OBSERVATIONS ON TORTICOLLIS, 
WITH PARTICULAR REFERENCE TO THE 
SIGNIFICANCE OF THE SO-CALLED HEMATOMA 
OF THE STERNO-MASTOID MUSCLE. 
BY 
ROYAL WHITMAN, M.D., M.R.C.S., 
ASSISTANT SURGEON TO OUT-PATIENTS, HOSPITAL FOB RUPTURED AND CRIPPLED, 
T TAr-r 
FROM 
THE MEDICAL NEWS, 
October 24, 1891. [Reprinted from Tlj October 24, 1891.] 
OBSERV ATIONS ON TORTICOLLIS, WITH PAR- 
TICULAR REFERENCE TO T H E SIG NIFIC A N C E 
OF THE SO-CALLED HEMATOMA OFTHE 
STERNO-MASTOID MUSCLE} 
By ROYAL WHITMAN, M.D., M.R.C.S., 
ASSISTANT SUKGRON TO OUT-PATIENTS, HOSPITAL FOR RUPTURED AND 
CRIPPLED, NEW YORK. 
Assuming that the treatment of any affection 
must to a great extent depend upon our appre- 
hension of the causes that produce it, I shall call 
your attention more particularly to etiology, the 
conclusions being influenced by clinical investiga- 
tion rather than by recorded theories. 
That the bearing of these conclusions on the 
question indicated by the title of this paper may 
be clearly understood, I quote from several of the 
more prominent writers on the subject. F. Busch,'2 
for example, says : “ Congenital wry-neck is caused, 
as Stromeyer was the first to show and as is now 
acknowledged, almost without exception by injury 
to the sterno cleido-mastoid muscle, at birth, and 
by subsequent shortening at the place of injury by 
scar-contraction. The deformity occurs almost ex- 
1 Read at the meeting of the American Orthopedic Associa- 
tion in Washington, September, 1891. 
2 Von Ziemssen’s Handb. der allg. Ther. 2 
WHITMAN, 
clusively in children delivered by forceps, or more 
frequently in breech or foot presentations.” 
In the Deutsche Chirurgie1 the subject is treated 
by Fisher as follows: “ It is certain that tearing of 
muscle at birth, as Stromeyer has shown, is a fre- 
quent cause of torticollis. A tumor appears at the 
seat of the injury a few weeks after birth, which 
slowly disappears, leaving shortening by scar-con- 
traction.” 
Volkmann and Vollert3 have resected and ex- 
amined portions of muscle in cases of supposed con- 
genital torticollis. In some no change was appa- 
rent ; in others the muscular substance had entirely 
disappeared to be replaced by fibrous tissue; while in 
the remainder the fibrous degeneration was diffuse, 
as shown by bands in the muscle substance. These 
changes they regard as the result of myositis caused 
by injury at birth. While these observations are of 
value as showing changes that may occur in per- 
sistent wry-neck, they can have but little bearing 
on the question under consideration, as no evidence 
is presented of original injury or of subsequent* in- 
duration, and because similar changes are found in 
cases of acquired torticollis of long duration, as 
reported by Robert, Marchessaux, Bouvier, and 
Witzel.3 
It is evident that the term injury is not used by 
these and other writers in a general sense, but ap- 
plies to partial rupture of the sterno-mastoid muscle 
1 Bd. xxxiv. S. 32. 
- Centralbl. f. Chir., No. 14, 1885, No. 38, 1890. 
3 Deutsche Archiv f. Chir., 1882, p. 181. OBSERVATIONS ON TORTICOLLIS. 
—caused, it would appear, by torsion 1 of the neck 
during delivery of the head, followed by effusion of 
blood,2 and later by an encapsulating inflamma- 
tion® at the seat of the injury, as shown by a 
hard, painless tumor in the substance of the muscle. 
