., 1883, p. 161) 
show that in the sciatic nerve of the frog moderate pressure 
increased the irritability, the maximum being reached at 500 
grammes (a little over 1 ounce), but that at 900 grammes (nearly 
2 ounces), it began to diminish, and was lost at 1700 grammes STRETCHING OF THE FACIAL NERVE. 
17 
(nearly 4 ounces). Baum is the only one who has used pressure 
as well as stretching, but the result was only a partial success. 
The after-treatment is simple. A few strands of horse-hair 
suffice for drainage, and with antiseptic dressing, the case should 
be well in a few days. In my own case the patient was out of 
bed on the third day; all the sutures were removed on the 
fourth day, and she went home on the tenth day, having staid 
in the hospital voluntarily some days more than was absolutely 
needful. Her highest temperature was TOO.40 on the day after 
the operation, being normal the next day. Rarely, if ever, 
should suppuration follow. In Godlee's first case the wound 
was not healed for six weeks. 
I think it important to bandage the lower jaw for two or three 
days, to insure quiet while the wound is healing, and for the 
same reason to give only liquid food during several days in order 
to avoid the muscular effort and movements of mastication. 
Results of the Operation. The operation is free from danger; 
no death has resulted; no serious complications, and, in fact, no 
serious illness. Paralysis of the facial muscles, more or less 
complete both in degree and extent, is always to be expected, 
indeed desired. But this paralysis has disappeared in every 
case after a few days, weeks, or months, and in two cases (15, 19) 
in which prior to the operation paralysis had existed, some 
degree of voluntary and electrical control was attained. Indeed, 
this fact, together with the experimental results before referred 
to as to the effect of moderate stretching in increasing nerve 
irritability, leads me to suggest that it would be highly proper 
in some obstinate cases of facial palsy, to stretch the seventh 
nerve moderately as a therapeutic operation. 
In Cases 2 and 18 no paralysis resulted, and in Case 1 it dis- 
appeared in half an hour ; yet, in Cases 1 and 2 there was decided 
permanent improvement, and in Case 18 a cure lasting for two 
years and eight months. 
In such cases as have been examined electrically, the reactions 
of degeneration have been found, but these have diminished as 
the nerve was regenerated, and have disappeared after some 
months. This is also in accordance with the results of experi- 
mental nerve-stretching in animals in which microscopic ex- 18 
KEEN, 
aminations have been made. More careful observations are, 
however, needed upon this point. 
As the paralysis has disappeared and the nerve has regener- 
ated, in not a few cases the spasms have returned, while in 
others the relief has extended over years. Hence, the opera- 
tion maybe regarded from two points of view: (i) as giving 
temporary relief (palliative) and (2) as giving permanent relief 
(curative). 
As a palliative operation the result has been as follows: 
Case 1. Absolute relief for eight or nine months. Since then 
great relief (two years). 
Case 2. Absolute relief for one day. Since then slight im- 
provement (two years). 
Case 3. Absolute relief for six months, then return of spasm 
in lessened severity. 
Case 4. Absolute relief for three months, then spasms returned 
with lessened severity (three years and two months). 
Case 5. Absolute relief for nearly a year, when spasms re- 
turned. 
Case 6. Absolute relief for three months, then gradual return 
of spasms in lessened severity (four months). 
Case 7. Absolute relief for nine months, then return as bad 
as ever (three years). 
Case 10. Bilateral operation. Absolute relief for twelve weeks 
on both sides, then return of spasms (two years). 
Case 12. Absolute relief for some months, then spasms re- 
turned. 
Case 14. Absolute relief for seven months, then spasms re- 
turned in lessened severity (ten months). 
Case 15. Great improvement for three weeks ; prior paralysis 
lessened. 
Case 16. Tic douloureux and convulsif both ; pains relieved 
for four days, then worse than before; spasms somewhat re- 
lieved. 
Case 19. Absolute relief for four months, when spasms re- 
turned with lessened severity. 
Case 20. Absolute relief for four days; on fifth day as bad as 
ever (four months). STRETCHING OF THE FACIAL NERVE. 
19 
Or, in brief, fourteen cases with 
I. Absolute relief under a week; three cases followed by im- 
provement for two years in one case and no improvement in the 
other two. 
2. Absolute relief three weeks to four months; five cases 
followed by improvement in four cases, and no improvement 
in one. 
3. Absolute relief four months to a year; six cases, followed 
by improvement in three, and no improvement in three. 
As a palliative operation only, therefore, it is well worth 
doing, since at no risk of life and but little suffering the relief is 
often prolonged, and if the spasms return it is with lessened 
severity. Indeed, my own patient would gladly undergo it 
again for even the brief respite so far assured, and far prefers a 
permanent paralysis to the persistent spasms. 
As a means of permanent cure we have the following: 
Case 8. Absolute relief for five years. 
Case 9. Absolute cure or very great improvement (it is not 
quite clear which) for twenty-five months. 
Case 13. Absolute relief for three months when last reported. 
Case 17. Absolute relief for three months. 
Case 18. Absolute relief for two years and eight months. 
Or, in brief, two cases of relief, when last reported, for three 
months, and three of relief for from two to five years. 
Of the remaining two cases, Navratil's (11) was only followed 
for three days, and in my own (21), though the result is perfect 
so far, yet, as it is only twenty-five days since the operation, it 
is too recent to classify. [Still cured as the proofsheets are 
corrected, five months after operation.] 
It would seem, therefore, that whether viewed from the point 
of palliation or of cure, with our present knowledge, the opera- 
tion is to be looked upon favorably. Further observation may 
show its inutility, but when we consider the utter hopelessness 
of improvement, much less recovery, from any other means, 
relief by this operation, even if temporary, is had at a very 
trivial cost, and would be welcomed by any sufferer, while 
permanent cure is not impossible.