THE TREATMENT 
OF 
TORTICOLLIS, 
(WRY-NECK.) 
BY 
CHARLES F. STILLMAN, M.Sc., M.D. 
CHICAGO. 
(Member of the American Orthopcedic Association 
Reprinted,ffrom the N orth American Practitioner, 
March, 1890. THE TREATMENT OF WRY-NECK OR TORTICOLLIS. 
CHARLES F. STILLMAN, M.Sc., M.D., 
CHICAGO, ILL., FORMERLY OF NEW YORK CITY. 
MEMBER OF THE AMERICAN ORTHOP.EDIC ASSOCIATION. 
IITRY-NECK or Torticollis, when diagnosed, should be at once placed 
' ' under treatment, because if not treated the condition progresses 
slowly but surely, the clavicle becoming bent upward, the spinal column 
becoming curved in a lateral rotary direction, and the vision becoming 
imperfect, owing to the eyes being placed upon a different level. The 
treatment may be divided into 1, preparatory; 2, operative, and 3, the 
after treatment. 
1. Preparatory Treatment consists in the daily use of the spinal ex- 
tension frames devised by the writer (see Figs. 1 and 2), which allow 
traction of the contracted muscles to be continued for a long time with 
Fig. 1.-Stillman's Vertical Frame for Producing Backward Curved Extension of the Spine 
during Exercise. 
very little fatigue to the patient, and if the case is a severe one, the 
conjoint use of a brace, similar to that shown in Fig. 3. In mild cases, 
this treatment will be sufficient to cure the condition. In most cases, 
however, it is necessary to resort to operative procedures in conjunction 
with the use of the apparatus just detailed. 
2. Operative Treatment. Before entering, however, into a detailed 
description of these procedures, it will be well to caution the reader not 2 
STILLMAN, THE TREATMENT OF WrRV-NECK. 
to resort to them too hurriedly, because perseverance in mechanical 
means very often leads to excellent results, and also because the opera- 
tions themselves are not unattended with danger, owing to the proxim- 
ity of the carotid artery and jugular veins; and numerous cases are 
recorded in which very troublesome and dangerous hemorrhages have 
occurred, several of them terminating in the death of the patient. 
As most of the cases of wry-neck demanding operative interference 
depend solely on contracture of the sterno-cleido-mastoid muscle, the 
operation that is most often performed, and which is usually sufficient, 
consists in the sub-cutaneous section of one or both origins of this 
muscle on the affected side. We will, therefore, first describe the 
method of doing this, and subsequently merely mention the procedures 
necessary in the rarer cases. In performing the operation of section pf 
the sterno-mastoid muscle, the patient should be placed upon the back 
and a small pillow' laid under the neck, the head being at the same time 
forcibly extended and rotated to the sound side; in this way the muscle 
is rendered tense and prominent. To divide the sternal attachments, 
a puncture is made close to its inner margin, and as near the sternum 
as possible, and a small tenotome cautiously inserted and carried behind 
the tendon, care being taken not to carry the knife too deeply, and al- 
ways to keep its flat edge parallel to the tendon. The knife is then 
turned so as to bring its sharp edge towards the operator, and the 
muscle is cut with a slightly sawing motion from within outwards. In- 
stead of the ordinary sharp instrument, a probe-pointed tenotome may 
be used. After the initial puncture has been made in the integument, 
and in those cases where the muscle cannot be made very tense, it is 
wise to first insert a grooved director behind the muscle and then to cut 
on this. The incision, although made freely enough to completely 
divide the whole of the origin, should not be allowed to penetrate the 
skin, and so convert the sub-cutaneous into a large open wound. Such 
an accident may be best avoided by cutting slowly and with a slightly 
sawing motion, at the same time easing up the forcible extension of the 
head as the last fibres are about to be divided, so as to prevent the sud- 
den jerk which is liable to occur at that moment. If, however, this 
accident does occur, the lips of the wound are to be brought together 
by catgut sutures and an antiseptic dressing applied, when union by 
first intention may be expected. As in all sub-cutaneous operations, 
the finger should follow the blade of the knife as it is being withdrawn, 
and then lightly pressed over the external wound, so as to prevent the 
entrance of air. Lastly, the external wound is to be dressed with some 
simple dressing, as a pledget of lint or carbolized gauze, etc. 