This induration slowly disappears, to be replaced by 
fibrous tissue, which, contracting, creates permament 
torticollis—in other words, a purely mechanical 
shortening, as distinct from the nerve irritation and 
spasm that we usually associate with wry-neck. As to 
the first part of this proposition—that injury of mus- 
cle may occur during labor, and that it is followed 
by induration at the seat of the rupture—there can 
be no doubt but that such rupture is followed by 
scar-contraction; that it is the usual cause of con- 
genital torticollis is extremely improbable. A partial 
subcutaneous rupture of a normal muscle would 
seem to present every requisite for quick and per- 
fect repair. Scar-contraction never follows similar 
injuries in later life, nor do we find in other situa- 
tions anything analogous after injury at birth. If, 
then, we are to accept this theory, it would seem that 
the supporting evidence should be very direct and 
conclusive, such as the recorded observations of a 
number of cases—from the original injury, with its 
succeeding induration and scar-contraction, to the 
persistent torticollis which is supposed to result. 
Such evidence, however, is not contained in the 
literature of the subject, although the theory— 
1 Kiistner: Centralbl. f. Gyn., No. 9, 1886. 
2 Bouchut: Traite prat, de Mai. de Nouv.-nees, Paris, 1875. 
3 Skrzeczka: Vierteljahrsschrift f. Gyn. u. obst. Med., 1869, S. 
129. Hiittenbrenner: Lehrb. f. Kinderheilk., 1886. 4 
WHITMAN’, 
originating fifty years ago with Stromeyer1 and 
Dieffenbach—has been endorsed by nearly2 all sub- 
sequent writers, gathering weight, it would appear, 
by reiteration, rather than from actual investigation. 
It should be stated that this theory of the origin 
of congenital torticollis has been vigorously com- 
bated by Peterson3 and flatly denied by Weiss,4 as 
follows: “Ruptures of the sterno-mastoid muscles 
are frequent enough during labor, but they are never 
followed by torticollis, and it is impossible to accept 
the theory advanced by Stromeyer and Dieffenbach. ’ ’ 
It is apparent that we may obtain reliable evidence 
on this question from two sources: cases of indura- 
tion followed to their termination, and cases of sup- 
posed congenital torticollis traced back to injury 
and subsequent induration, if such existed. 
In the records of the Hospital for Ruptured and 
Crippled were found eighteen cases of so-called hema- 
toma ; nine could be traced, and of these two were 
excluded for mistaken diagnosis—the first because 
the after-history seemed to point to an inflamed 
gland as the cause of the induration ; the second 
because the mother is positive that no tumor was 
present at any time. In both instances the torti- 
collis, that was the prominent symptom, quickly 
and permanently disappeared. The history and 
results in the remaining cases are as follows : 
Case I.—A male infant brought to the hospital 
on August 26, 1889, at the age of two months. 
1 Handb. d. Chir., Bd. ii. S. 426. 
2 Rust’s Handb. d. Chir., S. 625. 
3 Archiv. f. Chir., Bd. xxx.; Centralbl. f. Gyn., No. 48, 1886. 
* Nouv. Diet, de Med. et de Chir. OBSERVATIONS ON T O R TIC O LLI S . 
Fifth child, delivered by version, arm broken 
in the act. Three preceding children had died 
during labor. Tumor, size of a hazel-nut, in the 
middle of the right sterno-mastoid, hard, not sen- 
sitive; noticed by the mother at six weeks; no tor- 
ticollis ; no symptoms. The infant died eighteen 
days after. 
Case II.—Male, brought on August 16, 1889, 
at the age of three weeks. First child; delivered 
by forceps after tedious labor. Tumor, size of a 
large almond, in the left sterno-mastoid muscle; not 
sensitive to pressure ; noticed at ten days. No tor- 
ticollis; no symptoms The swelling disappeared 
in three months. Child examined at nineteen 
months; no trace. 
Case III.—Male, seen August 28, 1890, at the 
age of five weeks. First child ; forceps delivery 
after difficult labor. Tumor, size of a small pigeon’s 
egg, in the middle of the left sterno-mastoid ; no- 
ticed at three weeks. No torticollis or other symp- 
toms. The swelling disappeared in three months. 
Examined at the age of nine months; no trace 
remaining. 
Case IV.—Female, brought September 16, 1890, 
at eleven weeks. First child; breech presentation. 
Delivered by a midwife with some difficulty. 
Tumor in the middle of the right sterno-mastoid, 
size of a hazel-nut; noticed at eight weeks. No 
torticollis. The induration disappeared in four 
months. Examined at eight months ; no trace. 
