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reasonable diagnosis has been made, and that, as in a desperate case of strangulated external hernia, an exploratory operation should be performed in most cases. I believe that the physician or surgeon has vo right to waste time whilst he is speculating as to the exact seat of the obstruction or precise cause by which it has been brought about, since there is no room to doubt that during this ruminating process the prospects for recovery are rapidly diminishing. Indeed, I believe a surgeon may as well delay in cutting the rope in a case of suicide by hanging whilst he is speculating as to the influences which have led the man to perpetrate the act, as to delay operative interference in a case of acute intestinal obstruction with the hope that he will be able to make a scientific diagnosis of the case, or that something will turn up by which relief may be obtained.”
“I maintain that it is not required of the surgeon to diagnosticate the precise cause of the obstruction so long as the diagnosis of its existence can be determined ; and do not think, because such cases as these occasionally recover without operative treatment, we should forget that a large majority die miserably, unrelieved. I plead, therefore, for the majority.”
A CASE OF TORTICOLLIS CURED BY DIVISION OF THE STERNO-CLEIDO-MASTOID MUSCLE FOLLOWED BY ELASTIC TRACTION OF THE HEAD.
BY ALFRED C. POST, M.D., LL.D.,
FREDERICK PLATT, ætat. 16, admitted into the Presbyterian Hospital April 1, 1880. He was affected with torticollis in a very marked degree, and had been so from his earliest recollection. His face was strongly turned towards the right side, and his left ear was approximated to the corresponding shoulder. The left sterno-cleido-mastoideus was firmly contracted, and offered strong resistance to the movement of the head in the opposite direction. Its sternal and clavicular origins were very hard and prominent.
On the 9th of April, the patient being etherized, I performed the following operation: I made a horizontal incision, six centimetres in length, along the upper border of the sternum and clavicle, exposing the prominent tendons of the sternal and clavicular portions of the sterno-cleido-mastoid muscle. I then passed a director under each of these tendons successively, and divided them with a sharp-pointed bistoury. The division of these tendons scarcely produced any perceptible effect in liberating the movements of the neck. On careful examination, I found that there were other and deeper bands of muscular fibres, which kept the muscle in a state of tension, and which restrained the free rotary motions of the head. These bands were successively divided upon the director, and then the head could be freely moved in all directions. A few carbolized horse-hairs were then laid within the wound, which had previously been washed with a carbolized lotion 1 to 40. The edges of the incision were brought together with fine sutures.
Before the operation the house surgeon, Dr. John A. Wells,
had applied a plaster of Paris jacket around the chest, and over the right shoulder, with blunt metallic hooks over the sternum and over the right shoulder. A helmet had been constructed (Fig. 1) under my direction by Messrs. Tiemann & Co., consist
G. TIE MANN & CL
ing of a horizontal band of iron encircling the head above the ears, a vertical band of iron passing over the sagittal suture and riveted to the horizontal band in the frontal and occipital regions, and a leather strap passing transversely over the top of the head, and buckled beneath the chip. To the horizontal band of iron was attached a hook over the mastoid region, and two others, one a little before and the other a little behind that point, to vary the direction of traction, if it should be deemed necessary. This helmet was applied to the head of the patient, and an India-rubber muscle provided with a ring at the upper end, and a chain at the lower was then applied as nearly as possible in the direction of the right sterno-cleidomastoid muscle, the ring above being hooked over the right mastoid process, and the chain below being hooked over the sternum. This was found to accomplish the object for which it was designed in a very satisfactory manner. It turned the face to the left side, and it approximated the right ear to the right shoulder. Two days after the operation, about half of the horsehairs were withdrawn from the wound, and the remainder on the following day. There was scarcely any perceptible irritation about the wound, and union took place by the first intention. The Iudia-rubber
muscle was daily removed and reapplied with such a degree of tension as seemed to be required. Passive motion of the head was also freely made in all directions. Occasionally a supplementary India-rubber muscle was applied, extending from the right shoulder to the corresponding side of the head. The patient left the hospital on the 26th of April, seventeen days after the operation, having perfect freedom of motion. He was directed to wear the apparatus for a few weeks at night, but to leave it off in the daytime, and to practise systematically free movements of the head in all directions.
This case is remarkable for the rapid and complete cure of a marked and rigid distortion of the neck of many years' standing. The successful issue of the treatment is mainly due to the complete division of the muscle whose contraction produced the deformity, and to the admirable manner in which the elastic tube gently but firmly, and without weariness or intermission, drew the head in the direction opposite to that of the deformity.
With regard to the division of the sterno-cleido-mastoid muscle, I am satistied that the method of open incision with the aid of a director is preferable to the subcutaneous incision. If I had undertaken the operation by the subcutaneous method, I should probably have divided only the hard prominent and superficial bands, which could be readily felt through the skin, and shoulil have gained very little by their division. Or, if I had undertaken to thrust a tenetome beneath the deeper bands, I should have endangered the important vessels which lie in that vicinity. In conclusion, I would express my obligations to Dr. Wells for the application of the plaster jacket, and the Messrs. Tiemann & Co. for the skill with which they carried out my views in the construction of the helmet, which contributed largely to the success of the treatment.
NOTE.-Nov. 9, 1880. I bad an opportunity this evening to present the patient to the Surgical Society of New York. The cure bas stood the test of time, being as perfect as when the paper was submitted to the American Medical Association in June.