The diagnosis cannot present any difficulties after these explana tions. Muscular torticollis need he considered only if the degenerated shortened muscle is distinctly palpable as a hard, wire-like, protrud ing edge. If the muscle is merely contracted, it will be necessary to search for the cause of such voluntary or reflex contraction. The cause will usually be found in the presence of some painful process which causes the muscles of the neck to assume a permanent position in which the pain is least felt.
Examination of the vertebral column from the back of the neck and from thy pharynx, and Röntgen photographs from the side and through the open mouth, will give information about the conditions prevailing in the upper part of the spine.
In one of my cases there was marked deflection and torsion of the head with normal sternoeleidoinastoid in a boy of eight years. A lateral X-ray photograph, together with the history, showed that the cause was occipital periostitis which had involved the neighboring vertebral articulations, and had resulted in a subluxation between the first and second cervical vertebrae. The position adopted was due to the pain and the head became permanently fixed. Treatment by heat and a light extension effected a cure in a few weeks, although the condition had persisted for months.
Tuberculous processes located laterally in the bodies or arches of the vertebrte arc demonstrable by the X-ray picture. A diagnostic skin test (v. Pirquet, Moro) will aid the differential diagnosis. The treatment is then identical with that of spondylitis (which see).
The treatment of true congenital muscular torticollis can only be operative, and consists of open section or partial extirpation of the cicatricially changed muscle.
Subcutaneous section of the shortened muscle with a short, curved knife was practised a long time ago by physicians (see Joachimsthap.
In pre-antiseptic times Strohmcier and Dieffenbach were among the most enthusiastic adherents of this method.
When it became possible to treat open wounds without danger, subcutaneous section was abandoned, on account of its danger from close proximity to large vessels. The external jugular vein and the irregular transverse veins are near the field of operation, and, moreover, it is impossible, groping in the dark, to sever all the shortened cords of the muscle and enveloping fascia.
Open section is generally made at the lower portion of the muscle where it divides into t WO heads. In carrying out the operation the greatest importance should be given to the cosmetic result, and long, ugly incisions which are not well covered should be avoided.
A transverse incision a few centimetres long and lying exactly in the cervical fold is sufficient. Longitudinal incisions heal in irregular approximation to the fascia and cause a very objectionable scar.
The skin, platysma, and muscular fascia being incised, the muscle is at once exposed. The operation can be greatly facilitated by having an assistant push the muscle outward with two fingers. This also pre vents hemorrhage. The muscle is isolated in the wound itself and both heads incised over a grooved director, layer by layer, care being taken that all scattered strands are really cut through. By manipulat ing the edges of the wound the cavitycan be easily searched. The con nective-tissue strands which be in the muscular fascia must likewise be cut through.
If the eicatricial degeneration of the muscle is very extensive a partial excision (v. INlikulicz) may be done. By bending the head toward the affected side the eicatricial part of the muscle can be pulled out of the wound to a considerable extent and cut off, care being taken not to injure the spinal accessory nerve. In this way the objectionable longi tudinal incision, which had been proposed by v. Mikulicz, and the result ing scar are best avoided.
In cases with slight shortening of the muscle it is also possible from the same incision to carry out Foderrs plastic operation, which consists in severing the clavicular portion at the clavicle itself, cutting through the sternal head at the bifurcation, and then uniting both heads. In this way the length of the muscle is increased by the length of the clavicular portion. The skin of the neck being easily movable permits a satisfactory adaptation of the wound edges after a little practice.
After the operation the wound is closed without drainage. For this purpose .Nlichel's clamps arc best, as they approximate the skin broadly and leave no puncture canals. Otherwise a subcuticular suture should be made.