Case V.—Male, seen May 2, 1891, at two months. 
Breech presentation, spontaneous and easy labor. 
Tumor size of a hazel-nut in the upper third of 
the right sterno-mastoid ; noticed at three weeks. 
A gurgling respiration was apparent when the child 
nursed the left breast. There was no torticollis, 
though slight resistance on extreme tension of the 
affected side. 6 
WHITMAN, 
Examined at the age of six months. No torti- 
collis or restriction of motion. No symptoms. 
Tumor slightly smaller, otherwise unchanged. 
Case VI.—Male, brought July 31, 1891, at seven 
weeks. Third child, transverse with arm presenta- 
tion, delivered by version and forceps. Complete 
paralysis of the right brachial plexus; right in- 
guinal hernia. A spindle-shaped enlargement of 
the middle third of the right sterno-mastoid, one- 
half inch in diameter, hard, not sensitive. No 
torticollis. No symptoms. Last seen September 5, 
1891. No apparent change in the tumor. 
Case VII.—Male, seen August 5, 1891, at five 
weeks. First child; breech presentation, difficult 
labor. Tumor size of a pigeon’s egg, at sternal in- 
sertion of the right sterno-mastoid ; hard, not sensi- 
tive to pressure. No torticollis or other symptoms. 
Not again examined. 
With these I now include six cases recently re- 
ported by Quisling,1 in which the indications cor- 
respond to my own, although the actual results were 
not in all instances ascertained. Thus, of the thir- 
teen cases, nine were originally breech presenta- 
tions or delivered by version, two were extracted by 
forceps, and in two there is no history of interfer- 
ence with delivery. Of these cases, examined with 
especial reference to the subject of torticollis, in 
none was it present at the first examination, other 
than the slight limitation that might be supposed 
to follow a tumor of this size and character in the 
muscle substance, and in none of the cases traced 
did it follow. It should be noted, also, that there 
are on record other instances of complete disappear- 
1 Archiv. f. Kinderheilk., Bd. xii. H. 5, 6, 1891. OBSERVATIONS ON TORTICOLLIS 
ance of these tumors without succeeding deformity, 
as for example, cases reported by Brooks,1 by 
Smith,4 by Jacobi,3 and many others. 
Having considered the question from the stand- 
point of original injury, traced to recovery in all 
all the cases cited, we may now invert the method 
and examine the evidence presented by cases of 
congenital torticollis pointing to injury at birth as 
the exciting cause. 
At best, such evidence is unsatisfactory, because 
we must depend upon the mother’s statement as to 
the time when the affection appeared. Infants do 
not support the head for several weeks after birth, 
and unless the deformity is extreme it is not noticed 
until that time. If, then, an infant is brought for 
examination at the age of six months with a history 
of torticollis first noticed at four weeks, we may 
consider it of intra-uterine origin, or that it was 
acquired during the first month of life, or caused 
by injury at birth. If we favor the first conclusion, 
then congenital torticollis must be divided into two 
classes. 
First, cases of slight deformity, with no pain and 
but little spasm, except on extreme tension of the 
contracted parts, the contraction not being limited 
to the sterno-mastoid, but all the lateral tissues being 
involved. The resistance is not marked and the 
deformity can be easily overcome in a short time by 
stretching and manipulation. These cases are very 
similar to the mild condition of talipes calcaneus or 
1 N. Y. Med. Record, February 27, 1886. 
2 I'rans. Lond. Path. Society, iv. p. 70. 
3 Archives of Pediatrics, March, 1888. WHITMAN, 
of incomplete extension of arms or legs, equally 
amenble to treatment, whose origin would seem 
to be a constrained position in titero, leading to 
general shortening of tissues on the one aspect, with 
weakening and lengthening on the opposing surface. 
The second class is composed of cases where the 
deformity is more marked. It cannot be overcome 
by simple means, but persists and increases. The 
sterno-mastoid may alone be affected, or the poste- 
rior group of muscles, with compensatory curvature 
of the spine and displacement of the scapula, as in 
one case now under observation. Here, we may 
infer, there is an actual arrest of development or 
muscle-degeneration, arising, it may be, from causes 
more complex than appear in the preceding cases.1 
In regard to rupture of muscle as a possible cause, 
it may be said that the tumor of true hematoma is 
so prominent when the child turns the head, that 
it could hardly escape the mother’s notice, and her 
statement in this regard may be accepted as final. 
