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ON THE

CURE OF WRY NECKRY

DIVIDING THE STERNO-CLEIDO-MASTOIDMUSCLE BENEATH THE SKIN,

WITH CASES ;

By Professor DIEFFENBACH, of Berlin.

Communicated by ERNEST DIEFFENBACH,M.D., Hendon.

THE cure of wry neck, by dividing thesterno-cleido.mastoid muscle beneath theskin, is the ingenious invention of Dupuy-tren. Eight years ago I communicated somefavourable results of my experience in thisoperation in " Rust’s Surgical Cyclopaedia,"Vol. III., page 623, in the article CaputObstipuin, and since that period I have hadmany opportunities of repeating it, moreespecially since Stromeyer, by his admirableoperation on club-feet, directed our attentionto the division of other contracted tendonsand muscles. The advantages of this modeof operation by a small punctured wound,consist in obtaining a quick and durablecure, and in avoiding an ugly cicatrix,which generally produces new contractions.The former method, which consisted in ex-posing the lower part of the contractedmuscle, making an incision through theinteguments and dividing the muscle ona director, requires a loiig after-treat-ment. In this case the cicatrix unitingthe ends of the muscle adheres to the cica-trix of the skin, and an obliquity in a higherand much less curable degree takes place.In the old operation it sometimes happenedthat the pus found its way to the anteriormediastinum, or the whole cellular tissue ofthe neck sphacelated, and a relapse of thecontraction, or death followed. The newoperation of Dupuytren was at first receivedwith enthusiasm, and everywhere adopted.It is remarkable, however, that in trance itwas nearly forgotten until very lately revivedby Guerin, Bouvier, and Duval.The instrument which I use in this opera-

tion is a very narrow falsiform knife. Thepatient is placed in a chair; one assictantdraws the head to the opposite side, and an-other depresses the shoulder of the affectedside; by this means the muscle is rendered ’imore prominent. I now pinch up the skin a,and muscle, with the thumb and index-fin- I,ger of my left hand, and insert the knife,’under the muscle, then turn the edge of theknife towards the muscle, until the pointreaches the skin on the opposite side, which,however, is not pierced. While drawing outthe knife, pressure by the thumb of the samehand is employed, and the muscle is divided.At the moment of the division a dull, soft,cracking noise is generally heard, producedpy resonance vf thv thorax, and sometimes

this noise is very loud. The best place toinsert the knife is in the triangular spacebetween both portions of the muscle, half aninch above their insertions. If operating onthe left side I divide from this point the an-terior portion, and then, in an opposite di-rection, the posterior one. At the right sideI introduce the knife between the tracheaand the anterior portion of the muscle, andafter having divided the latter, I cut theposterior part if required. At the momentof drawing back the knife through the punc-tured wound I quickly press with the thumbupon the spot to prevent an extravasationof blood beneath the skin; I cover it with asolid dossil of lint and straps of adhesiveplaster, and then apply a bandage. Twoneck handkerchiefs serve to support the headin the former oblique direction, withoutstraightening it. This is done partly to pre-vent a collection of blood, and partly to pro-mote the union of the divided muscle. Thepatient is ordered to keep quiet, in a hori.zantal position in bed, and to take a mildantiphlogistic diet.

In most cases the wound heals very quick-ly. At the place of the divided muscle aswelling is commonly found ; sometimes afluctuation is felt, owing to a col,ection of fblood. In the latter case the plasters areagain applied more firmly, to accelerate theabsorption, and this has soon the desiredeffect. Lukewarm lotions, and frictionswith warm oil, are sufficient to cause theabsorption of any tumefaction B7hich mayremain. If suppuration takes place, the pusshould be evacuated by an incision and sim-ple dressing applied. The following cases,however, will show how rarely this is metwith.In my first cases, and in those in which

the vertebras of the neck were very muchdisplaced laterally, in consequence of themuscular contraction, I used to extend theneck gently some weeks after the operationupon the extending bed, cr with Glisson’sswing, in a sitting pasture. More recently,however, I confined myself almost exclu-sively to a collar half the breadth of theneck, made of pasteboard enveloped in thickcloth, which forced the patient to bend theneck to the opposite side. I found the latterof more use than violent extension, whichonly inclines the muscle to react, makes ittender, and therefore taust be removed, inconsequence of which the head again inclinesto the affected side.