To divide the clavicular attachment of the muscle, the same general 
directions are to be followed as above. The initial puncture may be made 
either at its inner or its outer margin, some surgeons preferring one, STILLMAN, THE TREATMENT OF WRY-NECK. 
3 
some the other site ; the inner is the one most often chosen, but in those 
cases in which the external jugular lies quite close to or overlaps the 
muscle, it is safer to begin the operation from the outer side. After the 
muscle has been divided, the operator may pursue one of two methods: 
either he may leave the head in its abnormal position until the external 
wound has healed and all signs of inflammation have disappeared, and 
then gradually rectify the deformity by daily manipulation and mechan- 
ical apparatus; or else he may at once correct the deformity and main- 
tain the head in a nearly normal position from the start. Up to within 
a few years, the former was the practice almost universally adopted, and 
it is still very generally pursued ; at present, however, the latter method 
is gaining favor, and Sayre especially advocates it in strong language. 
His reasons for so doing, as stated by himself, are as follows : (1) " The 
exuded material, being larger in amount, will, when organized, make a 
stronger and more useful bond of union than when stretched out into a 
fine cord, as in the former method of previous writers." (2) It does 
away with the daily stretchings (rendered necessary by the old method), 
■which demand the daily attendance of the surgeon, and which are often 
so painful as to necessitate their discontinuance. (3) In his hands it 
has never been followed by suppuration. 
In some cases, after division of the sterno-cleido-mastoid muscle, 
it will be found to be still impossible to rectify the position of the head. 
In these cases the difficulty will be found to depend on contracture of 
other muscles, the trapezius and scaleni; or else on bands of connec- 
tive tissue running up under the divided muscle. If it be the trapezius 
that is at fault, it may easily be divided sub-cutaneously either in toto 
near its occipital attachment, or partially near its clavicular attachment. 
If, however, it be the scaleni muscles that are contracted, the operation 
for their division assumes dangerous proportions, and is attended with 
great difficulty, on account of their lying deeply and being surrounded 
Fig. 2.-Stillman's Horizontal Frame for Backward Curved Extension of the Spine During Exercise. 4 
STILLMAN, THE TREATMENT OF WRY-NECK. 
by very important structures. Their division has, however, been effected 
by Bauer, but the dangers attendant on such an operation will prob- 
ably deter most prudent surgeons from its performance. If the 
reduction of the deformity be prevented by bands of connective tissue, 
Erichsen advises that they should not be divided, as they will generally 
yield in time to mechanical extension, and also because their division 
involves great liability of injuring the large vessels and nerves of the 
neck. 
There is yet to be considered the treatment of spasmodic wry-neck. 
In this form of the affection, tenotomy of the sterno-mastoid muscle 
has been followed by only temporary relief. Stretching of the spinal 
accessory nerve has been followed by permanent relief in several 
instances, but the best results have been obtained from excision of por- 
tions of this nerve. To reach it an incision should be made behind 
and parallel to the posterior margin of the sterno-mastoid muscle, and 
having its centre on a level with the thyroid 
cartilage. When the nerve is reached it should 
be dissected up into the substance of the sterno- 
mastoid muscle to a point beyond where it gives 
off its first muscular branches, and should then 
be exsected. 
The after-treatment consists in the use of 
the spinal traction frames, and a brace appro- 
priate to the condition. After the operation 
the head should be fixed upon the plan recom- 
mended by Dr. Little. 
With adhesive plaster and calico band- 
age, a band is formed round the head, encircling 
the forehead and occiput, and one round the 
waist. A ribbon is to be sewn to the head 
bandage just above the ear of the unaffected 
side, and carried down diagonally in the direc- 
tion of the normal sterno-mastoid muscle to the waist bandage and 
there fixed. This plan produces flexion of the head, a position which 
can be prevented by the use of an additional band reaching vertically 
from the back of the head to the Avaistband. After four or five days' 
rest, manipulative extension may be commenced and continued daily 
for several weeks, and the treatment will take from a month to three 
months or longer, and will consist of nearly the same procedures that 
are recommended under the head of preparatory treatment, but with 
the addition of massage and appropriate electrical treatment for the 
muscles, which are often very,weak, and if not treated, apt to cause 
relapse. 
Fig, 3. 
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