During the past six months I have had the oppor- 
tunity of examining four cases of congenital torti- 
collis in young infants, three of the first class and 
one of the second. Although there was a history 
of transverse presentation in one of the milder cases, 
in none of these, nor in those seen in later life, was 
there history or evidence of hematoma or of diffi- 
culty in delivery or probability of injury at birth. 
In considering the significance of hematoma, so 
called, several sources of error should be indicated, 
as leading to the present confusion on this subject: 
1 Archives de Tocologie, xv. p. 494. OBSERVATIONS ON TORTICOLLIS. 
9 
1. A muscle shortened in ntero may be ruptured 
at birth, thus presenting a deformity where the in- 
duration is a coincidence and not a cause.1 Such 
a case was reported by Bruns2 at the last Congress 
of German Surgeons. 
2. An inflamed gland, adherent to the muscle, 
with torticollis from nerve irritation, may be mis- 
taken for hematoma, as in the case mentioned. 
3. Similar enlargements may in certain instances 
be of other origin than injury—such as fibrous, 
sarcomatous,3 or syphilitic tumors, arising, it may be, 
inutero. Cases reported by Graser, Taylor,4 Hadra,5 
and Holmes6 would seem to support this view. 
It is possible, too, that injury in a tuberculous or 
syphilitic child might give rise to a myositis suffi- 
ciently exaggerated to cause permanent arrest of 
development and actual shortening. 
In regard to injury in general, this is undoubtedly 
an occasional cause of acquired torticollis. It 
might operate at birth as in later life, and hema- 
toma might be a coincidence, or we may fancy 
that fibers of the spinal accessary nerve might 
be involved in the induration following muscle 
rupture, with irritative spasm as a result. These, 
however, are simply conjectures, and are entirely 
distinct from the question of scar-contraction that 
we are considering. It may be objected that the 
1 Rennecke: Centralbl. fur Gyn , No. 22, 1886 
2 Centralbl. fiir Chir., No. 26, 1891. 
3 Graser: Munch, med. Wochenscli.. No. 13, 1887 
4 Trans. Lond. Path Society, xxvi. p. 224. 
5 N. Y. Med. Record, January 23, t886. 
6 Diseases of Childhood and Infancy. 10 
negative evidence presented is of value, com- 
pared with positive observations to the contrary, 
but it must be remembered that we are considering 
the usual and not the exceptional causes of wry- 
neck, and that neither Stromeyer nor any of the 
succeeding writers who have endorsed this theory 
have presented a single undoubted case in its sup- 
port.1 Of the hypothesis, then, that explains the 
origin of congenital torticollis by muscle rupture, 
myositis, scar-contraction, and permanent short- 
ening, we may conclude that it is simply an asser- 
tion unsupported by evidence. Further, I am con- 
vinced that injury at birth, of whatever nature or 
extent, is a possible, and not a probable, factor in 
the etiology. 
From the hospital records of the past nineteen 
years I have collected 264’cases of wry-neck. Dur- 
ing this time2 upwards of 3400 cases of congenital 
and acquired club foot came under observation—a 
comparison that will show the relative infrequency 
of the affection under consideration. 
The following is a brief summary of some of the 
points of apparent interest. 
Of the 264 cases 32 may be considered as con- 
genital, with the reservation before mentioned. As 
to sex, 155 were females and 109 males, which would 
tend to disprove the statement that the affection is 
much more common in males than females. In 77 
it might be considered as acute, and in 60 chronic, 
in 48 having existed for from one to twenty years. 
WHITMAN, 
1 Peterson: Zeitschrift f. orthopad. Chir., B. i. H. i. 
2 Townsend : “ Statistical Paper on Club-foot,” Trans. N. Y 
State Med. Soc., 1890. OBSERVATIONS ON TORTICOLLIS. 
Excluding congenital cases, the duration of the 
affection was mentioned in 137 instances. 
The affected side was mentioned in 187 instances. 