I will now detail some cases in which theoperation was performed with the bestre-sults :-CASE I.-Charles Meir, tailor, 24 years

old, suffered from a shortening of the rightsterno-cleido-mastoid muscle. From histhirteenth year he wore an iron instrument,

but the obliquity of the neck increased, andhe was obliged to leave it off. I dividedboth inscriptions of the muscle as asoarate

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times. I supported the bandage above-mentioned by a spicahumeri. No extravasatioiof blood nor suppuration followed. Thlpatient was confined ten days to bed, and ]afterwards extended the neck gently for !atime. The cure was completed in threl

weeks, and the patient’s neck became perfectly straight.CASE 2.-The son of the Councillor Dorn

five years old, was born with a shortening o;the right sterno-cleido-mastoid muscle. Ma.chines had been applied without any benefitI divided both origins of the muscle. ThE

hæmorrhage from the wound was so profusethat the patient fainted. I used the same

bandage ; there was ’no extravasation 01

blood, no suppuration, and the cure wascomplete at the end of the third week. -CASE 3.—A relation of the above-named

boy, living in the same family, eighteen yearsold and tall, was also afflicted with a consi.derable shortening of the right sterno-cleido-mastoid muscle, so that the head could onlybe moved from the right shoulder to the ex-tent of half a hand’s breadth. The divisionof both heads of the muscle occasioned avery loud cracking noise, partly arising fromthe strong extension, partly from the meagre.ness of the young man. Scarcely a drop ofblood was shed ; the wound healed in a fewdays, and in four weeks the young man wasperfectly cured.CASE 4.—A. Köpfer, of Frankfurt, six

years old, afflicted with contraction of theright sterno-cleido-mastoid muscle, had beentreated with machines two years withoutsuccess. I divided the muscle. The woundhealed in three days. Eight days after theoperation the child was sent home perfectlystraight.CASE 5.-F. Striech, a stout boy, ten years

old, had a strong contraction of the rightsterno-cleido-mastoid muscle. The wholemuscle projected like a hard, tendinous liga-ment, and the head was very oblique. Thedivided parts separated with a loud crack-ing noise. The wound closed in a few days,and the patient was cured by the use of aswing, and by a bandage round the neck.CASE 6.—The Baroness de Schalten, 11

years old, afflicted with contraction of theright sterno-cleido-mastoid muscle, had fora long time tried gymnastics, but had notused a machine. I divided both portions ofthe muscle: the lady was kept quiet duringeight days ; afterwards the ordinary band-age was applied, and she was perfectlystraight at the end of the third week.CASE 7.—F. P. Pietsch, three years- old,

affected with shortening of the anterior por-tion only, was perfectly cured in five days.In this case it was not even necessary to em-ploy a bandage.CASE 8.—The daughter of a servant of

Mrs. Scholz, five years old, was born witha strong contraction of the right sterno-clei-do-mastoid muscle, The treatment did not

differ from that already described, and thecure was perfect in the second week.

CASE 9.-C. Schmidt, five years old, suf-fered from a strong contraction of the sternalportion of the right sterno-mastoid muscle.He was discharged nine days after the ope-ration perfectly cured.CASE 10.—Mr. Eben, nephew of the pri-

vate Councillor Bethe, at Berlin, was bornwith a shortening of the right sterno-cleido-mastoid muscle, and in his twenty-secondyear was much disfigured by a great degreeof obliquity. I divided both portions of themuscle. The noise produced was so loud,that I was startled. In three weeks the curewas complete, and the young man perfectlystraight.CASE 11.—C. Sponholz, from Saxony, ten

years old, was affected with a strong con-traction of the right sterno-cleido-mastoidmuscle, by which the head was closely ap-proximated to the shoulder, and at the sametime displaced towards the vertebral column.This boy was discharged perfectly cured onthe twelfth day after the operation,

CASE 12.—Augusta Lienig, fifteen yearsold, distorted, meagre, scrofulous, with acontraction of the right sterno-cleido-mas-toid muscle like a fork. I divided themfrom one point. A fortnight afterwards thegirl was perfectly straight.

(To be concluded in our next.)

KENSINGTON UNION.

REPLY OF MR. CHINNOCK.HIS PUBLIC AND PRIVATE CHARACTER.

To the Editor of THE LANCET.Sir :-As I observe in your notice to

correspondents in THE LANCET of last week,that Mr. Morrah has addressed you, I feelit also to be my duty, however disinclinedto notice an anonymous attack, to troubleyou wittt the following observations on aletter bearing the signature of " JUSTITIAET MiSERICORDIA," in THE LANCET of the18th ult., in which my name is repeatedlyintroduced.If your correspondent had, with proper

courage, affixed his name to the epistle, Ishould then have known the degree of per-sonal respectability and weight to be at-tached to it, and have penned my answeraccordingly ; but the very attractive sig-nature he has chosen, renders it necessarythat I should be merciful as well as just inmy reply.Without any further apology for thus

occupying your valuable columns, I shallproceed to show, that every assertion in theletter signed by your correspondent 11 Jus-titia et Misericordia," bearing reference tomy name isfalse.

First, then, Sir, in taking your corre.-

spondent’s words, or assertions, seriatim,