In 98 it was on the right, and in 97 upon the left 
side, in contrast to the assertion that it is much 
more frequent on the right than the left side. Early 
childhood is the time of greatest susceptibility, but 
ten cases are noted at more than eighteen years 
of age. 
In 106 cases of acquired torticollis the cause 
seemed apparent. Of these nearly 50 per cent, might 
fairly be classed as from cervical gland irritation, 
often after some contagious disease. 
Age and sex of patient when first seen : 
Age. 
Congenital (?) 
Males. 
• 14 
Females. 
18 
Total. 
32 
6 months or less 
• 4 
4' 
8 
i year . 
• 4 
5 
9 
2 years . 
• 7 
9 
16 
3 “ • 
• 3 
4 
7. 
4 
• 7 
9 
16 
5 
. ii 
13 
24 
6 “ 
• 9 
14 
23 
7 
• 9 
15 
24 
8 “ 
• 9 
10 
19 
9 
• 3 
17 
20 
io “ 
• 13 
7 
20 
ii “ 
2 
8 
10 
12 “ 
2 
7 
9 
13 
. 2 
3 
5 
14 “ • 
. I 
4 
5 
15 “ • 
• 3 
2 
5 
17 “ . 
1 
1 
18 “ 
. i 
1 
Over 21 years 
• 5 
5 
10 
Total 
. 109 
i55 
264 12 
WHITMAN, 
The duration of acquired torticollis when the 
cases were first seen : 
i month or less 
Acute. 
• 49 
Chronic. 
2 months or less 
. 20 
a i< 
. 8 
6 “ “ . 
17 
From 6 months to i year 
13 
‘ i year to 2 years . 
8 
“ 2 years to 3 years . 
7 
“3 “ 4 “ 
“4 5 “ 
7 
“5 “ 6 “ . 
1 
‘‘6 " 7 
4 
“7 “ 8 “ 
1 
Of 12 years’ duration 
1 
Of 20 “ “ 
1 
Total 
• 77 
60 = 137 
The apparent causes of torticollis, as noted in the 
records, were : 
Enlarged cervical glands 
Cases. 
5 
. Suppurating cervical glands .... 
22 
glands following scarlet fever 
i r 
Torticollis following scarlet fever, condition of 
glands not noted 
7 
Torticollis following diphtheria 
4 
“ mumps .... 
5 
“ measles .... 
i 
“ sore-throat 
4 
Suppurating otitis ...... 
3 
Toothache ....... 
i 
From cellulitis of neck ..... 
2 
Other causes were: 
65 
Cicatricial, following burns .... 
Cases. 
3 
Caused by injury of the neck .... 
14 
Probably of congenital origin .... 
32 
49 OBSERVATIONS ON TORTICOLLIS. 
Torticollis was associated with 
Rheumatism ...... 9 cases. 
Fever . . . . ... . 3 “ 
Malaria ....... 4 “ 
Total . . . .16 cases. 
Torticollis was associated with disease of the ner 
vous system as follows : 
Chorea ....... 3 cases. 
Kpilepsy 1 case. 
Cortical irritation . . . . 1 “ 
Hysteria . . . . . . 1 “ 
Infantile hemiplegia . . . 1 
Meningitis . . . . . 1 “ 
Spasmodic torticollis . . . 1 “ 
Total .... 9 cases. 
That duration of the affection is in itself a very 
potent factor in prognosis is illustrated by the in- 
patient records of 39 cases; 17 were admitted when 
the deformity had persisted for less than six months. 
Of these 10 were cured, 4 were improved, and 3 
were not improved. Of 15 cases of more than 
six months’ duration none were cured, 6 were im- 
proved, and 9 were not improved. WHITMAN, 
Acute Cases. 
Sex. 
Age. 
Duration. 
Supposed 
cause. 
Duration of 
treatment. 
Result on discharge. 
M. 
15 
3 days. 
Cold. 
3 weeks. 
Well. 
]•'. 
9 
4 months. 
Abscess of 
angle of jaw. 
10 months. 
Not improved. 
]•'. 
9 
3 months 
Measles. 
4 months. 
Well. 
M. 
8 
2 weeks. 
Injury. 
4 months. 
Much improved. 
F. 
9 
3 weeks. 
4 months 
Much improved. 
M. 
9 
2 months. 
Abscess at 
neck. 
4 months. 
Well. 
F. 
8 
2 months. 
Mumps. 
14 months. 
Much improved. 
F. 
S 
r month. 
3 weeks. 
Well. 
1''. 
9 
6 weeks. 
Sup. glands 
after scarlet 
fever. 
4 months. 
Well. 
F. 
8 
2 months. 
Scarlet fever 
3 weeks. 
Well. 
M. 
8 
1 month. 
Injury 
6 weeks 
Well. 
M. 
6 
4 months. 
Scarlet fever 
15 months. 
Not improved. 
M. 
4 
5 months 
9 months. 
Improved. 
M. 
7 
2 weeks. 
Injury. 
i vear. 
Well. 
F. 
9 
3 months. 
Abscess of 
neck. 
2 years. 
Well. 
1-'. 
IO 
3 months 
Abscess after 
scarlet fever. 
2 months. 
Well. 
F. 
9 
2 weeks. 
Spasmodic 
torticollis. 
1 month. 
Well. 
Results. 
Well, 10 Average duration of treatment, 3 months. 
Improved, 4) „ „ „ „ “ 
Not improved, 3 j 
Total, 17 OBSERVATIONS ON TORTICOLLIS. 
15 
Chronic Cases. 
Sex. 
Age. 
Duration 
Supposed 
c^use. 
Duration of 
treatment 
Result on discharge. 
M. 
IO 
9 months 
Cold. 
i year. 
Much improved. 
F. 
14 
Long. 
Measles and 
mumps. 
4 months. 
Not improved. 
F. 
9 
SlA years. 
Enlarged 
glands. 
3 months. 
Not improved. 
M. 
9 
7 years. 
Scarlet 
fever. 
3 months. 
Not improved. 
M. 
7 
2 years. 
Myositis 
ossficans 
[sic]. 
1 month. 
Not improved. 
M. 
8 
7 months. 
Enlarged 
glands. 
6 months. 
Much improved. 
F. 
8 
i year. 
Nystagmus, 
hysteria, etc. 
14 months 
Much improved. 
I'. 
12 
2 years. 
Meningitis. 
6 months. 
Much improved. 
M 
IO 
.S years. 
Injury. 
5 months. 
Not improved. 
F. 
6 
Long. 
7 months. 
Not improvetl. 
F. 
12 
8 years. 
Scarlet fever 
4 years. 
Not improved. 
F. 
8 
1% years. 
Cervical 
abscess. 
4 months. 
Not improved. 
F. 
13 
6 years. 
After con- 
vulsions. 
Not improved. 
F. 
13 
i year. 
9 months 
Improved. 
M. 
IO 
9 months 
Cervical 
abscess. 
9 months. 
Much improved. 
Well, None. 
Improved, 6 Average duration of treatment, 8 months. 
Not improved, 9 “ “ “ “ 9 “ 
Total, 15 
Results. 
It should be noted that with few exceptions these 
patients were treated at a time when operative in- 
terference was not recognized as an attribute of 
orthopedic surgery as practised at this institution, 
otherwise every recognized method of treatment 16 
WHITMAN, 
seems to have been employed, in most instances 
for many months. Of four cases of long standing 
treated recently by open incision,'one was cured, 
two nearly cured, and one improved, the average 
stay in the hospital being but three weeks. 
It seems fair to assume that there is an actual 
arrest of development in a contracted muscle, and 
that the more persistent the irritation, the more 
rapid the growth, the more marked will be the de- 
formity. To overcome the contraction of such a 
muscle it must be overstretched to a degree corre- 
sponding to the amount of previous shortening. In 
the neck this is almost impossible by mechanical 
means when the affection has become chronic in 
character. This affords the rational indication for 
treatment: to hold the head by some appliance 
in perfect position from the outset of the affection 
when rectification is easy, especially if it appears 
to be caused by the presence of inflamed glands, 
which may persist long after the original source of 
irritation has been removed, not alone because rest 
is the proper treatment for inflamed glands, or for 
the relief of the strain upon the nervous system 
of a painful deformity of this character, in itself an 
important factor, but that we may not have the 
deformity-habit with shortened muscles and fascia 
to deal with when active contraction is no longer 
present. The removal of enlarged or suppurating 
glands, especially if they lie about the motor 
point of the contracted muscle, should certainly 
be considered. As this often necessitates a divi- 
sion of the sterno-mastoid we may at once take 
away the cause and remedy the result by this pro- OBSERVATIONS ON TORTICOLLIS. 
17 
cedure. My time will not allow me to speak of 
other causes of wry-neck or of general considera- 
tions in treatment which must be governed by the 
indications in the individual case. They are suf- 
ficiently described in works upon this subject. 
The induration that follows muscle-rupture usually 
disappears in from two to six months; if deformity 
is present, greater than may be explained by the 
character and size of the tumor, it is probably of 
intra-uterine origin and should be treated on the 
principles that apply to that affection—and, with 
certain modifications, to the acquired form that 
has persisted for any length of time; that is, free 
and early division of all contracted tissues that 
do not rapidly yield to milder methods, fol- 
lowed by the careful after-treatment which all cases 
of this character require. From the evidence pre- 
sented, I think we may conclude, contrary to the 
prevailing theory, that the causes of congenital wry- 
neck operate in a majority of cases before birth rather 
than during delivery. That acquired torticollis in 
very young children may be as persistent in duration 
and as disastrous in its results as the congenital 
variety—the age of the child, the persistence of irri- 
tation, the arrest of development in the contracted 
parts, and the rapidity of growth being the de- 
termining factors—and that here, as elsewhere, the 
prevention of deformity in the first instance, or its 
rapid rectification if seen in the later stages, should 
be the object of our therapeutic efforts. THE MEDICAL NEWS. 
A National Weekly Medical Periodical, containing 24-28 Double- 
Columned Quarto Pages of Reading Matter in Each 
Issue. $4.00 per annum, post-paid. 
That The News fulfils the wants of men in active practice is made 
clear by the steady growth of its subscription list. This increase of 
readers has rendered possible a reduction in the price of The News to 
$4.00 per year, so that it is now by far the cheapest as well as the 
best large weekly journal published in America. 
Every mode of conveying serviceable information is utilized. The 
foremost writers, teachers and practitioners of the day furnish original 
articles, clinical lectures and notes on practical advances; the latest 
methods in leading hospitals are promptly reported; a condensed sum- 
mary of progress is gleaned each week from a large exchange list, com- 
prising the best journals at home and abroad ; a special department is 
assigned to abstracts requiring full treatment for proper presentation ; 
editorial articles are secured from writers able to deal instructively with 
questions of the day; books are carefully reviewed; society proceedings 
are represented by the pith alone; regular correspondence is furnished by 
gentlemen in position to know all occurrences of importance in the district 
surrounding important medical centres, and minor matters of interest are 
grouped each week under news items. Everything is presented with such 
brevity as is compatible with clearness, and in the most attractive manner. 
In a word, The Medical News is a crisp, fresh, weekly newspaper, and 
as such occupies a well-marked sphere of usefulness, distinct and comple- 
mentary to the ideal monthly magazine, The American Journal of 
the Medical Sciences. 
The American Journal of the Medical Sciences. 
Published monthly. Each number contains 112 octavo pages, 
illustrated. $4.00 per annum, post-paid. 
In his contribution to A Century of American Medicine, published in 
1876, Dr. John S. Billings, U. S. A., Librarian of the National Medical 
Library, Washington, thus graphically outlines the character and services 
of The American Journal: “ The ninety-seven volumes of this Journal 
need no eulogy. They contain many original papers of the highest value; 
nearly all the real criticisms and reviews which we possess; and such care- 
fully prepared summaries of the progress of medical science, and abstracts 
and notices of foreign works, that from this file alone, were all other pro- 
ductions of the press for the last fifty years destroyed, it would be possible 
to reproduce the great majority of the real contributions of the world to 
medical science during that period.” 
COMMUTATION HATE.—Postage paid. 
The Medical News, published every Saturday, 
The American Journal of the Medical 
Sciences, monthly 
in advance, $7.50, 
LEA BROTHERS & CO., 706 and 708 Sansom St., Phi/a.